Booby Traps Series: Five frequently missed or mismanaged breastfeeding issues in the hospital

This post is the 42nd in a series on the Booby Traps, made possible by the generous support of Motherlove Herbal Company.

While things have come a long way since the days when mothers were routinely given injections to “dry up” their milk, there are still a number of breastfeeding issues which are often overlooked during our hospital stay.

How do I know?  Because when I see moms in the community and notice these issues, they report that no one did in the hospital.  Or if they did, it was often either ignored or mismanaged.

This is my short list of issues, but there are certainly more.  Please tell me what would be at the top of your list in the comments!

The “impostor baby” (late preterm/near term).  Those of you who had babies born at 35, 36, 37 and even 38 weeks gestation may recognize this description:  A sleepy baby, who konks out a few minutes or seconds into a feeding, even if (maddeningly) there’s plenty of milk there.  Because he’s so sleepy and can’t really finish a feeding, he doesn’t gain well at first.  And because he doesn’t gain well he gets more sleepy.  Maybe he gets jaundiced and needs phototherapy.  Maybe formula is recommended to get him gaining. Suddenly you find yourself in a downward spiral leading to the end of breastfeeding.

This is the classic pattern of the baby who might go by the name “late preterm,” “near term,” or “early term.”  They’re called “impostor” babies because in most other respects they look just like a baby born at 40 weeks.  They might be normal weight, and they just look like a term babies.  But when it comes to feeding they are just not the same.

With pregnancy getting shorter and shorter, and the rate of elective inductions before 39 weeks remaining high (such a significant Booby Trap that the March of Dimes has launched a campaign against it), this “impostor” scenario is frighteningly common.  The Booby Trap here is that hospitals usually respond to these babies as if they were no different than the 40-weekers.  The story I shared above represents a real threat to breastfeeding, and deserves far greater attention than it gets. The Academy of Breastfeeding Medicine has a special protocol just for these babies, and you can listen to a podcast interview I did on the topic as well.

Water, water everywhere: Breast edema and “excessive” weight loss in babies.  A while back I wrote about “What your cankles want you to know about breastfeeding.”  The problem is this: When you’ve had a lot of IV fluids in labor, the fluid can collect in certain areas, including your breasts.  This fluid retention is called edema, and while it may be mistaken for engorgement, it’s quite different.  It can be very painful, and make it quite difficult for your baby to latch on and remove milk.  This inadequate milk removal can cause you to not develop a milk supply adequate for your baby.

This could be resolved, and breastfeeding saved, with a technique called reverse pressure softening, but I don’t think it’s going out on a limb to say that it rarely is.

Another effect of a lot of IV fluids in labor is that babies are born with extra fluid on board.  These babies appear to have lost an excessive amount of weight, when judging by her ‘un-waterlogged’ birth weight she might appear to have weight loss that is within normal limits.  Of course, the larger a baby’s weight loss the greater the chances that a mom will be told to supplement with formula, possibly starting the downward cycle which leads to early weaning.  Two recent studies, from 2010 and 2011,  have pointed to this problem, but I haven’t heard any rush to change policies as a result.

Tongue tie.  You’d think by this point that all hospitals would be routinely identifying tight frenula, counseling parents, and offering a quick “snip” of the frenulum if parents chose it.  But that unfortunately isn’t yet the case.

For the 3-4% of babies born with a tight frenulum, and the mothers who can experience wrenching pain with feedings if it isn’t addressed, lack of evidence-based practice can amount to a breastfeeding disaster.  There are problems with providers recognizing that a tight frenulum is causing breastfeeding problems.  One, admittedly older, study found that “Sixty-nine percent of LCs, but a minority of physician respondents, believe tongue-tie is frequently associated with feeding problems.”  Some parents face an additional hurdle trying to find a provider who can (quickly!) address it if they so choose.

While there may have been progress made on the more common “simple” or “classic” tongue ties, fewer providers know of the “posterior tongue tie,” and very few are able to treat it.  Until recently parents in my area would drive for over an hour, crossing into another state, in order to see the lone doctor in our region who could help.

Insufficient glandular tissue/breast hypoplasia.  Women with insufficient glandular tissue (also known as breast hypoplasia) often suffer at home when “the booby fairy doesn’t arrive,” but few providers recognize or counsel mothers about this in the hospital.  It’s a tricky subject, because some moms with what look like hypoplastic breasts go on to nurse normally.  But I believe that better support could and should be offered to these moms in the hospital, and I think it’s possible to do it without dealing a blow to their confidence.  That could start with something simple:  If a provider recognizes that a mother’s breasts have the hallmark signs of low glandular tissue, they should receive increased follow up and support after leaving the hospital.  Only time will tell if a mother will produce enough milk, but providers should be ready to discuss the issue of glandular tissue if a problem develops.

Nipple shield information.  I won’t discuss the hot button issue of nipple shields here.  But whether you think nipple shields are a godsend or a patch covering poor breastfeeding support skills, there’s one “fixable” thing I hear all the time:  Moms are sent home with little or no advice about how to stop using them.  This is a shame, as many mothers become engaged in a protracted struggle with their babies to kick the nipple shield habit, while good information, such as this page on kellymom or this list I wrote a few years ago could have been provided when the shield was dispensed.

Did you get snared by any of these Booby Traps?  How did it effect your breastfeeding experience?



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13 Comments | Last revised on 05/23/2012


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13 Responses to Booby Traps Series: Five frequently missed or mismanaged breastfeeding issues in the hospital

  1. Yes, yes, yes – with the exception of hypoplastic breasts (which i have only rarely seen and never yet counselled a mother about), I could have written this list myself. I would also add “those bloody scales” which start their booby trap with more than 10% weight loss in hospital (because babies are losing all that extra IV fluid too) and continues their work at each weigh in. Babies are then endlessly topped-up while their mothers endlessly pump, instead of A & B being put together more often and more effectively. “Just express and top-up after each feed” is the most onerous advice given to new mothers.

  2. Cristy says:

    Both of my babies were born at 38 weeks. My son because I was induced and then ended up needing a c-section because I just wasn’t progressing and then my daughter was scheduled at 38 weeks because she came 9 days shy of a year from her brother. I had such a hard time breastfeeding, both would fall asleep as soon as I put them to the breast. I basically felt bullied to use formula especially with my daughter because I was told that either I get her to latch on and eat for at least 10 minutes straight or the nurse would be sending someone in with a bottle that would make my daughter eat. I tried with both to continue to breastfeed when I got home and I managed breast and bottle fed breastmilk for 6 weeks with my son and 8 weeks with my daughter and then my milk dried up and I had no choice but to turn to formula. I tried everything I could think of to try and boost my supply but I just could not replenish it. I wish I would have found better support. I will always wish I would have never let them induce me and would have just let my babies come when they wanted to. I don’t know if that would have changed the outcome of my breastfeeding but I’ll never know!

  3. Sarah S says:

    Yes! My son had tongue tie, (which went undiagnosed until he was 4 months when I read about it on dirty diaper laundry’s blog…clipping it was such a help!) so my nipples were bleeding by day 2 in the hospital, so I got a nipple shield but they never told me how to stop using it. Thankfully, we figured it out. I stuck with it, though it was ridiculously difficult until we got his tongue clipped, and I breastfed for 13 months. I am 7 weeks away from baby #2 and am doing all I can to learn about how to beat the booby traps!

  4. Ashley B says:

    I have to admit I just clicked on the link I saw for this out of simple interest. I had no idea the very first thing listed would send me into tears because it was someone offering more assistance for the very problem I’ve gone through with two of my babies. My LCs have been super supportive so far with my late pretermer this time, but my pediatrician is less than helpful and getting closer to yelling at me even more every day that passes. I want to breast feed so badly this time, I don’t want to succumb to the problems thinking they can’t be solved at all and end up exclusively pumping for six months again until my body says why am I feeding a pump and I say I am so sick of pumping it’d affecting my relationship with my child.

    Thank you for posting this. I’m reading the linked protocol for late pretermers now.

  5. amber says:

    YES!!! I had the “imposter” baby! The LC at the hospital was of no help she just kept telling me to wake her up. Much easier said than done. After the hospital I basically nursed her around the clock just to make sure she was gaining weight. It was awful! I was so worried she wasn’t gaining enough weight because she wouldn’t eat well because she kept falling asleep shortly after latching that I almost gave up so many times! If it wasn’t for Hubz support I would have! He didn’t care if all we did was lay in bed all day nursing, but as I’m sure you know it did get tiresome to always have a babe attached to the breast. She eventually grew out of it but it seemed to take months (six months is when I noticed) for her to be able to stay awake for a whole feeding. Here we are over 9 months later and still going strong! Luckily we fought through this Booby Trap along with a whole list of others thanks to your page among others! It is so nice to put a name to it and know I’m not alone! Thank you!

  6. Jackie says:

    I have IGT/hypoplasia and know many other women who have it as well through a support group. None of us were EVER counseled about IGT and when we couldn’t make enough milk we were almost universally told to just give formula and stop BF. I was “diagnosed” by an IBCLC in the hopsital who looked at my breasts and said “you probably won’t make enough milk.” I started to cry and she walked out of the room. No support, no counseling. I didn’t even know what was wrong with me until I started googling. It was awful. BUT I am still Bfing at almost 10mos and supplementing w donor milk (and whole foods since 6 mos).

  7. Jessica says:

    We were given a shield with no info on how to use it or stop using it. Thankfully my midwife was able to give me the right advice, and I read lots of info online. (“nipple sandwich”)
    We stopped using it at 2.5 weeks and have been EBF without it for 6 months.

    I’m glad I did my research and it’s something I do with EVERYTHING. It’s not just breastfeeding, people need to be responsible about their decisions and plan & research.

    Choose your providers wisely and be prepared.

  8. hillary says:

    Yep, count me in for #5. I had a non-latching baby and despite LLL leaders, lactation consultants, and lots of coaching from my midwife, she just wouldn’t latch without a nipple shield. She never had a bottle (we syringe and cup-fed pumped milk for her first week while we were trying to figure out how to get her to latch) so it wasn’t nipple confusion. Maybe I didn’t do it right, but I offered the breast without the shield at literally every nursing session, with no success…for 2.5 years of breastfeeding. Then one day she latched when I offered without the shield and we nursed for six more months shield-free. I think those last six months were as much for me as they were for her! She weaned at her third birthday. So I think I had a successful breastfeeding experience regardless of our inability to stop using the shield. Wish I could have gotten rid of it earlier, though. It was so much more convenient to nurse without it!

  9. Elizabeth Mathis says:

    Thank you for this list, I am sharing on FB. My third child born this past April was an imposter baby with a posterior tongue tie that we didn’t catch until 5 weeks of age. At that point my supply had dropped and he was losing weight. I had nursed two other children for 2+ years each, so I never thought I would have problems with this one. It was so stressful and in the end, he loves his bottle and refuses to nurse. I have found some amazing mommies that donate breastmilk for him, but it still breaks my heart that things didn’t work out differently.

  10. Heather says:

    Wow. I had 4/5. No wonder I had difficulty breastfeeding!! Still do. Heartbreaking to wonder if things could have gone differently.

  11. Nina says:

    My son was born in january at 42 weeks after an induction and eventually a emergency c-section. He was a big baby and seemed to feed well during the two days we spend in hospital. He kept losing weight when we were back at home and the midwife kept reminding me to feed on demand, check latch etc. All things i did! He used to feed constantly and only fall asleep due to exhaustion as i now know. After 4 weeks i read about tongue tie online and the health visitor confirmed it, nobody had looked into his mouth until then! This still makes me angry. He finally had it cut at 6 weeks and started putting on weight slowly. Unfortunatly this only lasted a few weeks and then he stopped gaining weight again. I started supplementing with formula twice a day and felt like a complete failure. Eventually i found out about breast hypoplasia and i believe i have it. An other blow, but i did read that some women can still establish an adequate supply so being stubborn i carried on breastfeeding and supplementing when he just could not get enough. I really wanted to make at least 6 month. Now he is 10 month old and we are still going. As he is eating solids we could drop the formula and the pressure that i had put on myself and now we are finally enjoying breastfeeding! It was a long journey and i wish there was more support in hospitals and from midwifes, but we made it. And i am proud of that.

    • Bettina Forbes, CLC says:

      Wow, what an inspiring story!! You are one strong mama, with amazing perseverance. Congratulations on your baby and your beautiful breastfeeding journey.

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