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Breastfeeding: Going Home from the Hospital

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Breastfeeding: Going Home from the HospitalEarly Discharge and Early Follow-up
Too many new mothers are discharged to go home before they feel confident about breastfeeding or other aspects of their own or their baby's care. Unfortunately, the recent trend toward shorter and shorter maternity stays largely has been driven by financial considerations rather than the health and well-being of the baby and family. In an attempt to curb the problem of "drive-through deliveries," national legislation has been passed requiring insurance companies to extend coverage for normal deliveries to forty-eight hours. But even a two-day hospital stay doesn't guarantee that babies will be nursing proficiently by the time they go home. Early follow-up remains a crucial step in assuring breastfeeding success by identifying mother-baby pairs who need extra help shortly after going home. In late 1995, the American Academy of Pediatrics published a policy statement containing minimum criteria to be met before a newborn should be discharged. The statement strongly emphasized that all infants discharged before forty-eight hours of age should be examined by an experienced health care provider within the next forty-eight hours. In addition to the standard medical assessments performed at the follow-up visit, the encounter should include an observation of breastfeeding to assure the infant latches on and suckles properly.

While all these recommendations make the system sound fail-safe, the fact remains that most mothers go home before breastfeeding is really going smoothly. Early follow-up within two days is absolutely essential to assure that your baby is nursing effectively, especially once your milk comes in abundantly. Many pediatricians now see newborn babies in their offices a couple of days after hospital discharge, while other mother-baby pairs receive a follow-up home visit by a nurse. Still others return to a hospital-based follow-up program. While a telephone call from a nurse to check on your breastfeeding progress makes a nice addition to one of these visits, it is not an adequate substitute for being seen in person.

If you don't feel ready to go home when your doctor thinks you are, explain your concerns and request more time. If your baby isn't nursing well, ask if you can stay even an additional twelve hours to give you several more breastfeeding sessions where assistance is available. If that isn't possible, see if you can arrange for an appointment the following day with either a lactation specialist on staff at the hospital or a private lactation consultant in the community. Whenever you seek breastfeeding help from someone other than your baby's doctor, it goes without saying that the doctor must be kept informed of all such encounters and feeding recommendations. Your baby's doctor should be the one to coordinate all aspects of your baby's health care.

Babies At-Risk for Inadequate Breastfeeding
Doctors, nurses, and parents alike usually assume that because breastfeeding is "natural," it will proceed naturally. They expect that any problems experienced in the hospital will magically clear up once the family gets home and the mother's milk comes in abundantly. For most women, things do go better with each subsequent feeding and each passing day. But for a few mother-baby pairs, early small problems become serious chronic matters that threaten the success of breastfeeding and the baby's well-being.

After years of evaluating breastfeeding problems, I believe I can predict with some accuracy which mother-baby pairs are at increased risk for inadequate breastfeeding. These couples deserve closer follow-up and monitoring to help them be successful. Anything that could affect the mother's milk production or her baby's ability to latch on to her breast and suckle well can have a negative impact on breastfeeding. Some typical examples are listed below.

Lactation Risk Factors in the Mother
• Previous breastfed baby who didn't gain weight well
• Flat or inverted nipples
• Variation from normal in breast appearance (such as marked asymmetry)
• Previous breast surgery that may have cut some milk ducts
• Previous breast abscess
• Extremely sore nipples
• Minimal prenatal breast enlargement
• Failure of milk to come in abundantly after delivery
• Severe postpartum breast engorgement
• Medical problems, such as hemorrhage, high blood pressure, or infection

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Breastfeeding Risk Factors in the Infant
• Small (less than six pounds) or premature (less than thirty-eight weeks) infants
• Babies having difficulty latching on to one or both breasts
• Babies who don't suck well for any reason
• Babies with any abnormality of the tongue, jaw, or palate
• Twins or greater multiples
• Babies with medical problems, such as jaundice, heart or breathing difficulties, infections
• Babies with neurologic or muscle tone problems

Indications for Using a Rental Electric Pump
The preceding are just a few examples of mother-baby pairs who should receive extra help with breastfeeding after dis-charge. Some mothers will require only simple modifications in their breastfeeding routines. Others will benefit from using a hospital-grade rental electric pump to empty their breasts imme-diately after they nurse their babies. By regularly extracting any residual milk at the end of feedings, you can establish and maintain a generous supply even though your own infant might not nurse effectively. A baby who doesn't nurse very well is likely to obtain more milk during his feeding attempts if his mother manages to keep an abundant supply. By "drinking from a fire hydrant," an ineffective nurser still may be able to obtain sufficient milk. Without the pumping regimen just described, a mother's milk production may decline quickly when her infant nurses poorly. You will hear more about pumping after feedings to extract residual milk in other chapters of this book.

If you or your baby have any of the risk factors mentioned, your baby's doctor should monitor your infant closely after discharge until it is clear that breastfeeding is going well. Since few physicians have the time to evaluate and manage breastfeed-ing problems, you should ask to be referred to a lactation consultant who can give special assistance with breastfeeding technique, help you decide when and how to taper pumping, and communicate with your baby's physician about feeding pumped milk to your baby.

In-Home Weighing of Infants
In-home weighing of infants is another option to help new parents when close monitoring of breastfeeding is desired. New technology now makes it possible for concerned parents to follow their baby's weight at home, thus taking much of the guesswork out of breastfeeding. Parents can rent an accurate, portable, user-friendly, electronic scale to weigh their baby periodically between medical visits until they are confident that their infant is thriving with breastfeeding. Certainly a scale cannot substitute for your baby's health care provider. Rather, the information it provides is meant to make you and your health care professional a stronger team. Report the weights you obtain to your baby's doctor, who can interpret the results with you.

Special, highly accurate rental electronic scales also are available that allow you to measure your baby's milk intake during a breastfeeding by weighing him (identically clothed) before and after nursing. This procedure is known as infant-feeding test weights. The information obtained from in-home test weighing of babies can be very helpful in monitoring infants at risk for inadequate breastfeeding. If you have a breastfeeding problem and decide to perform infant feeding test weights at home, I strongly recommend that you also work with a lactation consultant who can help you modify your baby's feeding plan based on the information gathered from the test-weighing procedures. Of course, your breastfeeding specialist will need to communicate closely with your baby's doctor.