I first posted about this  baby last weekend.  She had lost a great
deal of weight (Jack, you are right, we really aren't sure how
accurate the figures are; how baby is doing is more significant
than numbers), was scrawny, "nursing all the time", fussy
most of the time, no stool output in last 3 days at day 5, and
innadequate urinary output.  Subsequent to this she was wet-nursed by
another woman, and then provided banked human milk from the Vancouver
Milk Bank (by bottle).  It is my understanding that the Milk Bank
just closed last week :(

Since my last update the baby has continued to do better.  On Monday
there was a team meeting on the island where the family lives with
the mother, doctor, public health nurse and social worker.  This was
a stressful situation for the mother, but she remained composed,
although later reported anger at being confronted with 3
professionals and little notice.  She also resented being told that
she had to have her daughter seen by the pediatrician the following
day (ped visits once a month and there happened to be a cancellation
for the visit the next day).  She was asked to see me following
the pediatrican appt which was at 10:15.

  She & baby came (1 hr late at 1 PM) with baby's father and the woman
who had wetnursed and is continuing to donate milk.  Baby was having
a bottle on arrival, but drinking slowly.  Mom said her breasts were
full, but she preferred to try pumping milk than to immediately put
baby to breast.  I had the pump ready so she double pumped with a
hospital grade electric pump for 7 or 8 minutes.  This was the first
time she had used a pump.  There were drops of milk immediately, but
after about 5 minutes milk extraction stopped, although she kept
going a couple of minutes to be sure.  She covered the bottom of the
collection bottles with a little more from the left breast.  I
estimate a total of about 1/4 oz.  While I was busy with mom & baby
the wetnurse used the same set-up to pump about 2 oz herself.

Mom reported the pediatrician had been satisfied with the appearance
of the baby.  He did not think domperidone would help.  She had
prolactin levels taken.  The results will be a day or two, and what
will they mean?

Mom put baby to her breast and there was non-nutrative sucking, no
swallowing (no surprise).  I then taught them how to use a nursing
supplementer and the baby took just under 2 oz by feeding tube at the
breast, in about 10 minutes.  Although mom was very awkward with this
system, she was expressed strong emotion in saying this is how she
would like to continue feeding her baby.

I examined mother's breasts.  As stated before her areola is of
unusual appearance, being more continuous with the nipple than with
the breast.  Although she is quite "flat chested"  I was able to
palpate mammary tissue.  Breasts are fairly symmetrical with the left
being slightly larger.  Kathleen A had advised I contact a couple of
L.C.'s who have worked with many similar cases.  These had  suggested
a space greater that 1 1/2 inches between the inner borders or the
breast to be indicative of mammary hypoplasia.The space on this mom
was 1 1/2 inches sitting slightly foreward, and 2 inches suppine.

Mom had been asked the day before to keep a log of feeding times and
behaviour and input/output.  She had been either unwilling or unable
to do so.  She stated that the baby feeds so slowly that it is hard
to know when one feed begins and the other ends.  As weight gain
continues to be hefty, the public health nurse and I are wondering if
mom is now forcing milk (by bottle) on a baby who has had enough, in
her desire to prove herself and avoid aprehension of the infant.

The family  left the office with the electric breast pump (on 9 day
loan), and the nursing supplementer.  They had put milk in the bottle
for the 2 hour trip home by ferry and car.  On leaving mom first
extended her hand, then gave me a hug.  She was clearly happy about
the prospect of feeding baby at the breast, although I had cautioned
her that supplementation may be long-term.

When I made a follow-up phone call 3 1/2 hours later it sounded like
mom had not yet used the supplementer since leaving my office.  She
did not wish to follow up with the island physician (she was angry
about the meeting), but seemed to relinquish when I pointed out that
he had been tolerant of the wet-nursing, had not insisted on formula,
had put in a medical requisition for the Milk Bank, and was willing
to try domperidone if we wished.  The physician had also helped
arrange the loan of a car seat (none was used for the first 2 weeks).
The financial aid/ social services people had also been helpful,
having paid for the shipping of the breast milk, and are now looking
into financing contracting with me for lactation support including
weekly on/off island travel for either myself for the mother.  All of
our public health nurses have recently completed an extensive
breastfeeding counsellor's course, and are very supportive as well.
There was no further night-time "check-in" with the maternity nurse
after the second night home.

This continues to be a challenging case.  I appreciate all the
comments that came both through LACTNET and personal e-mail.  Your
suggestions have been most helpful.

I will be out of town for meetings the next few days, and "no mail"
on LACTNET during that time.  Please copy any additional feedback to
my e-mail.  I am sure I can continue to use your collective wisdom as
I continue to follow this family.

Suzanne McBride