On 1/28/99 I saw a patient by referral from a local pediatrician in the
breastfeeding clinic we have at our hospital.  Date of birth 12-9-98.  Birth
weight 6 lbs, 14 oz.  Discharge weight from the hospital 6 lbs. 9oz.  This
is the third child for this mom, she nursed her first two for without
difficulty for over one year.  This baby was seen in the pediatricians
office at two weeks a little under birth weight, he was not concerned.  At
one month check up the baby was at the same weight, he did a test weight in
the office and the baby gained well at the breast-I think 4-5 oz.  Baby
spits up "a lot" according to mom, stools only every 4-7 days.  Mom pumped
that week after nursing and got an additional 18oz in 24 hours and feed that
to the baby.  After no gain that week the ped called me and asked me to
evaluate the baby.  I saw a thin baby, weighing 6 lbs. 13.3 oz with a good
suck, good latch that transferred 3.5 oz of milk from mom in the clinic
nursing.  Mom was very worried, did have trouble doing more than 7-8 feeds
in 24 hours.  I asked our Certified Breastfeeding Educator/Speech Language
Pathologist to look to see if I was missing anything.  Oral Structure, suck
and swallow are within normal limits.  I had mom increase feeds to 10 in 24
hours, to give 45 cc of her EBM through the SFS at at least 6 of the feeds
and to pump after 6 feedings.  We went over ways to increase milk supply and
she started more massage, fenugreek and blessed thistle.  We discussed fore
and hind milk.  She came back on 1-29 with baby weighing in at 7 lbs. 1.3
oz.  mom was encouraged and so was I and assumed we were on the right track.
The ped after getting my first day report and the speech report decided to
start the baby on propulsid.   On 2/1 baby weighed 7 lb and 4.7 oz. still
encouraging.  I told her to continue with the same plan of care until baby
was at 8 lbs and then we would wean from the SFS.  The pediatrician had her
stop the SFS when he saw her on the 2/4 because of the good weight gain to
7#10oz.  I saw her on  2/9 and baby weighed 7#8.1 oz. mom was distressed, I
encouraged her to go back to the original plan that was working, the ped.
increased her propulsid as the mom reported more spitting up.  Today they
returned 2/12 with weight at 7#8oz. , mom had not restarted the SFS as she
was afraid the baby would spit up more.  I spoke with her ped.  who is
baffled by a baby not gaining whose suck is normal, whose mom has nursed
easily before.  He has done an upper GI which is normal, and lab work-
thyroid, cbc, etc. all within normal limits.  He told me today he wants to
do an analysis of her milk and check the stool for fat, pH and reduction
substances to see if there is a malabsorbtion problem.  I am also puzzled
except that we were making gains for a while.
My questions to all of you:
1. Where to send the milk for analysis that would be accurate  and how does
she collect that milk to give a true picture as the milk is always changing.
2. For you dr. how long will it take the barium to clear with a baby that
doesn't stool often before an accurate stool specimen could be obtained.
3.Please e-mail me privately or post on lactnet Any thoughts and input.
I always gain a wealth of knowledge every day reading all your posts.  I
have been an IBCLC for 2.5 years now, OB nurse for 24.5 years, nursed for
over 7 years of my life.  Our clinic is very busy and I usually feel
comfortable with what is presented and how to handle it, but I need some
support this time.
Libby Rosen, RN, IBCLC
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Topeka, Kansas