Karen Clements continues to update us on the mother with a slow gaining baby
possibly due to low supply.
Karen, I agree that it seems several people missed important signs that
things were not going in the right direction.  It seems likely that as baby
approaches birthweight s/he will pick up strength and want to be fed even
more often, so I hope the mother is prepared to feed on cue, oftener than
every 3 hours if baby wants.

What you describe sounds to me like a pronounced case of baby dropping just
under the critical point in weight and vigor, and not being able to get
above it again without a concerted effort on part of mother.  I'd be
surprised if mother's hormones were anything but normal, and my hunch is
that in the next few days you will see a steady improvement in both supply
and baby's suck.  The 'oroboobular disproportion' could well have played a
role at the start and it's good that this is a big baby so it won't take
long to grow into the breast.

One piece of info we are missing (and I don't know that it is worth
obtaining it now, since things are progressing at last) is how much milk
baby is actually transferring during a feed.  Starting pre- and post-feed
weighing now seems superfluous since baby is gaining and stooling.

I couldn't help noticing you mentioned that the mother was to give the baby
a feed every 3 hours.  I know we often say that where I work, about babies
who need very frequent feeds.  I am struggling to get my colleagues to see
that 'every 3 hours' is not especially often - not for a healthy term
newborn unaffected by medication or intervention and certainly not for a 14
day old who is more than 10% below birthweight.  I've tried to change to
saying 'at least 8 times in 24 hours, and more is even better, if baby
wants', emphasizing that some babies will feed evenly throughout the period
and others will cluster feed at times and take a long nap at others.  The
problem is, clocks are notoriously bad instruments for determining infant
hunger or adequacy of intake.  We need to help mothers to LOOK AT THE BABY,
and let her know what signs should alert her that there is something wrong.
We need to help our colleagues do the same.

Recently we had a couple return to the hospital with their week-old baby,
very concerned because 'baby hadn't eaten all day'.  Baby got a full
pediatric work up, and was found to be healthy.  Nobody questioned them more
closely over the phone about what 'all day' meant.  Turns out they had
followed an 'every 3 hours' regime in hospital because baby had been
jaundiced and in phototherapy, and no one had clarified what demand feeding
was, nor said that when baby was discharged home she was considered entirely
well and could eat whenever she wanted so they had continued to wake her
around the clock if she didn't wake on her own, every 3 hours.  Baby had
been difficult to feed at some feedings but had not actually refused to feed
before the day they phoned us.  Baby had refused her 4 p.m. feeding and
parents phoned us at about 6.  At that point, 5 hours had passed without a
feed and this was the longest interval the baby had experienced since she
was put on a 3 hr. schedule in the hospital.  By the time they got to the
hospital, requiring over an hour's drive for them, baby was awake and hungry
and fed well, but it still didn't occur to anyone to weigh the baby naked or
ask about stools.  Instead they did several blood tests (glucose, bilirubin,
and infection status, all normal) and had pediatrician see the baby first,
because the staff assumed that the baby hadn't eaten 'all day' when in fact
she had 'skipped' one feed.
This points up two things: the importance of good phone triage and the
importance of clarity in teaching parents how to care for their babies if
for some reason there has been a departure from demand feeding at any time.

Sorry my digression made this so long, but I hope my point is clear.
Rachel Myr
Kristiansand, Norway

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