Hello all. 
I have persmission from the mother to post this. I have a coworker who I 
visited in the hospital 24 hours after delivery who had a history of low 
milk supply and continuous need for an SNS throughout the 2 years she 
brestfed her older child. I observed a latch and infant was sleepy and 
would not stay latched. We had her pumping after each feeding anyway for 
reassurance. Her breasts were "empty sacks of skin and little tissue". That 
is the only way I can describe them. I had an LC from the hospital assist 
with her and did not tell her a thing about my observations. She told the 
mother that she was concerned about the lack of changes in her breasts but 
that we just needed to continue with the frequent feedings and pumpings and 
wait and see. I told the mother that this was correct. I saw her on day 4 
and she was engorged (Yeah) but not able to pump much out after feedings 
and not getting relief after feedings. I assisted with the feeding and 
pumping and instructed breast compression which helped greatly. Infant was 
jaundiced and on a bili blanket. Her stools were dark brown. Mother was 
applying hot compresses and I told her to change it to cold compress 
between feedings which she refused to do since she felt it would decrease 
her supply. (I brought muliple handouts and referred to web sites etc.) The 
engorgement did eventually resolve. Infant had elevated bili levels-(bili 
lights started at 18)- for 2.5 weeks and remained under a bili blanket for 
that long. I encouraged supplementing after feedings with pumped breast 
milk by SNS or syringe etc during this time but mother stated that infant 
was full and would spit any supplements she would give. MD ordered 
supplements of 1 oz of formula after feedings at day 7 but mother was 
giving 5-10cc after some feedings and stated that infant wasn't tolerating 
the supplements. I talked with the MD and had this changed to EBM but 
mother continued to givn only 5-10cc and stated that infant spit if she 
tried to give her more. The stools remained brown( not green or black) for 
2 weeks. (I worked in a NICU previously and I've seen lots of stools of 
hyperbili kids and this did not look like that kind of stool but maybe it 
was.) The baby gained about 1/2 oz a day starting at day 6. She was up to 
birth weight at 2.5 weeks. Mother stopped pumping on a regular basis
(hospital grade pump) after the bili lights were discontinued but she will 
occasionally pump when she needs to prepare for an MD visit etc where she 
needs a bottle just in case. When I have observed feedings I don't hear 
much swallowing if any at all. The latch is good now though I had to 
correct this on a regular basis because she would let the infant nurse on 
the tip of the nipple because she was afraid to relatch her. (Afraid that 
she wouldn't relatch but fall back asleep.) The baby continues to gain and 
is now gaining 4-5oz per week which is WNL. Mother came to work with the 
baby this week and baby is now 7 weeks old. She was fussy upon arrival and 
nursed the entire 4 hours that they were there-or at least was at the 
breast the entire time. If mother tired to unlatch her she cried until she 
was relatched. This has really been the way it's always 
been.                                                                       
      Now to my questions. Should I be concerned? Baby is gaining wnl. What 
about the brown stools for the first 2 weeks? I was concerned but watched 
the weight first before saying anything and just told her to let me know 
when the stools changed to yellow. Now she has a stool every 7 days. I 
really wanted a big supply in the begining due to her history but in 
working with mother she was really not open to the extra pumping etc and I 
respected her wishes after giving her my rationale for everything. Am I 
overly concerned where there is no concern? Thanks,

Lisa Bell RN, BSN, IBCLC
Public Health Nurse

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