PTP

First time mom 35 years with IVF born in C-section. Due to surgical complication mother was given blood transfusion that helped her plunging hemoglobin status. Mother later developed abnormally fast heart rate (tachycardia) and was suspected for Swine flu, malaria, pneumonia and HINI infection and was treated for all of these conditions in the ICU and was finally sent home after 10 days postpartum and has been through a lot. Baby was healthy at 3.2 kg at birth and dint need any special care at NICU. He was given formula until mother returned home. Mother stated that ultrasound scan during pregnancy had indicated baby with Pelviureteric Junction (PUJ) Obstruction which can cause urine to back flow causing Hydronephrosis but after birth baby has been found to steadily improve and appears to move urine well and showing 10 good diapers and scan showed easing of the obstruction. Mom had a delayed lactogenesis but was highly motivated and began
 breastfeeding and baby slowly began to refuse any supplementation and showed 10 to 12 wet diapers and 3 to 4 good stools which is why mom never too it so seriously. Baby was weighed very few times during these 7 weeks. Yesterday when the mother consulted me baby weighed 3.14 kg still less than birth weight. (Lowest weight during hospital stay was 2.85kg). Surprisingly baby doc (pro-breastfeeding) had suggested that she see a lactation consultant (never happened before) and said he will need to advice supplementation and gave her 3 more days time to improve breastfeeding.

Mother stated that baby snacked all the time and was literally at breast all day and night expect for few shorts breaks. I noticed positioning and latch was poor and with changes, baby began good suck:swallow rhythm and completed an entire feed in 10 mins and seemed satiated which mother felt was the first time ever although baby was suckle for rest of the consultation time for comfort finally fell asleep. Plan of care included expressing several times a day and to supplement baby with expressed breastmilk immediately and discussed with the parents about needing to use direct breastfeeding, expressed breastmilk and formula for sometime until baby gains well. Mother reported that she managed to express only 15 ml twice a day until last night. I held back suggesting a SNS for baby because mom was not very confident of achieving a good latch with heavy pendulous breast and would find SNS overwhelming.

Mom called me and said her doc wished to speak to me and wanted to discuss beginning supplementation for this baby since he had given her 3 more days. (I am very excited about this opportunity of discussing a case with a pediatrician and want to handle the conversation well, little nervous too) 

Although baby seemed to have a excellent sucking with good positioning, he did have a high palate and less elevated tongue. He was however able to cup my finger well and sucked well with no retraction of tongue. He did have a restricted string like upper lip frenum not thick though.

I would like to know what else should I be looking at to manage the situation better. Could they be other hidden health issue that may need attention for no increase in weight gain for this baby? What else must I be looking at?


Thank you for all your help.

Yasmin
MA,HDSE,CLEC,LLLL,IBCLC in private practice
Mumbai, India
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