I have two cases I'd like to run by the readers of Lactnet.

1.     I'm going to be working with a woman whose second baby was born about
10 days age, had one good feeding at the breast, was discovered to be leaking
stool from a fistula around the unbilicus, and has just come home from NICU
with a temporary illeostomy.  According to the neonatologist, there are no
feeding restrictions for the baby.  Should I expect the child to gain at the
same rate as any baby?  Slower?  Will the baby have as many wet diapers, or
will the more liquid stool from the illeostomy decrease urine output?  If it
does, does the baby need more fluids than usual?

2.     I've been working with a first-time mother for about three months now.
 The baby had a very difficult time learning to feed at breast.  I  was
beginning to think he had some type of neurological impairment.  But the very
day he got back up to birth weight, around two weeks, after *much* work by
the parents, he opened his little mouth, latched on, and a test weight showed
intake of about 3 ounces, just like that.  A week or two later, the mother
developed sore nipples.  Looked like good attachment to me, no nipple trauma
but some occasional blanching.  Soon, she was having burning breast pain.  No
signs of thrush in the baby.  She saw her OB, who prescribed an antibiotic.
 No improvement.  She saw her ped, who didn't want to treat without signs in
the baby and suggested a nipple shield.  I finally cornered another of her
OBs and got a script for Nystatin cream, thinking we'd see a rapid
improvement in the mom, then could convince the ped to treat.  Instead, mom
had severe burning and discomfort when she applied the med, and the baby
"wailed" and didn't want to nurse, so after 24 hours, we stopped the
nyustatin.  She went back to the OB, who told her some women just can't
breastfeed.  She took an article from JHL re sore nipples to her family
practice doc, who put her on an antibiotic and a topical steroid, with
temporary, mild improvement, then recurrence of pain.  I finally convinced
her to see a dermatologist, who was, she thought, embarrassed to look at her
n-n-n-nipples, and who told her she had a dermatitis, not thrush, and said he
had no idea what to do about the burning in her breasts, as that wasn't his
speciality.  Some improvement with the stronger steroidal cream he ordered.
 He also advised her to stop the Lan.....h lanolin she'd been using, but when
she did, the nipples cracked and bled and got so sore, she went back to it
after several days. Somewhere in here, we tried Nystatin ointment, as the
dermatologist had told her it might have been the cream base that caused pain
the first time.  No improvement.  I finally called one of the Infectious
Disease docs.  He was leaving on vacation the next day and couldn't see her
but advised me to get an order for aerobic, anaerobic, and fungal cultures of
the milk, which I did.  The specimen grew a non-aureas staph and strep
viridens, no fungal growth.  Her family doc put her on Duracef daily, per the
sensitivity results for the strep, with little or no relief.  The baby, at
some point weeks ago, began to pull back and tug on the nipple, fight
attachment at times, and generally make his mother miserable. At that point,
the nipples began to appear slightly pinched after feedings. Throughout, he
continued to take four or five ounces at a feeding, by test weigh, and gain
about a half pound per week.  Two weeks ago, although the test weight showed
four ounces of intake, his gain had dropped to about 3.5 ounces that week.  I
figured it was just a temporary dip, but last week he had gained less than an
ounce--but the test weight showed an intake of SEVEN ounces of milk.  This
woman is an absolute saint.  She has spent a fortune on medical bills, has
persisted through three months of hard work and pain, but she's nearly ready
to throw in the towel, and I can't blame her one bit. I've totally lost my
perspective on this whole thing.  Does anyone have any idea what's going on?


Judy Dunlap, RNC, BA, IBCLC