breastfeeding woes

[Rhee]

I'm a relatively new postpartum nurse, and I've experienced this situation a few times over the past several months. A few weeks ago, I had a patient that really made me think. Ethically, if a mom says she wants to breastfeed exclusively, should I suggest bottle feeding if the nursing isn't going well? This situation was rather extreme. I don't want to undermine anyone's breastfeeding, but I also want to make sure that the baby is getting adequate nutrition.

My pt, a first time mom, wanted to breastfeed her baby. (I personally don't care if a mom wants to breast or bottle, after all the baby is hers. I just care that the baby is being fed an appropriate amount of an appropriate substance.) I was trying helping her position the baby and get her latched on. Although she said that she wanted to breastfeed and stated that she wanted no bottles for any reason, when it actually came to feeding the baby, the problems began. She sat in the bed with her arms at her sides with the baby on the boppy in front of her. I positioned the baby in her arms, and when I told her to hold her breast and rub her nipple across the baby's lips, she sort of leaned forward and shrugged her shoulder. I tried and tried to work with this new mother, I talked with her about the baby's nutritional needs, but ultimately, I can't hold her baby and her breast, and breastfeed for her. I tried very hard to be patient and understanding, but I still found the situation frustrating. Every nursing session was like this. Each time, the mother would sit with her arms at her sides. I tried to find a nice way to tell her that she need to participate; the baby can't do this by herself. I hope that I succeeded in being nice, I had the baby's best interest at heart. It was especially important to me that this little girl eat because the mother was GDM. Over four days, lactation saw her twice, and once the baby's lost 10% of birthweight, the peds ordered the parents to supplement. I just wonder if I should have encouraged supplementing sooner.

How do you handle this type of situation? If a mom wants to breastfeed, I want to do all I can to help be successful, but in situations like the one above, I also want to make sure the baby is getting enough calories. I also feel that it's part of my job teach parents the basics so they know how to take care of the baby once they get home (and when to ask for help.)

Sorry this is so long, and thanks for any advice.

Rhee

[crysobrn]

I'd look at the hospital policy and see what it says about supplementation. Then you can tell the parents... the hospital policy or our pedis suggest ____________fill in blank with type of supplementation after ______________number of hours, or unsuccessful attempts at breastfeeding...

And for those women who really make no effort I usually help them the first or second time but then I tell them to take ahold of the babies head like this (and show) and then hold your breast like this (and show). Most of the time even the most reluctant participant will do what they have to... I generally also tell them that I'm here to help them and teach etc but they will be going home in a very short amt of time and they will have to be able to do it alone. At least you have a LC... we are the only ones available... I am very pro breastfeeding and I've had some 12 hr shifts where I even get frustrated.

[HappyNurse2005, RN]

[QUOTE]Then you can tell the parents... the hospital policy or our pedis suggest ____________fill in blank with type of supplementation after ______________number of hours, or unsuccessful attempts at breastfeeding...

\and all that will do is cause further breastfeeding troubles, giving formula instead of continued support. she knows there is formula available. maybe she's tired, or scared, or whatever, but offering formula to her will just reinforce teh idea to her that she is doing something wrong and she can't feed her baby.

if the baby has lost the 10% of its weight, thats different.

[crysobrn]

So... do you have a suggestion.

[Elvish, BSN, DNP, RN, NP]

If in doubt, check your policy, as you then will have something concrete to point at and go by. I tell my mamas up front that breastfeeding is a team effort, and both baby AND mom have to learn what to do. Baby usually learns a lot faster if Mom's doing what she's supposed to do. I think some moms (esp first timers) are afraid they'll hurt the baby if they hold them & bring them to the breast as fast as they need to. I reassure them that if they survived being born, being shoved into a soft breast is not going to hurt them.

I believe OP says that the baby did indeed lose 10%, and the pediatricians then ordered supplementation. That's pretty par for the course where I am too in terms of ordering a supplement. And when it happens, I try to reassure mom that this is almost always a temporary thing, and once her milk comes in, she'll be able to go back to exclusive breastfeeding.

[Snugglibumkins]

I would reassure the mother that breastfeeding is pretty difficult sometimes to get started. It maybe mom had a medicated delivery, or a prolonged pushing period that contributed to the baby not being quite interested right now.

Checking your hospital policy is the first step.

If there is a LC on staff, I'd recommend a consult.

Since the doc ordered formula supplementation, I would continue to assist mom with latching the baby on, then using the formula supplementation, instruct on finger-feeding to feed the baby while strengthening the suck reflex.

If the baby does not latch on before the finger feeding session, mom needs to use a hospital grade pump to stimulate her breasts to bring her milk supply in. Assure her that by pumping, she is not looking for volume (as she will only get a very, very small amount out), but looking to stimulate her pituitary gland - her powerhouse for milk making.

Follow the rules of - 1. Feed the baby 2. get a milk supply going - and you will do fine.

Lastly, be sure she knows of any and all support at time of discharge - our hospital has a 'warm line' to call and leave a message and a peer counselor will call back to talk the patient through lactation problems. Also be sure she knows of new-mom support groups, give her the meeting dates/times/locations. Sounds like she's going to need to be around some other breastfeeding mothers for good on-going support.

My afterthought is when checking the hospital policies, see if there is any reason why mom can't keep baby on her chest. Easy access to the breasts will relax both parties involved. As well as the heat from mom and a hat on the baby will keep the baby warm and help to decrease changes in the metabolism which could lead to further rapid weight loss.

It would be wise to refrain from any artificial nipples until the baby's latch is good and you have evidence of good milk transfer (poops changing to yellow by day 4, increase in weight)

[rn/writer, RN]

Our LCs have told us to encourage skin-to-skin contact even if (especially if!) baby won't latch. Just the smell of the baby and the feel of the wee one on the chest can stimulate prolactin and help the mother's milk to come in.

I also try to stress that supplementing in the case of weight loss is not a failure but a way to buy a little time for success to happen. Too many moms feel that it is an all-or-nothing proposition, and that giving the baby a bottle means they have lost the battle. It shouldn't BE a battle in the first place.

Another concept that can be helpful is explaining that breastfeeding is like a dance. Each partner has to learn the other one's signals and together they have to find a comfortable rhythm. This takes time. And lots of practice.

The biggest thing is to help the moms relax and enjoy their wee ones. Pumping is good. Dribbling a couple of ccs of formula on mom's nipple can sometimes "wake" the baby's taste buds and get them excited. I also show a mom how to let the baby suck on her finger. That sometimes helps the baby figure out how to make his mouth work and it can tell Mom if the baby is pushing the nipple out or just mouthing it without sucking or some other problem.

I try to find positives, no matter what is going on. Even if the nursing attempt goes poorly, a half hour of skin to skin can do wonders for everyone.

Keep in mind, too, that there may be moms who are really divided in their wishes. Some don't really want to breastfeed and they feel too intimidated to say so. Others are exhausted and don't see how they will manage. There are even a few who find the whole process crude or primitive and they are actually repelled by the idea. It's our job to help them express what's really on their minds, regardless of whether we agree or disagree. Once the unspoken comes out in the open, we can help them to decide the best choice for themselves and their families.

[jessbee]

Since BFing is definetely a learned art I'd try to get a LC involved if at all possible. Sometimes new moms want to breastfeed but generally don't know how or they begin to get a little bit of PPD or just baby blues and are internally struggling with their feelings. Some mothers believe that breastfeeding is something that will come naturally and are disappointed when it doesn't happen that way. There are also times when they are disappointed in their birth experience for some reason and it affects their feelings toward the baby in the beginning. Breastfeeding takes a lot of support but if she expressed the desire to BF exclusively then it should be honored as long as the baby isn't suffering, for the first few days the baby isn't getting any real milk anyways, just colostrum, so volume won't be a big problem at first but it is important for the baby to be suckling to bring the mothers milk in so she needs to be aware that if the baby isn't latching properly and suckling then the milk won't come in as fast as it would otherwise which can compromise the BFing relationship. Did she have a c-section or anything that would cause her to be in a lot of pain postpartum? that can also have a huge affect. hopefully she gets the hang of it quickly and begins to participate otherwise the doctor will be left without a choice when the well being of the baby comes into question. I think as the nurse though all you can do is teach her what you know and continue to encourage then chart the progress or lack of it accurately. good luck it's a tough situation.

[klone, MSN, RN]

She should have had a LC consult. I get really upset when the nurses just give bottles to moms who have expressed that they really want to breastfeed, without telling us that there is even a problem. Let the LC and the ped decide if supplementation is truly necessary.

[vashtee, RN]

I was taught that it is normal for a newborn to lose 5-10% of their birthweight.

[klone, MSN, RN]

10% is the cutoff for acceptable weight loss. It's recommended that more than 7% is considered a "yellow flag" and intervention should be done by a lactation professional to assess latch and milk transfer.

[Elvish, BSN, DNP, RN, NP]

As I reread the post, I see that lactation did in fact see this mom twice.

I think Miranda's post is wonderful - hits the nail on the head. I have also had moms put babe skin to skin and it really does make a difference.