Parents have given permission to post this case report. The subject line is a reference to the saying that when you hear hoofbeats in Texas, it’s probably not a zebra. Girl born at term, normal birth, baby vigorous at birth despite cord breaking spontaneously at moment of birth and not discovered for several minutes as baby was skin to skin with mother and completely unremarkable clinically. Birthweight 3270 g (7 lb 3 oz) Baby showed no signs of difficulty at any time in the period of observation postpartum, and haemoglobin was checked routinely because of the cord mishap, at 6 hr. It was in lower level of normal range, routine screening pulse oximetry showed over 99% saturation at same time. Baby stayed with mother in line with procedure after normal birth, went to breast and attached spontaneously a half hour after birth, suckled well and settled, had normal color and temperature, slightly rapid respirations. Transferred home at ten hours post partum, home visits by midwife planned for follow up the first three days until peds exam done. Second day of life baby was observed to have rapid respirations, 80 per minute at rest. She was otherwise normal, breathing was not labored, no stridor, but shallow breaths, normal color, no fever, baby awake, alert, feeding on cue, having transitional stools by end of day 2, and no other investigation was deemed necessary. Seemed to be feeding well though mother developed blisters on one nipple, other side fine. Examined by paediatrician on day 3, again according to routine procedure, who found nothing abnormal, no heart murmurs or abnormal breath sounds. Naked weight on day was 3110 g or 6 lb 14 oz, about 5% under birthweight. Stools and urine output normal (generous). Apart from newborn screening blood test (PKU and hypothyroid) no blood tests ordered. Continued to have rapid, shallow, non-labored respirations throughout this time and did not show any other signs of deviation from normal. Over the next days, baby continued to feed well while mother had a few days of painful engorgement, treated with simple home remedies and ensuring effective milk removal by baby. Blisters on nipple resolved as lactogenesis II began, assumed to have come from negative pressure on skin of nipple before milk in abundant supply. Rapid respirations continued at same level as on day 2, continued to be no signs of respiratory distress or infection, only an isolated but unmistakable tachypnea. After the initial engorgement subsided, baby and mother showed signs consistent with moderate oversupply: frequent discomfort from overfull breasts in mother, and baby spluttering, choking, and coming off breast occasionally, generally at time when MER was at its peak. Baby’s stools frequent and almost frothy. Infrequent signs of stomach pains, possible gas, and some spitting up but baby never seemed to have discomfort for more than a couple of minutes at a time and continued to be happy to be at breast. Mother also reported baby ‘vomiting’ and described this as distinct from spitting up. When baby vomited she was at the breast, and would first swallow several times in a row without taking a breath, then pull off, look worried or uncomfortable, and milk would then spew out of her mouth and sometimes nose. After a few moments she would then come back to breast and feed normally, rarely vomiting or spitting up more than once in any given feed, and not doing this at every feed. Mother concentrated on positioning and attachment, emphasizing deep latch to minimize swallowing air even during MER at a full breast. Mother described ‘spitting up’ as what happened if she changed baby’s diaper right after a feed and lifted her legs higher than her belly, or if baby burped without being in upright position for a few moments first. Because of the signs of possible oversupply, mother tried out the complete drainage followed by block feeding method as described by Gonneke, and her discomfort subsided while the feeding features in the baby improved. Due to phenomenally slow mail sorting system in the community care dept in her area, baby had not been seen by public health nurse by day 19 and mother contacted one of her midwives from the birth, at urging from grandparents, because of the continued rapid respirations. Midwife made home visit, did a new haemoglobin test and found Hgb of 14.5 Observed and auscultated baby, did not hear any abnormal sounds but confirmed rapid, shallow respirations and thought this should be investigated. Tried to refer to pediatric service in hospital where baby was born, was told by paediatrician on call that this symptom on its own was not grounds for an acute referral and instructed to send mother to her GP who should evaluate baby and refer to specialist if needed. Mother got appt the following day, GP ausculated heart and breath sounds carefully and slowly, palpated abdomen, found nothing out of the ordinary except the rapid respirations. This being Norway, GP did not have scales in office so baby not weighed. New Hgb level was measured and found to be 14. Infection parameters in blood checked, all normal and this was a formality as baby showed no clinical signs of infection. Due to baby’s age (3 weeks) GP sent referral to the regional center requesting evaluation by a specialist paediatrician. The next day the public health nurse made her first home visit, and when the rapid respirations were pointed out to her, she was also informed that a referral had been made and she assumed the appropriate instance was on the case, took no other action. Weighed baby and found normal gain from lowest weight on day 3, abundant yellow stools and wet diapers every day and baby appeared satisfied in every way. When another week passed with no word from the pediatric service to which baby had been referred, during which the vomiting seemed to increase a bit and baby started showing more signs of discomfort after feeding, and the rapid respirations were unchanged from day 2, the grandparents scared the mother into calling her GP to ask again for evaluation by paediatrician. GP then phoned specialist clinic in hospital and baby was given appt the following day, when she was exactly four weeks old. This appointment seemed to be to humor the anxious mother more than anything else. Saturation monitor applied on arrival, sats in low eighties. Baby awake and content. Echocardiogram seemed to show left ventricular hypoplasia but this was ruled out by a more extensive echocardiogram at center for pediatric cardiology where baby was transferred quickly from the first clinic due to findings. Diagnosis, made by echocardiography, was totally anomalous pulmonary veins. This complication affects one baby in 10 000 and is treated surgically. The diagnosis was made last Wednesday and my amazing little granddaughter is now in intensive care, recovering from her surgery done on Saturday. I couldn’t possibly write this post before she had gotten through the surgery. My daughter and son-in-law were happy to consent to having it posted, in the interests of making people who work with breastfeeding aware of the condition. Children with it usually get picked up when they are much sicker. It is excruciatingly difficult to detect since it does not cause any abnormalites on auscultation and the baby can look great as long as the compensatory mechanisms are still working. When they are no longer able to compensate they deteriorate over the course of a few days to the point where they need emergency surgery to survive. My granddaughter was well-nourished, well-hydrated, and not at all stressed because her basic needs have been met so well by her parents, from the moment she was born right up to when her father handed her over to the anesthetist. (I hope I never see that expression on his face again. But the smiles on our faces when she was brought to ICU following the surgery were just as far on the other end of the spectrum that goes from despair to joy.) She is not out of the woods yet but the biggest wolves have been vanquished and she has fabulous people, in addition to her parents, looking out for her for as long as she’s in there. I’m not one to cry zebra often. But once in a long long while, the hoofbeats you hear in Texas aren’t horses or a cattle stampede, they are a zebra escaped from the zoo. So if your gut tells you that there is something wrong, and it won’t leave you alone, please respect yourself enough to get it investigated before calling it a horse. I hesitated to make my daughter anxious but the bottom line was, I was anxious and my husband even more so. Our concerns, as put to our daughter’s health care providers, were heard in time. But it’s scary that it was all down to us because there IS no planned contact between newborns and the health services besides the visit from the public health nurse, who comes on ONE home visit, theoretically within two days after family are discharged from hospital. <http://ammehjelpen.no/paamelding-fagseminar-2011?id=1132> *********************************************** Archives: http://community.lsoft.com/archives/LACTNET.html To reach list owners: [log in to unmask] Mail all list management commands to: [log in to unmask] COMMANDS: 1. To temporarily stop your subscription write in the body of an email: set lactnet nomail 2. To start it again: set lactnet mail 3. To unsubscribe: unsubscribe lactnet 4. To get a comprehensive list of rules and directions: get lactnet welcome