Laura,

I totally agree with Laurie Wheeler's and Jaye's advice.  This baby  needs
the supplement for now and maybe how it's delivered or when can be  adjusted.
Mom could try the bottle first method of supplementing and  finish at the
breast; paced feeding via Kassing method should be used for bottle  feeding.  Long,
unproductive breastfeedings are tiring for both mother and  baby and
especially discouraging for mom who should pump after feeds to maintain  and even
increase her supply as a robust supply will help this baby.  Don't  forget breast
compression during breastfeeding, too.  I'd give the 1-2 oz  EBM before the
breast, having that take 10-15 min, then breastfeed for 15-20 min  tops so
feeding takes not an hour+, but more like 30-40 min.  Then mom can  pump.

I'd look for oral tone issues, (I've seen more low oral tone in tongue tied
babies, especially in soft palate function; remember tongue tie is a mid line
defect so other structures can be affected), be certain frenotomy was
sufficiently done to begin with (was this an anterior frenum or posterior?) and  if
the oral or body tone may be an issue refer to SLP/OT feeding  specialist.
Follow up closely as you've been doing and I'd give this mom  lots of praise and
encouragement and take things slowly so as not to overwhelm  her.  She's done
a fantastic job of giving baby her milk and the fact that  her little one
lost so much weight initially is terribly frightening for  her.  This in and of
itself is difficult for moms to overcome, the fear and  doubting of her milk
producing capability.  I've had moms tell me they'll  likely always be doubtful
of their lactation abilities and I just agree how  scary it was, so validate
her feelings, and give her time to emotionally  heal.  It's hand holding,
letting mom know you're there for her, referring  when appropriate, sending info
for connecting with other moms who've gone  through what she has, making sure
the reassurance given is based on sound  clinical judgements, and only done as
appropriate.

Perhaps, you're feeling unsure, too, and that's when you do what you're
doing, reaching out to others for your own guidance in approach and letting mom
know you may not know so will get her help from those who may have more
experience.  Most of the time moms are right about their babies and  encouraging
this use of instinct is important, rather than applying what's been  true for you
in the past with babies who've regained sucking vigor with wt gain,  listen
to what this mom is telling you and then it's a learning experience for  the
clinician.

Hope this helps and do let us know how things proceed.  I'd also  encourage
mom to wear her baby to encourage more frequent feedings for then babe  is at
least "at the restaurant," and cues to feed are more readily picked up by  mom.

Barbara Latterner, BSN, RN, IBCLC
*****************************************************************

He was referred from pediatrician newborn visit after losing almost 20% of
his birth weight, jaundiced, having difficulty latching and unable to stay
awake  for feedings.  Mom started pumping regularly, waking him
regularly and  per her choice was giving EBM supplements via bottle after
feedings, 1-2  ozs.  A tongue tie was noted and monitored.  He was quick to gain
weight with supplements, however after weaning from supplements, was quick to
 lose weight again.  A frenotomy was done and latch was improved and baby
more able to stay on the breast.  Baby is content at breast, enjoys being  at
breast, latch is much improved, deeper and more coordinated, however feeds  are
long, lasting a minimum of an hour with much encouragment.

In the  past week, days 10-17, he has gained 11 ozs.  He is able to take up
to 2 oz  transfers at the breast, although feeds are still long and suck is
still sort of  poor.  He is still quite sleepy and lazy!  Mom says he won't wake
for  feedings and she will pump and force a feeding into him via bottle.
After  a "good" feeding, she is frustrated, reporting that he has not emptied the
breasts, leaving 1-2 ozs. and will insist on giving a supplement, saying he
sucks it down.

He is just about back at his birth weight and with  supplements is gaining 2
ozs per day.  Mom is extremely stressed out about  the situation, she
percieves her milk supply to be low, regardless of my  reassurance.  She started
taking a kitchen scale and weighing baby before  and after every feeding as well as
weighing baby daily for weight gain, against  my better judgement.  I am
trying to explain that breastfeeding is natural,  not calculated and should be
regulated by the newborn.  Considering the  above average weight gain, I would
like Mom to discontinue supplements and see  how he does on his own, however she
says he would sleep for hours on end.   She has little confidence in herself
or her baby to regulate his own  feedings.  He is officially healthy and
thriving.  I had her waking  the baby to feed him regularly due to weight loss,
however, I feel that if given  the chance he will wake on his own and be more
alert at the breast when able to  feed on demand.
Perhaps his atypical feeding schedule is normal to him.   She says he has a
period of alertness for a few hours during the day and cluster  feeds for hours
at night.  My gut feeling is that although he may only gain  an
acceptable1/2-1 oz per day without the supplement, he will not allow himself  to lose.

So, my question is, is it good advice to allow the baby to set  his own
feeding schedule, even if he will at times sleep up to 5-6 hours during  the day?
I'm afraid if I push her to "experiment" and allow her baby to regulate
feedings and he loses weight, she will truly lose all confidence in herself and  me.
 I feel the
more time he spends at the breast and without the bottle  supplements, his
suck will improve.  He needs a little suck workout.   The bottle supplements
were only to be a short intervention to get him gaining  weight and able to keep
gaining on his own.  Now that he's gaining, I can't  get mom to ditch the
supplement and I think he's confused.

Unfortunately,  I think I've allowed her lack of confidence to reflect back
on my  confidence.  In my experience, once a baby really establishes weight
gain,  the sleepiness usually improves and the baby will become a more vigorous
nurser,  as naturally they have more energy to do so.  He is gaining weight,
however  he is still sleepy and rather lazy at the breast.  He sucks, it's just
not  vigorous.

Any advice?  What would you do?

Thank you,
Laura  Miller, RN, LCCE
future IBCLC (in July :)  )


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