Perhaps my verbosity obscured my point (common problem ;-D). I think
stooling patterns are a very useful *assessment tool*. My concern is with
the creation of written-in-stone protocols that may be based on unrealistic
output scales. Where is the science? It doesn't seem like we have hard data
on stooling "norms" in the first few days. I cringe when I think of the
rules that have been created over the years based on pseudo-science. We are
still trying to extinguish the dogma about "three minutes on each side,"
first feeds of glucose water, aggressive treatment of physiological
jaundice...I don't want to see another layer added.

Personally, I think it is overly optimistic to expect colostrum fed infants
to start having 3 stools a day from day one. The suggestion that one look
for as many poopy diapers as the baby's age in days seems more realistic;
however, in my practice I often see babies who have no stools days 2 through
4 --and they typically make up for lost time on day 5. (These babies have
passed meconium stools in first 24-48 hours.) The majority of "my" babies
are from techno deliveries (our HMO uses a large teaching hospital that
caters to high-risk population, and has a very strong anesthesiology dept.)
If they have been under warming lights(instead of next to mom) they have
very high insensible fluid losses; babies who have been dried out in this
way often cannot make up their fluid losses in the first two days. Maybe we
could work to get rid of those #$@* warming lights and have protocols to put
babies in skin contact with their mothers :-)

I do not simply "wait and see" while baby withers! "Feed the baby" is always
"rule no. 1" In-person evaluation is imperative when parents report no
stools in the early days. If one ascertains baby is feeding, baby looks
well, weight is ok: then I stand by my preference to wait-and-see. Babies
that are too sleepy to feed need intervention of some kind, whether it is
mother-led frequent breastfeeds or alternative feeding of expressed milk--or
that other stuff. The ability to fit the treatment to the situation is what
makes us each a professional.

For those of you struggling as LC "Davids" against the "Goliath" hospitals
in creating enlightened standards of practice I congratulate you. I
see the need for parent handouts noting the relevance of diaper watching--I
use these in my practice. Please do not think my grinching about the laying
down of protocols has anything to do with devaluing your struggles.

I just worry about shooting ourselves in the foot with unrealistic
"protocols."

Margery Wilson, IBCLC
Massachusetts Institute of Technology
Medical Department
Breastfeeding Support Program (A tribal support oasis)