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

by Tanya Lieberman, IBCLC | May 23, 2012 7:27 am

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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