A mother I have been working with has asked me to post this case. Though
at 6 mos. this baby no longer breastfeeds, she takes exclusively EBM by
bottle. We were wondering if anyone has seen a case like this in their
practice
Baby girl born full term weighing 7 lbs. 2 oz. Weight at discharge was 6
lbs. 10oz. Baby regained birth weight by sometime early the second week
and was 7 lbs. 6 oz. by day 13. Mom reports that baby nursed at the
breast well for the first two weeks, averaging 10-15 mins. per side every
2-3 hrs. At around 2 weeks postpartum, mom developed burning of nipple
and breast and was prescribed all purpose nipple ointment by a
breastfeeding-knowledgeable MD. It may be coincidental, but around that
time, baby began nursing on only one breast per feeding and nursed for
shorter durations. At about 4 weeks, baby commenced a course of
Nystatin, but began having vomiting episodes, so med was discontinued.
At the same time, mom started a 28-day course of Diflucan.
I was consulted during week 5 because baby had lost 2 oz. since the end
of week 2. At visit, baby’s latch was shallow and her sucking motion
seemed non-nutritive, with infrequent audible swallowing. Digital
assessment revealed a high palate with some tongue bunching, but no
tongue-tie. I believed that baby had not been sucking properly since
birth, but gained sufficiently at first by passive means due to great
milk supply. Mom was instructed in latch techniques and sucking
exercises to encourage baby to open wide and keep tongue down. I
recommended continuing work on latch/suck with supplementation by
finger-feeding as necessary. Mom pumped to keep supply up while baby’s
nursings were erratic. At 7 weeks, a pre- and post-feed weigh showed
that baby got 1 ¾ oz. after 6 minutes at the breast.
Time at and interest in the breast fluctuated and mom supplemented more
w/EBM in bottles, finding alternative methods unworkable. By about 2 ½
months, baby started showing less interest in the bottle as well and
gained only 3 oz./wk. between then and 4 mos. During this time, daily
intake of EBM by bottle was 19-21 oz/day. A pacifier was introduced at
month 4.
At 4 mos. baby started Mylanta, 1 tsp. 2x/day, which was recommended by
ped because of fussiness, arching and crying during attempts to
bottle-feed. Daily feeding volumes increased to 21-24 oz from month 4-5
and then decreased early in month 5. It was becoming a struggle to get
the baby to take even bottle-feedings. Mother has tried different
nipples, different feeding positions, etc., to no avail. She is
currently using the medium-sized Avent nipple.
Between 4 mos. and 5 mos., baby continued to show less interest in the
bottle, would breastfeed occasionally and only gained a few ounces. At
the end of the month 4, baby started a 14-day course of diflucan which
was prescribed by the ped over the phone based upon mother's report of a
white tongue. At about 5 mos., mom started fortifying her EBM with cream
skimmed from settled EBM. At that time, baby had blood work and
urinalysis done which was negative for infection or abnormal thyroid. The
baby was referred to a nutritionist at 5 ½ mos. who recommended mom
fortify her EBM with formula (8.5g of Similac w/iron powder to 10 oz.
EBM) to help baby gain weight. During month 5, mom introduced rice
cereal and bananas, which baby had little interest in. Baby had some
very loose stools this past month. Otherwise, stooling has been
adequate.
In the last two weeks, (between 5 ½ and 6 mos.), daily milk intake has
been decreasing to < 18 oz./day. Baby will generally only take the
bottle when in a near-sleep state. Baby has gained no weight this month
and is currently about 10 lbs. 15 oz. During the last few days, daily
intake has decreased to 12-13 oz. of fortified EBM. Baby spits bottle
out or pushes it away with hands after she has taken only an ounce or so.
Baby's diapers are less wet.
Baby was seen by a ped GI doctor last week who did a 24-hr. pH wire test
for GERD (negative) and ruled out celiac disease. An endoscopy is
planned and the baby has an appointment in mid-March at a suck-swallow
clinic. No evaluation yet for heart problems. Otherwise, baby is
generally a happy, alert, "easy" baby who has achieved all developmental
milestones. The GI doctor has said that if feeds drop off any more, it
may be necessary to insert a feeding tube while testing for a feeding
disorder proceeds.
This mother has managed to maintain a great milk supply (pumps more than
35 oz./day). She is desparate and feels that the baby is now on the
borderline of taking enough for hydration. If any has had any
experiences with babies like this, please reply.
Thanks in advance,
Ellen Maughan, JD, IBCLC, LLL Leader
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