Recommendations on Improving Hospital Safety to Prevent Newborn Starvation and Brain Injury

1) Mothers should be instructed on how to manually express to confirm presence of milk. 

2) Twice daily weighing for exclusively breastfed newborns in the hospital and at home as it has been shown that the least-fed newborns can lose the maximum recommended weight loss of 7% within the first 24 hours.  This practice should be continued at home until breastfeeding meets the child's full metabolic requirement as signaled by the onset of daily weight gain.  The 7% weight loss threshold should be provided to the mother to help signal the need for supplementation in the hospital and at home.  

3) Universal daily transcutaneous bilirubin checks and glucose monitoring for exclusively breastfed newborns before the onset of daily weight gain as the scientific literature has now identified them as a high-risk population for hypoglycemia.  The physical exam is insufficient to rule out hypoglycemia and pathological hyperbilirubinemia.  Any inconsolable child should also have a glucose check as this is an often-missed sign of hypoglycemia.  Supplementation with breast milk or formula as available to the mother should occur immediately at a glucose level less than 50 mg/dL, to provide a margin of safety, as well as bilirubin levels exceeding 15 mg/dL or any level considered high risk on the bilirubin nomogram. 

4) Pre- and post-breastfeeding weights after lactogenesis II to measure the amount of milk transferred to the baby, which should be around 2 ounces per feed.

5)  Next day after discharge follow-up with pediatricians and universal bilirubin and glucose checks in the office.  Follow up within 48 hours as allowed by the current guidelines is enough time to disable an underfed child.  

6)  I advocate for mothers to be informed of the possibility that their child can become dehydrated, jaundiced and hypoglycemic from insufficient breast milk intake and that these conditions can cause brain injury. Signs of this are a child that is not sleeping or crying repeatedly after breastfeeding and feeding near-continuously.  Lethargy, poor feeding, seizures, hypothermia and bradycardia are late signs that suggest the presence of profound brain injury from near-complete glucose deprivation to the brain.  These babies deserve brain MRIs to support parents so that they can closely monitor their development and obtain early intervention as needed.

7)  Every mother should be educated on supplementation after nursing sessions in order to continue the stimulation needed to promote milk production.  Supplementation can be offered 15 mLs at a time as the newborn stomach has been in fact measured to be 20 mL in size at birth, much larger than commonly taught to mothers and health professionals.  Supplementation should be offered until a child is no longer in distress. Supplementation is a valid choice as NO BENEFIT of exclusive breastfeeding justifies the risk of life-long disability caused by hypoglycemic brain injury. Any mother sent home without a supplementation plan is being sent home to potentially starve and disable her child if her milk does not arrive on time.