Unfortunately, the goal of exclusively breastfeeding in the hospital is often elusive. From mom complications to baby complications, there are so many factors that impact how breastfeeding goes in the hospital. In this post, I’ll share a common scenario that I see. I’ll share what happened, what could have been done differently, and what the research says.

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Situation

Primiparous mom having trouble with breastfeeding.

Background

• G1P1
• Induced at 37.1 for HTN
• Failed induction resulted in cesarean delivery.
• Mom on Mag for 24-hours after delivery.
• Baby Boy born at 37.1 weighing 2438g
• Baby very sleepy, few sucks on DOL 1
• Attempted latch with and without nipple shield
• Mom was set up with pump, taught HE, gave syringes for syringe or finger feeding
• Transcutaneous Bilirubin (TCB) elevated- serum bili draw- also elevated
• Phototherapy started on baby

Day of Life 1

For mom, she’s a typical first-time mom who plans to breastfeed. She has no known hormonal issues. Mom was induced due to hypertension, but due to continued elevated pressures, mom delivered via cesarean. Following the delivery mom was put on magnesium sulfate for 24 hours to lower blood pressure.

Baby Boy did well after delivery and was not separated from mom. However, he was very sleepy on day 1 of life and not very interested in eating. The lactation consultant assisted mom with latching and ended up trying a nipple shield to provide more oral stimulation to baby to facilitate latching. Baby latched and suckled once or twice, but otherwise just slept. The LC taught mom hand expression and was able to get a few drops of colostrum out to feed to baby.

At the next feeding, baby continued to be sleepy and uninterested in feeding so the LC set mom up with the electric breast pump and instructed the mom to pump for every feeding that the baby wouldn’t latch. Mom requested to give the baby formula due to not latching and only collecting a few drops of colostrum. The LC gave the mom syringes and helped the mom to feed the baby via syringe 8ml of formula.

Day of Life 2

At 24-hours of age, the baby’s transcutaneous bilirubin test was done and the result was elevated. This necessitated a serum bilirubin test to confirm the findings. The serum bilirubin was elevated and baby was put on phototherapy. The pediatrician for this baby encouraged breastfeeding and formula ad lib, but did not order a specific volume or specify how the baby should be fed.

At 36-hours of age, baby continued to only suck once or twice at the breast, even when the LC introduced a couple of drops of 5% glucose water as an incentive. Due to the elevated bilirubin and poor intake, a slow flow bottle was introduced to try and facilitate sucking and better intake in baby. The LC taught the parents paced bottle feeding, but it was not able to be used because baby’s suck was poor and uncoordinated, even with high flow. The LC had to increase the flow and provide chin and cheek support to get baby to transfer 10ml of formula from the bottle.

Breaking it Down

Why wouldn’t baby breastfeed in the first 24-hours?

It is normal for newborns to be fairly sleepy in the first 24-hours. Typically, they are very alert for the first hour following delivery, then they go into the recovery sleep, which can last several hours. Newborns are usually able to be roused for feeds about every 3 hours after the first 6-8 hours of life, though. He is also on the cusp of being late-preterm. Late-preterm babies are typically more sleepy and immature than term babies.

Another thing to consider is that Baby Boy’s belly could have been full of amniotic fluid. Babies delivered via cesarean don’t get the great squeeze that babies born vaginally get, and they often are spittier and hold on to fluid longer. Sometimes these babies have so much fluid in their bellies that they don’t feel hungry. If this was true, no matter how many times we put a nipple in his mouth, he doesn’t feel the urge to suck.

What could we have done differently in the first 24-hours?

For mom, we may not have done much differently. Being on magnesium makes moms feel terrible. Despite being taught that she needs to pump every 3 hours or breastfeed every 3 hours, mom might not have felt up to it. Magnesium makes moms feel so terrible, that we don’t leave babies with moms on mag unless there is someone else in the room who is able to care for the baby. Studies have shown a reduction in breastfeeding initiation and a delay in onset of Lactogenesis II in some mothers who had been treated with intravenous magnesium sulfate ¹. For baby, it is important to continue attempting to breastfeed at least every 3 hours or for mom to hand express and feed baby any colostrum she can collect. It is a great situation when the partner or another family member can be very hands-on and help mom with positioning and latch or helping to hand express and feed whatever colostrum can be collected. These partners can even help to hold the pump to make sure mom is pumping consistently. This was not the case for this mom. My hospital doesn’t use donor milk for babies older than 34 weeks GA, so donor milk wasn’t an option for Baby Boy. Whatever mom chooses to use to supplement, this baby was having trouble taking the milk via syringe or bottle. One procedure that can be done when it is suspected that baby has a belly full of fluid or for a very spitty or gaggy baby is to do a gastric lavage. “Gastric suction or gastric lavage is used to remove the gastric contents in neonates by suctioning it out or using a saline solution to wash it out, either at birth or during first few hours of life. The procedures are considered to prevent aspiration and reduce GI symptoms such as vomiting, retching, and regurgitation, as well as feeding difficulties caused by foreign material in the stomach, which stimulates these symptoms" ². This is a simple procedure that is generally done at the bedside. If a full belly was the cause, the lavage will fix it and baby will be interested in feeding right afterwards, generally.

Why wouldn’t baby breastfeed in the second 24-hours?

I suspect a couple of reasons why baby wouldn’t breastfeed in the second 24-hours. First, baby continues to behave more like a late-preterm baby than a term baby. If he truly is late-preterm, that explains why he continues to be very sleepy on day 2 of life. Second, the elevated bilirubin would cause Baby Boy to be more sleepy, resulting in less feeds and less stooling. According to Flaherman et al. (2017), “ Strong evidence suggests that increased serum bilirubin in the first few days is highly correlated with suboptimal enteral intake; serum bilirubin concentrations are highly associated with greater weight loss in breastfed infants. Ineffective suckling with inadequate caloric intake during the first days of life increases TSB levels because of relative starvation" ³.

How can we protect breastfeeding going forward?

First, we need to help mom understand why pumping consistently is important. We need to remind her that she is putting in the order for when the milk comes in. The more she pumps now, the more milk her body will make. We need to do the best we can with the flange sizes available in the hospital to ensure a good fit so no nipple damage occurs.

Second, with elevated bilirubin, feeding the baby is very important. We want to help ensure that baby is taking adequate, but not too much, milk at each feeding. According to Flaherman et al. (2017), “In the first 24 hours of life, exclusively breastfed infants may receive no more than 1–5mL of milk per feeding26–29 or 5–37mLin total.30,31 Encouraging breastfeeding within the first hour of birth and frequently thereafter maximizes caloric and fluid intake and stimulates breast milk production" ³. Using the Academy of Breastfeeding Medicine Protocol for supplementing volumes can help here.We need to figure out what method of supplementing is going to do best to help protect breastfeeding. Syringe feeding is not the best recommendation as it doesn’t allow baby to practice sucking. Finger feeding can be a good option if mom or the partner feels comfortable doing it. An SNS will allow baby to suck at the breast and get the appropriate milk volume, but can be very difficult for some moms, particularly if they feel uneasy just holding the baby. The bottle with a slow-flow nipple may be a good choice if parents are taught paced bottle feeding and the volumes are restricted to normal physiologic volumes. “Supplementation of breastfeeding should preferably be undertaken using a cup, spoon, syringe, or supplemental nursing system (if infant is latching) simultaneously with or immediately following each breastfeed. However, there is no evidence that any of these methods are unsafe or that one is necessarily better than the other" ³. While baby is on phototherapy for jaundice, baby’s access to the breast is limited because baby should remain on the lights as much as possible and be taken off only for limited amounts of time to feed. Baby will likely not breastfeed well while jaundiced because he will be too sleepy. The most important thing while baby is being treated is to feed the baby and get the bilirubin to a safe level where baby can be done with the lights.

I tend to tell moms that we can start brand new with breastfeeding once baby is done with phototherapy. As long as she does the work of pumping consistently, we can get baby back to the breast!

Do you have experience with a case like this?

I’d love to hear how you managed it!

Have questions?

Comment below or send me a message!

References

“Magnesium Sulfate.” Drugs and Lactation Database (LactMed®) [Internet]., U.S. National Library of Medicine, 15 Jan. 2024, www.ncbi.nlm.nih.gov/books/NBK501339/.

Phattraprayoon, Nanthida, et al. “Benefits and harms of gastric suction or lavage at birth for gastrointestinal outcomes: A systematic review and meta-analysis.” PLOS ONE, vol. 18, no. 7, 13 July 2023, https://doi.org/10.1371/journal.pone.0288398.

Flaherman, Valerie J., and M. Jeffrey Maisels. “ABM Clinical Protocol #22: Guidelines for management of jaundice in the breastfeeding infant 35 weeks or more of gestation—revised 2017.” Breastfeeding, 2022, pp. 950–958, https://doi.org/10.1016/b978-0-323-68013-4.00059-6.