Thanks to everyone who has given a suggestion so far.

Nikki - I LOVE your scenario, and it would certainly be ideal.  I, too, prefer hand expression, and have had some success with moms using it.  I do however have a lot of moms who are reluctant or nervous, and seem to be more inclined toward gadgetry.  I think we can make lots of progress in this area.  As far as skin to skin, if I could, I'd keep baby 24/7 skin to skin with mom.  Unfortunately, with some glorious exceptions, I find many moms are eager initially to do skin to skin, then the amount of skin to skin time rapidly diminishes, and I find baby spends more and more time bundled in a cot at the parents request.  Again, an area we can greatly improve upon.

Nina - I appreciate your suggestions too.  I do realize that the breasts are never empty, however, and this is a generalization, I would say that many of my families want clear distinctions in feeding times, with a definitive time 'off' in between.  As in 'now I feed/express etc, then I GET to rest for 2+hrs'.  The moms that are willing to do copious amounts of skin to skin and hand express every 1-2hrs in addition to feeds is, at least in my experience, not the more common occurrence.  

In lactation, I think we spend a lot of time helping to undo decades of inculturation into the separate sleep, widely spaced feeding culture.  For many of my moms, despite prenatal education and best intentions, the reality of frequent feeding, using her hands on her breasts to elicit food for her baby, prolonged skin to skin contact, is a HUGE adjustment, and for some, the ideal scenario is too intense.  Whatever I might like to see happen, I still have to meet moms where they are at, and support them where they are at, giving them options that they perceive to be manageable.

So, though the ultimate ideal would be kangaroo care, frequent expression and spoon feeding small amounts of colostrum regularly, I am trying to come up with an intermediate plan, as we encourage our parents in that direction, that still accomplishes the goal of maximizing breastmilk intake and reducing/avoiding formula use.

Currently, I think most inpatient infant feeding plans tend to focus on every 2-3hr feeds, with the idea of consolidating all the aspects relating to nourishment (breastfeeding, supplementation, pumping/hand expression) into a period of time, such as 45 minutes, and then repeat in a little over 2hrs.  Whether this is the best way forward or not, I am not certain, but it is the framework within which I am hoping to reduce/minimize the use of formula.

Again, thanks to anyone with any suggestions, I just love this list, it is such an awesome resource!

Casey Clubb, RN, IBCLC
West Linn, OR USA

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