I wrote last week about a 2 month old baby who is gaining weight very poorly
and has green stools.  I received many very helpful replies to this
situation (thank you all!) and wanted to write an update of the continuing
saga, and seek more wisdom.

To recap, this is Mom is 43, this is her 7th child, all other children were
breastfed successfully.  Birth wt was 6# 2oz and baby has gained 1-3 ounces
a week since birth.  He has green stools which had been frothy but the
frothiness decreased when we worked hard on increasing hindmilk intake.  Dad
has Celiac and many other food allergies.  He had been nursing every 2 hours
for 1 hour at a time with switch nursing and breast compressions.

Mom lives 40 miles from me and can only visit once weekly.  I saw them again
today and baby had only gained 3.5oz since last week, bringing his weight up
to 7# 7.5oz, which is well within the FTT range.  He continues to have green
watery stools with much gas.  Today I noticed a light red raised bumpy rash
on baby's chest and shoulders, neck, and cheeks.  

As I stated previously, mom was indeed getting very worn out with the
frequent long feedings and decided to only feed baby ad lib on demand.  He
continued to eat every 2 hours during the day but only fed for about 30-40
minutes each time rather than 1 hour at a time.  He slept for one 4-5 hour
stretch every night.

I re-examined his mouth and found no obvious tongue tie or palate issues. 
His tongue was extended and cupped.  The suck was pretty weak, although he
was very gassy and fussy at the time of the exam and would not maintain
sucking past about 5-6 sucks.

Mom's nipples are rather large and baby is very small, so achieving a deep
latch is difficult.  We were able to latch him very asymmetrically today and
a little deeper, and mom was surprised with this.  Hopefully this will
increase efficiency.

Mom has been eliminating gluten from her diet for about 3 weeks now (Dad has
Celiac) but we have seen no improvement.  I talked her into going to an
almost complete elimination diet, continuing to eliminate gluten (I believe
that soy is already out with this) and add diary, peanuts, and eggs to the
off-limits list.  She didn't want to cut out strawberries and beef yet.

I also advised mom to start supplementing baby with Alimentum QID, amount as
demanded by baby.  She prefers to supplement with a bottle.  She will
continue to nurse as before, so the supplement will be in addition to
current intake, not replacing.

My questions:
1. I recommended she use an Avent bottle.  I like the rounded base, but I'm
not sure about the flat tip of the nipple as I've read that this can
encourage baby to chew while sucking.  Does anyone have an opinion about this?

2. The doctor initially suggested that mom pump and bottle feed exclusively,
with human milk fortifier added.  Mom neither wants to pump nor has the time
(with 7 children, a husband with severe medical problems, and a home
business).  If pumping were an option, what are the thoughts on this route
rather than formula?

3.  I had initially suggested Nutramigen but the doctor wanted to use
Alimentum "to avoid the corn base".  What is the base of Alimentum?  (I had
no luck researching the Similac website)

4.  I would love comments on the supplement amount advice of QID, amount
determined by baby's response.

I know this is long...thank you all for your time!  I've learned VOLUMES
from all of you and this case has been both frustrating and interesting.

Julie Conaway, RN
(Still studying hard for the exam, but learning more from these experiences!)

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