I thought the Lactnet members would be challenged by the cases which will be
presented at the annual Milk Club meeting which is held in conjunction with
the annual meeting of the Pediatric Academic Societies in Washington, DC.
The Milk Club is the pediatric academic breastfeeding/lactation interest
group.  Everyone is invited and welcome to attend.  If there are any
questions about the meeting, pleased contact me. I would be interested in
responses to the cases and thought they might generate some interesting debate.

THE MILK CLUB
In Association with Pediatric Academic Societies Annual Meeting
(APS  -  SPR  -  APA)

PROGRAM
MONDAY     MAY 6
    9:00 am-NOON

Omni-shoreham HOTEL
Washington, D.C.

Diplomat room

9:00 am   The  Science of Milk Storage
        Margit Hamosh, PhD
        Georgetown University
9:45 am  The Use of Human Milk for the Premature Infant
        Richard Schanler, M.D.
        Baylor College of Medicine
10:30 am   Clinical Challenges:  Problem Solving
        Wendy Slusser, MD
        Wellstart International
        Expert panel with audience participation

CASE 1
Jaundice and Breastfeeding
CC: Jaundice and slow weight gain
PI: 9 day old of 40 wk primip with hypertension and UTI; epidural and
episiotomy.  BW 6'11".  BF started at 5 hrs.  Attachment difficulties,
sleepy baby, sore nipples, breastfed every 3-5 hrs.  Jaundice noted on day 3
with bili at 22 mg/dl; mother O+; baby O+; admitted for PT and fed formula
for one day.  Mother used battery pump q 3-5 hours and discarded milk.
Discharged on day 4.  BF resumed q 3-5 hrs.  Mother also pumping 3-4 oz bid.
Infant reluctant to latch on, crying prior to attachment.  Nipple pain
toward end of feed.
        Mother had normal breast enlargement during pregnancy and planned to BF 6-9
mos.  Mother experiencing "relationship difficulties".
PE:   Mother: Wt: 232 lb.  Breasts and areola: WNL.  Nipples: right: flat;
left: protuberant with scabs.
         Infant: WD, WN.  Wt: 6'7" Skin: ruddy hue; normal.  Oral-motor: lips
passively pulled in, gums, tongue, frenulum, mouth and jaw WNL.
Breastfeeding: Once mother was shown proper techniques of positioning and
attachment, mother could easily attach infant with good downward root in
side-sitting position without pain.

Questions:
        Diagnoses?  Infant?  Mother?
        Additional information?
        How would you have managed infant on days 1, 2 and 3 of life?
        What are the risk factors for low milk production in this case ?

CASE 2
Contraception and Breastfeeding
CC:  Gaining weight slowly
PI:  21 day old of 42 wk uncomplicated pregnancy to 20 yr old G2P1 mother.
No anesthesia or episiotomy for NSVD.  BW 8'10".  BF started 30 min after
vigorous oropharyngeal suctioning for unknown reasons.  BF 8-12 times on
demand on day 1 without difficulty.  On day 2, mother had Norplant placed in
left arm; mother and infant discharged 26 hours postpartum.
        Infant fed well q 3-4 hr for next two weeks.  At 14 day visit her weight
was only 7'14".  PE: normal.  Mother instructed to supplement infant with
formula and return in 3 days.  Mother fed 2 oz. formula per day X 3.  Wgt
increased only 1 oz.  Wellstart was consulted by phone and suggested that
mother continue to breastfeed every 3 hrs., express brestmilk after each
breastfeed and supplement with breastmilk or formula using cup. Given an
appointment for full evaluation on Monday following the weekend and phone
contact was maintained through the next 2 days.  Mechanical hand pump barely
produced an ounce each time.  Infant still seemed hungry after giving the
ounce and mother used a pacifier to calm baby down.  Mother also reported
that after about 5 min of feeding the infant would fall asleep.  The day
prior to coming to Wellstart the mother and father decided to stop
breastfeeding, but then changed their minds because they felt the closeness
and bonding associated with breastfeeding were too important to give up.
        Maternal grandmother and uncle have eczema.  The mother successfully
breastfed her 4 yr old son for 2 months, but stopped because of social
reasons.  She was 16 years old at the time.  Breast size increased during
pregnancy;  she experienced increased fullness in both breasts on days 3-4
pp.  No history of thyroid disease.  Mother expresses hope of stopping
formula supplementation and breastfeeding the infant for 8-9 months.
        Mother was feeding infant every 3-4 hrs, (2 oz formula and 2 oz breastmilk
by cup) but infant was not fed for 8 hours prior to the appointment.
Mother has been expressing her breast about 4 times per day for past two
days.  Mother complains of frontal headache every day since the Norplant was
inserted.  It responds to acetominophen.
PE:  Mother: Wgt: 226.5 lbs. (Pre-preg 150 lb) Breast, areolas, nipples: WNL.
         Infant: WDWN.  Wt: 7'15".  Pharynx: small healing erythematous sores.
Oral-motor WNL.
         Breastfeeding: Fed well.  1:1 suck to swallow.Good attachment and
positioning in cradle hold, but fell asleep after first let down.  After
demonstrating use of side sitting position, infant fed more vigorously and
continued through 2-3 let downs.  Mother then expressed 1/2 oz. breastmilk
and fed this to infant by cup with good technique.
Questions:
        Diagnoses?  Mother?  Infant?
        Additional information?
        What are the breastfeeding risk factors for low milk production? illustrate?
        What are the general recommendations regarding contraception and breastfeeding?


CASE 3
Oral-Motor Dysfunction
CC: Baby not attaching to breast; mother anxious to breastfeed.
PI: 16 day old was 8'11" product at term of G2P1 with uncomplicated
pregnancy.  Forceps under epidural with question of facial nerve palsy.
        Mother reports that she was never sure that feeding was going well and as 3
days of age saw a private pediatrician who reassured her.  At 4 days the
infant was admitted to NICU for dehydration, hypoglycemia and jaundice.
Hospitalization lasted 6 days and included IV for hypoglycemia.  Final
assessment was that baby had not been latching on well because her tongue
remains up on the palate most of the time.  Since that time mother has been
pumping (supply initially low, but increased quickly) to provide all of the
infant's feedings with expressed breast milk, but the infant has
consistently "refused" to latch on, either crying or shutting down at the
breast.
        The mother had planned to breastfeed for 3-6 months or longer.
PE: Mother: Wgt: 140 lb.  Somewhat tense but pleasant.  Relaxed more as
visit progressed.  Breasts: full, firm with protuberant nipples.  Mother
pumped 6 oz. milk with double set-up in 10 minutes.
        Infant: Wgt: 9 lb.  Fussy infant.  Marked asymmetry of tongue; left side
larger and stronger.  Entire tongue slanted about 45 degree from horizontal.
Tongue remained up against the palate most of the time.  Infant tended to
keep head tilted toward the right.  Oral-motor examination revealed most
prominently a chompy vertical pattern with fair cupping of the tongue around
the bottle nipple.
        Infant rooted well initially and had mouth well back on the breast, but
would not suckle.  No let-down occurred.  After several attempts, baby shut
down, closed eyes and refused to root..  After a few minutes accepted
feeding from bottle.  Coordination on bottle good.
Questions:      Differential diagnosis?
                Further work-up?
                How can breastfeeding be established?



Lawrence M. Gartner, M.D.
Department of Pediatrics
The University of Chicago
5841 S. Maryland Avenue
Chicago, IL 60637

Phone: (312) 702-0389
FAX: (312) 702-4523
E-Mail: [log in to unmask]