Approaching middle/end of Day Two of life:

I recommended a consult with an Occup Therapist to teach mom how to handle
baby. Mom & Dad are involved with a Long Term Care Home which has an OT on
staff. Mother's mother lives nearby and spends lots of time at their home
caring for mom.

They called me to help with feed at 11am. Babe was already on R.breast
"football" hold, nursing leisurely, relaxed, eyes closed, mom smiling.
Latch is wide, breast being tugged, no nipple pain. When he slid off (no
popoff like yesterday) retured him to her chest, he rooted a little, & put
him in place at L.breast. He parted his lips and searched, but did not
latch effectively. I speculated he was just satisfied w/one breast at this
particular feed. I had not seen the initial latchon and early feeding.
Parents reported baby "fed well". (Retrospective: he was behaving like a
drugged <6 hrs old baby.)

Mom's breasts appeared rounder. Asked her if she felt more dense and
heavier. She said yes. Nursery is still after them to feed q 2-3 hours.
Baby is staying in mom's room on our L&D Unit so dad can stay with her
overnight. We discussed again feeding cues vs clock. s/s good latch,
positioning, swallowing, breast softening, stools & wets. It was during
this conversation that Dad said they were going to do Parent Directed
Feeding after baby was two weeks old.

I cautioned them about putting babe on a rigid feeding schedule because
baby may not get as much milk as he needs. I suggested that when someone,
even at their church, suggest a parenting method, consider if it is
respectful and loving. Is it something that makes sense for an adult? Would
Dad consider putting himself on that same schedule? Dad said he knows I
favor Attachment Parenting and explained it is a "flexible routine", not a
rigid schedule. (He used the term for AP, I never said it before.) I
continued with s/s effective feeding and how BFing is a nurturing thing,
not just a way to fill his stomach. The discussion continued calmly, if not
cautiously". They are happy with their church which has a large
congregation of young families who love the PDF program. I told him how
scheduled babies usually can't keep mom's milk up to sufficient levels and
weaning is often complete by/before 4 mos, and of the risk of FTT. He said
I gave him something to think about & thanked me.

The asked for me again about 3:30 pm to feed. At this time I intended to
stand back and observe while parents worked together to get baby positioned
and latched. No luck. Baby is asleep. Nursery RN came in to check glucose
again (55) and temp (normal). He's been checked so much, both heels are
bruised. Dad told her babe finished his last feed at 11:30am. Baby
complained about the heel stick, but fell asleep again before he reached
mom's arms. Dad said baby has stooled once today. They are happy to keep
baby in arms, at/near bare breast and keep petting, stroking, working with
babe to wake him up. 

Reviewed the basics with parents again, but bells are ringing in my head.
They should be complaining that baby won't come up for air by this time.
Nursery RN listens but doesn't talk.

Searched the internet for "PDF" and found Ezzo and GFI! I had been thinking
this was another Ezzo-like program. Talked to nursery RN who said baby has
lost weight. Checked baby's chart. Turned out to be about 9%! Explained
PDF/Ezzo/GFI and gave printouts. They never heard of this. Nursery RN said
they had been saying baby needs to be fed. True, but Nsy is always
insisting on q2-3 hr feeds and putting bottles in cribs. They never
mentioned this weight loss till now. I surprised them by agreeing, baby
needs to be fed now! I recommended pumping (so far mom's too tired to use
it) or formula topoff and a Social Service consult.

Went to L&D to chart in mom's file. OB RN reported mom is asking for
another Percocet after 5 hours. It's a q6hr medication. That explains why
mom is alternately bright, happy, alert, and later can barely keep her eyes
open. All conversations then are with dad with mom interjecting a few
comments with her eyes still closed. Wonder if this baby is affected by the
percocet? "Nothing reported via milk but observe for sedation", per Hale,
'06. He rates it as L3.

Nsy RN called the Pedi about a Social Service consult. He went in to talk
to parents. He said they are very nice and caring people and have an
excellent family and professional support system (yes, yes, yes, and....).
Doc got dad to feed formula. Baby took 35cc. Doc is happy; declined to
write an Order for Social Consult. After all, they will be followed up at
their Peds office within the first week of discharge.

(Well, shut my mouth!) Where's that bull's eye on the brick wall for my
head?
My colleague, Cozy, is covering tomorrow. 

My biggest error was not reviewing baby's file for overnight feeding &
diaper history before answering the "come help them now!" command at 11am.
What else should I have done so I can be smarter the next time?



Phyllis Adamson, IBCLC, RLC
Glendale, AZ
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