I am working on a case that I need some input on.  I know its a busy time of
year, hence the multiple copies sent to LC friends and Lactnet.  If anyone
has some insight please share it.  If you thinks tests should be done,
please give me some arguments to support the position.  Every time I request
tests to be run I hit a brick wall and cannot seem to break it down.  This
mother is getting discouraged and needs to go back to work in 1 month.   She
wants to make bfdg work desperately and I'm not sure there is anything more
we can do at this point, although I am a bit suspicious on a couple issues.

1st time mother, baby's birth weight was 6#9 oz.  At three weeks she weighed
6#7 ounces.  I checked her and found a classic bubble palate.  Mother did
not have sore nipples but the suck was quite poor and milk supply obviously
low.  Baby was at breast continually.  Urine and stool output appeared normal.

Due to a strong family history of milk allergy on both sides of the family,
I took mother off all milk products (this was 2.5 weeks ago).  Started
supplementation with Nutramagin at breast using a p-syringe and
finger-feeding.  Mother began pumping approx 8-10 times per day.  Baby
gained 12 ounces the first week.

Mother was instructed to cut back by 1/3 the amount of supplement (from 9
ounces per day to 6).   Discussed with mother how to do a frequency day with
the pump because her milk supply was stable at 1/2-3/4 ounce per session.

The milk supply increased nicely to 3/4-1.5 ounces per session.  Baby's gain
was 3 ounces the next week.  Baby's suck at breast is only good during
initial MER then it deteriorates to non-nutritive sucking with few audible
swallows and does not pick up until milk is reintroduced with syringes.
Urine and stool output still appeared normal.

On close examination of the amount of supplementation I realized the mother
had cut back to 4-5 ounces per day or 11-15 syringes only.  Baby had to be
coaxed to take these and slept well between feedings.

We increased the amount of supplement back to an absolute must at 5.5 -6
ounces per day (16-18 syringes).  Mother's milk supply is coming up nicely
to where she now gets 1-2 ounces per session.  She has baby almost
exclusively on breastmilk.  An ounce or so a day is the ABM.  Urine and
stool output this week is down with only 1 stool a day between Thursday and
Friday afternoon.  Talked to her over the phone.

I've had her experiment with switch nursing to improve the quality of suck
beyond the initial MER.  Mother feels it doesn't help.  Mother can
consistently pump 1-2 ounces immediately after breastfeeding.  I'm concerned
about milk transfer problems.

I've looked closely at the obvious, latch-on and positioning issues.  Mother
is thin, had trouble gaining weight the last trimester (gained only 6 lbs).
At 6 weeks ppd she has lost all her pregnancy weight (which totaled 24-25
lbs).  After discussing her diet which does include meat I had her add some
nuts and oils in an attempt to increase the fat in the milk.  I did this
after I had asked her to skim the fat off the pumped milk and give it to the
baby first so that if she couldn't get the whole supplement down her she
would at least get the high calorie milk.  Mother had never seen any fat
rise to the top of pumped milk.

Adding in the nuts and oils did change that.  Mother now reports seeing fat
rising to the top after pumped milk sits a short while.

At mother's five week check-up she was still bleeding red blood.  Midwife
felt this wasn't surprising since mom was so tired and stressed.  Midwife
commented that mother seemed constipated which mother denied.  Mother tells
me she feels abdominal pressure that was not there before the baby, she did
not tell the midwife about this.  Mother has no histroy of thyroid problems,
but has also never been checked.

Now mother is giving 16-18 syringes of pumped breastmilk or ABM a day.
Feedings have decreased to 7 per day.  Mother is incredibly stressed and
doesn't even feel she can handle things without help during the day.  She is
weepy a lot and wants it to be easier.

Overall, I think things are progressing nicely.  I am a bit confused about
the urine and stool output, it doesn't seem to fit, unless it has something
to do with the amount of fat baby is getting.  I would like to see a better
suck develop but I think that has improved too.  Am I missing something?  Or
am I letting this mother's stress influence me?  Any thoughts would be
appreciated.



Denise Parker, BA, IBCLC (La Crescenta, CA)
To Avoid Criticism, say nothing, do nothing, be nothing