A puzzling case has been referred to me three weeks ago and no answers have
been found yet so I am turning to the experts for some more ideas on
evaluating/resolving.
This mother is 27,  history with 1st is not unusual -induction due to
preeclampsia, 37 weeks, no milk supply developed when baby was hospitalized
beyond mother's stay and mother expressed with a Gen... Exp... for two weeks,
no engorgement, not more than drops expressed. Baby 1 never put to breast
-"showed no interest". Breasts show marked asymmetry but appears to have
abundant glandular tissue on one side. No maternal history of hormonal or
thyroid imbalance. Menstrual cycles normal.
This baby ,number 2, was also delivered early, at 38 wk gest, no induction,
blood pressure was high and an induction was scheduled but baby came first.
She did not take meds for bp but during labor after her epidural, BP dropped
"dramatically" and med was used to help stabilize. Her ob does not have the
hospital records yet and no one can tell me numbers or meds used for bp
dropping (could be a factor? Sheehan's?). I am going to pursue this as a
factor and hope to get  more info next week.
After baby 2, I saw the mother at 4 days ppm .Baby had been "going to breast"
but was very yellow and lethargic. My guess 15+ bili. At our observed feeding
the baby attached well but had no audible swallows. Test weigh showed 4 cc in
20+ min. Baby was 10% below birthweight with minimal output. I consulted with
the pediatrician who I work well with and does not treat for jaundice. We
agreed that supplimentation was appropriate and began finger feeding with a
syringe and expressing with a hospital grade pump. At 6 days, baby was taking
30-45 cc of formula, jaundice was resolving, output improved, and mother was
only expressing 4-6 cc total if she fingerfed and missed a feeding or
expressed after a feeding.
At this point we tried switch nursing, some herbal therapy (fenugreek),
improved diet, continued expressing, continued supplimenting. No signs of
engorgment at any time.
At day 10 she was back in the office for a reevaluation and the baby showed
appropriate gain, good color, alert behavior, and only 6 cc in a 20 min feed
per the test weigh scale. Feeding at this point included alert, vigorous
sucking at breast for 30-50 min ("baby loves breast") followed with
supplimentation and expressing. Milk yield still max 8 cc total. We switched
to a large glass flange for a trial, began Reglan qid, limited feeding to 10
min perside (mom getting pooped out), continued supplimentation and
expressing after feeding. Sent mom home with test scale to get 48 hr
evaluation. Still baby takes max 10 cc at one night feeding 4-6 rest of day.
On day 14 baby reached birth weight (+1 oz), ped. encourages mom to continue
"any amount of milk no matter how small is good for your baby"- nice words of
encouragement.
After one week on Reglan no change observed in supply, breast tissue, infant
intake. Her OB ordered a prolactin and thyroid test. Thyroid came back in
normal range. Prolactin showed baseline of 18 and post feed of 186. Ob
considers that normal but my understanding is that a baseline at 2.5 weeks
ppm should be higher? We began with a SNS at day 17. Today(day23) with Test
weighs baby showed 15 cc at one feeding which is 5x original levels but baby
is now taking 2-3 oz in SNS. Feeding frequency has remained consistant
q2-3hrs.
This mom seems very complient and keeps track of feeding times and output.
She has understood my course of treatment, beginning with the most simple
solution to evaluating the unusual. I have wanted to give each possible
solution a few days before revaluating. Any other suggestions?
                                           Debby Kearney IBCLC
                          Private Practice in rainy Florida. We do have that
once in a while!