Hi Adrienne,
There are a couple important points for this case. Because this has gone on
so long, it seems the physician is not convinced the baby can gain on
breastmilk. Read on to see what might have been done differently, and what
can be done now.
My philosophy is that one must first prove the baby is taking in sufficient
milk volume, and still not gaining. I have posted on this very subject many
times before, so if you have a chance, please check the Lactnet archives.
Here's what I've picked up from reading the case. Day 3 baby had very little
weight loss, so if he was exclusively breastfeeding, we can feel pretty good
that he was transferring colostrum. Soon after, things deteriorated, and I
am thinking perhaps a swallowing problem once the milk came in. It could be
tongue tie with sore nipples (altho you said anatomy appears normal) or some
suck/swallow/breathe problem. The baby will choose breathing over eating.
And even though you say baby "has good milk transfer" we cannot be sure of
this unless an objective measurement was done, especially at several feeds
to give a good overall picture. What I have seen many times is that baby
appears to be swallowing alot of volume, but is in fact consuming very
little (like 12 mls or 18 mls, for example). This is not enough to lead to
weight gain. Especially if baby has begun to feed at long 6 hr intervals. I
would want a thorough history, and observation of feeding, looking
specifically for latch problems, swallowing/breathing changes, and milk
transfer on digital scale (admitting the limitations of this method, however
I do find it useful for these types of cases).
It is totally crazy, IMO, to use AIM for feeding this infant, when mother
can pump 8-10 ounces of milk. Personally, I would choose to feed this baby
by alternate route to document an adequate feeding volume in a 24 hr period,
and wt gain on this amount, OR to document the inability of baby to take in
adequate volume and what his limitations are OR to document that baby IS
taking in adequate volume but IS NOT gaining weight.
I use a simple calculation of baby's birthweight in pounds x 75 mls as the
necessary 24 hr milk volume. For this infant, 7.25 x 75 = 545 mls or about
45 mls in 12 feeds. Obviously you might need a couple days to document this,
but no more than that. I would propose this plan and rationale to the
physician, and if he/she does not accept it, I would hope the family would
consider a second opinion or another physician, as this would show me
ignorance about and possibly non-support of bf.
Laurie Wheeler RN MN IBCLC
Mississippi USA

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