Sunday, November 22, 2009

Carnival of Breastfeeding: Your Breastfeeding Experience in the Hospital
The Nipple Intervention

Welcome Carnival of Breastfeeding readers!

This month's theme is "Your Breastfeeding Experience in the Hospital."

Please visit the other carnival participants, listed below.

(More entries will be added through the end of the day on November 23, 2009, as they are posted - check back!)

The following is a letter that will probably never actually be sent.

My therapist, Dr T, actually suggested writing it several months ago, after we'd spent a good bit of time discussing how traumatized (her words) I was by the "nipple intervention" - as I refer to the "conversation" that I describe in the letter.

I wrote my breastfeeding story several months ago, and that went a long way toward helping me to "let go" some of my anger, but the idea of an actual letter to the people responsible has been in the back of my mind since then.

When I saw this month's topic, I knew that this was the push I needed to actually write it.

If, through some miracle of the Powerball and assisted reproductive technology, I were to find myself preparing to deliver another baby in that hospital, I would definitely not only send the letter, but also schedule a meeting with the medical director to discuss it in person.

I can't imagine going through a pregnancy and labor with the possibility of a repeat of this experience hanging over my head.

Even a year later, I am still very angry about not only the bad advice we were given, but that what should have been a simple conversation was handled so unprofessionally, and turned into an unnecessarily traumatic experience.

To the Medical Director of MyCounty Pediatrics:
(cc to Hospital Lactation Consultants, Risk Management Department)

I am writing to share some concerns that I have about how my daughter's care was handled, and how I was treated, during our hospitalization after her birth.

To refresh your memory, Peeper was born on October 27, 2008, at 36 weeks gestation, in a non-medicated vaginal delivery, with vacuum assistance. Her birthweight was recorded as 5 lb, 4 oz.

I was very eager to get her started breastfeeding, and when she was less than enthusiastic about it that evening, I asked to see a lactation consultant as soon as possible.

LC#2 visited us the next morning, and one of the first things she told me when she walked into the room was that, "Most of our preemies need to be supplemented. I recommend a breast pump and a nipple shield and she may need some formula."

As Peeper had recently nursed, she did not observe us nursing at all, nor did she check Peeper's latch or suck with her finger.

A while later, both a breastpump and a nipple shield were delivered to my room, with little or no explanation of how to use them.

When Peeper was about twenty-four hours old, her weight was 4 lb 4 oz, and when you examined her you told me that you suspected the birthweight to have been off, since "this doesn't look like a baby who's lost a full pound," but that we'd have to assume she had lost a full pound, and go from there.

According to several different sources, I now understand that it's not uncommon for babies whose mothers have received IV fluids during labor (as I had) to be over hydrated at birth and to safely lose well over 10% of their birthweight, but it did not seem that possibility was taken into account at the time.

Assuming she had lost 20% of her birth weight, you said that we would have to start supplementing her, with breast milk if possible, or formula if "necessary."

I was very concerned that introducing any artificial nipples would jeopardize her ability to breastfeed by creating nipple confusion, so we began by finger feeding her using a supplemental nursing system, and also used the SNS at the breast, when she was willing to latch.

I was also very strongly against her receiving any formula, but you required that she take in a certain amount of milk, supplementing with formula if I could not pump that amount.

I don't remember the exact amounts, but after two pumping sessions, I think I got about five or six milliliters, and you wanted Peeper to have fifteen, so we mixed it with about ten milliliters of formula.

However, by the next feeding, I was able to pump enough to match the amount that she was required to take, so I feel that had we been given just a bit more time, we could have avoided her receiving any formula at all, as was my goal, which I'd very clearly stated, both to you and your staff and to the lactation consultants.

Peeper was born on a Monday afternoon, and on Wednesday afternoon, I was discharged and she was transferred to the Pediatric ward, where my partner Shrike and I roomed in with her.

The routine at that point was that, every three hours, I would put her to the breast and attempt to get her to latch, usually using the SNS, and then Shrike would finger feed her expressed breast milk while I pumped for the next feeding.

On Wednesday, it was determined that Peeper was jaundiced and she began phototherapy. That evening, she was hypoglycemic, and received glucose (also finger fed with the SNS) which brought her blood sugar back to an acceptable level.

On Thursday, I made several requests for the lactation consultant, but it was evening before she made it to the Pediatrics ward to see us, and she'd just arrived when Dr. L. came in to talk to us.

Of our entire hospital stay, it is this conversation that bothers me the most. I feel that it was not handled professionally, nor were we fully informed of the options available.

Peeper had been having trouble keeping her temperature up, while laying under the bililights in just a diaper, so the heat in the room had been turned up, and I was sitting on a chair in the corner of the room, directly under the ceiling heat lamp, making it even hotter.

Peeper was in her bassinet, and Shrike was somewhere on the other side of the room. In the tiny room with us were the lactation consultant, the pediatrician, Shrike's mother and sister, and one or two nurses.

Dr. L. started by saying that "I know that breastfeeding is important to you, and it is the best thing for Peeper, so we definitely want her to do it, but . . . ."

She told me that both breastfeeding and finger feeding were too much work for Peeper, and she still wasn't keeping her blood sugar up like she should, and we had to get milk into her more quickly, so we were going to have to give her bottles.

I expressed a concern about using artificial nipples, and the lactation consultant said that we could use Nuk nipples which "are much less likely to cause nipple confusion."

When I asked if there were any other options, Dr. L did not suggest either cup or syringe feeding, either of which, I have since learned, would have been appropriate solutions, and would have avoided the risk of nipple confusion.

Shrike was neither being consulted by Dr L, nor was I even able to discuss it with her, as she was on the opposite side of room the whole time.

Because of the large number of people in the room, including my inlaws who were being very unsupportive of my desire to exclusively breastfeed Peeper, and the fact that no alternative feeding methods were even being acknowledged, I felt that I had no option but to agree with what Dr. L was "suggesting," although it went against my desires, against all recommendations for avoiding nipple confusion and against my better judgement.

I feel that I was not so much consulted, as I was intimidated into agreeing with Dr. L's opinion that bottlefeeding was the way to go.

A more appropriate way to have handled the situation would have been for Dr L to have spoken with me and Shrike alone, not with our entire family and several of the hospital's staff in the room, and for her to have given us a complete list of the options for alternative feeding methods.
I would have happily agreed to cup or syringe feeding, which would have just fed Peeper just as efficiently, without introducing artificial nipples and jeopardizing her ability to breastfeed.

Over the next day, Peeper's blood sugar stabilized, and her weight continued to go up, and we were discharged on Saturday.

The bottles had been successful in getting the milk into her more quickly and easily, but as I'd feared, she had become nipple confused, and was almost completely refusing the breast by that point.

For nearly six weeks, I pumped and bottlefed Peeper almost exclusively, with her only latching and nursing occassionally, although I was offering the breast several times a day.

During this time, I suffered incredible nipple pain, not only when I was pumping, but constantly.
I attribute this primarily to a lack of training in how to properly use the breast pump. I was not fitted for properly-sized pump flanges, and was not told how to adjust the pump suction.

Too-small flanges and too-high suction during the first week seriously damaged my nipples, and they were unable to heal until I stopped pumping completely.

Thanks primarily to the advice and support of my La Leche League leader, I stuck with it and eventually, Peeper was able to latch using a nipple shield, and stop requiring bottles when she was six weeks old.

Once she was finally able to breastfeed on her own, she has never looked back, and has been bottle-free since then, other than immediately following her open-heart surgery.

She was exclusively breastfed until just past six months and now, at almost thirteen months, still nurses quite frequently. It is my hope that she will continue to breastfeed for at least the full two years recommended by the World Health Organization.

However, had I not had the support of La Leche League and had I not gone into the situation absolutely determined to breastfeed, I very well might have given up before she ever learned to latch.

I dare say most mothers would have.

During Peeper's first six weeks, I did a great deal of research on nipple confusion, and found very little advice on how to correct it, but a great deal of advice on how to avoid it, all saying essentially the same thing:

However, using an artificial nipple (i.e., any nipple that's not attached to mom) to feed a young breastfeeding infant is likely to lead to nipple confusion. The sucking technique which baby learns from the rubber nipple does not work at the breast, and baby quickly becomes frustrated. This is why bottles are not the best choice for giving supplement to infants less than four weeks of age. Alternatives include cup-feeding, spoon-feeding, an eyedropper or feeding syringe, or a nursing supplementer. (Dr. William Sears)

If at all possible,delay introducing the bottle until the baby has well established nursing and latch on skills. If baby must receive supplements early on, use a Supplemental Nursing System, feeding cup, medicine dropper or spoon to feed baby. (Dr. Jack Newman)

Breast and bottle feeding require different oral-motor skills, and rubber nipples provide a type of "super stimulus" that babies may imprint upon instead of the softer breast. As a result, some babies develop suck confusion and apply inappropriate suckling techniques to the breast when they switch between breast and bottle. (The Breastfeeding Answer Book)

Last on the list, but most often thought of first in discussions of supplementation, is bottle-feeding. The timing and frequency of these feedings are most often implicated in later problems with breastfeeding (Neifert, Lawrence & Seacat 1995). Therefore, bottle-feedings should be avoided or delayed until after the baby is well acquainted with breastfeeding and accomplishes it with ease. (La Leche League website)

If this simple, well-known advice had been followed by Peeper's pediatricians, I might have been spared a great deal of pain, both physical and emotional, and we might have been able to spend our first six weeks as a family concentrating on bonding with our baby, rather than on trying to correct a problem which never should have been allowed to develop in the first place.

Over the past year, we have been generally pleased with the care that Peeper has received at your practice, and I hope to continue this relationship, but I just could not let these things go unsaid any longer.

I hope that you will discuss my concerns with Dr. L and the other pediatricians on your staff, and that in the future, you will offer families more breastfeeding-friendly options when babies are not successfully nursing.

I also hope that you will be more sensitive to the needs and emotions of new parents, and will hold these sort of discussions in private, so that the parents can make decisions for themselves, without undue pressure and influence from family members or medical staff.

Thank you,

Other Carnival of Breastfeeding Posts
(Keep checking back - more will be added through the end of the day on November 23, 2009)


  1. Oh, sad. I'd heard some of your story before, but I read this letter with a horror of expectation for what that bad conversation would be. It's so unfortunate that this happens so very often in hospitals, where people who are supposed to be wiser and more helpful than you railroad and intimidate you into following their outdated rules, or else. I'm mad for you. I hope writing the letter gave you some measure of peace, just to state it out and be validated (by me, for what that's worth, but by all those breastfeeding experts you quoted, too!) that you were right, and they were wrong. It sounds like you have an ongoing relationship with the hospital, and maybe you don't want to create ill will, but I wonder if you should mail the letter, just to educate them and maybe prevent some other new mother from going through that. It wasn't a ranty letter but clearly and reasonably written and might do some real good. But I can understand if you don't want to subject yourself to any more emotional encounters with the people involved.

    I'm sorry you had to go through so many weeks of pain and distress from that one inappropriately handled conversation, but I'm glad you've come through the other side and can keep being the breastfeeding example you are. Thanks for sharing your letter with us.

  2. Hmmm, how does a medical conversation taking place with visitors in the room square with HIPPA regulations?

  3. How frustrating! I'm so sorry that your doctor and the others who were supposed to be helping you breastfeed did not provide you the support and information you needed and deserved. I think that is a fabulous letter, and if you ever get the urge, I would say it is well within reason to send it.

  4. Wow, that's a tough story. I feel lucky that I had fairly good breastfeeding support in the hospital and first week at home, but even so I also was pressured into some early formula supplementation. I've since had a few friends who tried unsuccessfully to breastfeed, and I worry that they might have gotten bad advice like what you described above. We really do need to keep pushing for better education of all maternity/peds providers and stronger policies of breastfeeding support overall. Thanks so much for sharing your story!

  5. Yeah, yeah, yeah - I hope it brought you peace; send the letter. I watched them give Sarah less than stellar advice with Charlie; I thank God that Ruth Ann would have spoken up to correct any misinformation after the "lactation consultant" was gone. Nathan, Sarah (the parents) and Ruth Ann (father's mother) all hated the woman before it was over and would make faces before and after she came. It's not just that hospital and - tragically - it wasn't just you. It wasn't even just premies. Send the letter.

    "She was exclusively breastfed until just past six months and now, at almost thirteen months, still nurses quite frequently. It is my hope that she will continue to breastfeed for at least the full two years recommended by the World Health Organization." Did you flip them off when you wrote that? I flipped them off when I read it.

  6. Good for you!!!! Although I can't ever understand what it would feel like to want to breastfeed I've felt your pain through this entire thing.. and your joy when Peeper (and you and Shrike) worked it all out. :) Hugs to you!!!!

  7. I think you should send this letter. It might help another mama in the future to avoid the same situation. It's an excellent letter.

  8. I agree, this should be sent. Thank you so much for sharing this - your persistence and determination are incredible. Right on.


What say you?