I have heard that maternal (then subsequently infant) zinc deficiency can present with skin rashes that are unresponsive to other treatments/elimination diets.
Amy Wagner, BS, RNC, CCES, IBCLC
On Apr 27, 2014, at 12:13 PM, Trisha Wierenga <[log in to unmask]> wrote:
> PTP the whole story - very long, sorry. Four and a half month old baby born 12/5/14, birth weight 6# 9 oz. Birth history - full term, placenta pulled out in 24 pieces, thin, cord not centered on placenta. NICU for 8 days for respiratory issues, breastfed well (per mom) since birth. Mother states weights at pediatrician were normal until 3 month visit. Baby had history of green, mucousy stools, skin sensitivities, very frequent feedings. Ped suggested elimination diet and supplementation with Neutramigen and rice cereal for weight gain (I know, I know...). Mother removed dairy (including hidden), eggs, wheat, soy for one month without improvement. Baby has never taken a bottle for mom. Visit with another lactation consultant on 4/3 - baby 9#, transferred 1.6 oz in 10 minutes of feeding. IBCLC assessed for posterior tongue tie/lip tie and discussed issues with allergies/skin. Recommendations given to improve weight gain and transfer of milk.
>
> Admission to hospital on 4/22, my co-worker spoke with mother and baby on 4/23 and 4/24, but she did not get called to the peds floor to see a feeding. Mother was also vague when talking with her. Stated she was ready to switch to formula just to put weight on baby (not grasping that baby will not take a bottle or other method of supplementation). Milk spun in crematocrit obviously showed normal calories and fat (we have never had an abnormally low reading on any milk).
>
> I saw mother and baby starting on 4/25. Weight 4200 gm/9# 4oz. Visual assessment - baby has clearly been low on calories for a long while, listless, blank stare, not much interaction with me. Skin is very scaly, cradle cap that is treated and returns every 3 days, rashes come and go, plastic ID band irritated his leg, psoriasis-looking rash at hairline across forehead, tight mouth/lips. Oral assessment was very difficult due to extreme oral aversion. Upper lip at rest is extremely tight, assessment of tight labial frenulum, poor tongue lift, tight posterior lingual frenulum. Suck assessment is unsuccessful - gaggy, oral aversion. Speech therapy was consulted and concurs with our assessment of extreme oral aversion. Recommended oral stim, pacifier for suck training. Mom has a wonderful milk supply (lots of milk in freezer from NICU stay - hasn't supplemented with this due to fear of dairy sensitivity). Mother pumped milk for supplementation. Feeding assessment notes a terrible suck, baby continues to have a weak suck through letdown - coasting off of her supply. Attempts at tube at breast were infrequently successful throughout day - plan to supplement with at least one ounce of her breast milk with each successful tube at breast (small tummy size probably from low transfer). Two weighted feedings with me - 84 mL transfer (55 mL per tube supp, 106 mL transfer (32 mL per tube supp). Attempts at cup feeding were unsuccessful.
>
> 4/26 morning - weight 4194 gm (no weight gain). Mother reports tube at breast supplementation since I saw her yesterday was only successful for 3-4 feeds total, very small amounts were able to transfer. Three feedings with me - 52 mL, 35 mL (supplement - mom forgot to weigh baby before feeding), and 94 mL (no supp, all from transfer). Plan included weighted feedings for all feeds, supplementation attempts with each feeding, compression during the feedings, increase frequency of feeds to see if we can make up some calories with frequency.
>
> Today, 4/27 morning - weight 4192 gm (no weight gain). Total recorded intake for 24 hours - 18 oz (possible a smidge more since mom forgot to weigh him for one feed). Goal was 25 oz. Discussed more history. Mom mentions baby's paternal uncle (13 years old) has celiac disease. Discussed signs and symptoms of B12 deficiency, cystic fibrosis, mom's and dad's allergies (none) to see if I have missed anything. Mom denies any of the above issues. MD ordered gavage feedings after breastfeeding to make up the difference of intake since baby will not take other methods. Plan for the day includes breastfeeding (weighted), expression of milk for supplementation by gavage feeding to total 3 ounces per feeding. MD ordered blood tests for tomorrow - ammonia, immunoglubulin a, tissue transglutiminase (IGA), TSH, and I asked for a 25 (OH)D to be added. I also talked to mom about having her levels checked.
>
> My questions - calories and quantity are the only things we can really work on here in the hospital. CST, tongue/lip, and assessment of allergies, etc. have to wait until after discharge. I think all this probably started with a poor suck or restrictions from the first days. With mom's huge milk supply, and baby's suck trouble, he probably was scared to feed appropriately. The pediatric hospitalist is only concerned with putting weight on baby... he even suggests mom can go home with NG tube for supplementation. Unfortunately, that does not get to the root of the problem... and my job with her continues for a long time as we figure that out. Any other tests we should run in the hospital? Anyone seen the function of the suck improve with just a healthier baby that is gaining weight? Any other opinions on how to supplement an orally averse baby? Direction on allergy issue? Can all these problems be related and feed the other problems? Sorry, that was even longer than I thought it would be. Thank you for your input!
>
> Trish Wierenga, BSN, RN, IBCLC, LLL leader
>
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