Who should get donor milk? Who should it be offered to?

Dou-la-la's post on encouraging the informed milk use of donor milk over formula supplementation got me thinking. At the hospital where I work, I have a lot of parents ask me about supplementation. They want to do los dos from the beginning, or they believe that the mother's colostrum isn't sufficient, or they're concerned that the fussy baby who wants to nurse constantly is starving, or they're tired of the fussy baby nursing constantly and just want to sleep. If they're really set on it, I encourage them to supplement at the breast vs. with a bottle, and not to give too much. If they're considering it but haven't decided yet, I do my best to educate them about risks of supplementation, including compromising future milk supply and altering the baby's gut. But in the end, it's their baby and their choice if they want to supplement.

Sometimes, I have to tell parents - even parents who don't particularly want to hear it - that we need to supplement. Because their baby has lost too much weight, or because there are latch difficulties, or because there is persistent hypoglycemia not helped by just direct breastfeeding. We do our best to supplement with only the mom's own expressed milk, but sometimes we have trouble getting enough of it out. In the end, those parents have to supplement - it's a medical necessity.

The thing is, no one at our hospital actually has to supplement with formula. We have banked, pasteurized human milk available for our NICU babies, and the term babies can access it as well if the parent requests it and gets a physician order. We don't need to ration it; the milk bank will tell us if they're running low and will ration appropriately on their own. We can offer it to anyone we want and they can use as much as they need while they're in the hospital, with the cost covered completely by the hospital, regardless of their insurance (or lack thereof). But once they go home, they have to purchase it from the milk bank directly themselves (unless they can convince their insurance provider to reimburse) or they have to find donor milk through other, less formal channels (as Dou-la-la discusses).

The other day one the nurses made an observation to me about who she usually sees using donor milk and who she doesn't. She asked if we offered it to everybody or if there was some discrimination going on. It got me thinking about it, and I talked to one of the other LCs about who gets offered donor milk and who should get offered donor milk. We had fairly similar feelings about it, but I won't say right now what we thought. I would like to ask all of you.

Since there's now a fairly active blogosphere conversation about donor milk being the ideal supplement for babies who are not being fully breastfed by their mothers for whatever reason: Who should be offered donor milk when the decision to supplement arises - for personal or medical reasons - and who should not? Why?

If you have a problem when you breastfeed, then you have a breastfeeding problem!

Recently I went to visit with former doula clients. (It was so nice to see them. They are such wonderful people and have such a cute baby. And I got to hold the baby for a long time! I know not all doulas/midwives/other birth professionals are baby fans, but I am definitely a huge sucker for an itty bitty baby. But I digress.) Their baby breastfed beautifully all through the hospital stay - frequently, happily, no concerns whatsoever.

Apparently when they got home the baby went in for a check-up. Due to weight concerns, the pediatrician told them to supplement with 1 oz of formula after each feeding, and they did, reluctantly. Fortunately baby soon became more wakeful and interested in eating (my guess is, the baby just got a few days older and grew out of the sleepiest phase). They weaned off the supplementation rapidly and are back to exclusive breastfeeding.

But ack! That was the first line of a tale too often told...weight problems, doctor recommends supplementation, leads to supply problems, leads to more supplementation, more supply problems, and now we're in the downward spiral.

I say to all my clients at our immediate postpartum visit, "Just call me if you have any problems or questions about breastfeeding." But this has happened more than once: I find out weeks or months later that the doctor recommended supplementation, and I don't hear about it until long after the fact. Mulling it over, I decided that maybe not everyone perceives the need to supplement as a breastfeeding problem. And I think it reveals the norm in our culture of: "It's good to breastfeed, but when it's not working supplementation is the answer". When instead, the norm should be "Women make enough milk and babies transfer it effectively, and if this does not happen there is a problem that needs to be solved".

If I had talked to them when they got that recommendation, I would have recommended they make an appointment with an LC to make sure baby was transferring milk effectively and that mom's supply was OK and being maintained. I would also have talked to them about ways to avoid confusion while supplementing with the bottle, and/or alternative supplementation methods to prevent nipple confusion. Am I glad that they didn't need this help? Yes, but it's that dodged-a-bullet feeling.

I asked one of the LCs about how she gets people to call when they get the order to supplement, and she said she tells parents, "If the doctor tells you to supplement, please call me so I can show you how to supplement without using a bottle." I think that's a good way to 1) avoid nipple/flow confusion and 2) get in to assess what other problems are contributing to the situation. I'm going to try that line in the future.

And pediatricians: Hello. You have a mother in front of you who wants to exclusively breastfeed. Her baby is not gaining enough weight on exclusive breastfeeding. Obviously, the first thing to do is always "FEED THE BABY" (as a page in my breastfeeding educator manual says in huge bolded letters). So now you have fixed ONE problem by ensuring the baby is eating enough. Take another step to get to problem number TWO: what is going on with breastfeeding and how can it be fixed? Yes, this is your responsibility, particularly since your fix to problem one is likely to make problem two even worse. It is so discouraging when pediatricians talk a great line on breastfeeding but don't do much to support it.

I'm not hating on all peds; there are great, supportive, knowledgeable pediatricians out there, and they can and do give excellent advice and refer to lactation consultants when needed. It just sucks when you run into the ones who do NOT.