Breastfeeding support

**LibraSunCNM, BSN, MSN, CNM** · Jun 8, 2017

I've had similar frustrations throughout my career as a nurse and a midwife. It sucks. If you work in an institution where breastfeeding isn't supported and staff is uneducated about it then moms will fail, plain and simple. Moms need so much support and encouragement throughout the breastfeeding relationship, but most crucially in those first few weeks, and they look to their postpartum nurses for that critical early help. If you get off to a bad start at the hospital, you're less likely to succeed, it's just how it goes.

In reference to sleepy babies, I have also suspected in past institutions where I worked that the cocktail of meds in the epidural anesthesia contributed to babies being extra sleepy and poor latchers, but I have no evidence to back this up. I recall a story being told in my CLC course of a hospital where it was actually figured out that this was a problem, and when they changed the drugs, the problem went away, but alas, I have no references in front of me about that either. But definitely think it's possible.

If your CLC (is that all you have for staff to help with breastfeeding? No IBCLC?) is giving out a nipple shield to a majority of women, they need reeducation. Nipple shields should be used very sparingly, particularly in the first few days before moms have mature milk, because the colostrum tends to be too thick to make it through the holes in the shield and babies can have difficulty latching to the breast after using a shield.

As for your experience witnessing a nurse stick a bottle of formula in a baby's mouth while a mom was trying to breastfeed, that is appalling and completely inappropriate, but I'm very sad to say, not unheard of. It just depends on the culture of your hospital whether this is tolerated. You can do your best to combat practices like this by presenting evidence to your leadership about current guidelines and trying to implement new policies. However, you say you're "supposed to be baby friendly"---does that mean you have Baby Friendly certification, or are working towards it? If so, it seems like your hospital is disregarding the very foundation of the BFHI, and that is a bit puzzling.

Finally, on a personal level as a new mom, I strongly believe that breastfeeding is such an emotionally loaded process, that women's own experiences with breastfeeding greatly influence their opinions about it related to other people. Healthcare professionals like nurses are not immune to this, and thus, I think a lot of incorrect information and advice is given to women because of how those professionals' experiences color their thinking, if that makes sense. All you can do is try to educate your own patients the best you can, while advocating for evidence-based practice to your management.

klone, MSN, RN · Jun 9, 2017

I became an IBCLC in the era of "nipple shields are bad!" However, newer research shows that the ultra-thin silicone shields do not interfere with lactogenesis II and infant weight gain, and for mothers who do use them, there is a high degree of maternal satisfaction. I have found that if you're spending 5-10+ minutes at every feeding trying to get an infant latched on, then it might be a good idea to try a shield. It can cut WAY down on maternal (and infant) frustration, which leads to lower attrition rates.

**LibraSunCNM, BSN, MSN, CNM** · Jun 9, 2017

Thanks for that info, klone, I hadn't seen that research. I definitely don't think nipple shields are always bad, but that "almost every mom" getting one seems like a lot. Although if almost every baby there is sleepy and not latching, maybe that makes sense.

klone, MSN, RN · Jun 9, 2017

I agree, I don't think "almost every mom" should be getting one. When I started managing my current OB unit (after 4 years out of inpatient OB), I was a bit taken aback at how often nipple shields were given out (maybe 2-3 out of every 10 moms). Then I actually started reading the more recent research (and yes, I'm ashamed to admit that even as an IBCLC, I'm not up to date on the literature) and was surprised to read that the opinion on nipple shields has shifted, and that it doesn't decrease milk supply as I was always led to believe (which was based on old research on old shields that were much thicker).

adventure_rn, MSN, NP · Jun 9, 2017

I breastfed both of my children, the first only for a month due to lack of knowledge and support, they second is still nursing at 15 months.

I think this is part of the problem. In a busy PP unit, there's only so much time to provide one-on-one education, and moms are out the door relatively quickly. It's awesome if you have access to a lactation consultant, but they're also incredibly busy. I think that part of breastfeeding success is building or offering access to a strong support network when you go home (some of the hospitals where I've worked have outpatient lactation consultations). For a lot of moms, breastfeeding is way harder than it looks. People assume it's easy since humans have been doing it for thousands of years, but it isn't always.

As far as formula is concerned, parents should definitely always have a say in the feeding plan, and should be consulted before formula is used. That said, I believe there are times when formula is an appropriate choice. In the case you described, it's possible that the kid was totally frantic, and needed a tiny bit of formula to settle down before s/he could get organized at the breast (we see this a bunch in the NICU); ideally this would be done with drops of colostrum, or even donor milk, but that isn't always available. It's quite possible that the baby had become frantic and 'hangry' specifically because the mom was waiting for help from a nurse or lactation consultant who got tied up (see first paragraph).

There is an interesting organization called Fed is Best (Our Mission - Fed Is Best) which talks about certain medical indications for giving formula when mom's milk is still coming in. Breast milk is certainly preferred over formula, but not at the expense of severe hypoglycemia or hyperbilirubinemia.

ama3t · Jun 9, 2017

Of course there are occasional medical indications for giving formula, adventure_rn, but this mom didn't have any. Had the mom chosen to give a bit of formula it would have been one thing, but that wasn't the case I'm not a fan of the "fed is best" organization myself. I think it's the mom's decision but I don't agree with putting out the idea that formula is just as good, outside of when it's medically necessary. I say that having formula fed my first.

And sorry, I should have clarified we do have IBCLCs. But they have so many patients to see in a day that they can't spend much time with each. I didn't know that about the new nipple sheilds though that makes me feel much better.

That's also very interesting about what meds are used in the epidural. I am going to pay more attention to that. We have a lot of C sections and they Duramorph (needed of course) but I haven't paid much attention to whether those babies struggle more. I do know that the one mom I saw that used only nitrous had a more alert baby.

We are not designated BF but we are kinda working on it? I can't say too much without being too identifying, but basically we are working toward following all the guidelines, but there is one obstacle preventing us from certifying. We do all the breastfeeding education and stuff. I'm hoping it was just that particular nurse who is so quick with the formula. Although I also saw a nursery nurse pushing a mom to give formula when baby wasn't wanting to nurse post circumcision...

I'm hoping to be an IBCLC one day myself, I look forward to being able to focus on breastfeeding education and support, although they don't really get to spend any more 1:1 time with moms than we do...

adventure_rn, MSN, NP · Jun 9, 2017

Of course there are occasional medical indications for giving formula, adventure_rn, but this mom didn't have any. Had the mom chosen to give a bit of formula it would have been one thing, but that wasn't the case I'm not a fan of the "fed is best" organization myself. I think it's the mom's decision but I don't agree with putting out the idea that formula is just as good, outside of when it's medically necessary. I say that having formula fed my first.

I definitely don't believe that formula is 'just as good' as breast milk, although I do think that giving an occasional bottle (preferably with fresh pumped breast milk, or with formula if necessary) may be the best solution if it keeps the baby out of the NICU and rooming in with mom. I also don't think that Fed is Best argues that formula is just as good as breastfeeding. Rather, they argue that quality breastfeeding is better than formula feeding, but formula feeding is better than an exclusively breastfed baby become severely hypoglycemic and starving (i.e. due to poor quality breastfeeds).

I'm just playing the devil's advocate here, but perhaps in situations like the one you described there can be indications to bottle feed.

For instance, sometimes when we have term or late pre-term kids with borderline low blood sugars who are struggling to effectively breastfeed, we say they can have 10-15 mins to attempt to breastfeed; if the baby is doing well they continue, if the baby still doesn't effectively latch, then they follow with a bottle (ideally fresh pumped breast milk, but formula if necessary). That way, if the baby really isn't getting sufficient intake at the breast, they don't expend too many calories 'spinning their wheels' without actually getting anything. We always try to get baby to latch at breast first (unless the baby is totally frantic, in which case we may give a couple of sucks/drops before breast). Of course I wasn't present for the instance that you described, but it seems plausible that before starting the feed, the nurse could have discussed giving the baby x number of minutes at breast before switching to a bottle if necessary (rather than just aimlessly popping a bottle of formula into the baby's mouth).

Of course breast milk is better than formula. And of course, nurse laziness isn't an excuse for grabbing a bottle of formula. When we do bottle feed in the NICU, we always try to use expressed breast milk rather than formula (although pumping is probably more common for NICU than in PP since NICU moms are separated from their babies). However, I think that giving a few supplemental bottle feeds (breast milk or formula) and keeping baby rooming in with mom is preferable over refusing (or denying) formula, then ending up with a hypoglycemic baby in the NICU, tied to an IV pole, separated from mom on an entirely different floor (which makes exclusively breastfeeding exponentially more difficult). Maybe it sounds like I'm nit picking over one specific type of case, but we do see some frequent NICU admissions that could have been prevented with bottle supplementation.

jennylee321 · Jun 10, 2017

Babies on postpartum really don't ever need to be given a bottle, there only a couple of days old and don't need full bottles of formula. In order to support breastfeeding, moms should be encouraged to hand express 3 hourly until baby is latching. Whatever colostrum is expressed can be given on a spoon or via oral syringe. When the milk volume increase baby can be fed with a cup if they still aren't latching. If they are latching but mom doesn't have much milk yet and they need more intake due to sugar/dehydration formula can be given at the breast via a supplemental nursing system/supply line. This way baby is getting formula and stimulating moms breast to produce more milk at the same time.

Until I did my LC theory training I didn't really realise all these alternatives to bottles existed. I'd rather see a non-latching baby get expressed milk from a syringe then starting them on a shield. It's so hard to get them off the shield so I feel like you just add another problem onto the list. And they don't transfer colostrum well either.

In terms of sleepy babies yes the drugs given for pain relief/epidural are probably contributing. Are these sleepy babies swaddled in a cot and not demanding, because keeping them skin to skin with mom would be the ideal situation to get them breastfeeding successfully.

Semper_Gumby · Jun 11, 2017

Babies on postpartum really don't ever need to be given a bottle, there only a couple of days old and don't need full bottles of formula. In order to support breastfeeding, moms should be encouraged to hand express 3 hourly until baby is latching. Whatever colostrum is expressed can be given on a spoon or via oral syringe. When the milk volume increase baby can be fed with a cup if they still aren't latching. If they are latching but mom doesn't have much milk yet and they need more intake due to sugar/dehydration formula can be given at the breast via a supplemental nursing system/supply line. This way baby is getting formula and stimulating moms breast to produce more milk at the same time.
Until I did my LC theory training I didn't really realise all these alternatives to bottles existed. I'd rather see a non-latching baby get expressed milk from a syringe then starting them on a shield. It's so hard to get them off the shield so I feel like you just add another problem onto the list. And they don't transfer colostrum well either.
In terms of sleepy babies yes the drugs given for pain relief/epidural are probably contributing. Are these sleepy babies swaddled in a cot and not demanding, because keeping them skin to skin with mom would be the ideal situation to get them breastfeeding successfully.

Some hospitals aren't set up for or don't support spoon/cup/syringe/SNS feedings, unfortunately. My first was like that. The peds would have had a cow if a nurse tried one of these! And with only one part-time lactation consultant, moms got a minimum of one on one attention beyond what the nurses could spare.

My second hospital did utilize all of these options (except spoon) and it was really neat, but a lot of moms still used formula for these feeds because they couldn't pump or hand express anything beyond a few drops.

Having seen how frantic babies get when they've not been latching well or are not getting adequate transfer of milk (or maybe mom's not yet making enough for them, I'm not sure), I definitely supported any mom who asked for a bottle when breastfeeding was a struggle because the baby was too upset to work with. Sometimes they'd take half an ounce to an ounce, sleep for a few hours, and it was like somebody hit the 'reset' button and they went on to latch beautifully and didn't need any further bottles while they were there. Bottom line was, they're the mama and my job was to educate them and support them however they chose to feed their baby, because they're the ones taking that baby home. Not me. (and we were a Baby-Friendly hospital, and saw a direct correlation between exhausted moms who couldn't get a break asking for a bottle, and moms who sent their babies into the nursery and were still exclusively breastfeeding at discharge--but that's a story for another thread!)

However, I am pretty appalled at the nurse who went and stuffed a bottle in a baby's mouth without even obtaining mom's permission! Definitely not the way to go about it.

Elvish, BSN, DNP, RN, NP · Jun 24, 2017

I second the skin-to-skin as much as possible and hand-expressing if baby isn't latching. Hand expression can be done anywhere and isn't as overwhelming as a pump and all the accoutrements can be, though it does require mom to have a certain level of comfort with touching her own body.

Hand Expressing Milk | Newborn Nursery | Stanford Medicine

This is a great video that isn't very long and gives a nice introduction to hand expression.

There are reasons when formula is appropriate but it shouldn't be the norm for healthy term babies without mother's request.

boquiabierta · Jun 24, 2017

Seconding all the comments that it is absolutely not normal for "almost every" mom to be getting a nipple shield. As one of my favorite IBCLCs likes to say, "it's not called nipple-feeding!" Even moms with flat or inverted nipples can latch their babies most of the time with appropriate support and tips 'n' tricks. (Making a "sandwich", etc). I would say on our very busy postpartum floor (we have something like 40+ beds, major destination/teaching hospital) we only have patients use nipple shields maybe 5% of the time or less -- and they are only available to the IBCLCs to be provided after a lactation consult. All of the RNs and CNAs are trained to help with breastfeeding but we work closely with IBCLCs too for patients who need more support.

Babies being very sleepy, I find tends to correlate with their first day of life and the fact that they go through the birth process too! Whether there's correlation with epidural/spinal anesthesia use I have no idea, but anecdotally I don't find that moms who have had epidurals have a harder time breastfeeding. Maybe c-section moms do but I chalk that up to a c-section just being a more difficult recovery in general and they've lost more blood, etc. The main thing we tell moms of very sleepy babies who are reluctant to latch is to do as much skin-to-skin time as possible. Often that makes the baby realize they're hungry and they start to root. Even if they don't (because skin-to-skin also acts like a sedative!) we know that keeping babies skin-to-skin helps keep them stable, regulate their blood sugar and breathing and temperature, and has benefits for mom's milk production and bonding too. We attempt to latch the baby at least every 2-3 hours, and if they don't latch then we hand-express and feed the baby by syringe, spoon or cup. Usually syringe -- we discourage introducing a bottle or artificial nipple until breastfeeding is established. We do get more concerned and are more likely to intervene if baby is still very sleepy after the first 24 hours of life, but that first day we're fairly lenient if the baby doesn't eat much, assuming they're not on hypoglycemia protocol or anything.

It's totally unacceptable for a nurse to just give the baby a bottle of formula without getting the mom's permission. Unless the baby was critically hypoglycemic or something, I can't think of any scenario where that would be okay.

But it's also absolutely true that without sufficient institutional support and training, moms are set up to fail at breastfeeding. Even moms who breastfeed relatively easily usually have at least SOME difficulty, whether it's sore nipples, cluster feeding and exhaustion, or just plain old difficulty figuring out how to position and latch the baby. We are "baby friendly" (something I have major issues with, honestly, even though I 100% believe in breastfeeding and do everything in my power to help moms who want to breastfeed achieve their goals) but we are so often understaffed and overworked that it's just not always possible to support breastfeeding moms as much as they need and deserve.