Hello all, my mind is working overtime with ideas today, in spite of the
diaper bag fiasco.
This thought occurred to me today as I was doing an outpatient consult
with a mom whose infant is 10 days old. Let me begin with what led me
to the thought...
During her pregnancy mom did not have an increase in breast size, but
she also was admitted once for dehydration and weight loss because she
couldn't keep anything down. She did gain weight over all during her
pregnancy.
Her baby was born term (39+5wks), weighing 6#10 ounces, (3010gms)
uncomplicated pregnancy/vaginal delivery. Mom came in labor, requested
epidural on admission. She labored about 2 hours getting hydrated before
epidural placed. At that time Pitocin was started as well. Infant was
born about 11 hours after admission, had some variables and mom was
turned on her side a few times, which probably also means that she was
given more IV fluids. Infant delivered with apgars 9/9. Infant was
breastfeeding great from the start, good latching, mom had absolutely no
nipple trauma, infant nursed frequently, about every 2-3 hours and
nursed for about 20-30 minutes each time. Mom was discharged at about
42 hours after delivery (delivery happened at about 2:30 a.m. ) Infant
was 6#7 ounces (2920 gms) at discharge.
This is mom's account of what happened: At discharge mom states that
the pediatrician told her the infant weighed 6#2 ounces and since there
had been a weight loss of 8 ounces the pediatrician told mom (by the way
she was discharged at 6 in the evening) to supplement after feedings
with a formula bottle. Mom was ready to leave when he gave her those
instructions. She did not get started pumping before she went home. She
had baby at pediatricians office the next morning and the ped at the
office told her to continue supplementing after feedings as infant's
weight was still low ( yes infant was less than half way through her 3rd
day of life). So, now mom continues to do this for several more days
until she returns a follow up call to check on how things have been
going with breast feeding. She is now 10 days post delivery, infant is
now 6#4 ounces. The baby that was nursing frequently in the hospital
doesn't feed that frequently at home, about every 3 1/2 - 4+ hours. She
has been nursing first, then following up with a formula bottle of 1-2
ounces. Infant barely takes more than an ounce most feedings. On rare
occasion has taken almost 2 ounces. Mom never experienced fullness, or
engorgement, she never started pumping although she has pumped once
using her Avent manual pump and had minimal results.
So here's my thought, there are monthly meetings (some places it may be
weekly but every hospital has some kind of OB review board) when certain
red flags are discussed, cases where the outcome was not optimal, cases
that have unusual circumstances or events, etc. charts are pulled and
that particular case is discussed by the OB doctors, midwives and
pediatricians/neos and L&D, post partum and nursery managers.. they
review the cases to be sure protocol was followed etc.
Wouldn't it be great if there was a monthly peer review of the
breastfeeding outcomes with this same group? Any baby who is
supplemented would fall into the review category and their individual
circumstance called to question by a group to ensure protocol is
followed. If we were to review my patients chart today we would be
asking that pediatrician why he felt the infant who had been nursing
well, had been content or easily comforted throughout hospital stay, had
only 3 ounces of loss in over 24 hours with an augmented and epidural
mom (so we know she got several bags of fluid in labor) needed to be
supplemented and WHY did mom think the baby had lost 8 ounces? The
oddest part is that the weight was obtained when infant was less than 24
hours old since weights are done between about 10pm and midnight each
night, so if the infant had lost what was mistaken for 8 ounces in less
than 24 hours wouldn't someone have looked at that before she was
walking out the door? And if they had looked at it they would have seen
that it wasn't 8 ounces (which would have been little more than 7% of
BW) but 3 ounces which is about 3% loss.
There was no mention of the doctors direction to mom at discharge so we
(the LCs) had no idea that this patient needed a follow up appointment.
If mom had not had such a great experience in the first day or so with
infant latching without pain and no nipple trauma, she would have given
up on breastfeeding already I suspect. Luckily this mom just didn't
realize that supplementing was going to affect her supply and of course
the pediatrician never mentioned it to her. Also, although they kept
pushing supplementing, no one ever told her how much or how often her
infant should feed and since she was giving formula she assumed that
infant was getting enough, but infant should be gaining weight better
than she has, today she weight 6#4.2 ounces. And since she wasn't
having BMs and was formula feeding the pediatrician had her give the
infant a suppository for constipation. Instead of actually looking at
how much or how often infant was getting fed. I wonder if they just
assumed that infant was getting fed enough since it was being
supplemented without even looking at the fact that baby wasn't gaining
weight.
So now, mom has to pump after feedings to get her supply recovered,
supplementing at the breast to get baby feeding better at the breast,
increasing intake and wean the formula down as her supply comes up. And
arouse infant for feedings more frequently to get number of feedings up
to at least 8 in 24hours. She has started on a galactagogue and she
rented a pump. She might have had supply issues, big maybe, its odd
that she never got engorged or felt fullness, but we will never know
whether the intervention is the cause. After nursing today mom was able
to express almost 10cc and the milk was very creamy looking so her milk
is there, and seeing that made her feel very reassured.
If any hospitals are doing a meeting like this, could you please email
me privately, I would love to find out how to get something like this
started or how well received it is. I would imagine though that no one
is doing this since insurance companies are not chomping at the bit to
demand that breastfeeding is protected and calling into question whether
protocols are followed correctly.
Ok, down off my soap box for now... to be continued!
Pam Price IBCLC, RLC
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