Hi Diane, Thanks for the further info on your dyad. From what you have described, it seems the mother did experience a milk surge. This would lead me to believe that the baby was feeding ineffectively from day one. The sore nipples goes with that too. The baby lost alot of weight between birth and discharge and became quite jaundiced by the sound of it. This is a red flag too of course.
Here is what I have experienced several times: A mother has quite flaccid breasts or assymetry or tubular shape. She reports that her "milk came in" however to me the breasts were not really very full at all. The baby nurses briefly and falls asleep, appearing content and sated. Here is what I have seen also several times: the baby is peeing and pooping within the range of "normal" like 6x pees and 3-4x poops. Often the pee is not very saturated in the diaper, often there is some "brick dust" in the urine reported if you ask. Often the stools are small and maybe still greenish, not always. Here is a generalization, but usually, thriving babies who come in for their checkup are wet or dirty when we undress them for the weight, or they pee all over me or the scale. Babies who are not doing so well are often dry when we undress them.
Well, to me, with your dyad, the bottom line is still weight gain. The pediatrician may be thinking that the baby is taking in adequate amounts, and if so, then other organic causes would be looked for: sepsis, uti, heart, metabolic, etc. What I usually do is call the peds doctor, explain what I think is going on by the objective/subjective info I've obtained, and state what I recommend we do, and if he concurs with that, we proceed. I'm not sure if he has any devious motives for considering blood work, really he is probably just worried about the baby, and not very comfortable with letting things go along as they are. He is seeming to be very patient, to me.
Are you seeing this dyad in person, or are you helping over the phone or email? Did you get to see her breasts during the first week? How much is she pumping out after bf? How much is she supplementing of her own milk? Again, I wonder, if baby is nursing and taking in say 12 ml, then is supplemented with say 30mls, this could still be far short of what his intake should be. My suggestion would be to generously supplement the baby, giving approximately 656ml in divided feeds in a 24 hr period. This could be done by supplementer device or bottle or whatever method. I would not even count the intake at breast at this point, unless I had a documented pre/post measure. I have often seen where a baby is taking only 6ml or so at breast. I would have baby come back next day, at this point, and I would expect a several oz gain. I've often seen 4-8 oz gain overnite once generous supplementation is offered. I would continue the supplementation (while working on supply of course and bf skills of both) til supply was full and baby was bf effectively. Continue close followup and support.
Laurie Wheeler, IBCLC, MN, RN Mississippi, s.e. USA
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