I am having one of those situations that really make me want to bang my
head.  I have a mother-baby pair, baby now 2 weeks old that are giving me
fits.  This is a second baby.  First baby was born by cesarean birth due to
breech and preterm rupture of membranes at 34 weeks.  He was small, required
oxygen for a little while, was a poor feeder, had jaundice.  His mom pumped
for him, breastfed him directly, and supplemented with AIM for almost 6 mos.
 She has always felt sort of ambivalent about breastfeeding, originally
thinking she'd just pump and bottlefeed, but once the baby came ended up
nursing him directly also, and enjoying it, although she was never convinced
he could get enough to eat that way.  She was definitely able to produce a
full supply, though, as she could easily pump his needs, although she
offered AIM in between because she felt he needed it.

Now this second baby has arrived, also a little early, at 36 1/2 weeks,
vaginal birth after cesarean with epidural after again preterm rupture of
membranes.  Baby was 6 lbs even.  Initially she latched very well, but was a
typical near term baby, falling asleep often, having to be woken to feed.
Our unit was terribly busy when this baby was born, and although she got
some education, somehow we failed to drive home how important frequent feeds
were.  On discharge, the plan was for her to nurse baby as often as she cued
(but no less than every 3 hours) and pump postfeeds during the day, comping
with that milk if baby did not have a good nursing session.  She was to
follow up with me 2 days after discharge (day 4 of life)  She ended up not
coming until day 6 of life.  Baby was already 2 oz over birth weight (an 11
oz gain in 4 days) and mom reported baby was spitting up constantly.
Feeding history revealed mom was letting baby sleep generally about 3 hours
between feeds.  She would, however, feel very full after about 2 hours, so
would pump at about 2 hours.  Then when baby woke she was offered the breast
(with varying success per mom, sometimes seeming to drain them, sometimes
not nursing very long) then given the pumped milk by bottle (usually 50-60
ccs) then also being offered AIM, and usually she would coax her to drink
1-2 oz of AIM also.  I figured baby was getting at least 4 oz per feed, plus
what she took at breast, so no wonder she was spitting a lot.  Baby looked
well and was stooling 8 or more times a day.  Mom was encouraged to not
force such large feeds, breastfeed the baby more often, skip the AIM, watch
diaper output well, and return in 1 week for follow up.

Baby returned today, 8 days later.  On the same scale she has now lost 7 oz
since last week (now 5 lbs 11 oz).  Feeding history now reveals mom is
feeding only every 4 hours (baby is "so good" and doesn't wake more
frequently than that.)  She is still feeling full at 2 hours, so she is
pumping at 2-3 hours still, so that baby is then feeding usually 1 hour or
so after pumping.  Baby is mostly directly breastfeeding, but getting some
EBM by bottle.  The freezer, however, is getting quite full of expressed
milk.  She is now stooling only about twice a day.  Baby fortunately looks
hydrated, was alert and active in the office (with a pacifier in her mouth!)
 She has terrible thrush, though, and mom's nipples are bright red and sore
as well (which somehow she thought was normal, despite never being sore with
her first.)

I don't know what part of "feed the baby" she is missing here, but we went
over it again, and put it in writing.  The plan is to feed the baby, 8-12
times in 24 hours, and keep a record of each feed.  Mom will continue to
pump, post-feed, during the day, to help protect supply, and will supplement
with expressed milk anytime baby does not nurse vigorously.  She is to again
watch diaper output carefully, and call me frequently.  No pacifier use for
now, as we want baby to suck for food.  Mom was strongly encouraged to
practice skin to skin, and not to wrap the baby and put her down in her crib
between feeds in the daytime so that she may cue more to eat.

It is so tempting to tell her to just pump and feed so many ounces every so
many hours, since it is so hard to teach this mom how to read the baby's
cues, and to accurately assess whether she is eating enough.  Also, this
poor near-term, now under-nourished little girl can't be counted on to cue
to feed enough right now, I think.  There is clearly enough milk, mom is
pumping plenty of volume, but some how I have to help this mom see that the
milk is meant to go into the baby, not into the freezer, and that if she is
feeling full, this is time to encourage the baby to feed.

Any other ideas?

Jennifer Tieman
Family Physician
Mom to 4, including my toddler nursling Caroline Rose

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