I  really need your help on this one.  Permission to post, and I am very sorry but this is long.

The mother is a  37 y/o G3P3 who has successfully breastfed her two previous children x 2-3 years each.  Mother had bilateral breast reduction when she was around 20y/o, 17 years ago.
 She did experience nipple pain with each previous baby for about a month, but was able to exclusively breastfeed and went on after that with almost no trouble.

This baby was born on Aug. 18, (3wks ago now) at 9lbs 14oz successfully at home with a CPM midwife.  The midwife felt that the baby may have tongue and lip tie and referred her to a local pediatric dentist who did release both of them and gave the parents exercises to do which they have dutifully done.  The baby weighed 8lbs 12oz at 5 days of age (before the release), which by my calculations is a touch over an 11% wt loss.  That is when I first saw the mother and baby.

Having had experience with this mother with her previous two children, I knew that the reduction would not impede her ability to breastfeed exclusively, barring new circumstances.  She had not had any surgeries since, is taking no medications and came to me because of the weight loss and the extreme pain she was experiencing at the breast.  At that time, the 5 day mark, and the baby having lost 11%, I recorded that the baby had not had any stool at all since day 2 and that at that time it was still dark in color.  The mother reported that there was copious urine and that its color was clear.  I noted that her milk appeared white in color, was very easy to hand express and she stated that she had not pumped at all nor given any supplements.

Upon observing a latch I suggested a few minor tweaks in positioning, was able to hear audible swallow, and noticed that maybe every 3rd or 4th suck the baby appeared to release the breast of her deep latch and commense "chomping".  At the time I did not feel that the issue was oversupply since the weight loss had been so great, and noted that the baby had a hard time maintaining a seal.  I suggested a "baby moon" and seeing a practitioner of CST (thinking that possibly the baby had developed poor suckle in utero due to the ties).  I also strongly encouraged her to see the pediatrician, to begin pumping if she felt that the feed wasn't 

She went to the pediatrician in a few days time and he was not at all concerned!  There was still no stool.  The weight was still below 10% loss.  When she called me afterwards she said he didn't want to see them again until the 2 mo visit.   I asked her if the midwife was still willing to come by and weigh the baby every few days and she said yes. 
 By day 10 she had gained up to 9lbs., she had stooled one or two more times and the stool is brownish yellow and thick (not like I am used to seeing with breastmilk poo). My plan was: pump every 4 hours or so and give the baby the supplement of EBM until she regains birthweight, continue with the exercises for the tongue & lip, breastfeed on "demand" or at least every 2 hrs, when baby detaches calm her down and reattach her for a duration of at least 20 minutes or up to 40 one side or both sides, if there is no stool call the doc., and continue to see if the midwife will weigh her at least once a week., and if necessary give formula to add up to 2oz of supplement if she cannot continue to supply EBM (we do not have a milk bank).

So, I went on vacation and today (baby is 3 weeks) she called me to say the baby is still at 9lbs., her latch is very uncomfortable and she is using a shield!  She is pumping about 2oz every 3h, there is more stool now (still not every day) and it is a little softer, and that while we were out of touch she took the baby to the doc for what she thinks is thrush and he wants  to all sorts of blood work now (about time!)  The baby is still at 9 lbs.

Please tell me if I am missing something!  I do feel that this is out of my scope, but I'd like to know if there is a giant omission on my part.
THANK YOU!
ljb

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