I first saw baby J when he was 3 days old and he hadn't gone to breast
since his circumcision on day 2. He had also been induced out of his cozy
womb, without his initiation, had the "benefit" of his mom's epidural, and
his vaginal descent was very fast. Many things that can cause a sleepy baby.

Mother's areolas were edemic from the Pit, as were her feet, legs and
hands. After a few vigorous tries with a good rooting style, J gave up and
went to sleep. Mom began pumping, getting 1 1/2 oz. of milk which, after
rousing him again, she gave him with finger feeding and eye dropper. He
also took a nipple shield with some good milk transfer.

I recommended her eating watermellon and applying cabbage leaves to relieve
swelling. J had a second feeding 2 hours later with the shield and 1 oz of
expressed milk and began wetting and stooling, followed by another good
feeding in 2 hours. There was no visible jaundice and he fed with vigor.

Then they got a call from the Ped. saying, "I am very worried about your
baby.  I talked to a neotologist and you must take him to Children's
Hospital Emergency Room immediately." This was at 8:30 PM and the parents
were terribly frightened. They called me and I was most puzzled, as this
Ped is usually reliable.  I told them to be sure to take the sheild and
breast pump.

The trip was 45 mins, they were in a general waiting room for 2 hours, and
knew of no place to pump.  The exam and blood work took another hour.  J
was hungry so the hospital gave the parents a bottle of abm to feed him.
They were back home 5 hours after they had received the call. Mom pumped
and got only 1/2 oz so baby was fed abm in addition to the milk. They were
all exhausted but mom pumped 1 1/2 oz every 2 1/2 hours.

When they called me the next morning (Friday) they said that the ER doc had
said that the baby was in fine health and that the bili was just 13, and he
recommended that they keep him in a bright room.  So I thought we would
resume work that morning, but they had received a call from the Ped. to
take baby in for a check and another heel stick.

I said something modest like, "WHAT?!!!"  Then I found out some "vital
information. The call from the Ped was on her car phone as she was leaving
for the weekend. The check was to be with another doctor who was covereing.
The Ped knew that I was working with the family because she referred them
to me. I had tried to get in touch with her several times and got the
"service" which said that she was not reachable. She never called me for a
report.

So the work to get baby to breast had to wait for another half day. The
parents assumed that this trip would be short so baby was fed and they
didn't take pump or shield.:( Baby was checked and sent to the hospital for
the heel stick--another very long trip.
Baby is now at day 5 and this bili count, after all of this riding in cars
and waiting in waiting rooms without eating, was 14.  Alarm was expressed
and bili blanket was ordered, to be delivered that evening at 7, and
another heel stick ordered at 10 AM the next morning. They couldn't find
anyone to come out to the house to do the "blood letting" so the parents
were ordered to make the long trip back in to the hospital.

We did find a window of opportunity on Friday afternoon to get baby feeding
at the breast.  Mom's edema was resolved and baby latched on easily.
Throughout all of this fiasco, baby was peeing and pooping like crazy, and
was still not visibly jaundiced, except for a slight yellow of the whites
of his eyes. His face and rest of body were beautifully pink and his vigor
was great.

So Saturday comes along with a return trip to the hospital. J is feeding
like a pro now and everyone is thrilled.  That morning's lab results show a
bili of 11.1.  The covering doctor said that she stops lights at 11, and
since it was 11.1 they would need to continue the lights and return on
Sunday for another heel stick.

My response *may* have been a bit stronger than "WHAT?!!"  J doesn't like
the bili blanket and isn't real fond of the heel sticks either. He is also
changing from a mellow kind of guy to a fussy one. We talked about options.
 Dad wanted to "lose" the blanket and still take him in for Sunday's test.
But I said that if they were going to play the numbers game with the docs
they had better play it all. I mentioned the rebound effect that sometimes
happens after lights are discontinued. I also reminded them that J is their
baby, and that they can choose to take care of their baby at home, and take
him to the Monday appointment with their Ped.

I just called and they took him in for the check and the present covering
physician (the 5th one to get in on this baby's "crisis" situation) said
that the count is 11.2 so they should continue the lights and give
Pedialite to flush out the bili. (!) Baby is having 10+ wet diapers and 6+
large bms a day.

Now, here we have a case that could have been a 2-day consult with good
outcome, including a baby who had never had his GI tract disturbed by
foreign proteins and who just needed for his mom's edema to recede in order
to get going with feeding. He might have experienced some normal, slight
jaundice due to a slow start, but regular feeding would have taken care of
it in good order. Mom was even breastfed so I was expecting few if any
problems with food sensitivities.

But doc is leaving town, baby is sleepy at day 3 but can be roused to feed,
consults with Neo. who says that any baby who is sleepy at day 3 is in
serious trouble, orders a trip to emergency room, ER miraculously sees that
baby is in good shape, first abm taken, covering Ped is very new (not an
issue in itself, of course) and wanting to do a "good" job, baby feeds less
than he would have if they could have stayed at home where they belonged,
bili of 13 and 14 are seen as cause for alarm, more trips with more abm,
bili lights begun, 11.1 seen as cause for alarm, another heel stick, bili
is 11.2 with continued alarm, prescribed pedialite to flush out bili.

Little J is paying the price for a lot of ignorance and laziness. I don't
know what I am going to do about this.  I can't just let it go.  I know
that my ego is bruised by the Ped not seeing that this baby *was* in the
care of a HCP. (Maybe some chocolate would help me.) She preferred that he
be treated by anyone he bumped into rather than trusting that I would know
if he was in trouble.  I really believe that if she had been here and
*seen* the baby there would have been NO treatment, not even the first heel
stick.  She has consulted with me with other of her patients and usually
displays a good knowledge of breastfeeding.  We have to talk!

One thing I was wondering is, wouldn't J have had some visible skin
yellowing with a count of 14?  Even his eyes weren't noticeable if someone
wasn't looking for it.  I have another client whose baby looks like a
pumpkin, but whose doc hasn't ordered tests because he is vigorous and is
feeding well after the mature milk was a bit slow.

Well, 2 1/2 days may not seem like a long time to many, but to J it is 1/2
a lifetime and he deserves better than this!

This could be considered simply as a rant, or if anyone wants to use it to
enlighten the rest of us please feel free to do so.

Patricia Gima, IBCLC
Milwaukee
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