I have been an advocate for LCs not having to be RNs, mostly because we are
dealing with breastfeeding issues and expect the others to be dealing with
the other health issues of the baby.
Also, though I am an RN, I am NOT an NICU nurse, nor am I listening to
baby's hearts and lungs often enough to know what is normal or what is not.
Now I have a situation that has me very worried, but I don't know if it's
my imagination, is this really normal and I hadn't seen it before, never
noticed it before (I doubt it) or should I keep pushing this mom to get a
FOURTH opinion???
(Wednesday )I called her as part of our LacTrack system and the mom said
she was a bit worried, her baby was 8 days old, wetting > 4 diapers at day
3 and had 2 yellow stools, but he was "getting yellow", being difficult to
awaken, and would only stay at the breast for a short time. I decided to
make a home visit and found a baby who was born at 6lbs 3 ounces now
weighed (naked) 6 lbs 8 ounces. His jaundice did not appear to be very far
progressed, he was difficult to awaken, and as he had just eaten we were
unable to get a good feed. I did see a tight frenulum, but mother reported
no pain when breastfeeding. Intake was only .2 oz, but as I was actually
concentrating on teaching her the football hold to get more breast deeply
in the mouth (breasts were full but not hard, baby easily drew in plenty of
tissue), rather than observe a feeding as he was really sleepy, and the
weight gain made me less concerned about the small intake. I did note very
fast respirations, and I asked mom about this. She said she had taken the
baby to the ER at day 3 and again called the MD and was taking him for a
checkup tomorrow.
(Thursday) Next day, baby was seen by MD (third), he said the fast
respirations were normal, not to worry, babies do this. Weight (on his
scale) was 6 lbs 6 oz.
Yesterday, as it was a Friday before a 3-day holiday, I decided to check up
even though MD had seen her the day before, so after calling and getting
the same report: very short feeds, > 6 wet, > 4 stools in 24 hours. Weight
( on MY scale, totally naked) was up to 6 lbs. 11.8 oz. I observed a feed:
Baby would latch on pretty well, suck erratically, some swallows heard.
Then he let go, respirations, which were getting faster and faster during
the feed were now at 80 per minute (I counted the full minute, not just
counted for 10 seconds and multiply). No signs of flaring of the nostrils
or chest retractions, no signs of nose stuffiness. He would let go of the
breast, start mouth breathing for 15 minutes or so, then go to nose
breathing and the respirations would slow down to about 60. Never did I
see any signs of blueness to lips, fingers, mouth, etc. Intake was .3 oz.
How emergent is this? Am I being excessively concerned? It's just not
something I've ever seen. Baby is gaining weight, mom is feeding often in
these short spurts, but he seem to not be able to stay at the breast
because he chooses to breathe through his mouth instead of eat (bright
baby!).
I discussed the case with my supervisor who recommended I tell the mom to
keep bugging the doctors. Mom is a nurse (thank goodness) and has friends
in the local hospital NICU that she said she'd take to them for a check
today. (Saturday) I recommended she keep a log of respirations and pulse
before, during and after feeds. I also explained the results of the Meier
studies which found that babies maintained better oxygenation with
breastfeeding than with bottle feeding, so that she would feel reassured
she was doing the best for her baby.
How much do I push? To whom?
Jeanette Panchula, RN, IBCLC
Vacaville, CA
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