Sorry to chime in a day late, but I have some thoughts to share. I do pretty 
much exactly what Kathy Eng said in her post, using birthweight x 2.5 as a 
24 hr ounces amount. Mom can choose the supplementation method (alternate 
feeding) but it needs to be a method that gets that amount into the baby in 
the 24 hr period and allows for mom to pump and all to get some rest. I find 
bottles to be chosen often and I am fine with that. I have a handout about 
'best practices which, of course, recommends exclusive bf and no artificial 
teats. However, it goes on to say that moms need to express for babies who 
are not FEEDING ALL FEEDS VERY WELL BY DISCHARGE (and even before). When I 
talk to moms about babies who are not yet feeding very well, I say the first 
part of the best practices handout is Plan A but we are now on Plan B. So 
bottles are now ok because we have moved to Plan B (sts, pump, alternate 
feed, continue bf work, follow-up).

Supplementers can work provided baby has good seal and suction on breast, 
which these babies often do not.

Initial wt loss was about 8% at 48hrs. This already would have been a red 
flag to me. Sometimes one gets a baby or call and does not know the 
discharge weight. If I had known the weight, then I want to see the baby bf 
prior to discharge, schedule a f/u visit and wt check unless the milk supply 
is increasing already and baby is nursing great by discharge and then do an 
early f/u call at the very least in 24 hrs.  Another red flag is "Mom has to 
continually stimulate infant while she is at the breast to keep her actively 
suckling."  This usually means no or very low milk transfer is occuring.

"Mom pumped after pre and post wt. and got 1 oz from each side", so mom 
would be able to supplement with her own ebm, hopefully exclusively. Use 
formula if donor milk not available to make up the 24 hr volumes if ebm not 
enough.   "Mom stated she had been pumping with manual pump at home 
occasionally and was giving 1/2 oz of breastmilk per dropper 1-2 times per 
day." It goes without saying that mom needs a hospital grade pump 8x per day 
and that 1/2 oz 1-2x was not nearly enough.

Big red flag in my experience "Pt stated she felt that her infant was 
gaining wt."  They will also say the infant does not appear jaundiced. I do 
not want to sound patriarchal but I find that parents are not good judges of 
infant wt gain nor jaundice in early days.

"Her ped recommended supplementing formula 2 times per day, starting with 2 
oz. per feeding. " This may not help either if baby is not really 
transferring at breast, and instead of getting 1/2 oz 2 x per day, he's now 
getting 2 oz  2x per day. This is not even close to the MINIMUM 18 oz he 
needs. A better plan is to calculate and give mom a "prescription" for 
amounts and use ebm then formula (if needed). It is a VOLUME THING NOT A 
WEAK MILK THING. (" Mom is questioning if her milk is "bad")I have found it 
is not unusual for babies in these conditions to be voiding the right number 
of times, but not stooling much like yours was ("Infant is having 6+ wet 
diapers per day but stools are infrequent and are brown/mucousy.").

I have found using a 24 hr log with feeds and pumpings and voids and stools 
on one page each 24 hrs, to be a great tool and mom can bring it in or read 
it to you over the phone, and know exactly how many feeds and total volumes 
and how many pumpings and total volumes, and voids and stools. Remember, a 
baby who needs 18 oz minimum will lose wt on 16 oz.

This type of case is fairly common in my experience, and it is one of my 
soapboxes because these babies go home with a 2 wk f/u appointment.

Laurie Wheeler, IBCLC, MN, RN
NE Mississippi, USA

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