I first posted about this baby last weekend. She had lost a great deal of weight (Jack, you are right, we really aren't sure how accurate the figures are; how baby is doing is more significant than numbers), was scrawny, "nursing all the time", fussy most of the time, no stool output in last 3 days at day 5, and innadequate urinary output. Subsequent to this she was wet-nursed by another woman, and then provided banked human milk from the Vancouver Milk Bank (by bottle). It is my understanding that the Milk Bank just closed last week :( Since my last update the baby has continued to do better. On Monday there was a team meeting on the island where the family lives with the mother, doctor, public health nurse and social worker. This was a stressful situation for the mother, but she remained composed, although later reported anger at being confronted with 3 professionals and little notice. She also resented being told that she had to have her daughter seen by the pediatrician the following day (ped visits once a month and there happened to be a cancellation for the visit the next day). She was asked to see me following the pediatrican appt which was at 10:15. She & baby came (1 hr late at 1 PM) with baby's father and the woman who had wetnursed and is continuing to donate milk. Baby was having a bottle on arrival, but drinking slowly. Mom said her breasts were full, but she preferred to try pumping milk than to immediately put baby to breast. I had the pump ready so she double pumped with a hospital grade electric pump for 7 or 8 minutes. This was the first time she had used a pump. There were drops of milk immediately, but after about 5 minutes milk extraction stopped, although she kept going a couple of minutes to be sure. She covered the bottom of the collection bottles with a little more from the left breast. I estimate a total of about 1/4 oz. While I was busy with mom & baby the wetnurse used the same set-up to pump about 2 oz herself. Mom reported the pediatrician had been satisfied with the appearance of the baby. He did not think domperidone would help. She had prolactin levels taken. The results will be a day or two, and what will they mean? Mom put baby to her breast and there was non-nutrative sucking, no swallowing (no surprise). I then taught them how to use a nursing supplementer and the baby took just under 2 oz by feeding tube at the breast, in about 10 minutes. Although mom was very awkward with this system, she was expressed strong emotion in saying this is how she would like to continue feeding her baby. I examined mother's breasts. As stated before her areola is of unusual appearance, being more continuous with the nipple than with the breast. Although she is quite "flat chested" I was able to palpate mammary tissue. Breasts are fairly symmetrical with the left being slightly larger. Kathleen A had advised I contact a couple of L.C.'s who have worked with many similar cases. These had suggested a space greater that 1 1/2 inches between the inner borders or the breast to be indicative of mammary hypoplasia.The space on this mom was 1 1/2 inches sitting slightly foreward, and 2 inches suppine. Mom had been asked the day before to keep a log of feeding times and behaviour and input/output. She had been either unwilling or unable to do so. She stated that the baby feeds so slowly that it is hard to know when one feed begins and the other ends. As weight gain continues to be hefty, the public health nurse and I are wondering if mom is now forcing milk (by bottle) on a baby who has had enough, in her desire to prove herself and avoid aprehension of the infant. The family left the office with the electric breast pump (on 9 day loan), and the nursing supplementer. They had put milk in the bottle for the 2 hour trip home by ferry and car. On leaving mom first extended her hand, then gave me a hug. She was clearly happy about the prospect of feeding baby at the breast, although I had cautioned her that supplementation may be long-term. When I made a follow-up phone call 3 1/2 hours later it sounded like mom had not yet used the supplementer since leaving my office. She did not wish to follow up with the island physician (she was angry about the meeting), but seemed to relinquish when I pointed out that he had been tolerant of the wet-nursing, had not insisted on formula, had put in a medical requisition for the Milk Bank, and was willing to try domperidone if we wished. The physician had also helped arrange the loan of a car seat (none was used for the first 2 weeks). The financial aid/ social services people had also been helpful, having paid for the shipping of the breast milk, and are now looking into financing contracting with me for lactation support including weekly on/off island travel for either myself for the mother. All of our public health nurses have recently completed an extensive breastfeeding counsellor's course, and are very supportive as well. There was no further night-time "check-in" with the maternity nurse after the second night home. This continues to be a challenging case. I appreciate all the comments that came both through LACTNET and personal e-mail. Your suggestions have been most helpful. I will be out of town for meetings the next few days, and "no mail" on LACTNET during that time. Please copy any additional feedback to my e-mail. I am sure I can continue to use your collective wisdom as I continue to follow this family. Suzanne McBride