"Baby Friendly"

[aerorunner80]

Is anyone else going through the Baby Friendly designation at their hospital right now? We have done all of our training and are now waiting for the visit. I'm having some issues with it though.

Not much has changed in our unit as far as our practices, which I'm thankful for. What I am noticing is an increase in admissions from NBN of babies who are dehydrated because the nurses and/or practitioners are refusing to give breastfed babies formula when needed.

I'm really concerned that with this training, people are learing to become very inflexible and not giving formula when really medically necessary.

I can understand not wanting to give formula for the majority of breastfed normal newborns but sometimes the mother's milk supply isn't sufficient enough and the baby suffers for it.

We have seen an major increase of babies being admitted because of low blood sugars and lethargy and/or seizures. When we do our lab work, we are finding that these babies are dehydrated but before we get that diagnosis these babies are getting full septic workups including urine caths and lumbar punctures.

I am really feeling that the designation of "Baby Friendly" is being misapplied or some education is missing.

I want to talk to someone about this. I'm probably going to start with my unit director becuase this really bothers me.

Has anyone else experienced this? What are your thoughts?

How would you present this as a concern? Ideally I'd like to bring this up with the unit directors and the medical directors to find out what exactly is going on.

[IrishIzCPNP, MSN, RN, APRN, NP]

Yeah, my three formula babies have grown into healthy, active, intelligent kids with whom I share a very strong bond with. Imagine that.

And where did I or my post say that formula will cause definitive ill effects opposite of the claims of your children? I didn't. But people need to recognize that yes, just a small amount could do a lot of damage. Moms should have that education when they ask for one bottle or are told "one bottle won't hurt". It may. It does ruin the virgin gut and that is something important.

You can make your choice for formula. It should be done knowing the risks associated with formula and not "well my kid did just fine".

[TiffyRN, BSN, PhD]

It does ruin the virgin gut and that is something important.

I'll acknowledge your "virgin gut" and raise the topic of pain exposure from IV attempts. There is support for long-term effects from painful experiences infants experience in the NICU:

Are There Long-Term Consequences of Pain in Newborn or Very Young Infants?

I cannot express how strongly I support human milk for human babies and make a strong effort to call formula "cow milk" to parents so they realize I am feeding their child the milk of different species. When our NICU started a human milk initiative (including using human milk based fortifiers) for the smallest and most delicate infants our rates of NEC dropped dramatically. Here's the thing though, our (smaller) infants get donor milk until mom can produce their own. They get IVs as needed but it's because they are premature and their intestines are not ready to support them. We've had late preterm and term infants that parents request no formula and they are offered human donor milk if IVs are not needed for other reasons. They are made to understand that the cost (which is not outrageous as we use an all volunteer bank) will not likely be covered by insurance.

Here's my issue regarding the topic more at hand, which is depriving infants of nutrition as we wait for mothers to produce the needed breastmilk. We must remain humane in our efforts. Repeatedly (it's rare a child needing IVs will have one stab) sticking a healthy term infant just really strikes me (and many others) as inhumane. There is human donor milk available. If a hospital is really dedicated to being baby-friendly, then they should contract to provide this to infants.

I have this opinion (and that's all it is, not science but maybe a future research topic) that human infants were not designed to be starved the first few days of life. I believe human infants were designed to be supported by a community including matrons who knew how best to help mom through labor/delivery and other lactating mothers who would help nurse the infant while mom's milk supply came in. I absolutely do not believe this to be something for today, I just think we are on the wrong path if the options we offer are:

1. Mom must lactate quickly or baby must starve until then (possibly becoming dehydrated).

2. Stab the infant repeatedly with needles as a punishment for mom not lactating quickly enough or mother/infant dyad not being able to latch & feed well enough.

3. Destroy the infant's virgin gut (and I acknowledge this is not a trivial matter) by giving cow milk that comes with the proteins designed for another species.

We can do better than this folks.

Sorry for the rambling, just spent 3 nights in a row working.

[IrishIzCPNP, MSN, RN, APRN, NP]

I'll acknowledge your "virgin gut" and raise the topic of pain exposure from IV attempts. There is support for long-term effects from painful experiences infants experience in the NICU:

Are There Long-Term Consequences of Pain in Newborn or Very Young Infants?

I cannot express how strongly I support human milk for human babies and make a strong effort to call formula "cow milk" to parents so they realize I am feeding their child the milk of different species. When our NICU started a human milk initiative (including using human milk based fortifiers) for the smallest and most delicate infants our rates of NEC dropped dramatically. Here's the thing though, our (smaller) infants get donor milk until mom can produce their own. They get IVs as needed but it's because they are premature and their intestines are not ready to support them. We've had late preterm and term infants that parents request no formula and they are offered human donor milk if IVs are not needed for other reasons. They are made to understand that the cost (which is not outrageous as we use an all volunteer bank) will not likely be covered by insurance.

Here's my issue regarding the topic more at hand, which is depriving infants of nutrition as we wait for mothers to produce the needed breastmilk. We must remain humane in our efforts. Repeatedly (it's rare a child needing IVs will have one stab) sticking a healthy term infant just really strikes me (and many others) as inhumane. There is human donor milk available. If a hospital is really dedicated to being baby-friendly, then they should contract to provide this to infants.

I have this opinion (and that's all it is, not science but maybe a future research topic) that human infants were not designed to be starved the first few days of life. I believe human infants were designed to be supported by a community including matrons who knew how best to help mom through labor/delivery and other lactating mothers who would help nurse the infant while mom's milk supply came in. I absolutely do not believe this to be something for today, I just think we are on the wrong path if the options we offer are:

1. Mom must lactate quickly or baby must starve until then (possibly becoming dehydrated).

2. Stab the infant repeatedly with needles as a punishment for mom not lactating quickly enough or mother/infant dyad not being able to latch & feed well enough.

3. Destroy the infant's virgin gut (and I acknowledge this is not a trivial matter) by giving cow milk that comes with the proteins designed for another species.

We can do better than this folks.

Sorry for the rambling, just spent 3 nights in a row working.

Donor milk is a huge help that sadly is underused, expensive and not always well received. If donor milk would become readily accessible we would have a better option!

[Jory, MSN, APRN, CNM]

Donor milk is a huge help that sadly is underused, expensive and not always well received. If donor milk would become readily accessible we would have a better option!

I agree that donor milk is a better option, but if mothers are not ok with this (and I would wager, that the majority won't be), then the solution is formula.

IV drugs, are hard on the liver and our goal in the NICU is if an IV is necessary, to get the baby off the IV as quickly as possible. I also believe that just because a baby cannot speak for itself, it shouldn't be allowed to suffer. Babies died from years ago because if the mother didn't have any milk, unpasteurized milk was the only choice to save the baby and unfortunately with it, so came all kinds of nasty things.

Today, there are many quality formulas. There are some that are on the market that are pure junk and are not fit for human consumption. A good example is Good Start.

Breastfeeding becomes MORE difficult if a baby is allowed to get too hysterical from crying, because the hunger is painful to a baby and a new, very scary sensation. I see no point in letting a baby get that way just because we are waiting for mother's milk to come in or even worse, a NICU admission because of low-blood sugar and dehydration. I don't know if you have ever seen a NICU admission, but it is a completely different animal from newborn nursery.

I do agree that many L&D nurses are not encouraging Mom to breastfeed. I have seen TONS of L&D nurses START THE BREASTFEEDING conversation by asking, "Do you want to do breast or formula? Don't let anyone make you feel guilty because you don't want to breast feed." Mainly because they don't want to review the labeling, get Mom a pump if she wants one, etc.

Our job as nurses is to educate. I have done L&D admissions and when I ask the same question and Mom says she wants formula. I always ask, "Has anyone ever told you what the benefits of breast feeding are?" 90% of them say they have not been---this is huge folks. Most of the mothers that I have sat down and speak with CHOOSE breast feeding...I am not bias...I tell them over and over again that it is there choice, but I say, "As a nurse, if you are asking if it makes a difference, medically in your baby's health, I have to tell you that it does." Even moreso if the baby is a NICU baby or premature.

You would be surprised at the reasons they give you for choosing formula. They think that if they don't produce enough milk that the staff will let their baby starve (they will, for awhile, but I also tell them that they can supplement with formula upon request) or that their baby will stay on IV fluids longer (3 days is our limit). Some assume that they cannot breastfeed because of medications they are on, only to find out that they are 100% safe.

The point is YOU HAVE TO ASK AND EDUCATE.

[Marymoomoo]

We've had babies with a 10% weight loss in less than 48 hrs.

Excess Weight Loss in First-Born Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance

http://pediatrics.aappublications.org/content/127/1/e171.full.html

Here's just one study to review on the subject of newborn weight loss. There's more evidence mounting that initial birth weight may be misleading.

[Marymoomoo]

No offense to any Lactation Consultants out there, but it's the LC's that are driving this nutty practice. Someone who has been smoking weed and allowed to practice came up with the idea that the baby's stomach holds only 2 to 3 ml, so if the mother cannot produce breast milk that is OK.

I personally think it is cruel an inhumane to let a baby scream it's head off in hunger, get stressed, etc., over breastfeeding. It is dangerous to allow the blood sugar to drop and anyone who has worked in the NICU, once a NICU admission happens, that baby is subjected to all kinds of needles, IV fluids that is 100% preventable.

One or two days of formula isn't going to kill the baby until the milk comes in and once it goes home, if it gets hungry enough IT WILL breastfeed.

Stomach capacity:

On day one, stomach capacity is 5-7 ml. The stomach capacity increases by day 2 and 3, right along with the amount of colostrum that is produced.

Here's a list of references:

http://webcache.googleusercontent.com/search?q=cache:Chs9jQFWLscJ:http://www.cdph.ca.gov/programs/breastfeeding/Documents/MO-StomachCapacityReferences.doc+&cd=1&hl=en&ct=clnk&gl=us

Here's another resource that explains stomach capacity (and includes references): http://webcache.googleusercontent.com/search?q=cache:lj4xgKTVpJMJ:http://www.sandiegomidwifery.com/Assets/Physiologic%2520Stomach%2520Capacity%2520of%2520Newborns.doc+&cd=8&hl=en&ct=clnk&gl=us

This information isn't just pulled out of thin air; there is a biological basis for the numbers, and scientific evidence to back them up. :)

Feeding the baby:

No practicing IBCLC I know would ever say that if a mother couldn't produce milk, that's ok. Rule #1 (ALWAYS!!) is feed the baby. If a mother is not producing milk (or enough milk), or the baby is not able to effectively transfer milk, we want to know why and we want to come up with a plan for resolving it. In the meanwhile, baby must be fed either mom's own expressed milk (if available), donor milk, or formula.

Hypoglycemia:

ABM Clinical Protocol #1:

Guidelines for Glucose Monitoring and

Treatment of Hypoglycemia in Breastfed Neonates

http://www.bfmed.org/Media/Files/Protocols/hypoglycemia.pdf

Supplementing:

ABM Clinical Protocol #3: Hospital Guidelines for the Use

of Supplementary Feedings in the Healthy Term

Breastfed Neonate

http://www.bfmed.org/Media/Files/Protocols/Protocol%203%20English%20Supplementation.pdf

ABM Clinical Protocol #5: Peripartum Breastfeeding

Management for the Healthy Mother and Infant at Term

http://www.bfmed.org/Media/Files/Protocols/Protocol_5.pdf

Breastmilk is more than just food. It is an extension of the mother's immune system, which is passed to the baby. It is one of the means by which the baby's gut is colonized with bacteria. There are specific components of breastmilk that feed the friendly bacteria necessary for immune function, digestion, and metabolism. There are specific components of breastmilk that "feed" the thymus gland. Did you know that there are differences in the gut bacteria of exclusively breastfed babies and those who have been supplemented with formula? With all the recent findings about the human microbiome and long term health, this is very important info! There are risks in feeding formula, even as a supplement. No, formula is not evil. It is simply a substitute for breastmilk, and one that is generally regarded as safe. The point is that formula and breastmilk are not equal--there are many components found in breastmilk that cannot be replicated in formula. Supplementing shouldn't be done in a blase' manner, especially when the mother wishes to exclusively breastfeed.

It is not accurate to say that if a baby gets hungry enough, he will breastfeed. In fact, if a baby gets too hungry, he may not be able to breastfeed. Beyond that, if he is unable to breastfeed (unwilling is also unable), we need to know why. Is he in pain? Did he suffer a birth injury? Is there some kind of body asymmetry? Does the baby have ankyloglossia? Is the baby lip tied? Are the mom's nipples inverted? Maybe mom is engorged and baby is unable to latch on? Was the baby handled roughly at any time? Is the baby being forced to the breast? There's much more to breastfeeding than just hunger.

[NicuGal, MSN, RN]

Donor milk keeps getting brought up. Many insurances will not pay for it, especially if there is not a "medical" reason for it. And being a hospital that is mostly welfare/Medicaid/ etc we just can't absorb the cost. And many people are very misinformed about it or are eeked out about it and don't want it and won't sign the permits. I think that we need to get all insurances on board to pay for at least a month to get the gut colonized. But we are slaves to insurance companies. I know our insurance we carry at work all fight tooth and nail to not pay for donor milk ( one of my co-workers had a 24 weeker and was on so sick and on a lot of Meds). The finally agreed after much fighting on our attending a part.

So when it isn't an option you only have formula left.