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When Breast and Bottle Both Are Best

A Medical Necessity
Clara's situation -- her baby simply wasn't getting enough breast milk -- is one in which a breast/bottle combo may be medically necessary. Usually, your child will give you an indication that feeding's just not going right, but for many moms, it takes a good pediatrician to back up their hunch. "If I see a newborn who just seems miserable and hungry and who cries all the time, I look at that very seriously," says Dr. Neifert. "It can't be a positive early life experience for a baby who is frantically hungry to be put to the breast and not get enough milk."

If you suspect that breastfeeding isn't satisfying your baby, ask your baby's doctor to help you confirm the problem. Your baby's weight is a good indicator of how well she's feeding, and there are two ways to evaluate this. Since newborns shouldn't lose more than 10 percent of their birth weight in the first few days of life and should surpass it by 2 weeks of age, your pediatrician may weigh your infant while she's naked to compare her current weight with her birth weight. Another weight test involves what doctors call a "representative feeding," which will give your pediatrician an idea of how much milk your baby takes at a typical breastfeeding. To do this, he'll weigh your baby with her clothes on, ask you to nurse her, and then reweigh her in the same clothes. The change in her weight after a feeding represents the amount of milk she drank from your breasts. "By two to three weeks of age, for example," says Dr. Neifert, "a baby should be taking in about one ounce of milk per hour. So, we would expect her to have gained about two ounces two hours after she nursed. If the gain is considerably less than this, there may be a problem."

Dr. Neifert also suggests that you ask your ob-gyn to do a thorough "lactation assessment," which should include a medical history to uncover any conditions, such as breast surgery or hormone problems, that could interfere with successful breastfeeding. Ask your doctor to evaluate your breast appearance as well -- including size, shape, and symmetry. Some women, says Dr. Neifert, through no fault of their own, have underdeveloped breasts that render them unable to make enough milk, and small-breasted women may have to nurse more often because their breasts may not hold as much milk, increasing the chance of nipple sores, cracks, and bleeding. "This is a biological difference in women that no one will admit to," says Dr. Neifert.

When faced with a mom who is physically unable to supply enough breast milk to her baby, Dr. Neifert usually recommends what she calls a "triple feeding":

1. Temporarily restrict the duration of breastfeeding to 20 minutes (10 minutes per side).

2. When you finish breastfeeding, have your spouse or another caregiver feed the baby as much extra milk (either previously expressed breast milk or formula) as necessary to satisfy her. (A breastfed baby often accepts a bottle more readily from another caretaker because she expects to breastfeed from her mother.)

3. While your baby is drinking her supplement, use an electric double breastpump for 10 minutes to extract any residual milk in your breasts and stimulate additional production. Refrigerate the milk you express.

4. At the next feeding, repeat the cycle. After breastfeedding, supplement first with your expressed milk, then offer additional formula as needed.

Over time, says Dr. Neifert, triple feedings will help build up your milk supply while assuring your baby is adequately nourished, and you may be able to return to exclusive breastfeeding if you wish to. The rigors of a triple feeding schedule aren't for every woman: some are too exhausted or have too many other responsibilities to devote the necessary time and energy to this demanding regimen. "It's important for the mother to choose whether she feels she can add in pumping," says Dr. Neifert. If you'd rather not, you might want to follow the instructions below.