Dear Wise Ones,
I need some input into a case I’ve been following just to make sure I’m not
missing something. I have mom’s permission to share.
Mom’s 3rd baby, 5th pregnancy, questionable infertility issues. Took Clomid
but conceived without. History of insufficient milk supply with last 2
babies despite constant feeding, pumping, Fenugreek, Rescue Remedy for poor
MER, flaccid, “empty sac” breasts, both boys very poor feeders. She
supplemented with some EBM but mostly ABM. I was her LC with the last baby.
Now she has a girl who latches on right after birth with good suck, some
swallows, leaves the hospital exclusively breastfeeding, looking good except
she didn’t pass the hearing screen with several tries. Follow up with Peds
ok in 1-2 days. (Don’t have my notes with me so not clear on chronology).
I see her biweekly for weights, feeding assessment and pre- and post-feed
weights. Baby gets about 1.5 ounces per feeding but is still not gaining by
day 8, almost 10% total gradual weight loss. She is pumping 100 minutes/day
in addition to nursing every 2-3 hours and is taking several galactagogues
including, at different times according to availability, More Milk special
blend (?), Goat’s Rue tincture or capsules, saw palmetto. She does breast
compression throughout the feeding due to poor MER. Has had her thyroid
tested normal in the past. She’s using an SNS sometimes with EBM, other
times with a syringe (her choice, not mine). Baby refuses ABM via SNS or
bottle. Baby consistently has good urine output and yellow seedy,
occasionally green frequent stools of good amount. She sees Peds again,
weight is higher on their scale, no jaundice, normal behavior, he says keep
doing what she’s doing as long as she’s followed closely.
I see her at Day 11 and baby is finally gaining weight, not as much as I’d
like to see, but baby still looks good, good output. Mom is consistent and
realistic in her management of the situation, but very determined to get as
much breastmilk as she can for this baby. She feels her breasts are heavier
with this baby and that this baby is a completely different (better) feeder
than her boys. She has another hearing screen at the hospital and fails but
we’ve been having trouble with the machine and it’s being repaired.
I go on vacation and one of my (not as experienced) colleagues sees her for
her biweekly weight check, baby is still gaining slowly but not enough and
mom starts supplementing with ABM. I need to stop at work 2 days later and
called mom to check on progress, says baby’s taking supplement well and she
continues with same management in addition to ABM. She’ll continue the
weight checks until gaining at least ½ to 1 ounce per day. She’s getting
about 6 ounces/day of additional EBM for supplement compared to 1-2
ounces/day before starting the Goat’s Rue.
Yesterday my colleague calls to tell me that the baby looked “horrible” at
the weight check (before I spoke with mom on the phone), was “literally
starving”, that she made mom give ABM, that she is very concerned about her
neurological development due to the starvation. She says mom took baby to
an audiologist, baby failed the hearing screen again, and audiologist told
her that the baby was too weak neurologically to clear the fluid from the
ears. She says baby is finally back to birth weight at about 18 days.
Okay, what am I missing here? Does slow weight gain have an effect on the
hearing screen and/or neurological function? What does that have to do with
clearing fluid in the ears? Baby appears normal to me and the Pediatrician
neurologically. I would have preferred mom supplement earlier than she did
but she did try and baby refused it. She has been diligent in her
management of the situation. How slow is too slow when all indicators but
weight show that baby is doing okay? Was there just a slow decline to a
crash? Or was my colleague’s assessment inaccurate? I have a long history
with this mom and now this baby. I thought baby looked too scrawny too and
baby’s weight loss peaked at 10% before she started to gain. Baby’s oral
anatomy and suck assessment are normal, her tone is good, a little pale but
no jaundice, baby wakes to feed except at night so mom wakes her. Mom’s
eyes are protuberant but always have been, and she’s overweight, not obese.
Is another thyroid screen warranted for mom and maybe baby too? Anything
else we should be assessing baby for? Not sure if or when another hearing
screen is scheduled. I will not see mom again until July 6 for FU visit
after my vacation but my colleague will see her. Any input greatly
appreciated. Thanks Lisa Marasco and Cathy Watson-Genna for help already
with this one.
Linda S. Anderegg, RNC, IBCLC, RLC in Chicago
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