Hi all, thanks to all of you who've said such nice things about our BFHI
practices recently.

However, new case, where insisting on exclusive breastfeeding during
hospital stay has been rather fraught.  Nice, older German mother, first
baby, Caesarean emergency delivery 5 days ago, big healthy 4OOOg baby boy,
"referred" to me on Day 2 postpartum because mother was experiencing
difficulty latching baby.  Entonox during labour (no pethidine) and general
anaesthetic.  Mother thinks lost "a lot of blood", but her haemoglobin is
lO.3, fairly normal.  Has NOT experienced excessive bleeding or passed clots
since delivery.  Breast exam revealed fairly large pendulous breasts, very
flat nipples, and she experienced some breast tenderness during early
pregnancy.  She has scarring on her neck and had surgery some years ago on
her thyroid.  Thyroid levels were checked before she became pregnant and
found to be normal.  We worked on positioning and latching, mother
developing good technique and able to latch baby in football hold. Baby has
normal oral anatomy, good suck.

Day 3 baby starting to become very irritable, bilirubin 12.5, paediatrician
not concerned, mother giving tiny amounts of glucose water (2Oml in previous
24 hours), manual expression of breasts, by mother and me, showed only tiny
"glisten" of milk.

Day 4, no change, except baby becoming lethargic, skin looking crepey, and
mother says baby's cry has changed - from strong and angry - to "like a
little bird".  Baby now receiving expressed droplets of colostrum (about 2O
in 24 hours) and another 2O ml glucose, becoming very difficult to latch
again because he is so impatient and hungry when he IS awake.  Mother
prescribed sulpiride, 5O mg three times daily.  I voice my concerns to
paediatrician who examines baby, tells me that newborn babies in San
Francisco survived a whole week after the earthquake with no nourishment,
THIS baby is nice and big and he is reluctant to order formula supplements
at this point.  Ditto Sister in Charge of postpartum ward, everyone looking
sideways at me because I am supposed to promote BREASTFEEDING!

Day 5, mother and baby discharged, baby weighing 335Og, i e loss of 65Og
which represents 16.25% of his birthweight.  Paediatrician finally discusses
formula supplementation with mother, (soy) but gives no info on how much.
(Don't worry - I have covered this!)

Day 6, follow-up at home today.  Mother looking wonderful.  Baby now being
fed soy supplements by teaspoon, mixed in glass drinking tumbler - this
mother has no bottles at all, she expected to breastfeed.  Baby back again
to bright, healthy, alert and DEMANDING.  However, ANOTHER breast exam
reveals no change.  Mother has good expressing technique, but not able to
express even a glisten of milk today - she is continuing with latching the
baby when he will (now he's either asleep or starving) and stimulating the
breasts several times per day.

My question - WHERE is the milk?  What is the cause of NIL breastmilk
production this length of time after delivery?  I have recommended an office
visit to her gynaecologist (locum delivered the baby) to ask for medical
opinion, request check thyroid levels, ask if there is any way to check for
retained placental fragments; meanwhile continue breast stimulation,
sulpiride, continue unlimited supplements, monitor urine/stool output.

Would anyone care to express an opinion?  Is it possible to test for
retained placenta by blood tests (estradiol, progesterone, anything else? -
if so, what levels would be "normal" during pregnancy, after delivery?).

Pamela, Zimbabwe (where we believe that breastfeeding ALWAYS works!)

P.S.  Adoptive mother (on Logynon) now expressing 60 ml per day and over the
moon!