Unfortunately, many HCP are not aware of any methods to assist with
breastfeeding management.  They tend to view breastfeeding as a yes/no sort
of thing.  If baby is breastfed and not gaining, the answer must be to add
formula, while of course those of us with any breastfeeding knowledge know
there are many things that can be done to optimize the breastfeeding, if
this is needed.
My partner is an older pediatrician with no good breastfeeding knowledge
base.  I'm slowly encouraging her to send her "poorly gaining" breastfed
babies to me.  I find that many of them are simply constitutionally small
babies (often with matching small parents and siblings.)  These babies often
look great -- developmentally appropriate, happy, excellent output.  Often,
if I break down the weight gain on these babies I find that they have been
consistently gaining, with some plateaus when becoming mobile, or during
illnesses, or other not unexpected times.  I talk to these parents about
genetics, and point out all the positive signs that make me not worry about
their baby.  I encourage them to continue right on doing what they're doing.
 Some babies truly are not gaining well.  For these babies, I explain to mom
that my first goal is to feed the baby, and my second goal is to preserve
breastfeeding since it is so important to the baby's health.  Then we come
up with a care plan to help the baby gain weight (sometimes including
supplementation.)  Often, telling the parents that maintaining breastfeeding
is an important "medical" goal helps them keep going if baby is not able to
get all their calories from mom.
Interestingly, I've seen two babies lately that were weaned because my
partner felt "mom's breastmilk was insufficient."  One continues to be a
very petite, but active and healthy infant.  In the last 2 mos on formula,
her weight gain continues to be just barely at the low end of normal, the
same as it was on the breast.  The other baby clearly has something else
going on.  He has gained only 15 oz in the last 2 mos (despite formula and
high calorie solids), but also at 10 1/2 mos is not crawling or pulling up.
  I referred him to neurology for what looks like right arm weakness, and
early intervention for occupational and physical therapy.  I think neither
one of these babies "problem" had anything at all to do with breastfeeding.
If you have no breastfeeding knowledge, then you have no idea that there are
things you can do to improve it.  While I can make a difference in my
partner, I'm not sure what to do about other HCPs.  I do think sending a
care plan to physicians is very helpful.  If baby is gaining acceptably
despite a worried MD, perhaps siting a source for acceptable weight gain in
the breastfed infant is helpful.  For the baby who is truly not gaining
well, listing detailed instructions on what will be done to help the dyad,
and what the follow-up will be may make peds more likely to wait and see wha
happens.
Jennifer Tieman
Family Physician
Mom to 4, including nursling Caroline Rose born 5/31/03

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