Hi Halle

Welcome out of lurkdom. Interesting case. The basic questions, to me, are:
(1) Are you dealing with a maternal problem that could be called primary
lactation insufficiency/insufficient milk syndrome? vs (2) Was this caused
by poor feeding management or technique from the beginning?

As is often the case with lactation consults, there seem to be many
variables and possibilities here. However, I think you are dealing with #1.
The things pointing to this would be that she "had same issue with her
now-two year old, wound up 'fully' supplementing" and "Mom never got
engorged." These are 2 big red flags. {By the way, I don't use the term
engorged when referring to what I consider to be normal postpartum breast
'fullness.' I really consider engorgement to be OVERfull, hard breasts,
which I don't see much if mothers are breastfeeding effectively, frequently
and from early on. I mostly see engorgement with mothers who choose to
regularly supplement with formula from day one. Some call this physiologic
vs pathologic engorgement.}

Anyway, getting back to your case. More red flags would be "baby STOPPED
pooping and NEARLY STOPPED peeing at 5 days" and "baby lost nearly two lbs
by day 9, was hospitalized for dehydration." Yes, babies who are feeding
poorly do have decreased wets and especially dirty diapers, but this sounds
extreme. This is a very large weight loss, what was the original birth
weight anyway?  Of course scales can be wrong and there is human error, but
the scant output and the re-hospitalization points to the believability of
the weight loss. I bet there was a high degree of hyperbilirubinemia too
(jaundice). Other confounding or contributing factors: did the late term
abortion have some psychological or even physiological effect ("her breasts
grew substantially during that pregnancy but not during the subsequent
two")? Also, you said they went home on day 3. You said it was unmedicated
easy birth, so I assumed vaginal. Was there some reason for the day 3
discharge? I am used to about a 24 hr stay with easy vaginal births. And of
course others have said that the feedings may have been assessed as good,
when in fact they really weren't. Or maybe there was adequate colostrum and
some infant reserves which could not sustain baby past a few days. As
Barbara W-C recently posted, when the milk supply is low, the baby often
sleeps and then the downward spiral really begins.

Swallows heard can be deceiving, I've seen some babies seem to be swallowing
frequently and then on pre/post weight check have only consumed few cc's.
(Not even getting into the pros and cons of said 'test weights'.) This post
got lengthy, sorry, and different people would use different interventions,
but the guiding principles would be: feed the baby, increase/protect the
milk supply, and return the dyad to as full a breastfeeding relationship as
possible.

Laurie Wheeler, IBCLC, MN, RN
New Orleans Louisiana, s.e. USA




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