Hi All,

I had an alarming consultation on Friday evening which is still in the
works, but I wanted to hear from some of you as to what I should do next
time this happens, as I'm sure it will.  My Friday night 5:30PM consultation
was a 5-day-old homebirthed boy who was being seen for weight loss and lack
of stooling.  When I heard the staff member talking to the parent on the
phone, who said it hadn't stooled since d1, I said, "I don't want to see him
until he sees a doctor."  Then the staffer talked a little longer and the
parents reassured her that he had stooled daily, so I agreed to see them. 
The parent hadn't specified that the stools were really only skid marks and
were still meconium on d5 -- it wasn't that they were trying to withhold or
alter information, it's more like they didn't know what to expect so they
thought this was normal.

The color of this baby was unnerving to say the least, but not as unnerving
as seeing him undressed to a diaper.  His skin and eyes were dark yellow,
his skin hung off his thin little bony arms and legs, and I felt his little
pelvic bones poking through his diaper.  He was 6# 12oz at birth and was 6#
1oz five days later when I saw him.  I kept poking his bony little legs
trying to see if the jaundice was down to his legs (meaning a count of over
20, from what I recall) but there was nothing to poke into, it was just bone
and muscles that felt like beef jerky.

The parents said they were unable to wake him for a feeding for the past six
hours but that he cried and slept on and off during the 60-minute drive from
their home.  He woke up, cried very weakly, but was aware and very
responsive when I held and talked to him (whew!).  Mom's nipples were all
scabs but she said they didn't bother her in the least compared with the
extensive tearing she had when she pushed him out.  She refused to take any
medication whatsoever for pain so she could hardly move without making a face.

I helped the baby get latched on and he did so very eagerly, with surprising
strength in this little scrawny body.  He sucked eagerly for 15 minutes on
the breast mom said felt like it had milk in it, while the mom and I tried
using breast compression to help him.  Baby transferred .1 ounce in 15
minutes -- eeeek!  We had asked the parents to bring formula just in case,
so they mixed a bottle, which was his first supplement ever.

Here is my first question: When do you (LC) refuse to feed a baby because it
is so malnourished, unless you have a HCP's OK?  Isn't there a risk to
feeding if it has been extremely undernourished for a period of time?  I've
been re-reading my lactation textbooks and I can't find any guidelines or
explanation.

We ended up giving him (very slowly, using paced bottle feeding) a total of
two ounces over 30 minutes.  I would have preferred not giving him so much
in his first "real meal" but he didn't even burp.  He dozed off happily and
was still responsive as we carried him around, dressed him, and so on, so I
know he wasn't "passed out."

Here is my next question:  Where can a family get a baby's bilirubin checked
at 7:00 on a Friday night?  Doctors' offices and urgent care were already
closed, so the only facility open was of course the ER.  I gave the parents
directions to the nearest hospital (which, BTW, is known for its wonderful
pediatric ER) to get a bili count before heading home, because I was so
concerned about it continuing to rise and lead to complications.

The dad told me the next day that the head nurse chewed them up one side and
down the other for "bringing a newborn to a place full of sick people."  She
declared that the baby's heart rate, blood pressure, temperature, and oxygen
levels were all within normal range and that they were negligent for
bringing him there.  What other options were there?!?!?

Now on to the final question, and I'll try to make this as brief as
possible.  Where's the milk?  The mom, age 38, is obviously producing very
little milk, but she said she produced plenty of colostrum on the first few
days.  She fed the little guy constantly, day and night, so everything
should have fallen into place.  I know adrenaline can block oxytocin, but
could her pain from the birth injuries restrict her milk that much?

Background: She developed just like her sisters during puberty: maybe an A
cup.  She got silicone implants through axillary incision about 16 years
ago, but she says she has lots of sensation in her areolae.  She was a
bodybuilder from ages 19 to 22, during which time her cycle was very
irregular (I didn't ask if she took steroids).  She said her hormones and
cycle were "really screwed up" until she was 35, when she used dong quai,
vitex, and progesterone cream to normalize them.  When she decided to get
pregnant, she had no problem conceiving.  She reports having a dream
pregnancy with no complications whatsoever, except her breasts did not
change at all.  She noted her L breast became hard and painful on d3 but
quickly went away 1.5d later; R breast seems completely inactive.  She had
2" long hair growing on and between her breasts (and she's Caucasian!).  She
was not overweight at all, even after pregnancy.  Her lochia was bright red
as of Friday night but she said as of yesterday it was much less and getting
darker, so she suspected she may have been tearing her stitches when trying
to do too much.

Right now baby is getting hoers d'oeurves at the breast while they fix him a
few ounces of formula, then mom tries pumping both for added stimulation. 
She's starting herbal and/or prescription galactogogues ASAP, which I hope
kick in strongly because they despise formula.  I suggested she have her
thyroid checked and talk to her midwife about the possibility of a retained
placenta.  I also reassured her that most pain medications do not affect
baby, and it's important that she is comfortable so she can be a good mommy. 

Any ideas/suggestions?

Thanks in advance for reading this far, and for any wisdom you can share :)

Debbie Gillespie, IBCLC
Sunny Warm Tempe, AZ

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