Hi wise ones!
I have a question about a patient I've been working with (permission to
post). She has a now-12-week old baby, we've been working together for about
5 weeks. She came in with essentially zero milk, having been bottle-feeding
since day 5 when her milk was not yet in and she began supplementing. She
was pumping only a few drops twice a day. Started her on domperidone and
pumping 7x/day, w/ high compliance from mom. Baby didn't want to latch at
first, so we didn't push it until there was more milk present - just
encouraged lots of skin to skin and comfort sucking after bottles, which he
would do maybe once a day. She had tried an SNS initially, so wasn't excited
about going right to that, so I held off until he was more comfortable at
breast. We transitioned the baby through bottles at breast-position, finger
feeding at breast, and finally latching at breast with a feeding tube in a
bottle of formula, and after only a few days of practice, he's latching and
feeding well at the breast! (a very exciting success story for a very
dedicated mom, I might add). My question is this - at the most, mom was only
able to pump 5-6 oz per DAY in her seven 15 minute pumping sessions. Now she
reports via phone (I will see her tomorrow) that the baby is seeming
satisfied at the breast and refusing more than an ounce of supplement just a
few times a day. This is a big baby who was taking 5oz of formula every 3
hours (except at night), and now (1 week after starting feeds at breast) is
breastfeeding on his old feeding schedule with little-to-no supplement. Mom
reports his diapers are not as soaked as before, but that urine is still the
same pale color. She's (reasonably) concerned that he's not getting enough,
but when she tries more supplement, he spits it up. I suspect that she did
not respond very well to the pump in terms of let-down, but has noticed
breast changes (large pendulous breasts) and sprays milk when baby latches -
so it appears she has more milk than she was able to extract with the pump.
She also has very soft compressible tissue behind the areola, so it may be
her ductal structure was not very well suited to pumping either. HOwever, it
does make it really easy for her to manually squeeze super-big mouthfuls of
breast into this little guy's mouth!
We'll get a naked weight on baby tomorrow (which I only did at initial
visit, have not been tracking consistently) for baseline, and I'll observe a
feed, maybe do pre-and post-feed weights. What else do I need to be watching
for here? I'm consulting with my IBCLC coworkers on this, but none of us has
enough experience with transition from bottles back to breast to really know
what to watch for in terms of this baby getting enough. He's old enough that
he signals quite clearly when he's hungry. He routinely falls asleep at
breast, but it seems due to contentment rather than fatigue. He's a
roly-poly boy, so now that he's self-regulating feeds more, he may slim
down, too. Should mom keep a diaper chart at this point? I'm tempted to just
let her nurse him on demand and not stress too much about the supplement,
and just track weekly weights for a while, but he's also approaching that
point where bf babies slow way down in growth anyway, so he may not gain
much if at all, and I'm not sure how concerning it would be. He does get 2
bottles/day (primarily formula) due to a complicated situation with 2 older
foster kids, but other than that is at breast whenever he wants to be.
Looking forward to any insight as to whether it's possible this little boy
is actually getting enough at breast!
Thanks,
Kirsten Berggren, PhD, CLC
Lintilhac Breastfeeding Clinic and
www.workandpump.com
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