I haven't been reading the accounts closely as I've been too busy lately.
But, along the lines of the theme, I'd like to tell about a few recent scenarios.

I had a case this past week whereby the parents didn't want to use a
breastpump, thought the baby was doing well, pediatrician thought the baby was not
dehydrated despite losing 12-13% of her birthweight, and the parents really
didn't want me to follow-up with them.  I chose to press on with them, explaining
my reasonings with them of my concerns for 1.) mom's milk supply and 2.) baby's
health.  Once the pediatrician's viewpoint was given to the parents that the
baby was fine, it was really hard to explain my rationale for why I was
concerned about the baby without jeopardizing the parents' established relationship
with the peds.  I chose to focus on the lack of proper stimulation for mom's
milk supply, and to commend the peds. for her support of
breastfeeding.....telling the parents to keep breastfeeding was great!  Beats telling them to stop
and to supplement.  But, I also wanted the parents to realize that though baby
was not dehydrated right now, I chose to prevent further problems by feeding
the baby now to get her weight back up rather than playing the wait and see
game.  I also explained that the job of the peds. is for the baby, so obviously
she is not thinking about the mom in terms of her milk supply.  It's just not
her job to do so....I wouldn't expect the peds. to do so.  I wanted to take the
stance that the peds. was not doing anything wrong.

To make a long story short, the parents agreed to have me come and follow-up.
 We did a volume check and baby took only 4cc's from breast.  You should have
seen the look on the faces of those parents....I had to do some fast talking
for recovery so as to rescue their confidence in parenting.  Didn't want to
condemn them over the situation as obviously their intent was in the right
place.  So, I presented them with choices of supplementation and fingerfeeding was
primarily chosen if SNS at breast didn't work.  Pumping was initiated and
mom's now pumping 2 oz. per pumping.  Baby is back to breast and another vol.
check will be done tomorrow, and I'm hoping her weight's up nicely and her intake
is improved.  Parents have noticed baby is acting better, and they called me
this morning to thank me for pursuing them as on hindsight they realize they
needed to do this, but that they didn't know it at the time.  What would have
happened had I left them alone?

Another scenario of the week:  A mom struggling to latch baby onto breast
shortly after birth calls for help.  I assist with assymmetrical latch and baby
gulps colostrum.  All is well, and I leave with mom resting with baby on chest.
 The next day I get a call to come back and help because mom's sore.  I
reiterate proper latching technique and despite still being sore, mom continues to
improve her technique with latch.  She puts on the hydrogels I've given her
and she feels relief immediately.  Now, on her bedside table lay Purelan,
shells, a nipple shield, and Soothies.  These are what I call "unnecessary gadgets".
 I simply inform the mom that she can tell her nurse later on to take the
stuff back as they aren't needed at this time.  Leave the mom and baby alone
without the gadgets and they'll do fine!  Yes, I always say "go back to basics -
correct the latch", and the rest is history.  My callback to  mom yesterday
revealed that she's home and breastfeeding well.  Her milk came in the day before
and she's spraying everywhere, her husband's getting a kick out of it, her
nipples are healed, and baby's wetting and pooping.  Now, had this client been
left alone, I'd be willing to bet she'd have had persistent sore nipples,
possibly cracked by now, lack of adequate milk production, and/or severe unrelieved
engorgement, a baby lacking adequate wet and poopy diapers, and we'd probably
have to start pumping to stimulate milk production, perhaps baby would become
jaundice, or sleepy at the breast, necessitating another feeding method
besides strictly breast, and the list goes on and on..........

Another scenario of the week:  Mom of 36 week twins goes home pumping
breasts.  Babies have not done more than being at breast once briefly; no volume
check, no shield use, no plan in place.  Mom states she's told by an LC that her
milk production is low because she's using an inferior pump, and she's told to
try the babies at the breast once a day.  I call her to follow-up with her
regarding her Symphony pump rental, and she informs me of the conversation
regarding type of pump.  As we pursue our conversation, she decides to contract with
me for consultation.  My primary goal in this scenario is to get these babies
to the breast.  Again, let's get "back to basics", meaning in this situation,
let's get these babies onto breast.  What are we waiting for?  I decided not
to focus on which type of pump function is best, but in getting babies to
breast....in a sense, focusing not on the gadgets, but bringing the babies back to
basics with guidance, of course.

As I entered her house the next day for her consult, she was already nursing
one of her twins.  She had the proudest look on her face!  She told me that
she's been nursing her little one since she spoke to me and she was surprised
that he took it well.  The other twin was  more sleepy at breast, but this one
latched right on to her amazement and had been nursing everytime.  Despite the
baby's feeding already taking place for approx. 10 min., I suggested we weigh
him once he detached anyways.  We did and within not even 5 min. he took an
additional 6 cc's.....meaning, he probably had approx. 10-15 cc's, which isn't
bad!  Beats nothing at breast because we didn't even try!  Out of 45 cc's he
was meant to have according to the doc, this meant he took 1/3 of his feeding at
the breast!  Mom was thrilled with this accomplishment!  Now doesn't it pay
off in terms of her milk stimulation to have the baby suckling at breast, and
doesn't it encourage her to keep trying, and doesn't it help a baby to relax,
and isn't this indeed going to help us reach her goal of getting her babies to
breast, because we didn't leave these babies and this mom alone, but we helped
them to breastfeed?  I realize these babies were not normal newborns, but
along the subject of leaving babies alone, I think we need to discuss the needs
of the not normal cases, as often times, unfortunately, these cases are also
inappropriately left to fend for themselves.

So, along the lines of leaving babies alone soon after birth or helping them
to breastfeed, I feel it is indeed a gray zone we're all dealing with.  The
situations differ with each baby and each mom.  That's why what we do cannot be
done as a cookbook recipe.  Every situation varies according to the dynamics
of each mom and each baby.  When to prod/nudge and when to leave them alone is
a judgement call each and every time we approach a new situation.  Giving each
mom who struggles with breastfeeding a gadget such as a nipple shield or a
pump is not the right approach.  Yet, being permissive of letting nature take
its course each time is not the right approach either.  The gray zone is the
arena of our entire profession.  And in light of our current society, the gray
zones will be there for many years to come!

Happy New Year Everyone!

Carol Chamblin, RN, MS, IBCLC
Breast 'N Baby Lactation Services, Inc.
St. Charles, IL

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