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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