The exception to "feed the baby" is when there is strong suspicion of
hypernatremic dehydration. During starvation, the infant body breaks
down fat to produce chemicals called ketone bodies. These ketones
provide both an alternate fuel for the brain, and have a high affinity
for water, preventing the brain from dehydrating. This is why a
breastfed infant who is dehydrated is not going to look it until he is
in very bad shape. (Any formula given seems to disrupt this protective
ketosis process. Patricia Drazin can tell you more about this, its
something she researched).
Anyway, when a lot of volume is given to a baby in hypernatremic
dehydration who has a lot of ketone bodies in his brain, the ketone
bodies are going to attract the water in to the brain cells and they are
going to swell. Swollen brain is NOT a good thing, because there is
nowhere to go in the hard skull. Increased intracranial pressure reduces
blood circulation and does mechanical damage as well if unrelieved.
Generally, if I see a starving, lethargic baby, I give a small volume of
manually expressed colostrum or milk (when baby is in that shape, there
only is a small volume available) and send him off to the hospital, with
a "heads up" call to the pediatrician. If the baby is alert and somewhat
active, it is unlikely that the starvation is severe, and that there is
an elevated sodium level and severe ketosis, and I'd give more food, and
notify the pediatrician with a request to please see the baby immediately.
When jaundice and starvation coexist, the enterohepatic recirculation of
bilirubin increases. In other words, the baby takes back that bilirubin
that he worked so hard to congugate and excrete back from the gut,
rapidly increasing the bilirubin levels. Generally plasma proteins fall
during starvation, so more bilirubin is free and potentially available
to pass the blood brain barrier. Most of the recent cases of kernicterus
have been due to health care professionals not taking significant
jaundice seriously enough. I'm very concerned about this baby, and the
way the mom was treated by the emergency room triage nurse.
Unfortunately, I've seen babies with hypernatremic dehydration and
babies with bilirubins in the 20s and 30s. In these cases, rapid action
is necessary to save the baby's life and neurological health.
Catherine Watson Genna, IBCLC NYC
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