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Date: | Wed, 30 Apr 2008 08:14:22 -0400 |
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Dear all:
Even after all my obsession with figuring out the limits and appropriate and inappropriate
uses of the weighing scale felt like weighing the diapers was a new one on me. At first
glance this might appear to be a less intimidating method to gather some objective data
about a baby's intake rather than direct test weighing of the baby with a mother that
clearly shows some signs of insufficient glandular tissue in one breast. Test-weighing the
baby immediately emphasizes the insufficiency of intake, whereas the diaper is one step
removed.
However, after watching Laurie Nomsson-Rivers (I may have misspelled this but I'm in a
rush so don't have time to double check her name) talk at ILCA and then really looking
carefully at the data she sent me, the number of diapers is not a great indicator and I
agree with her conclusions that diaper counts alone are simply not adequate for judging
intake. The sensitivity and specificity at their optimal point on the ROC curves are really
very poor.
It also dawned on me that the initial evaluation of the baby who has lost weight and the
mom has assymetric breasts has already provided sufficient information for a plan
anyway. I use my scale to test weigh on the initial eval for reassurance in a culture
where test-weighing has never been routinely used to evaluate every feeding, so it
doesn't have the same emotional impact as it would in cultures such as some areas of
Europe and Australia that went through a period of time when every baby was weighed
before and after every feeding. I also use my scale as an additional piece of information
to pick up those babies who are not feeding well and I do not make my judgements in
isoluation from the total picture.
In this case, I'm thinking I would not do any test weighing at this moment because the
baby has already lost weight and one breast shows indications that it may not have
sufficient glandular tissue. Sufficient information is available to intervene. In addition, I
would not test weigh the nappies because it is just extra work for a mom who is going to
need to do frequent feeding --- possibly for the duration of her breastfeeding experience.
Moreover, even though it has a number attached, it really won't provide any useful
objective information about the feedings because even number of diapers are not all that
predictive.
More useful for this mother would be to teach her how to spot her own babies swallowing
cues. That would also be more helpful than timing the feedings ONCE she develops those
skills. I'd only use time guides until she feels confident with her observational skills. I just
recently worked through two cases of insufficient glandular tissue who are happily
breastfeeding and emotionally at peace with the fact that they don't quite make enough.
The interventions differed. What I found was common is that the baby stops swallowing
faster on the breast or breasts that don't have sufficient tissue than a breast with more
tissue. AND breast switching often helps because the breast will fill a little and the baby
can get a little more after a 5-10 minute breast on the other breast. So, I almost always
watch how the baby swallows and suggest 3 or 4 breasts at a time depending on the
swallowing pattern. Usually I find the swallowing stops long before the 15 minute mark.
So, with a 30 minute time span --- I usually find that the baby will take more using 4
breasts than sticking to 2 breasts.
As for a specific time span between feeds - I also find that rigid routines for bumping up
a supply can really wear a mom out if she sticks to the clock alone. I usually have her
do a simple tally sheet and encourage mom to offer at any signs of waking. That means
any time the baby's eyelids flutter, the baby stirs, the baby even opens it's mouth ---
assume hunger and offer the breast. With a specific time span, I often find mothers are
spending more time waking the baby than actually feeding the baby because they are not
paying attention to when the baby is in deep sleep. One of my moms came up with a
new term for it --- don't wake the baby when the baby is like "flan". I had been calling it
the "limp noodle baby". Again, teaching this mom to look for cues that she will have
success in rousing this baby for a feed are likely to keep her exhaustion to a minimum in
what looks like a situation where she is most likely going to have to frequently feed for
the long haul. She is in a marathon, and shouldn't be made to sprint all the way through.
With a 24 hour tally sheet she can manage the feeds with a little more flexibility and feed
more frequently at times when the baby is willing and less frequently when her baby is
not really rousable.
And given that there is sufficient info to intervene, I probably wouldn't test weigh this
baby until mom has implemented the interventions for a while. I would do this after the
intervention has had an impact to guide her how to back off the interventions to a long
term plan.
Good luck with this one.
Best, Susan Burger
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