I am trying to help a mom whose 6 week old (today) baby vomits once or twice after every nursing. 
Her pediatrician suspected pyloric stenosis and admitted him to a teaching hospital.
Her baby has been hospitalized 5 days, and he has not gained any weight. 
Previously he gained about 10 oz in 5 weeks (if you calculate a theoretical low as birth weight - 
7%) 
He was given IV fluids while he was made to fast 11 hours for an ultrasound- it did not confirm 
pyloric stenosis. A barium swallow after a 3 hour fast indicated reflux. He has been on an acid 
reducer and Reglan for three days. No change in weight. No change in vomiting except one 
nursing at night is now free of the usual vomiting. The hospital physicians wasted two days 
focusing on the mothers milk production making her pump and bottlefeed to prove her 
production was not the problem. One actually hypothesized the baby was being overfed.
Attending Physician wants to move to exclusive formula feeding with cereal.

Mother at my urging has requested to see pediatric gastroenterologist. I would like an Allergist/
Immunologist and maybe neurologist called to consult but attending is saying one thing at a time. 
Attending just ordered a clean catch urinalysis today. Mother was told blood tests (whatever they 
were ) were normal. Stool samples have been taken on two ocassions to check for undigested 
lactose, luckily we haven't heard back about that except to say there was no blood in stool. I was 
worried that perhaps the baby's stool would show undigested lactose because the baby seems to 
be digesting the whey fraction and just vomiting up curd. He is staying well hydrated and vigorous 
but his body looks wasting...it's as if he is compensating for throwing up the curd by nursing very 
frequently so he can at least get more of the whey fraction...I was concerned there might be a little 
undigested lactose simply because he is consuming so much of it. I know I'm going out on a limb 
here but the vomit never has the look of fresh milk as it often does with a baby who is a happy 
spitter..it is always very cheesy almost dry looking...the mother and grandmother and 
greatgrandmother all report they can't drink whole milk, only skim...and they describe themselves 
as having stomachs that are quick to throw up...mother reports her own mother tried out every 
available formula on her as a baby looking for one she could keep down...

Is this malabsorption? What kind of specialists should the mother request? What tests? She is 
nineteen and I feel like the general pediatricians want to hang onto this for educational purposes...

Thanks for any help you can give,
Jen

Background if you need more info:
On day 3 and 4 mom experiences engorgement.
On the 6th day she was told to formula-feed for 24 hours because the baby's billi was 17.
Day 7 she resumed exclusive breastfeeding immediately after the 24 hours were up, but she had 
not pumped during the 24 hours because no one told her she should.

At two weeks of age the baby weighed 7 lbs 4 0z. His birth weight was 7 lbs 8 oz.
The pediatrician instructed  the mom to supplement with formula 8-10 oz per day but the baby 
actually lost another ounce over the next 3-4 days. 

At 2 1/2 weeks the pediatrician switched the formula  at which time the baby resumed gaining 
weight at the same pace he was when he was exclusively breastfeeding.  The pediatrician office 
asked me to see the mom when the baby was 5 1/2  weeks old. 

I was not told by the office that the baby was vomiting and I'm not sure if the pediatrician was 
aware of the problem. My impression was they wanted me to help the mom get back to exclusive 
breastfeeding. 

At the visit I weighed the baby and found him to be a little over 7 lbs 10oz.
He looked a little yellow to me but sclera were white.
He had no buccal fat or fat anywhere but he was vigorous and alert as she offered the breast and 
the mom leaked profusely in anticipation of latching him on. She had longish nipples and he 
latched deeply with ease. She nursed him until he fell asleep on one breast and then offered the 
second side which he roused enough to take until he dropped off the second side in about 10 
minutes.

During the nursing she told me he had 4-5 bowel movements a day with one copious enough to 
overflow his diaper. Most were mustard yellow but some green, and he had normal urinations. She 
told me once he was started back on formula at two weeks he began vomiting. She said he spits 
up after every feeding whether at the breast or bottle but more after bottlefeeding. She said she 
never exceeded the doctors advise of 8-10 oz of supplement per day.

 About 10 minutes later after I was finished taking her history and listening to her describe her 
breastfeeding experience she sat him up and he promptly vomited. This was about 40 minutes 
after the initial latch. We weighed him and he had retained 40 grams. As she lifted him from the 
scale he vomited again this time on his clothes so we did not weigh him a third time.

She took the scale home with her and I called the pediatrician's office to tell them about the 
vomiting and to preliminarly report that the mother had a good supply especially in light of all the 
supplementation, and that I thought if she had in fact an undersupply I thought it would be 
recoverable, but I would like them to see the baby about the vomiting the following day. They 
agreed to let the mother try a return to exclusive breastfeeding.

I spoke to the mother in the evening and the baby was consistently ingesting about 40 grams per 
nursing though he could not keep it down. She nursed him about every hour and a half except for 
one three hour stretch at night.

The next day, a Friday, at the pediatrician's office the baby had lost an ounce over the last two 
days according to their scales. The pediatrician was comfortable with the baby exclusively 
breastfeeding through the weekend, and he did not prescribe reflux medication.

 I visited the mother in her home that evening and observed a breastfeeding followed by two 
episodes of vomiting. They were both preceeded by sharp cries of pain.The next day with the baby 
still vomiting after more than 24 hours off formula and his general appearance being so poor and 
the advent of pain immediately prior to the vomiting, I phoned the pediatricians office and they in 
turn contacted pediatrician and he in turn alerted the local children's ER that he was sending in a 
baby with suspected pyloric stenosis. (I never saw projectile vomiting and I never got to speak with 
the pediatrician- everything I reported was relayed through a third party.

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