Thank you Laurie! I don't think you're picking the post apart at all. The
more feedback the better. At this point I correspond with the parents at
least 10 times a day (they call, text or email with questions almost
constantly) and have seen the baby 3 times. I observed a very good latch
each time, textbook good. Her nipples are now everted and very elastic.
Perhaps they were more flat at birth and nursing/pumping has drawn them out
more in the week between birth and when I first saw the patient. In doing
pre- and post-weights she in transferring on average 2 to 2 1/2 ounces
(sometimes more in the morning) and then getting a 1/2 ounce to 2 ounce
supplement shortly after a nursing session. Parents recently bought a scale
and have been doing pre and post weights as well. Right now the infant's
intake is around 40 ounces a day. Nursing an average of 10-12 times a day,
6-8 supplements a day after feeding (although in the last 48 hours she has
been cluster feeding quite a bit so the parents have begun to lose count).

Mom is only pumping right after nursing. In the morning she will usually
yield closer to 2 ounces in a pumping session directly after a feed in the
evenings closer to only 1/2 ounce. This seems fairly normal to me
considering how long the infant is nursing and that she is only pumping
after nursing sessions. After 2 nights of cluster feeding on the 3rd night
she was able to pump 4 ounces after a nursing session so at the very least
all that sucking is paying off in terms of building a supply.

I initially recommended a SNS but the parents ultimately decided not to get
one and after doing pre and post weights multiple times I don't see the
need for one at this time. I agree with the parents assessment and have
witnessed the behavior multiple times myself. The infant's stomach is very
hard and distended. The 4 times she has had a bowel movement she was a new
baby for the 24 hour period afterwards. She was content, no crying except
for wet diapers and very alert. As the days progress with no bowel
movements it is clear she is increasingly uncomfortable and unhappy.



Take Care,

*Alicia C. Simpson MS, RD, IBCLC, LD*
Maternal and Pediatric Dietitian
International Board Certified Lactation Consultant
Main Office: 1164 North Highland Ave, Atlanta, GA 30306
*Now serving patients at our new offices in Alpharetta/Roswell *
Phone: 678-607-6052
Fax: 770-909-1402
Email: [log in to unmask]
*www.peapodnutrition.org <http://www.peapodnutrition.org>*


On Tue, Aug 26, 2014 at 9:56 PM, Laurie Wheeler <[log in to unmask]> wrote:

> Hi Alicia,
>
> I am playing devil's advocate, as they say, and just maybe the original LC
> saw that the baby was not actually latched effectively and therefore
> suggested the shield. (I do realize nipple shields can be and often are
> overused and not needed). I had a family today with a non-latching infant
> who said to me that the baby latched earlier very well but only a few
> seconds and was making loud smack smack noises. To them the baby had a
> great latch.
>
> Your client may have interpreted that the nipple shield caused more
> problems because w/o it the baby again could not latch. ???
> The mother had delayed LII til day 8, so maybe the original LC did see
> some anatomical or other problems and felt she should give mom some
> anticipatory guidance. Again ??? not sure.
>
> The infant is gaining on the low side 1/3 oz per day even with some (you
> say minimal) formula supplementation and 1/2 to 2 oz ebm after each
> feeding. This seems to point to ineffective milk transfer. One thing that
> could be tried if the infant is resistant to the bottle supplements, would
> be a lactation aid at the breast.
>
> You also say the "infant also has a very high suck need sucking nearly
> constantly. I believe the high suck need is due to the fact that the infant
> is not passing stools." Here are 2 red flags, usually pointing to
> insufficient calories/volume, although it is not out of the realm of normal
> (I think) for babies to go one good poop a week, large and soft, after
> usually 4 to 6 wks but 3 wks maybe, *provided they are gaining weight well
> and content.*
>
>  You say the pre/post weights show more than appropriate intake, I wonder
> exactly what the intake is. What did the baby weigh at birth and what catch
> up growth might still be needed? I said in a recent lactnet post that a
> baby may get a 2 oz feeding but only get that 6 or 7 times a day, taking
> only 12 or 14 oz / 24 hrs or even 16 oz in 8 feeds, which is not enough. I
> definitely have seen babies wetting diapers plenty but not pooping and
> virtually all of them are not getting sufficient calories for growth, but
> are hydrated.
>
> Other comments that are red flags to me for infant hunger and insufficient
> intake: "after nursing 40 minutes the infant took a 2 oz bottle" ... "this
> is well over her stomach capacity". "should have either spit up or passed a
> bowel movement when being overfed"...."she made a gurgling sound as if
> the milk was stuck in her esophagus".
> I am thinking here that the milk transfer  is very low, that the parents
> believe she should only be taking maybe 2 oz per feeding, that she is being
> overfed, and that her stomach gurgling is a medical problem. Certainly
> there could be absorption problems if the child is being given sufficient
> volumes and frequency of feeds but still not gaining, but I think this is a
> horse and not a zebra problem, if you know what I mean. Is her tummy soft
> and not distended?, I'm guessing it's fine in that she has been checked by
> her doctor a few times. Not sure if parents describe "fussy, gassy, and
> sucking hands alot, constipated" but that is a very typical description in
> my experience for a hungry baby and not a tummy problem baby.
>
> I am also guessing that mother's milk production might be somewhat low, as
> I am not sure if she is expressing just the 1/2 oz at some sessions. I hope
> you don't feel I am picking your post apart, as that is not my intention,
> just trying to address each point, and before some major investigations,
> tests, or referrals are done for this infant, to first maximize the baby's
> intake, very generously, the baby could take 4 or 5 oz even, and see what
> the results would be.
>
> Laurie Wheeler RN MN IBCLC
> MISSISSIPPI USA
>
>
>

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