Debbie
Hi Debbie

This is an intriguing case history.... but the piece of the puzzle 
missing for me is what the baby's actual weights are.  You say 
"Weight gains are good", but I still want to know what they are..... 
ie what this baby weighed at birth, now, and at any intervening 
weight checks before I could hazard a guess at what is going on with him :-).

Pamela Morrison IBCLC
Rustington, England
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Date:    Sun, 15 Mar 2015 13:18:32 +1100
From:    Debbie Dixon <[log in to unmask]>
Subject: JAUNDICE

Hi all
It is interesting this discussion has just started, as only this week 
I have had a client with a 6 week old baby who has unresolved 
jaundice. I wanted to post here to get some responses from other 
practitioners here. She is understandably very concerned & thinks 
something is wrong with him.
PTPMy first communication with her was when baby was 10 days old & 
she rang to enquire re my services as she "couldn't get the 
attachment right" and felt very clumsy handling him. He is her first 
baby. She booked an appointment with me and then cancelled it the 
next day, saying she had decided to wait a few weeks "to take more 
time to get more comfortable with what she is doing". I checked in 
with her once over those few weeks and she said he was very unsettled 
and wanted to be close to her for the last few days. She thought 
feeds had improved a lot though and that she didn't want an 
appointment yet. I said to call anytime when she wanted to go ahead.
She contacted me about 10 days after this and wanted an appointment, 
as baby was extremely sleepy and wouldn't stay awake long enough to 
feed properly. She had tried all the usual ways to wake him up but 
they don't last long.
Baby was born by planned C-Section at 38+4 weeks due to a breech 
presentation. Mother and baby were both well at birth. Pregnancy was 
good (no medical problems). She had immediate STS contact & early 
breastfeeds which continued 3-4/24 over 1st week. Mum says he has 
always been sleepy and was jaundiced from birth (but there was no 
concern about this from doctors or midwives in the hospital or on 
early post-natal midwife visits).  Weight gains have been good - no 
concern (and has seen GP and midwife several times since birth).
Cues normally to feed, looks interested initially, searches for 
breast, will attach, but then doesn't maintain the interest in the 
feed. I do not notice the normal sucking pattern & don't think the 
attachment is good (but have been working with her on ways to 
optimise that). I found him fairly lethargic (and noticeably 
jaundiced, but appears mostly on head) and only attaches for a few 
minutes and then just nibbles or goes to sleep. Mum is needing to 
wake him for feeds and has started expressing with an electric pump 
now to maintain supply, and is feeding him top -ups in bottle. She 
thinks he's getting "nothing" from the breast directly.  She thinks 
his nappies have not been as heavy as they were, but they are not 
concentrated, and the dirty nappies are loose yellow & are at every feed.
She is seeing her child health nurse this week coming for a 6 week 
baby check and vaccinations and the doctor for her post-natal check. 
The doctor she saw this week (when baby was lethargic & not feeding 
well) said all was OK but they wanted to check bilirubin levels this week.
I have suggested she offer both breasts, waking baby every 3 hours if 
not waking, then to feed previously expressed milk  by a bottle (as 
that was what she had been doing, and she is very anxious & stressed, 
and I don't think she can handle any other feeding methods, and is 
probably best left with the bottle just for now). Then she would 
express (both breasts) with electric pump. I said to do this 
intensively over the weekend and we can reassess this early in the week.
Does this sound like an extended jaundice (breast milk jaundice or 
non-breatsfeeding jaundice, or both)?
Does anyone use any methods to get baby awake enough to feed at 
breast, or is this not likely to happen until the bilirubin levels go 
down (as I feel sure this is at the bottom of the problem). Would an 
at-breast supplementer be useful, or pointless with a baby not 
staying awake to actively suck? Or could you deliver the milk faster 
to stimulate him to wake up and swallow? Of course, I have encouraged 
her to keep in close touch with the GP and child health nurse (and to 
have the bilirubin testing done).
Thank you for any suggestions.
Debbie Dixon IBCLCDUBBOAUSTRALIA


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