In the meantime he may benefit from 22 or 24/oz kcal formula or enriched ebm
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On Saturday, August 10, 2019, 2:42 AM, Carmela Baeza <[log in to unmask]> wrote:
Hi all!
Lactnet is on fire!! ;) I love having so many Lactnet posts to read!!
I wanted to share a recent case, a bit like the one recently commented
here. Family got an appointment for a 5 month old baby. When they walked
in, it turned out they are twins. The girl twin is exclusively breastfed
and thriving, a chubby, active child. The boy twin is small, failing to
thrive and is being exclusively bottlefed with formula. Mother had taken
the baby to an osteopath to see if he could detect why baby did not want to
eat, and the osteopath (whom I often work with) has referred them to me -
although this is not a breastfeeding issue, since the baby has not
breastfed since the first week of life and mother´s goal is not to
relactate but to understand what is happening.
Anyway, I put on my family doc hat and took a goood history.
I will not mention twin one, as she is normally breastfeeding and thriving.
Twin 2 latched after birth but would only nibble for a few minutes and then
became desperate so he was started on bottles very early. At two weeks he
was exclusively bottlefed with expressed milk and formula. And a month he
was exclusively bottlefed with formula, as mother had no more time and
energy to spare (rememeber the other twin).
About the feeding, mother explains that baby has always had a hard time
taking the bottle nipple, as he frequently gags. He often regurgitated milk
from the nose, and coughs and chokes during the bottle feed. This has
slowly gotten better as months pass, but baby refuses to eat except when he
is almost asleep or desperately hungry. His weight has remained below P1
(twin is in P75; they were born at 38 weeks, both of them in P5).
The baby also has a small cardiac wall defect, which is being followed up
by the cardiologist. It has practically disappeared and the cardiologist
says it is not responsible for the thriving failure.
His pediatrician sent the baby to the gastroenterologists, who are giving
him extremely high doses of ranitidine, believing it is reflux.
At 4 months, pediatrician recommended adding cereals to the formula, to
make it thicker and to add calories to the baby´s diet.
So, to sum up, we have a 5 month old baby who has a small cardiac defect,
is failing to thrive, having a hard time feeding (although he is doing
better), and to manage that (unsuccessfuly) he is receiving cereals and
ranitidine.
Hmmmmm... somebody is CLEARLY missing something here...
Babies are wired for survival. To survive, one must first breathe, and then
eat. It a baby does not eat, first thing we have to check is, can he
breathe? Can he manage breathing and eating? Because if he can´t, he will
prioritize breathing.
Milk coming out of the nose, gagging, gasping, coughing and choking all
smack of a palatal/vellum/top part of the airway defect, anatomical or
functional. Sometimes these type of defects are compounded by other
"midline" defects, and this baby has a heart one.
During our consultation mom offered baby, who was hungry, a bottle. Upright
postion, horizontal bottle (mom had figured this out on her own). He took
about 50 ml calmly (no choking or coughing) and when a bit of milk pooled
in his mouth he immediately let go and refused to eat more. He then calmly
suckled on his pacifier (which has a small nipple and does not produce gag
reflex, baby likes it).
It must have been really scary for this baby to eat!!! I think he´s eating
just enough to survive... The defect I suspect (I have referd this familly
to an ENT and don´t know the results yet) might have gotten smaller as
months have passed and maybe that is why baby is doing a bit better with
the feeds - although the fear remains.
I did explore baby´s mouth, he has a slighty restrictive sublingual
frenulum and what I could feel of the hard palate seemed ok, but with
baby´s sensitive gag reflex I did not want to disturb him, since the ENT
will be doing enough of that.
As feeding strategy, we tried using a tube with the pacifier (like finger
feeding or tube feeding at the breast, but with the pacifier) and baby
calmly took in 20 more ml, so that seemed to work...
So, I´ll keep you updated...
Cheers!!
Kika
--
Dra. Carmela K Baeza
Médico de Familia, IBCLC
www.centroraices.com
Facebook: Consulta.Lactancia.Raices
<http://www.facebook.com/Consulta.Lactancia.Raices>
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