Donna asked about managing a baby who isn't feeding at the breast.

>The infant has good rooting reflex and will open fairly wide.  Breasts can
be
>shaped well enough that infant should be able to latch on if sucking good be
>established.  After 15 min of trying to get a latch  and using a little ABM
>on the nipple for encouragement.  The most that could be achieved was one
>little suck and then the baby would push away.

This sounds like the kind of suck problem we see frequently in the hospital
where I'm the LC.  It may not have anything to do with bottles or the mom's
flat nipples, although they probably did complicate things.  Do you know
whether mom had anesthetics or analgesics in labor?  If the baby suffered
some sort of CNS insult from drugs, he may not attach well for days or weeks.

> Mother was told to discontine
>all artificial nipples and pacifiers and was sent home with SNS to finger
>feed and pump breasts.  Skin to Skin contact was also reccommended and to
>watch for rooting and to keep trying to get the baby latched on.

Sounds like good advice, although I'd be cautious about how I phrased the
part about trying to latch the baby on.  Some moms get so focused on
attaching the baby, they wear themselves and the baby out trying for
prolonged periods to get him to feed.  They spend hour after hour working
with the baby at the breast, pumping, finger or dropper feeding, and cleaning
up the equipment.  Then they start all over again.  In two or three days, the
whole family is so exhausted they're ready to throw in the towel so they can
sleep.

>Mother is to return to office on monday to check
>weight again and further evaluate.  Diaper checks were also explained and
>only about 15 cc abm in the sns was recommended every 3 hours, instead of
the
>full ounce the baby had been receiving with the bottle.  Mother called in
>today...infant very distressed and not satified with 15cc of sns.  Only
happy
>with a finger to suck on constantly.  Still will not latch on to the breast.
> Pedi wants to increase the amount of ABM and even told mom if she has to
>give a bottle as a last resort to go ahead.  I should also mention that the
>baby is having "gassy" spells that also lead to prolonged crying.

The baby's probably hungry rather than gassy.  He was a little more than  5%
below his birth weight at two days and is probably down more than that now.
(Ruth Lawrence's third edition says that most normal infants lose about 5%
before beginning to gain.  I think Marianne Neifert says she doesn't like for
babies to lose more than 7.5%.)  I've found that letting a neonate be hungry
all the time is seldom effective in teaching him to suck.  My experience has
been that the baby gets jaundiced, loses too much weight, is fretful and
fussy, or, more likely, just sleeps all the time, and eventually is too weak
to feed well.  If the baby is of average size and isn't attaching at all,  I
usually suggest a half-ounce to an ounce of milk q 3 hours starting toward
the end of the first day, then increase it to the average baby's caloric
needs (I figure 120 cal / kg / day--I know some people will think that's too
much) by the third or fourth day.  Moms are told to use any pumped breast
milk first, then follow with formula if needed.  I'd prefer all breast milk,
of course, but most moms don't pump enough in the first couple of days.

Expecting a new mother to cope with a constantly screaming, hungry baby, or a
lethargic one, seems counterproductive at best and dangerous at worst. ( I've
worked with some parents who didn't seem to realize the baby was in big
trouble---a weight loss of nearly 15 percent, for example, a baby who's limp
as a dishcloth and too weak to open his eyes.)  I'm more comfortable feeding
the baby adequate amounts, even if it means using some formula. As for using
a bottle, I *always* teach an alternate method of feeding as the first
choice, but the number one rule is "feed the baby," and I give parents
"permission" to feed with a bottle if they can't get milk into the child any
other way.  Very seldom do they resort to a bottle--but they have the
security of knowing it's an option.

I think a vigorous infant is more likely to attach and feed at some point
than a starving one, but I'm always open to new slants on that idea.  I'll be
curious to see how others manage this.

Judy Dunlap, RNC, BA, IBCLC