In case it is difficult to find previous post, here is the history:

PTP. Mom's words below.

"[Baby had an uncomplicated homebirth.] He was originally hospitalized 16 hrs after birth for PPHN; we came very close to losing him, but once he turned the corner he recovered quickly. He was on TPN for about a week, then was introduced to breast milk. We spent 3 weeks in NICU. While we were there his direct bilirubin spiked. 

He had a prominent tongue tie clipped in the NICU, but I suspect a posterior tie remains. 

He is 6 weeks old. 

Birth weight was 11 lbs 8 oz, he has hovered right around 11- 11 lbs 2 oz for the last 3 weeks. Plenty of dirty and wet diapers. 

It was discovered that he had a choledochal cyst--a cyst on his bile duct that was completely obstructing the flow of bile. He had surgery Tuesday to remove the section of duct containing the cyst as well as his gall bladder, and reattach the bile duct directly to the jejunum. 

He currently takes a sodium bicarbonate supplement for an as yet unexplained sodium deficiency. He also is on ursodiol (Actigall), and a vitamin AEDK. He recently started Augmentin as well as a prophylactic after surgery. Baby is currently 4 days post-op. Baby is not gaining weight, and in fact has lost some the last two days. He's eating between 75-90mL per feed (bottle feeding breastmilk and tending toward the upper end of that range), which are roughly every 3 hours. Coaxing and cajoling as much as we can, 90 has been his max so far (they have said they'd like to see 95 per feed). He's not on pain meds or anything anymore. He was NPO for two days following surgery. Here are his weights [in Kilos]: 

5.06 (pre-op) 
5.075 (still on IV fluids)
4.97 
4.905

All that is background for my question: we are meeting with the dietician tomorrow, and I have gathered from talking with her previously that she is quick to fortify and use formula. Two options that were tossed around were MTC oil and Progestamil (?) which a nurse described as a powdered formula they would mix in with breastmilk. Now, I recall seeing posts from you about how you should never mix a powder undiluted into breastmilk, so why are they going to suggest that? What info do I need to know to make an informed decision and if necessary refute them? 

Are there truly cases when breastmilk is insufficient? He's happy and content between feeds. I am also offering the breast after bottle, but he hasn't been interested. They really want him primarily bottle fed to monitor ins and outs."

My reply to her was, "Some illnesses can cause metabolic issues requiring more calories than a baby can consume with typical volumes of breastmilk. I do not know about this one in particular...

Yes, there is a risk of using powdered infant formula without adding it to water hot enough to kill bacteria in the powder. These risks need to be balanced with the nutritional needs of the ill infant.

There are other ways to increase the calories in breastmilk. You can skim the fat off the top and add it to pumped breastmilk to do this. You would need excess milk for this. Are you pumping enough? Can you get milk from a milk bank? Will they work with peer-to-peer donation of milk?"

Mom replied with:

"Incidentally, since I first messaged you today, he was weighed again and gained 125 grams in a 24-hour period. This weight was on the same scale, after a big dirty diaper, and right before a feed. 

I haven't kept track of my daily pumping totals... I pump every three hours and on Tuesday (first day not nursing baby) I would get 80-90mL per pump, and today I'm getting 40-50 per pump. The last 12 hours especially I have seen a drastic decrease in output."

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