Cathy - Been there, done that, I *hate* these kind of things, which are so
nail-bitingly stressful - feel for you!  Happy Birthday - take this case as
a "coming of age!"

Firstly, it sounds as if your concern is justified - baby with poor skin
tone shutting down and sleeping too long, following inadequate intake and
consequent inadequate output. I'm wondering if there is "brick-dust" urine
too which is always a red flag for me if a baby has already been discharged
from the hospital and the paed is not around to check the baby. What amazes
me is how often parents don't really jump around quickly enough when a baby
is quite obviously not getting enough to eat, perhaps it is some kind of
denial.  How to strike the right note (FEED this baby!) without putting them
into a total panic is tricky.

What you have done so far - "pushing" parents to get the baby to eat
regularly, and urging pumping regularly sounds just right.  Also all the
other little tricks, bedding in, skin to skin etc.  I also agree that urging
feeding by bottle (gasp!) if this is the only way that the baby will take
the milk is appropriate. I find that for cup-feeding to work the baby has to
be at least half-awake.  Sometimes when babies are really not getting enough
they conserve their energy by sleeping and becoming virtually unrouseable.
If this is happening, then stimulation of the 'S' spot with a bottle-teat or
finger can result in the baby sucking and swallowing in his sleep - not
ideal of course, but at least the baby eats.

It will likely be necessary to wait until the baby's nutrition has improved
sufficiently for him to be more awake in order to get him to breast again.
If the mom has flattish nipples, could *this* be another cause of the
screaming and fighting you describe at breast?  That the baby is simply not
able to attach?  I would use a nipple shield as a transitional tool once the
baby is awake enough to be rooting.  Then mom could use breast compression
to keep the milk flowing and the baby drinking, cut down on pumping after it
is obvious that the baby is nursing well, and wean from the shield after
baby has learned what to do.

If mom is able to pump 50 - 60 ml at a time, yet the breasts "are not
engorged" I would not interpret this as meaning that a mom has delayed
lactogenesis, or "not enough milk".   I often find that very large breasts
do *not* seem to become overfull or engorged - I see this as a warning sign
actually - with smaller breasts the mom might be so uncomfortable that she
would pump often, and I assume that larger breasts just have more "room" for
the milk-producing tissue to expand into so the mom may leave it, thus
setting the scene for low production in the second/third weeks.

Sounds like your care-plan is perfect, Cathy.  Your main worry is whether
parents are complying, right?  Document, document, document ....

Best wishes, keep us posted (we're worrying *with* you).

Pamela Morrison IBCLC, Zimbabwe (who sometimes phones paediatricians at home
after-hours if I'm really frantic - they all know I'm neurotic!)