"The infants stomach is hard and distended." Not normal. Even when she is not crying? How much does this child weigh? If you are looking for a zebra, try Hirschsprung's disease.

Gail Hertz, MD, IBCLC, FABM 
Author of The Little Green Book of Breastfeeding Management
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> On Aug 26, 2014, at 10:16 PM, Alicia Simpson <[log in to unmask]> wrote:
> 
> Thank you Laurie! I don't think you're picking the post apart at all. The
> more feedback the better. At this point I correspond with the parents at
> least 10 times a day (they call, text or email with questions almost
> constantly) and have seen the baby 3 times. I observed a very good latch
> each time, textbook good. Her nipples are now everted and very elastic.
> Perhaps they were more flat at birth and nursing/pumping has drawn them out
> more in the week between birth and when I first saw the patient. In doing
> pre- and post-weights she in transferring on average 2 to 2 1/2 ounces
> (sometimes more in the morning) and then getting a 1/2 ounce to 2 ounce
> supplement shortly after a nursing session. Parents recently bought a scale
> and have been doing pre and post weights as well. Right now the infant's
> intake is around 40 ounces a day. Nursing an average of 10-12 times a day,
> 6-8 supplements a day after feeding (although in the last 48 hours she has
> been cluster feeding quite a bit so the parents have begun to lose count).
> 
> Mom is only pumping right after nursing. In the morning she will usually
> yield closer to 2 ounces in a pumping session directly after a feed in the
> evenings closer to only 1/2 ounce. This seems fairly normal to me
> considering how long the infant is nursing and that she is only pumping
> after nursing sessions. After 2 nights of cluster feeding on the 3rd night
> she was able to pump 4 ounces after a nursing session so at the very least
> all that sucking is paying off in terms of building a supply.
> 
> I initially recommended a SNS but the parents ultimately decided not to get
> one and after doing pre and post weights multiple times I don't see the
> need for one at this time. I agree with the parents assessment and have
> witnessed the behavior multiple times myself. The infant's stomach is very
> hard and distended. The 4 times she has had a bowel movement she was a new
> baby for the 24 hour period afterwards. She was content, no crying except
> for wet diapers and very alert. As the days progress with no bowel
> movements it is clear she is increasingly uncomfortable and unhappy.
> 
> 
> 
> Take Care,
> 
> *Alicia C. Simpson MS, RD, IBCLC, LD*
> Maternal and Pediatric Dietitian
> International Board Certified Lactation Consultant
> Main Office: 1164 North Highland Ave, Atlanta, GA 30306
> Thank you Laurie! I don't think you're picking the post apart at all. The
> more feedback the better. At this point I correspond with the parents at
> least 10 times a day (they call, text or email with questions almost
> constantly) and have seen the baby 3 times. I observed a very good latch
> each time, textbook good. Her nipples are now everted and very elastic.
> Perhaps they were more flat at birth and nursing/pumping has drawn them out
> more in the week between birth and when I first saw the patient. In doing
> pre- and post-weights she in transferring on average 2 to 2 1/2 ounces
> (sometimes more in the morning) and then getting a 1/2 ounce to 2 ounce
> supplement shortly after a nursing session. Parents recently bought a scale
> and have been doing pre and post weights as well. Right now the infant's
> intake is around 40 ounces a day. Nursing an average of 10-12 times a day,
> 6-8 supplements a day after feeding (although in the last 48 hours she has
> been cluster feeding quite a bit so the parents have begun to lose count).
> 
> Mom is only pumping right after nursing. In the morning she will usually
> yield closer to 2 ounces in a pumping session directly after a feed in the
> evenings closer to only 1/2 ounce. This seems fairly normal to me
> considering how long the infant is nursing and that she is only pumping
> after nursing sessions. After 2 nights of cluster feeding on the 3rd night
> she was able to pump 4 ounces after a nursing session so at the very least
> all that sucking is paying off in terms of building a supply.
> 
> I initially recommended a SNS but the parents ultimately decided not to get
> one and after doing pre and post weights multiple times I don't see the
> need for one at this time. I agree with the parents assessment and have
> witnessed the behavior multiple times myself. The infant's stomach is very
> hard and distended. The 4 times she has had a bowel movement she was a new
> baby for the 24 hour period afterwards. She was content, no crying except
> for wet diapers and very alert. As the days progress with no bowel
> movements it is clear she is increasingly uncomfortable and unhappy.
> 
> 
> 
> Take Care,
> 
> *Alicia C. Simpson MS, RD, IBCLC, LD*
> Maternal and Pediatric Dietitian
> International Board Certified Lactation Consultant
> Main Office: 1164 North Highland Ave, Atlanta, GA 30306
> *Now serving patients at our new offices in Alpharetta/Roswell *
> Phone: 678-607-6052
> Fax: 770-909-1402
> Email: [log in to unmask]
> *www.peapodnutrition.org <http://www.peapodnutrition.org>*
> 
> 
>> On Tue, Aug 26, 2014 at 9:56 PM, Laurie Wheeler <[log in to unmask]> wrote:
>> 
>> Hi Alicia,
>> 
>> I am playing devil's advocate, as they say, and just maybe the original LC
>> saw that the baby was not actually latched effectively and therefore
>> suggested the shield. (I do realize nipple shields can be and often are
>> overused and not needed). I had a family today with a non-latching infant
>> who said to me that the baby latched earlier very well but only a few
>> seconds and was making loud smack smack noises. To them the baby had a
>> great latch.
>> 
>> Your client may have interpreted that the nipple shield caused more
>> problems because w/o it the baby again could not latch. ???
>> The mother had delayed LII til day 8, so maybe the original LC did see
>> some anatomical or other problems and felt she should give mom some
>> anticipatory guidance. Again ??? not sure.
>> 
>> The infant is gaining on the low side 1/3 oz per day even with some (you
>> say minimal) formula supplementation and 1/2 to 2 oz ebm after each
>> feeding. This seems to point to ineffective milk transfer. One thing that
>> could be tried if the infant is resistant to the bottle supplements, would
>> be a lactation aid at the breast.
>> 
>> You also say the "infant also has a very high suck need sucking nearly
>> constantly. I believe the high suck need is due to the fact that the infant
>> is not passing stools." Here are 2 red flags, usually pointing to
>> insufficient calories/volume, although it is not out of the realm of normal
>> (I think) for babies to go one good poop a week, large and soft, after
>> usually 4 to 6 wks but 3 wks maybe, *provided they are gaining weight well
>> and content.*
>> 
>> You say the pre/post weights show more than appropriate intake, I wonder
>> exactly what the intake is. What did the baby weigh at birth and what catch
>> up growth might still be needed? I said in a recent lactnet post that a
>> baby may get a 2 oz feeding but only get that 6 or 7 times a day, taking
>> only 12 or 14 oz / 24 hrs or even 16 oz in 8 feeds, which is not enough. I
>> definitely have seen babies wetting diapers plenty but not pooping and
>> virtually all of them are not getting sufficient calories for growth, but
>> are hydrated.
>> 
>> Other comments that are red flags to me for infant hunger and insufficient
>> intake: "after nursing 40 minutes the infant took a 2 oz bottle" ... "this
>> is well over her stomach capacity". "should have either spit up or passed a
>> bowel movement when being overfed"...."she made a gurgling sound as if
>> the milk was stuck in her esophagus".
>> I am thinking here that the milk transfer  is very low, that the parents
>> believe she should only be taking maybe 2 oz per feeding, that she is being
>> overfed, and that her stomach gurgling is a medical problem. Certainly
>> there could be absorption problems if the child is being given sufficient
>> volumes and frequency of feeds but still not gaining, but I think this is a
>> horse and not a zebra problem, if you know what I mean. Is her tummy soft
>> and not distended?, I'm guessing it's fine in that she has been checked by
>> her doctor a few times. Not sure if parents describe "fussy, gassy, and
>> sucking hands alot, constipated" but that is a very typical description in
>> my experience for a hungry baby and not a tummy problem baby.
>> 
>> I am also guessing that mother's milk production might be somewhat low, as
>> I am not sure if she is expressing just the 1/2 oz at some sessions. I hope
>> you don't feel I am picking your post apart, as that is not my intention,
>> just trying to address each point, and before some major investigations,
>> tests, or referrals are done for this infant, to first maximize the baby's
>> intake, very generously, the baby could take 4 or 5 oz even, and see what
>> the results would be.
>> 
>> Laurie Wheeler RN MN IBCLC
>> MISSISSIPPI USA
>> 
>> 
>> 
> 
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