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Red Flags for Post-Hospital Follow-Up

Mother in pink sweater holding newborn infant on hospital bed.

Some years ago, the director of our perinatal service asked, “Marie, what would you consider to be red flags for post-hospital follow-up? I shrugged and said, “Well, I just know.” (Often, an expert “just knows.”) And she replied, “Great! Would you write that down, please?”

It took me a few weeks to write what was in my head. But in the years since she asked, I haven’t changed my mind. Here are the 6 factors I consider to be red flags for post-hospital follow-up.

1. Delayed breastfeeding or restricted breastfeeding

If you’ve taken one of my courses or followed me for any length of time, you know my mantra: Early and often, early and often, early and often.

By “early” I mean where you’re describing breastfeeding initiation with minutes, not hours, since birth.

Early and often has multiple advantages including early onset of lactogenesis, early passage of meconium (and hence, a lowered likelihood of jaundice), and early imprinting to avoid sucking disorders or suckling dysfunctions.

Restricted breastfeeding means anything that limits breastfeeding. This includes but is not limited to:

  • skipping night feedings
  • severe time limitations for early suckling
  • long intervals between feedings
  • use of pacifiers

There may be legitimate reasons for delayed or restricted breastfeeding. The point is, such delays or restrictions are for sure a red flag for post-hospital follow-up.

2. Non-exclusive or indirect breastfeeding

Non-exclusive breastfeeding means that supplementation has occurred or is still occurring. This interferes with maternal milk supply during the first month when lactation is becoming established.

Indirect breastfeeding means giving human milk, but without the baby suckling the breast. Usually, the milk is given by bottle, syringe, cup, or some other indirect method.

Indirect breastfeeding often happens when infants are born many weeks before term, or when they are compromised in some way. You might argue, “But Marie, in that case, they aren’t discharged from the hospital, right?”

Right. But their mothers have been discharged. Even with a hospital grade pump, the stimulation isn’t the same. Meaning, a piece of equipment on the breast is not the same as a warm, moist, happy little mouth on the breast. There is even some weak evidence that the infant’s saliva affects the components of the mother’s milk.

Mothers are fairly good about pumping every 3 hours for the first few weeks. The next thing you know that 3-hour interval turns into 3 ½, and then 4, or more hours. Night feedings get delayed or skipped entirely.

I’m not saying this happens with all mothers. But I’m saying that it often happens. I’m also saying that without adequate stimulation every 3 hours around the clock, milk supply is highly likely to diminish, especially in that first month, which is a red flag for post-hospital follow-up.

3. Adequate milk volume is questionable

Any mother who has a prior medical or surgical condition should be considered at risk for having an inadequate volume of milk. Keep your eye open for mothers who are diabetic, obese, or those who have had breast reduction surgery. But it could be other conditions such as an undiagnosed or untreated thyroid condition, having had cesarean surgery, or any number of other conditions

Some mothers have lifestyle habits that interfere with milk volume and/or let-down. For example, be aware of mothers who smoke.

Medications and other substances interfere with milk volume or milk let-down.

When adequate milk volume is questionable, there is a red flag for post-hospital follow-up.

4. Milk volume cannot meet infant’s need

Often, we jump to the conclusion that the mother doesn’t have enough milk to feed a baby. That might not describe the real situation.

Sometimes, a mother is producing appropriate amounts of milk for a baby. But if the mother has an infant with a pathological condition, she might not be producing enough milk for her infant.

For example, infants born large-for-gestational age (LGA) may need more milk than the infant who is average for gestational age (AGA). Similarly, infants who have a cardiac anomaly may have caloric needs that exceed what the mother is producing.

5. Adequate milk transfer is questionable

This list is probably endless, but some situations deserve mention.

Term infants who are suckling but do not have audible swallowing are waving a big red flag for post-hospital follow-up.

Typically, both parents and providers are waiting to see the diapers and the scales.

I’ll tell you, straight up, if you don’t hear swallowing right now, you won’t see the wet or dirty diapers or a bigger number on the scale later. If nothing is going in now, nothing will come out or go up later.

I’ll repeat: Lack of audible swallowing is a cause for concern and a red flag for post-hospital follow-up.

The opposite, however, is not always true. Sometimes, you can hear the swallowing, but the baby is not necessarily getting enough milk.

Lack of alertness might be a red flag. For sure, many babies are sleepy in those first 24 hours of life. The key here is to look at the whole clinical picture. If all else is going well, this might not be a big hairy deal. Or it might be.

Infants with any type of neurological issues, or any infant who has undergone trauma (especially head trauma) during the birthing process may not suckle effectively in the first several days (or more) after birth.

Similarly, “sore nipples” are often associated with poor latch, and poor latch is a classic predictor of inadequate milk transfer.

6. Psychological and social factors

Sometimes, it’s easy to observe lack of family support, or overt criticism from family. That’s not a good sign.

Lack of self-esteem and self-confidence are, in my opinion, an underestimated factor in early breastfeeding discontinuation. If we could dispense confidence pills, rates of breastfeeding initiation and continuation would soar.

I’ve always been hyperaware that it’s very difficult to instill confidence in new parents. But, as one person sitting in the back of the room at my comprehensive course in Dallas once said, “Yes, Marie, but it’s very easy to take it away.”

That was an all-too-true observation.

These factors may not cover everything, and, as usual, this is for information only, it’s not medical advice, But if you always consider these factors as red flags for post-hospital follow-up, I think you’ll have a clearer understanding of families who are most in need of later follow up.

Stay tuned for a forthcoming post where I’ll talk about some possible strategies to head off these issues before the couplet is discharged.

Have you noticed these “red flags” in clinical practice? Share your thoughts in the comments below.

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