Saturday, June 19, 2010

Why do babies get supplemented in the hospital? A story from my first week on nights

While I have told myself I was going to try to pick up the posting rate in June, this week was my first doing night shifts (11 pm - 7 am) on lactation support at the hospital where I've been training to be an LC. I feel pretty comfortable there at this point, but it feels so strange to have my own electronic charting ID and not have to wait for anyone else to log me in - before, we were being supervised by the LCs and so I would chart on their accounts under their supervision.

Obviously, I've been a little anxious about whether the night nurses would be welcoming, whether people would be willing to call me - basically whether I'd have any work at all! While all the staff I've talked to so far have been nothing but happy and excited to have lactation support available, the first night was really quiet. I saw a few people in the first couple of hours, then sat around, and then things picked up from 5 am - 7 am when people started to wake up and call for assistance. I told myself that the census was low, and staff were still getting used to me being there, but I wondered if every night would be so quiet. The big hope was that having someone overnight on lactation would help prevent a lot of the bottles and supplementation that happens at night. Was I going to be able to do that?

The following night answered that question for me. I basically never sat down except to chart. I spent at least an hour with in three different rooms. And my big victory was helping keep a hypoglycemic baby from being unnecessarily supplemented. The cut-off for hypoglycemia in the newborns here is 45. The nurse caught me in the nursery and said she had tested twice, baby was just below the cut-off and heading in the "wrong direction". To the nurse, formula seemed like a medical necessity at this point. She asked if maybe I could do it at the breast. When I came into the room, though, mom was crying - she didn't want to supplement. I offered to handle the situation from there and the nurse said that was fine - she left us to it. The mom told me the baby had been hungry and about to feed, right before the nurse had come in and taken him for the blood sugar testing. I said "Well, if he's hungry, he can nurse and if he nurses well, he won't need any formula."

So, we put the baby to breast - and this baby was, indeed, very hungry and nursing fairly well. Still, I was anxious - I did not want to screw this up, I was going to get all the colostrum into that baby that I could. The nurse had brought a couple of dental syringes for the formula. I took one and popped the stopper out, and asked mom if we could hand express into it from the other side and supplement the baby with expressed colostrum. Mom said OK very readily and wow, she had plenty! I was boggled to think this baby could have ended up with formula with so much colostrum available. The mom's sister was spending the night to help her out and happily assisted with hand expression (with mom's agreement, of course) - it was so nice to see such good family support! Who says other family members can't participate in breastfeeding?

Between nursing and supplementing, by the end of the nursing session I was having to take him off and wake him up repeatedly, and he would fall asleep as soon as he got back to the breast. This kid was full. (But I was not going to let him go to sleep without getting every last drop he could!) Finally, I put him skin-to-skin with mom (also good for blood sugar!) and called the nurse to tell her "went great, no formula needed!" And you know what? The nurse was totally fine with that. She gave the baby a full hour before rechecking his sugars and - yay! - baby was back above the cut-off - "heading in the right direction". The nurse was actually very gracious and helpful about all of this, and I realized after talking with one of the other LCs that it's not a "breastfeeding is bad" mentality at all on the nurses' part - this nurse just wanted to fix the blood sugar, and the formula could be the fix, or my help with breastfeeding could be the fix. Of course, since I'm not always there, it would be nice if this experience helps her have more confidence in the future with putting baby to breast as the first line of treatment. But one step at a time!

After all this drama about avoiding what probably would have been just several milliliters of formula, you may be wondering, what's wrong with just a little supplementation? Just to get the baby's blood sugar up - then they could go on breastfeeding, no problem. And I think it's a fair question. It doesn't seem like a single bottle would do that much harm. And yet we know that babies who are supplemented - even a single bottle - in the early days tend to have shorter durations of both exclusive and any breastfeeding. And is that so surprising? After all, we say to mom "You need to supplement with formula because your baby's blood sugar is low", what is the message we are sending? "Your milk has not been feeding your baby adequately, and it will not feed your baby adequately; we cannot trust that it is there in sufficient amounts and/or that your baby can get enough of it." Any wonder that these moms go on to mistrust their ability to nurse their babies? Additionally, even just a little formula affects baby's gut flora for weeks, changing the balance of beneficial flora that exclusive breastfeeding establishes (for more information on all of this, see this article by Marsha Walker, particularly the section "Some Cautionary Words About Supplementing with Formula").

Does all this mean we should not give formula when medically necessary? Of course not! But as you can see, medical necessity in this situation was somewhat blurry. With no breastfeeding support, it's possible that this baby would have needed to be supplemented with formula. But in the end, it turned out not to be necessary at all. Babies get those bottles of formula not necessarily through malice, but because of staffing issues, longstanding habit, and lack of education and lack of trust in breastfeeding. They get formula without the understanding of the risks of "just a little bit".

What can you do to avoid unnecessary supplementation in the hospital? A few things:

1) Prepare yourself for breastfeeding - read, take a class, attend La Leche League meetings - boost both your knowledge and your confidence.

2) Choose a certified baby-friendly birthplace - this won't eliminate the possibility of unnecessary supplements, but it will greatly decrease them!

3) Make sure breastfeeding is going well - let the staff know you are committed to breastfeeding, ask for a lactation consult, and solicit outside help from La Leche League or a lactation professional if you need to. Yes, those people can come visit you in the hospital!

4) Surround yourself with family and friend support. Maybe the sister-in-law who keeps asking whether the baby is "too hungry" is not the person to spend the night with you!

5) Be ready to advocate for yourself if needed, and have all that knowledge, preparation, and support ready. I saw another mom a few months ago who confronted the same night-time pressure to supplement for hypoglycemia. She insisted that she get a chance to breastfeed first and, lo and behold, that baby's sugar came up too. Self-advocacy is not always easy (and unfortunately not always successful), but it is very important!

So that's my first dispatch from nights! I'm currently in recovery from the crazy schedule-shifting and ready to get back to regular sleep patterns for a few days. Any nurses out there have tips on shifting back and forth? I'm used to doula work where you can't plan it - you just power through and then sleep it off over the next couple of days. Tips for actually planning your night shifts would be greatly appreciated!


Molly (First the Egg) said...

I have no tips. Just--well done, you! You're doing cool, wonderful things for people.

Well-Rounded Mama said...

Seems like breastfeeding the baby would be the FIRST remedy tried for hypoglycemia, with formula as a back-up if nursing didn't raise levels enough. And it always bothers me when they diagnose hypoglycemia when the baby hasn't even had a chance to nurse yet.

It's also interesting that 45 is the cutoff for hypoglycemia there. It's 40 in some places and 35 in others. Do you want to comment at all about the varying cutoffs? I'd be interested in seeing what the research says about it.

Anonymous said...

Awesome post! I have had a few doula clients who had bf messed up because of that "one bottle". I think you are so right that it messes a bit with moms mind and then they are unsure of their milk and abilities.

I wish that at the least if they need to supplement they use a spoon or syringe instead of a bottle.

Thanks for this great insight from an insiders point of view. :)

Rebecca said...

@Molly - Thank you! :-) It's little stuff, but one step at a time.

@Well-Rounded Mama - The protocol at the hospital is, indeed, to nurse first. Baby did have a chance to nurse earlier but maybe it was not effective enough? Who knows. That's why I was so intent on making sure that this was an effective feed + supplement. Still, the protocol says that baby should have gone back to breast before the formula. I would love to comment about the cutoffs if I knew more about them! I know our protocol was developed by someone who really knows her stuff, so I have been curious to ask her more about it now that I've had this experience. Hopefully I'll see her this week and can learn more. Maybe that will turn into a future post!

@Enjoybirth - the spoon or syringe definitely helps keep the baby at the breast! The spoon is great because it's so low-tech - all you need is a plastic spoon from the cafeteria.

Anonymous said...

I'm a nurse and I used to work days and nights on a postpartum unit. I totally empathize with your struggle to keep babies supplement free over night. When I would be working the day shift, it would be so discouraging to show up in the morning, and find out that the baby and mom you were caring for the day before was given unnecessary supplementation overnight...ugh. I would find myself starting from scrath, boosting mom's confidence and providing encouraging and evidence based breastfeeding support. Your hospital is so lucky to have LC support over night!

As for night shifts.....
Sometimes it's tought, but try to get to bed as soon as possible after your night shift, wear sunglasses on the way home, and of course...sleep in a dark room. You don't want your body to get used to the daylight and then be tricked into staying awake. I use to take Melatonin 3mg before getting to sleep, to help my body think it was nighttime. The night before a night shift, I just try to stay up late and sleep in late the next day. I don't do well with naps, they just make me groggy, so sleeping in as much as possible before the night shift worked for me.

Good Luck, and keep up the good work :)

Ps. I having been reading your blog with great interest...I will be starting my MPH program this coming fall, and hope to focus on maternal-infant health issues. Your blog is great food for thought!! :)