Thank you dear teachers for your guidance and advices.

Just to share from my follow up visit yesterday with mom after 6 days from my first visit on 5th May. Mom had taken baby to see a pedeatrican that night itself and was told to supplement with 2oz of moms EBM after every feed while following the BF plan that I had suggested to mom.

On Monday, May 9th, mom had a follow up visit again and baby had only gained 30grams in weight (birth weight on 16AApril was 3.01kgs, weight on 5th May was 2.65kg, weight on 9th May was 2.95kgs. That is like an average of 5g a day!) and the doctor had suggested to supplement with formula and was also told to refer to a Dietican in the Gov Hospital to get another "special formula" that will help baby to get extra calories. Apparently the formula given by the doctor only will help with 30 calories per feed while the formula given by the dietican will help with another 30more calories in total per feed.

My visit yesterday, baby was giving good diaper outputs (very heavy clear wet diapers, with at least 1 mustard seedy like soiled diaper per day) - this is prior to being supplemented with formula. This time, I had observed baby at the breast and it took baby about 15min from start to finish (unlatched by herself) and then mom gave her the supplementation. At this point, mom was telling me that she is unable to get a good amount of EBM per session after starting on the BF plan to feed every 2 hrs. Mom says that the most she can get now is about 0.5oz (with pump + hand compression) from one breast in 3-4 pumping sessions. But because of the frequent and narrow feeding intervals, mom sometimes is just too tired and unable to pump in time and she is finding pumping on the other breast while feeding on the other is a hassle as baby is really wriggly!

Baby is still very fussy at the right breast and mom says that baby does take the right breast but normally after a lot of persuasion and crying. However, baby is ok with the left side and normally will be more compliant to take the right side after a feed on the left. No signs of torticollis (also verified by the pedeatrican - I told mom to ask the doctor for an evaluation on the first visit itself)

So now mom is supplementing each feed with the formula (at about 1-2oz all with syringe feed. No bottles were introduced from day 1) after each feed at the breast and the pedeatrican's next visit will be this Thursday (4days after their 2nd visit on Monday) and if this time, baby is still not showing signs of a good weight gain then baby would need to be admitted to the Gov Hospital for monitored feeds. This is stressing the mom out now.

Baby is showing signs of alert quietness after the feed and will fall asleep by herself after that on mom's chest. 

The thing is, if the diaper output is good and there is no signs of dehydration (I'm seeing moist eyes and a pink moist tongue) how is it that baby is not able to gain any weight? 

Could it be a physiological or metabolic disorder? 

Mom does not have an overactive letdown as there were no signs of baby choking and gagging at the breast during the observed feed.

I feel really bad for not being able to be of any more assistance for mom and the sight of a emaciated baby really gets to you emotionally. (baby is so tiny and left with skin and bones!) I could not help myself but to shed tears after I had finished my visit. 

The methods that dear teachers (both personal emails and on Listserv) had suggested are indeed very much appreciated, however I think with my level of understanding and knowledge (Lactation Educator Counselor) I am afraid that I am lacking of the skills that an IBCLC will have and it could be due to this that I am not able to help mom better without having to resort to formula supplementation. I am the only one in the country who has a "proper" lactation specific education (there are no IBCLCs here in my country), and thus my only reference are to you teachers.

I am following up with the dyad progress and I do hope that they do not have to end up in the hospital come Thursday.

Thank you dear teachers for your generous guidance/advise and never ending support :)

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