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Wed, 8 Mar 2006 23:32:20 -0500 |
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I am trying to help a mom whose 6 week old (today) baby vomits once or twice after every nursing.
Her pediatrician suspected pyloric stenosis and admitted him to a teaching hospital.
Her baby has been hospitalized 5 days, and he has not gained any weight.
Previously he gained about 10 oz in 5 weeks (if you calculate a theoretical low as birth weight -
7%)
He was given IV fluids while he was made to fast 11 hours for an ultrasound- it did not confirm
pyloric stenosis. A barium swallow after a 3 hour fast indicated reflux. He has been on an acid
reducer and Reglan for three days. No change in weight. No change in vomiting except one
nursing at night is now free of the usual vomiting. The hospital physicians wasted two days
focusing on the mothers milk production making her pump and bottlefeed to prove her
production was not the problem. One actually hypothesized the baby was being overfed.
Attending Physician wants to move to exclusive formula feeding with cereal.
Mother at my urging has requested to see pediatric gastroenterologist. I would like an Allergist/
Immunologist and maybe neurologist called to consult but attending is saying one thing at a time.
Attending just ordered a clean catch urinalysis today. Mother was told blood tests (whatever they
were ) were normal. Stool samples have been taken on two ocassions to check for undigested
lactose, luckily we haven't heard back about that except to say there was no blood in stool. I was
worried that perhaps the baby's stool would show undigested lactose because the baby seems to
be digesting the whey fraction and just vomiting up curd. He is staying well hydrated and vigorous
but his body looks wasting...it's as if he is compensating for throwing up the curd by nursing very
frequently so he can at least get more of the whey fraction...I was concerned there might be a little
undigested lactose simply because he is consuming so much of it. I know I'm going out on a limb
here but the vomit never has the look of fresh milk as it often does with a baby who is a happy
spitter..it is always very cheesy almost dry looking...the mother and grandmother and
greatgrandmother all report they can't drink whole milk, only skim...and they describe themselves
as having stomachs that are quick to throw up...mother reports her own mother tried out every
available formula on her as a baby looking for one she could keep down...
Is this malabsorption? What kind of specialists should the mother request? What tests? She is
nineteen and I feel like the general pediatricians want to hang onto this for educational purposes...
Thanks for any help you can give,
Jen
Background if you need more info:
On day 3 and 4 mom experiences engorgement.
On the 6th day she was told to formula-feed for 24 hours because the baby's billi was 17.
Day 7 she resumed exclusive breastfeeding immediately after the 24 hours were up, but she had
not pumped during the 24 hours because no one told her she should.
At two weeks of age the baby weighed 7 lbs 4 0z. His birth weight was 7 lbs 8 oz.
The pediatrician instructed the mom to supplement with formula 8-10 oz per day but the baby
actually lost another ounce over the next 3-4 days.
At 2 1/2 weeks the pediatrician switched the formula at which time the baby resumed gaining
weight at the same pace he was when he was exclusively breastfeeding. The pediatrician office
asked me to see the mom when the baby was 5 1/2 weeks old.
I was not told by the office that the baby was vomiting and I'm not sure if the pediatrician was
aware of the problem. My impression was they wanted me to help the mom get back to exclusive
breastfeeding.
At the visit I weighed the baby and found him to be a little over 7 lbs 10oz.
He looked a little yellow to me but sclera were white.
He had no buccal fat or fat anywhere but he was vigorous and alert as she offered the breast and
the mom leaked profusely in anticipation of latching him on. She had longish nipples and he
latched deeply with ease. She nursed him until he fell asleep on one breast and then offered the
second side which he roused enough to take until he dropped off the second side in about 10
minutes.
During the nursing she told me he had 4-5 bowel movements a day with one copious enough to
overflow his diaper. Most were mustard yellow but some green, and he had normal urinations. She
told me once he was started back on formula at two weeks he began vomiting. She said he spits
up after every feeding whether at the breast or bottle but more after bottlefeeding. She said she
never exceeded the doctors advise of 8-10 oz of supplement per day.
About 10 minutes later after I was finished taking her history and listening to her describe her
breastfeeding experience she sat him up and he promptly vomited. This was about 40 minutes
after the initial latch. We weighed him and he had retained 40 grams. As she lifted him from the
scale he vomited again this time on his clothes so we did not weigh him a third time.
She took the scale home with her and I called the pediatrician's office to tell them about the
vomiting and to preliminarly report that the mother had a good supply especially in light of all the
supplementation, and that I thought if she had in fact an undersupply I thought it would be
recoverable, but I would like them to see the baby about the vomiting the following day. They
agreed to let the mother try a return to exclusive breastfeeding.
I spoke to the mother in the evening and the baby was consistently ingesting about 40 grams per
nursing though he could not keep it down. She nursed him about every hour and a half except for
one three hour stretch at night.
The next day, a Friday, at the pediatrician's office the baby had lost an ounce over the last two
days according to their scales. The pediatrician was comfortable with the baby exclusively
breastfeeding through the weekend, and he did not prescribe reflux medication.
I visited the mother in her home that evening and observed a breastfeeding followed by two
episodes of vomiting. They were both preceeded by sharp cries of pain.The next day with the baby
still vomiting after more than 24 hours off formula and his general appearance being so poor and
the advent of pain immediately prior to the vomiting, I phoned the pediatricians office and they in
turn contacted pediatrician and he in turn alerted the local children's ER that he was sending in a
baby with suspected pyloric stenosis. (I never saw projectile vomiting and I never got to speak with
the pediatrician- everything I reported was relayed through a third party.
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