i posted recently about the "good news" client who went on to breastfeed
despite her doctor and hospital staff nurses having never heard of rusty pipe
syndrome. this client now is having recurring plugged ducts, and i went to
see her today. of course my most burning question was "how did your doctor
react to the information about that" as i had given her a copy of the info
from lawrence.

she told me that he had gone around asking various people about it, and then
told her to just go ahead and nurse. he is a much older ob/gyn in solo
practice (no partners, how amazing) who doesn't even do ultrasounds. i was
greatly heartened that he would act on this information and just not dismiss
it out of hand.

when i went to see her today she was feeling really discouraged about the
plugged ducts, but was adamant that she wanted to breastfeed and partly
because she watched the 20/20 show the other night! (i didn't see it myself)
i also gave her a sling, something i offer to all of my clients, and she was
absolutely thrilled. she commented over and over about "all those babies on
the show in the sling with their mothers."

i know we can get her plugged ducts fixed, and i foresee a long breastfeeding
relationship for her "snatched from the altar of ignorance."

the interesting case is another one that i am looking for suggestions about.
i am particularly interested in knowing what type of workup to suggest next.
its complicated but i am not wanting to overlook the possibility of a
physical cause.

mother called me a about six weeks ago. her second baby (older son breastfed
successfully, no problems) had gone for his six month checkup and the weight
was only a couple of ounces above the last weight at the four month well
check (around 14 lbs.) the doctor, duly alarmed, ordered the mom to come back
for another weight check in a week, and did a workup including testing for
cystic fibrosis, zinc absorption, etc. all results negative. mother was
exclusively breastfeeding at this point, and when she returned for another
weight check a week later, the dr. told her to supplement or she would
hospitalize the baby. the mother got the impression that the zinc absoption
test covered all malabsorption problems.

mom called me at that point, and i saw her. the baby has reflux, which the
ped. had not wanted to treat because one of her children had had reflux and
did not have any problems and didn't need drugs, so therefore this baby did
not need drugs either. when i saw the baby i saw that he nursed poorly,
pulling off frequently, and exhibiting a lot of typical reflux nursing baby
stuff. (in fact, the mother had forgotten to tell me about the reflux until i
said after watching him, i think he has reflux, let's talk to the doctor
about treatment for it).

you can now see that the mother is a bit unusual and this is part of the
story. the baby had obviously had been having some level of difficulty
feeding from the beginning, and the mother did not understand how this
affected him. his weight gain was acceptable to his doctor until four months,
although i considered it marginal myself (he had a high birthweight, don't
have it here in front of me). the mother reported that he had intermittent
excessive spitting up and has had green, mucousy stools about 75% of the time
since birth.

the mother also reports that she has some unnamed condition that causes her
to not absorb cholesterol, and that her diet is extremely high in
cholesterol, but her levels are very low, and that this is familial.

when watching this pair i saw that the mother put the baby on and took the
baby off frequently, and after a very short time, during which the baby did
very little nutritive sucking, she pronounced him done with his feeding. she
complained that he was overtired and unable to sleep. it appears that at
about four months she decided that this already poorly feeding baby was old
enough to sleep for long periods of time and to go for long periods of time
between feedings, and she began to work towards this type of schedule.

it seems to me that what happened here is that a baby who previously was
managing a marginal weight gain by frequent nursing was suddenly limited at
the breast, so his weight gain stalled out. he looked terrible, too. the
mother did not understand that he needed lengthy feeds, and did not know that
he wasn't getting much, and interpreted what was a desperate need to eat as
being overtired.

i discussed things with her at length, and encouraged her to nurse him
constantly and get rid of the pacifier. i assured her that if she could get
him gaining, the doctor might reconsider the need for hospitalization. i
encouraged her to offer solid foods, which she had not been doing despite the
baby giving plain signals that he was ready. .

she went home, i sent the doctor a report, and then she called me frequently
over the next few days (of course she came over on a friday). by the time
five days had passed i began to see a clear pattern of this mother giving
conflicting accounts of what was going on, and of not complying with any of
the treatment suggestions . i began to think that this was not a physical
problem, but an emotional one on the part of the mother.

i convinced the mother to consider hospitalization by telling her that at
least if she agreed, they could do a workup for the reflux and get him
treated, which might make him a better feeder at the breast. she agreed, the
doctor hospitalized the baby at a large hospital specializing in treating
children (no more discreet way of putting this), and they did an upper GI
only, prescribed for the reflux, observed a couple of feedings, did test
weighings (different nurses did them differently at each feeding), the
nutritionist said the mom was indeed producing enough milk for the baby to
gain, and THAT WAS IT.

i am rather baffled about this, especially since i was there one afternoon
when the doctor came to visit, and the parents were trying to give the baby
the pacifier and get him to go to sleep in the crib when he obviously wanted
to nurse. i discussed this with the doctor. no family psychology workup, no
discussion by the staff LCs or nutritionists on ideas such as no pacifier,
introducing solids, etc. they claimed he had a weight gain that was adequate
and sent him home.

the mother went back to the clinic a week later and he was weighed again and
they told her he had gained "3 - 5 ounces per day" but even the mother knew
this was not realistic. she then took him back to the peds office this week
for another check, and his weight was only marginally above what it was
before the hospitalization. she claims to have started solid foods, and i
encouraged her to use more high fat foods (you have to envision that i talk
about these things many times with her).

early on i suggested pumping and giving him bottles of EHM or giving him
formula, (you know this shows how desperate i was to feed this baby) but she
reported that he had had an early experience with a bottle of ABM that caused
him extreme distress, so she had not wanted to try ABM again. upon my
suggesting this, she claimed to have tried several bottles of EHM, given to
him by her and other persons, but that he refused them all.

so you can see that i think this is not a "failure to thrive" but a "failure
to feed." however, since there are a couple of unusual factors here, such as
the unusual stools and the mom's claimed malabsorption problem, i don't want
to rule out the unusual. she is having a struggle with the baby over feeding
solids, she wants to feed him and he wants to feed himself, and i am not
convincing her this is a good thing ("but it takes him too long and he
doesn't eat enough"), so he should be gaining, right? but so far he isn't,
and i am going to get the exact recent weights to review tomorrow, but i
still think maybe there should be an evaluation of something else. the
problem is, what else?

i kind of think a pediatric gastroenterologist, whom they have not seen yet,
might shed some light on thing to rule out or test for. anyone have any ideas
of what should be next, though? although there are some real difficulties
with the family environment, i do not want to rule out a physical
contributing factor without more evidence. please copy me by private email,
too.

her regular ped. had to take an emergency leave, so she is kind of left in
limbo by everyone except me (her calls to the hospital clinic have been
answered with "we can't find your chart" and "the doctor will call you back"
except she never does). i intend to get her over here or better yet to get to
her house this week to observe more feedings, including solid foods. once
upon a time long ago i recall seeing a film about evaluating FTT children and
observing feedings and parent/child interactions. maybe i can resurrect my
memories of that and make some suggestions. he still needs to be fed.

carol brussel IBCLC

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