Barriers to Breastfeeding in the Hospital | By Jessica Wimer, RN, IBCLC
Happy Friday friends! Today's blog post is by guest author, Jessica Wimer, a labor and delivery RN, IBCLC, mama of two and founder of the blog Born and Fed. She's getting real about the barriers to breastfeeding in the hospital, something she experiences every day in her practice as an RN, and the steps we can take to prepare ourselves for what we may experience from knowing what is totally normal to overcoming some early hospital challenges. Major thanks to Jessica for writing this amazing post from the perspective of an RN/IBCLC and sharing her fun and informative infographics from her site, Born and Fed. Let's dive in!
My name is Jessica. I am nurse, lactation consultant and mother of two. I have a heart for women trying to find their footing in the rugged landscape of motherhood. Being a mother encompasses so much more than I ever understood as a health care professional. It was not until I became I mother that I understood the paradox. Raising children can be beautifully fulfilling and soul crushingly HARD all in the same moment. I needed strong women to help me find my way and it inspired me to be a light to others.
I primarily work in a hospital setting. I see women in the first few days of their baby’s life before milk has even come in. Dealing with this very narrow window of the breastfeeding journey, I frequently see the same problems and concerns emerge again and again. I know women come to the hospital with the intention to exclusively breastfeed. While 81% of women start out breastfeeding only 55% remain breastfeeding at six months (2). More than half of breastfeeding mothers state they did not breastfeed as long as they intended to. The question that begs to be answered is, “Why?”
Working in the hospital with new moms is an an opportunity to lay down a solid foundation for breastfeeding dyads before they go home. There are trained professionals on hand 24 hours a day to support new mothers. Conversely, the center for disease control’s Healthy People survey shows that 15% of newborns are supplemented in the first two days of life (2). A recent study reported that 22% of a group of 496 infants whose parents intended to exclusively breastfeed for at least the first 6 months of their life were supplemented with formula in the hospital. Of that infants, 75% of those babies did not have a medical reason for supplementation (4). Breastfeeding professionals know that early supplementation is linked to shortened breastfeeding duration. If our goal is to set mothers up for success outside of the hospital, we need to understand why so many couples are going off the rails before they even begin.
The longer I work in the hospital setting the more these patterns reveal themselves. I began to see the same scenarios unfolding again and again. My experience suggested that it was not lack of skin to skin, parent infant separation, or introduction of pacifiers that was the main catalyst behind many parents’ decision to introduce formula to an healthy exclusively breastfed baby.
The reason was because no one had prepared them for what life with a breastfeeding newborn was like and then supported them with options and information that did not lead to supplementation.
If parents believe their baby is hungry, they will supplement their baby. It seemed to me the main barrier to breastfeeding in the hospital was not always related to hospital policy but to parents’ misunderstanding of normal infant behavior and a lack of confidence in their ability to feed their baby. Parents come in with their own expectations about how breastfeeding will go and how their baby will behave. Yet many parents confess to me that they have had very little to no experience with infants before giving birth. The most basic and insidious barrier to breastfeeding is the culturally influenced expectations we espouse before becoming parents. There is the perception that all will go smoothly if we do everything “right.” Our baby will breastfeed for the first year, sleep on a schedule (in its own bed), and work neatly into our former lives.
The problem is, babies do not work that way.
They come into this world with their own needs and expectations that unfortunately do not align with ours. By understanding what is normal and expected followed by how we respond, parents are set up to succeed at breastfeeding and leave the hospital feeling more empowered to face difficulties as they arise.
WHAT CAN YOU EXPECT FROM YOUR BABY AFTER BIRTH?
Most term healthy babies are VERY sleepy for the first 24 hours of life. Generally, most babies will do one to two “good” feeds right after delivery and then go comatose for the first day of their life.
Labor is not just hard on mommas, it is hard on babies too.
Right of after delivery, mom and baby are both riding the endorphin wave. Many have heard mention of the “Golden Hour” for breastfeeding. This is the time after delivery when baby is alert and interested in feeding. Make the most of this time. As long as baby is interested at the breast, let them go. Generally after the second feed, baby is pretty well knackered and ready to sleep. If we made the most of our “Golden Time,” we can be confident that baby fed well, not once but twice. This can be reassuring to parents later when baby is difficult to rouse and feed.
Many parents often feel pressured to wrap it up during this time so guests can come meet the baby. Prepare your guests before hand. Immediately after birth is a sacred time. You just redefined the dynamics of your family. This is a time for you to meet your baby and lean into your partner. It is a time to let your baby feed uninterrupted. If this is your first baby, it is a time for you to focus on learning HOW to feed your baby without trying to entertain guests. Let your nurse or lactation consultant help you.
WHAT HAPPENED TO MY BABY?
After the first two feeds, many parents start to feel confident. This breastfeeding thing is not so hard. Baby fed like a rockstar on both sides for over an hour. I got this. Then… baby checks out. Rockstar breastfeeder starts to be difficult to rouse, only feeds for five minutes before passing out, or is completely uninterested in even latching. The baby is completely bushwhacked. Some parents start to panic. “What happened? They told me to breastfeed every 2-3 hours and now it has been 5 hours and my baby still will not wake up!”
Your baby is normal.
Mom and baby are supposed to sleep. You both just went through an epic ordeal. Take this time to be skin to skin with your baby as much as possible and rest. Your baby will feed when it is ready. Most term, healthy babies go a few long stretches between feeds during the first day. Just when you think your baby may never eat again, your baby will latch on and feed.
This is why I really like to make the most of those first two feeds when baby is awake and game to feed. We can be confident that baby is capable of a good latch, and that they had at least two good feeds. Then when baby becomes sleepy and difficult to feed, we can be encouraged that this is a temporary problem, and baby will breastfeed again when ready.
HOW DO WE COPE WHEN BABY IS SLEEPY?
Don’t panic if your baby goes long stretches during the first 24-36hrs. Offer the breast anytime baby seems interested and/or every 2-3 hours. When it is time to feed the baby, unswaddle your baby. Change the diaper.
WAKE THAT BABY UP.
Sit the baby up in a burping position and rub the baby’s back. Give a real concerted effort to rouse the baby and get their eyes open. Then bring the baby to the breast and be actively engaged in keeping the baby awake and stimulated during the feed. You may be begging for a 10 minute feed (which seems like a real comedown after the first hour long feed). That is okay.
If your baby does not rouse with all your efforts, or falls asleep the second you get your nipple in it’s mouth, then put the baby skin to skin and try again in an hour. Do not waste too much time and energy with each attempt to breastfeed. If you go through the waking up ritual and baby is still in dreamland, try again in an hour. Allow baby to recoup in the best place possible… your chest. This is a revitalizing time for your baby AND it puts baby in breastfeeding territory. You smell like food and being skin to skin will help your baby get in the mood to eat.
After an hour of skin to skin, try again. If the baby is still not interested, back to your chest and try again in another hour. Most hospitals have a policy requiring a blood sugar if the baby has not fed in 6 hours. Fine. If your baby is a term, healthy baby, their sugar will be just fine. Research has shown that skin to skin time actually helps stabilize newborn blood sugar (3). Just keep doing what your doing. The vast majority of babies will eat before they hit an 6 hour mark. If their sugar is fine, there is no need to worry and no need to resort to a bottle.
WHEN IS A BABY TOO SLEEPY?
If your baby is going longer than 8 hours, you need to start pumping or hand expressing to stimulate your lactation cycle and possibly collect a feed for your baby. Any colostrum you are able to express can be fed to the baby and count as a feed. Remember, 5-7mls is a full feed for a newborn. If a pediatrician is involved and concerned by how long baby is going between feeds, this can be a great way to avoid supplementation but ensure your baby’s needs are being met.
Generally, most pediatricians recognize this is a normal cycle. Doctors and nurses get concerned for the following reasons:
• The baby has NEVER fed well in life
• The baby is consistently going longer than 8 hrs between feeds
• Baby is sleepy for more than 36 hrs
• Baby has not had any wet or dirty diapers
• Baby is getting jaundiced
• Baby has lost greater than 10% of their body weight
• Baby’s blood sugar is below normal range
All of these are legitimate concerns. Most can be addresses by initiating a pumping/hand expression plan to supplement the baby along with breastfeeding. Continue breastfeeding and or offering the breast every 2-3 hrs and then hourly if baby is too sleepy. If baby goes longer than 3-4 hours, pump and hand express. Baby can be feed the expressed colostrum and you start the process again.
If you baby has any of the aforementioned issues, try to pump and hand express while consulting with your provider. Express your desire to exclusively breastfeed and be an active participant in formulating a care plan for your baby. If supplementation is required, be sure to pump/hand express every time your baby is receiving a bottle. This will help ensure your body is keeping in sync with baby and will be ready to pick up where you left off when your baby is ready to exclusively breastfeed again.
TIME TO WAKE UP
Sometime around day two your baby will decide it is time to WAKE UP. This can be equally confusing to new parents. Their angelic sleeping baby suddenly is wide awake, cranky and ravenous. This is nature’s way of making up for lost time. Baby has spent the first day recuperating and now he is ready to indulge at the all you can eat buffet. Even babies who have not been excessively sleepy and fed consistently through the first day will ramp up on day two. This behavior is called cluster feeding. It is when baby wants to feed on demand sometimes as frequently as every hour. Cluster feeding is a natural process that helps bring mom’s milk in and allow for baby to catch up on lost calories.
It is not uncommon for some babies to become cranky during this period, especially if they did not feed much the first day. Babies become restless, resist being laid down, and often act ravenous at the breast but then refuse to latch. This period is affectionately dubbed, “Second Night Syndrome.” It can be bewildering to parents. This is where I see parents go off the rails. They begin to panic that their baby is starving because they are not making enough milk and they start supplementing.
Here is the deal. NO ONE is making abundant milk at this stage because babies do not need an abundance of milk at this stage. Colostrum is the first milk and one of its main purposes is to give baby passive immunity through antibodies. Newborns are living off brown fat stores during the first few days of life. This is why we expect babies to loose weight.
Colostrum does a great job giving your baby life sustaining immunity but not such a great job putting on weight and filling bellies. This is how nature intended it. Baby is meant to be hungry so they put in a large order for mom’s body to transition to a mature milk supply. The lactation cycle is all about supply and demand. Baby’s high demand day 2 and 3 is the stimulus mom needs to start bring in her mature milk supply.
“Second night syndrome” is more than just ramping up the supply and demand cycle. This is when babies become aware. They have awoken form their deep slumber to find they are in a bright, loud, cold, foreign landscape and they are completely overwhelmed. Your baby is overstimulated and looking for comfort in the one place it recognizes as a safe haven… mom.
Mom and mom’s breasts are a safe place and bring comfort beyond food.
Recognizing that some of baby’s protesting is related to the monumental shift in environment is part of understanding “second night syndrome.” Western cultures do a poor job of acknowledging the 4th trimester and a newborn’s need to be close with its mother. We expect our babies to come into the world and fit neatly into our lives and expectations. We want to pass them around to share with our friends and family, have them sleep peacefully in their cots, and feed on a neat tidy schedule. This is completely counterintuitive to what our babies are searching for. They want to live on you. If you had a pouch, they would be happy to live in it. They want your warmth, your smell, your comfort, as well as the milk from your breast.
HOW DO WE HELP BABY DURING THIS TRANSITION?
• Recognize you cannot spoil your baby.
• Hold your baby… a lot. You are not setting yourself up for a lifetime of holding your baby. Your baby will grow and develop in the next three months and be more amenable to being put down. For now, hold your baby.
• Allow on demand feeding as much as your nipples can stand. Take care of your nipples by utilizing expressed breastmilk, lanolin creams, and saline soaks.
• Minimize guests. I know, nobody wants to hear this but you and your baby need rest. Guests who come to support you are welcome. Guests who come to socialize and are uncomfortable with you breastfeeding on demand in front of them are not.
• Use the help of your nurses and lactation consultants. Most nurses are trained in lactation and many hold special certifications to help breastfeeding mothers. They are a valuable resource and you only have them for a limited time. Use them.
• Make an appointment with a lactation consultant to follow up with you at home. Things change when you get home. Your milk comes in, new problems arise, and questions you never knew to ask come to surface. Many IBCLC’s take insurance. Check with your health plan and see if a lactation consult is covered.
• Give yourself lots of grace. This is hard. You are going to feel tired and overwhelmed. You just brought a life into this world and now you are nourishing it with YOUR BODY. Take help and take care of yourself. A well cared for mom is a better mom for her baby.
• Feed with confidence. However you ultimately feed your baby is perfectly fine. Let go of any self imposed or societal pressure to do it a certain way. Once you have your baby in your arms, you will know what it the right decision for YOUR FAMILY. Hold your head high. You don’t need permission. Real friends and woman’s advocates will support you REGARDLESS of how you feed your baby.
However you choose to feed your baby, do it with intention and do it with confidence.
Ready to learn more about your milk supply? Jessica makes the best infographics! Check out Jessica's awesome, easy-to-understand infographic below breaking down how we make milk and follow along with her @bornandfed.
About the Author
Jessica Wimer is a labor and delivery nurse, IBCLC and a mother of two! In her non-existent spare time, she writes breastfeeding and postpartum support articles for her blog Born and Fed (http://bornandfed.com). Jessica resides in beautiful country acres of Lancaster PA with her husband and two children.
1. Anstey, E. H., Coulter, M., Jevitt, C. M., Perrin, K. M., Dabrow, S., Klasko-Foster, L. B., & Daley, E. M. (2017). Lactation Consultants’ Perceived Barriers to Providing Professional Breastfeeding Support. Journal of Human Lactation, 34(1), 51-67. doi:10.1177/0890334417726305
2. Centers of Disease Control. (2018). Facts | Breastfeeding | CDC. [online] Available at: https://www.cdc.gov/breastfeeding/data/facts.html [Accessed 3 Jul. 2018].
3. Chiruvolu, A., Miklis, K., Stanzo, K., Petrey, B., Groves, C., McCord, K., Qin, H., Desai, S., Tolia, V., (2017) Effects of Skin-to-Skin Care on Late Preterm and Term Infants At-Risk for Neonatal Hypoglycemia. Pediatric Quality & Safety 2(4). doi: 10.1097/pq9.0000000000000030
4. Newhook, J. T., Newhook, L. A., Midodzi, W. K., Goodridge, J. M., Burrage, L., Gill, N., . . . Twells, L. (2017). Determinants of Nonmedically Indicated In-Hospital Supplementation of Infants Whose Birthing Parents Intended to Exclusively Breastfeed. Journal of Human Lactation, 33(2), 278-284. doi:10.1177/0890334417695204