In response to Cheryl Taylor White's comment that:

*********
It has to be remembered that it is a rare situation that requires
supplementation.
***********

I think it really depends on the type of practice.  While it may be true of
the general population, it may not be the case for a "high-risk" practice,
particularly one known for its ability to  deal with failure to thrive.

I guess I have had the good fortune to be able to observe numerous mothers
GRADUATE to exclusive breastfeeding from all sorts of alternative feeding
devices - though the SNS seems to be more successful in resolving problems
quicker or getting to lower levels of supplement than bottles. The practice
where I'm training DOES follow Cheryl's two statements: "Increasing mom's
supply should be the focus.  Getting optimal latch established for optimal
nursing should be concentrated on."

At some point (I can't find the exact post now) I remember Cheryl and
someone else mentioned the importance of looking at the infant rather than
just relying on instruments.  I think that is extremely important, but very
challenging for those of us who are starting out.

Just to share a case of where looking at the infant's feeding behavior did
not jive with the results from a balance scale:

*********
The infant weighed 7 lb 13 ounces at birth, 7 lb 3 ounces at discharge and
5 lb 2 ounces at the 2 week visit. The infant was exclusively breastfed up
to that point. At the two-week visit, the pediatrician recommended
switching to bottle feeding and had observed the infant feeding from the
bottle on two successive days. Using a BALANCE scale, the infant gained no
weight on the first observed feeding and gained 5 ounces on the subsequent
feeding.

The infant was seen by a lactation consultant just after the second visit
to the pediatrician because the mother wanted advice about how to increase
her milk supply while her infant was recuperating from excessive weight
loss.

The infant was well hydrated on observation, but had poor extremely poor
skin turgor and was irritable when awake. (FROM MY INTERNATIONAL NUTRITION
EXPERIENCE, THIS INFANT WOULD HAVE BEEN DIAGNOSED AS A CLASSIC CASE OF
MARASMUS.)

The lactation consultant observed how the mother latched the baby on and
the infant's behavior at the breast. No swallowing was observed. On the
bottle, the infant's suck swallow ratio was greater than 3 and the infant
stopped for frequent pauses. She switched the infant to a faster flow
nipple and the infant's suck swallow ratio improved. The infant took 1/2
ounce from the bottle, was unable to take anything with fingerfeeding, and
took < 1/4 ounce via cup feeding and then vomited.  Weighing before and
after (wearing the same diaper) on an electronic scale showed a gain of 1/2
ounce. The mother was observed while pumping and instructed in methods to
improve her milk ejection reflex.

The parent’s record of feedings over the two-day interval showed that the
infant had consumed 5 - 6 ounces per day, generally in 1/2 ounce
increments. The mother reported that she was not sure of the recorded
intake because her husband had been feeding the infant while she pumped.
She did mention that the infant was often wet with spit up when her husband
brought the infant back to her after pumping.

The lactation consultant called the pediatrician to express her concern
over the infant's poor condition and poor feeding behavior.  The
pediatrician felt that the infant was doing fine based on the weight gain
observed in her office and recommended continuing with the slower flow
bottle because she felt that the infant could not cope with the faster
flow. The lactation consultant advised the mother to call her pediatrician
if the infant's condition worsened.

The parents reported back the lactation consultant one week after this
incident.  After leaving the office, the infant did not take any more
supplement or latch on to the breast after the visit to the lactation
consultant. The infant had a seizure in the middle of the night. The
parents took the infant to the hospital in the morning. The hospital
informed them that the infant had suffered two strokes since birth. The
infant was being tube fed in the hospital and had regained birth weight.

*******
This was the third case in a week of extreme failure to thrive.  This week
is the week of three breast reduction cases.  Very humbling to observe such
serious cases when one is learning.

Susan Burger, PhD, MHS

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