Today’s Just Lori show, like so many of my other Just Lori shows, are fueled by my daily work as an IBCLC and what I see happening in real life, in real homes, all over the world.

Yes, my home base is currently in Arizona.  However, I do work with mothers all over the world.  How does this happen?  Well,  Since I have a podcast that is listened to people all around the globe and since I have an online breastfeeding class that has students from all over the world in it and since I offer Skype consults which moms all over the world take advantage of virtual consults, I get to see and learn about the lives of breastfeeding families not just in Arizona, but all around the world.</pWhen I have something stupid happen twice in one week, I get a bit crazy, need to talk about it, decide to do a show on it.. and that is how I get it out of my system.  Otherwise, I don’t know what I would do with all this anger  and frustration I feel at times or what I would do without the ability to educate you about different ways to go around solving a problem.  One that benefits and works towards meeting your goals and not someone else’s.,,, like your providers or a family members goals.

What happened this week is a problem I see quite often.  It happened with one of my students online and it just happened today when I did a home visit to a family in the suburbs of Phoenix, AZ.

The stupid thing that happened twice?  A mother being told that her baby is starving and she would need to switch from breastfeeding to formula feeding.  Oh wait a minute, excuse me, one of the families were told that they would allow mom to breastfeed for 10 minutes on each side and then give 2 oz of formula.  The other family, was just blatantly told – you are starving your baby and you do not have enough milk and so sorry, but you need to give your baby formula… at least until we see your baby put the weight back on and then we will decide about breastfeeding again.

We will decide about breastfeeding again?

Whose baby is this anyway?

Give 2 oz of formula after every breastfeeding?  There is so much wrong with this advise, but

Before we go any further I would like to thank all healthcare providers who make it their business to educate themselves about breast-feeding and breast-feeding management I would like to thank all healthcare providers who recognize that they may not be able to help a breastfeeding mother  Because they acknowledge that they either lack the time to do so or the knowledge to do so, however they excellently compensate for this by having a great referral source in their community for mothers. thank you to all of you.

My client Amanda was not so fortunate so Come along with me and learn from my lactation consult with Amanda

Let’s hang out in Amanda’s house for a while.   She has a 15 day old baby who is 5 oz below birth weight.  Now, considering the fact that her baby Erin should have been back to birth weight at 2 weeks old, her baby is about 5-6 oz less than what we would expect at 15 days old.  Amanda’s pediatrician is correct in that her baby is below expected weight.  However, she is slightly below and since she has been exclusively breastfeeding, this finding does not warrant an immediate stop breastfeeding and switch to formula care plan. I say this because only being 5 oz below expected weight tells me that she is getting a fairly good amount directly from the breast, which gives us the opening to evaluate breastfeeding and correct the problem, while continuing with breastfeeding.  The need to supplement and what to supplement with, will be determined by the end of our consultation.

I can see that Erin has good output and appears to be well hydrated.  Are there breastfeeding issues that need to be worked on… absolutely.  However, she is definitely not starving her baby.  Does she need to supplement with formula?  Perhaps, but this was never evaluated at her pediatric office.

Let me explain what I mean when I say that the breastfeeding and the need to supplement with formula was not evaluated at her pediatric office visit.

There seems to be this belief system in that if a baby is losing weight or not gaining as expected, that the mother is not producing enough milk for her baby.  Sure, this is sometimes an issue and it also is sometimes absolutely, hands down, NOT the issue.

As an IBCLC, who is a specialists in evaluating situations like this.  What do I want to see happen?  I  want to take the opportunity to assess moms health history, her breast and nipple anatomy.  I want to take the opportunity to assess her baby for structural issues, for oral motor function issues. I want to take the opportunity to assess position and latch as well as milk transfer. I also want to do a weighted feed, which basically means to weigh your baby before and after a feeding and see how much milk your baby has transferred. Now there is more to this, however, this covers the basics.

Doing just one of the above, all on its own, does not make a complete evaluation.  In other words, just checking your babies intake during the feeding alone, does not tell us everything.  Knowing your baby is latched on well does not tell us everything.

We need to take a good look at all the different angles to breastfeeding.  Something we don’t really need to do anything when breastfeeding is going well.  However, when it is not going well, I become what I call… an investigative reporter.  I am investigating all angles.  I am asking a lot of questions just as any good reporter will do.

It is only once all this has been done, that I can advise you on what to do next, on what your babies feeding plan should be.  So, why did Erins pediatrician make such a declarative statement without having done a full assessment?  Well, wait a moment, let’s step back for a minute.  You may be asking?  Why am I assuming that her pediatrician did not provide a full assessment?  Well, the investigative reporter in me asked Amanda one simple question? About how long did the Dr. spend with you and Erin.  Her answer – about 15 minutes.  Since my breastfeeding evaluation covers a full feeding and takes anywhere between 1-2 hours, I knew this could not have happened.

Let’s return to Amanda’s house.  Well, I would actually love to return to her house.  She lived about 15 minutes away from suburbia and her home was nestled in the middle of the desert  where homes are built about a half a mile away. Wildlife in this area is out in the open for all to enjoy. Her neighbors have horses and trailers and lots of dirt and many cacti in their front and backyards.  Have I mentioned how much I enjoy doing home visits in the beautiful Arizona desert?  Getting out of the office and into the sun makes me a very happy lactation consultant.

Okay, so inside Amanda’s house was a very quiet home.  She had no relatives visiting and this was her first baby.  Her partner Cathy greeted me outside and waved me on in.   I shook hands with Amanda as I introduced myself and I noticed that she seemed happy and well rested.  Then I asked her how she was doing today.  She started to tell me her tale of woe and about 2 minutes into her story tears started to well up as she uttered the words – My Doctor made it sound like I was the worst mother in the whole world.  If I need to give Erin formula I will, but I really don’t want to. And with that, Cathy grabbed some tissues, handed it to Amanda and said to me:  And that’s why your here.

We went to her bedroom where she has found it most comfortable to breastfeed.  I noted that she had a wonderful set up with a fully stocked changing station, her pump, a few bottles of water and I could see a granola bar on her nightstand. I listened as Amanda settled herself on her bed, held her baby on her chest and filled me on all the details of what has happened with breastfeeding since Erin was born.  I love hearing mother’s share their stories as it gives me great insight as to what happened and how they felt about it.  I use this opportunity to go down my fact finding mission without moms feeling like they are sitting on the witness stand under heavy Q & A questioning.

As I went through my whole assessment and did my investigate reporter thing… several things became quite clear to me.

Since she had been pumping the last 24 hours, I knew Amanda had a great supply as she was pumping about 3-4 oz each time she pumped. When I asked her why she started pumping yesterday, she said that a friend of hers told her that perhaps she was not making enough milk and she should start pumping.

I am very grateful for her friend because I find that many moms who are told to supplement, are not told to keep up a regular pumping schedule and to not do so will cause great harm to the milk supply and perhaps cause extreme breast engorgement and other problems.  I asked how frequently and for how long she pumped each time and based on her responses, I confirmed she had a good supply which should be meeting her babies needs at this time.  I asked how often her baby was eating, if she was waiting for her baby to wake up or had she been checking the clock and waking her baby up after a specific period of time.  Now that her baby was weighed and I had some preliminary information, like Amanda’s breast and nipple anatomy and assessed that her baby Erin had no specific issues that would impact breastfeeding, we went to the next step, which was for her to breastfeed Erin.

The latch was slightly off, but honestly not much to write home about.  I could make a few adjustments but that would be more to satisfy this thing that some lactation consultants have about moms needing to “do it the right way.”  I have long since gotten over that one, as I have learned that moms and babies don’t have to have this  100% “perfect” latch in order for breastfeeding to go well.

The real gold, the real story for me was in the “watching her breastfeed her baby part.”  Here I got to observe Erin feeding and I was able to ask more questions about feeding habits, why Amanda is going about certain things the way she is.  I enjoy learning from moms how they started off breastfeeding, who helped them initially, what changes, if any they have made along the way and how they feel about breastfeeding.

The gold is also in listening and watching the partner’s responses and their behavior and what they have to say, as their baby is breastfeeding.  Soooo much to learn from just observing and from getting the partner’s  perspective.

Here are a few crucial pieces to this puzzle that I learned just by watching Amanda breastfeed and listening to her and Cathy describe the last 15 days.  Each one has their own perspective and with some couples it seems like they have been living in 2 households. That was not the case with Cathy and Amanda, however, I did learn a few things.

#1  Amanda saw 3 lactation consultants during her 4 days hospital stay. She gave birth vaginally but because of a large weight loss and a diagnosis of jaundice for Erin, they stayed a few days longer than they might have otherwise needed to.

#2  Amanda also asked the advice of several pp nurses who took care of her.

#3  With 5 different people offering advice, Amanda became quite confused as to what she should do in some instances as the advice was quite inconsistent.

>#4  She did feel the lactation consultants were helpful, although she did recognize some of their information contradicted each other, and she didn’t know what to do about this.  She did not see the lactation consults on Day 3 or on Day of discharge.  Her pp nurse was in charge of discharge instructions and Amanda left the hospital with this basic breastfeeding advice:

Do not let your baby use you as a pacifier as you will never get any sleep.

Always feed from one side per feeding, so they get all the fatty hindmilk that helps them gain weight.

In 10-20 minutes your baby should be done breastfeeding, anything after that, they are just using you as a pacifier.

Your baby needs to eat every 3 hours.  If she wakes up before 3 hours, hold her off until it is 3 hours.  But also, Don’t let your baby sleep more than 3 hours.

Okay… so first let me say:  That stupid darn pacifier advise.

If I did not know what I know, this advice sorta sounds reasonable to me as a first time mother.  I mean, what do I know?  But stupid advice it is.

I took the time to explain in detail what I thought about the advise she was given.

Why this advice was causing her baby to not gain as well.

What I feel she should do instead.

And I explained the rationale behind each one of my suggestions.

I gave both of them plenty of opportunity to ask all their questions.

It took longer than what I am going to do here, however, this is the gist of it all.

Purposefully offering one side only, purely for the hope that your baby gets all the fattier hindmilk may mean that your baby not be getting enough volume each feeding.  Average newborns need both sides for most feedings.  Not to say that a mom with an abundant supply and an efficient breastfeeder can do this and her baby will gain really well, however, this is not most mothers and newborns. And this clearly is not the case for Amanda.  We did a weighted feed after one side and her 2 week old only transferred 37 mls which is not even 1 1/2 oz. But that’s okay, 37 mls is 37 mls. But, If this is all her baby gets each feeding on average,  no wonder her baby is not gaining well.  She is limiting her babies intake because she is paying attention to someone else’s rules and not paying attention to her babies cues.