No excuse for the dehydrated breastfed baby.

I read yesterday about how a mum "nearly starved her child due to breastfeeding pressure", but it's not the first time I've heard "pressure to breastfeed" quoted as the reason some infants end up back in hospital on drips, dehydrated, "starving".

The rationale for the argument is that mothers are so stubborn, adamant and determined to breastfeed this is putting babies at risk!

Those pesky mothers being adamant they want to give their child milk of their own species and not a second rate substitute!  If only they weren't so stubborn and would just use formula - there would be no problem right?

As my Nanna would have said "poppycock".

The media talks as though there is a group of people doing the "pressuring" of these poor mothers to breastfeed.  I think that's quite insulting to mothers!  The more research and information we have, the more we find out about what is in breastmilk, that's not in formula - the more pressure there is to breastfeed I agree.  But not from some external source, from mothers themselves!  Once I knew that formula wasn't "nearly as good" of course I "put pressure on myself" to breastfeed (granted my first had formula alongside breastmilk before I knew this!)  - just like I tried to find and save up for the safest car seat.

But even if every mother in the world was adamant about breastfeeding - this is still no excuse for a baby ever needing to be readmitted due to severe dehydration or "starvation" as the mother yesterday called it, due to breastfeeding "going wrong".

Why? 

Because from day one we can tell if a breastfed baby is getting enough, and we can tell this right the way through.  Sure a new mum might not know this, why on earth would she? But those health care professionals around her paid to support her through the postpartum period should right?  They are employed to ask the right questions, to be absolutely confident that baby is taking enough.

Of course there are times when "lactation fails" - maybe due to a retained placenta or a thyroid issue; there are times baby can't milk the breast effectively, and times something else other than mum's own breastmilk may be required (be that donated milk or formula)  Please do not think I am saying all mothers without question can breastfeed.  What I'm saying is there are so many signs things are not ok, and there are signs things are getting more serious, LONG before the critical stage.

Yet all the cases I hear about the "dehydrated baby", the mum was regularly seeing health care professionals and in the case yesterday even a "lactation consultant" (I use inverted commas as I'm not suggesting this was an IBCLC)  According to others the mum had "amazing support from health care professionals, family AND online"....

These are not mothers sat at home alone, not attending appointments and ignoring advice.

So tell me again how babies get to the severely compromised stage without a single HP picking up on this and taking positive action to prevent the situation deteriorating?

Weight would be continuously dropping and output would be nothing as expected as two big tell tale signs - but as you can see from the example protocols below; there is no excuse for a HP not picking up on a developing problem:

1.  Assessment of breastfeeding - at each postnatal visit. Any abnormal finding (see table) triggers further action - Management Plan 1.

Baby
Jaundiced and sleepy or difficult to rouse for feeding Engorgement or mastitis
Demanding to be fed fewer than 6 times in 24 hours and/or not sustaining an effective suckling pattern
Feeding very frequently, i.e. consistently more than 12 times in 24 hours
Consistently feeding for longer than 45 minutes
Unsettled after feeding

Breasts
Trauma to nipples, nipples misshapen or ‘pinched at the end of feeds
Engorgement or mastitis

Breastfeeding
Difficulty with attachment
No change in sucking pattern, i.e. from initial rapid sucks to slower sucks with pauses and audible swallows
Baby is ‘fussy’ at the breast - on and off the breast frequently during the feed, or refuses to breastfeed


2.  Assessment of output - at each postnatal visit, together with ongoing monitoring by the mother. Inadequate output (i.e. less than that specified - see table) triggers weight assessment and implementation of appropriate Management Plan.

Urine - number of wet nappies per day

DAY 1-2: 1-2 or more; urates may be present*
DAY 3-4:  3 or more; nappies feel heavier
DAY 4-5: 5 or more
DAY 7 & BEYOND: 6+ Heavy
* Urates are normal bladder discharges in the first few days but persistent urates may indicate insufficient milk intake.  Urine should be pale/clear.

Stools - number per day, colour, consistency
DAY 1-2: 1 or more, dark green/ black ‘tar-like’(meconium)
DAY 3-4:  2 or more, changing in colour and  consistency - brown/green/yellow, becoming looser (‘changing stool’)
DAY 4-5: 2 or more, yellow; may be quite watery
DAY 7 & BEYOND: 2 or more, at least size of £2 coin, yellow and watery, ‘seedy’ appearance

3.  Weight - at approximately 72 hours and again at least once prior to transfer to health visitor. Weight loss of 8% or more triggers further action.
Amount of weight loss & Management Plan indicated
8-10% of birth weight - Management Plan 1
10-12.5% of birth weight - Management Plans 1+2
>12.5% of birth weight - Management Plans 1+2+3

Management Plans
Plan 1

• Observe a full breastfeed - ensure effective positioning and attachment
• Observe for effective suckling pattern & milk transfer
• Ensure minimum 8 feeds in 24 hours
• Skin contact to encourage breastfeeding
•  Observe for change in frequency/amount of urine and stools
• Reweigh day 7 If weight increasing, continue to monitor closely and provide support. If no or minimal weight .

Plan 2
Follow Management Plan 1, plus:

• Refer to breastfeeding team/drop-in clinic
• For sleepy babies, consider ‘switch nursing’ & breast compression
• Express breastmilk after each feed and offer to baby by cup
• Consider referral to GP if infection or other illness suspected
• Weigh again in 24-48 hours. If no or minimal weight increase, move to Management Plan 3

Plan 3
Follow Management Plan 2, plus:

• Refer to maternity unit for review by paediatrician & breastfeeding team
• Frequent breastfeeds and expressing, using hospital-grade breast pump
• Carry out investigations* to determine ongoing care. This may include formula feeds by cup or intravenous fluids, if breastfeeding ineffective or EBM unavailable Reduce formula offered as .breastmilk supply increases. 
• Weigh again in 24 hours.
• Continue to monitor weight twice weekly until clear trend towards birth weight demonstrated

* In order to ensure safety, this particular hospital decided that a serum sodium level in excess of 150 mmol/l, when found together with a clinical picture of weight loss in excess of 12-13% and diminished urine and stool output - with or without jaundice - indicates a need for supplementation.
End


Clinical - yes.  But these are health care professionals, ultimately responsible for the life of a young infant.  As you can see, when everyone is aware what the red flags are - there is no reason any baby should reach the critical stage weeks down the line!

For more on this subject see: Is my breastfed baby getting enough? (and things you can do if not)

To see a similar plan used by another hospital to train staff click here.