Hello Lactnetters,

I am hoping to draw on the knowledge of those who have more medical training than I or more experience.

Permission to post:

Tuesday of this week, I got a call from a local Doula who asked me to see a client of hers whose 7 day old baby was having difficulty latching and had few diapers.  I was at this mom's house within the hour.

Baby was sleeping in another room when I got there, so I began taking the history with mom.  She told me that baby had a hard time staying on the breast, woke every 3-4 hours and nursed for 15-20 min, baby had 2 meconium stools before LII (on day 4) then 1 yellow stool on LII day and had not stooled since (now 3 days later), she was having 2-3 scant pees per day.  The RN had visited about 24 hours earlier, weighed the baby and noted that she weighed 3480 g, a loss of 215 g since d/c weight of 3660 g, at 2 days old.  Birth weight was 3875.  She was now 10.2% below birth weight.  The only suggestion the RN had offered was a recipe to increase milk supply, the only ingredient that I could see that might have an impact on milk was brewer's yeast.  The RN said the latch "looked good" and commented about "what beautiful pale skin she has."  At this point, I tell the mom that I am concerned about the weight loss and lack of diapers.  I ask her to bring the baby out so I could observe a feed.  It had been about 2 hrs since she had fed.  Mom brings baby out, she is  very pale, not healthy but just naturally pale, pale as in sickly pale.  She is still in deep sleep.  Mom holds her while I look at her.  I gently feel her head for assymitry and alarmed by her fontanelle which is depressed.  I check her mouth, no tongue tie, but I cannot seem to stimulate her to suck, she is dry.  We move her around a little bit, no reaction.  Her limbs are flacid.  Mom feels, she is just in deep sleep because it had only been 2 hrs since she fed instead of the usual 3-3.5.  I disagree and tell her that she is lethargic and needs milk.  Now.  So I instruct mom to pump and feed EBM when she wakes next, and top up with formula, and aim for 400ml/24 hrs 30-40 mls at a time.  I suggest using either just a syringe or tube at breast/finger using syringe to push milk.  I tell her baby should see a doctor within 24 hours, and if she can't stay awake long enough to take significant amounts, then she needs to go to the pediatric emergency.   I stay in touch by phone, baby is able to take the formula, but only 10-20 mls at a time, but they are giving this amount frequently enough.  She is starting to be more alert and awake.  By the next morning, she had passed stool, mom has continued to work at pumping and is getting more now, 20 mls per session or so.  I continue to keep in-touch by phone baby continues to take larger amounts at a time, and mom is able to provide more EBM.  Baby is much more vigorous, has had 3 more stools.  The following day, (2 days after initial visit) I do another home visit.  Mom is now providing 3/4 of baby's intake and baby's colour has returned, she has good tone, limbs are flexed as they should be, mouth is moist, she is awake and alert.  We do some latch work, I show mom compressions, I set her up using a tube at the breast for supplementation.

So, it is a good thing I saw this pair when I did, but my question is shouldn't the RN who visited them 24 hours prior to my visit seen some of these signs?  Baby's ill-health was very pronounced.  If she was to the point of having a sunken fontanelle, was lethargic and pale, surely there were some signs the day before?  How quickly can this develop?  Is it at all possible that she was fine and responding well the day before and then quickly became lethargic?

This is the first time I have encountered inadequate intake to this degree, so I don't really know how quickly things can develop.  Now that baby is stable and they are moving in the right direction, I have had a chance to process everything.  I am quite upset that the RN did not intervene more than giving some weird concoction.  Am I out of line?  Is there any way the signs were not beginning to appear 24 hours earlier?  Just the weight loss alone is an alarm for me.

Thanks!

Jennifer Welch, IBCLC (2010), LLL (2006)
Montreal, Quebec  

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