Has anyone heard of an apparently healthy term baby loosing 23 % of
birthweight in the first week of life?

I  have been "no-mail" for a long time, but am sharing the story
(with the mother's permission) now that there is some improvement (on
donated milk.   I'm an IBCLC and LLL leader in an isolated  town on
the west coast of Canada.  Due to water and mountains the only way of
leaving our community is by ferry or airplane.  The baby's mother is
even more isolated, living on a nearby island with daytime ferry
connections to our town.

This 20 year old mother had late and sporatic prenatal care with a
physician and  an unattended  planned"home birth" at 42 weeks
gestation  by history.  Mother refused all prenatal blood testing,
ultrasound etc. being of "natural alternate life-style" persuasion.
The birth actually took place in a local motel as the physician had
convinced them to leave the island and at least be in town where they
could access the hospital.  Apparently there was some question of
"rough patches" on the placenta.  The couple presented in the
hospital emergency room with the baby in arms and the placenta in a
plastic bag.  A nurse was called down from mat/labour & delivery and
assessed the baby and placenta and they went home.  Birthday was
February 13th.  The hospital weight was 7 pounds 7 ounces.

I first heard about this baby on February 18th at 4 PM at the health
unit clinic, where I was working at the breastfeeding drop-in.  A
public health nurse  (PHN) had just returned from visiting the island and
had done a first home visit that afternoon.  She had been struck by
how scrawny the baby looked, however there were no signs of marked
dehydration.  She was also concerned about bowel movements as there
had been none since the passing of meconium in the first couple of
days.  Urinary output was hard to assess, as the mother did not
believe in using diapers for a newborn, and was basically providing
kangaroo care in a receiving blanket.  She estimated 3 pees in the
last 10 hours.  The nurse had weighed the baby in pounds and the
hospital weight had been in grams so she didn't immediately calculate
the % loss.  She did tell the mother that the weight loss far
exceeded what we normally see.  She observed latch and noted
non-nutrative sucking with no swallowing.  She did not examine the
mother's breasts but noticed that they were very small, and that the
areola was pale in color.  The mother and a visitor (who had
successfully nursed her own child), assured the nurse that the baby
wasn't feeding because she had just finished a good feed, and that
she is at the breast almost all the time.  The nurse instructed the
mom to keep up frequent feedings and see the doctor on the island
first thing in the morning.  On the ferry home she calculated the
weight loss.  The baby had gone from 7 1lb 7 oz to 5 1lb 14 oz in 5
days!!!
I told the PHN that this baby was in trouble.  The 23% weight loss
was almost unbelievable, and perhaps there was an error in one of the
weights, but it was clear that things were far from normal, and that
the baby needed to be seen by a physician and be fed.  The PHN
contacted the mother after I left work.
I got a call from the mother about 9:45 PM.  She had been given my
name by a doula.  She was tearful and frightened.  She said that the
PHN had phoned her about 5 PM and had scared her, and told her that
her baby was starving.  She said that she didn't want anything to
happen to her baby, but she didn't want the baby to have any formula.
I told her the baby needed to be fed every two hours.  She should
listen for swallowing sounds.  She said she didn't know what that
sounded like (perhaps there were none).  No stools in 3 days but she
refused to believe that this was significant.  I asked her to manually
express milk and if she could even just get a spoonful to feed this
to the baby, and to do so after every feed.  I also asked her to
phone the hospital immediately and talk to a maternity nurse and ask
about emergency measures for the island at night.  By the time I
called the hospital a few minutes later the maternity nurse (only one
on at night) was already talking to the mother on the other line.  I
gave the nurse a brief run-down, and she phoned me back at 11 PM.
She felt, although she said she couldn't promise the mom things would
be OK, that since the baby had urinated several times.  I later heard
that the mat nurse and the mother talked several times through the
night.  The mom was beside herself because the baby was fussing and
crying all night.

At 8:30 AM the following morning, Friday Feb 19th,  I phoned the mom.  Baby had
a "large pee" at 4 AM.  Still fussing.  Mom had nursed all night and
had only been able to express 1/4 tsp. after feeds which she
spoon-fed the baby.  I reiterated that she needed
a medical assessment.  She said she was just waiting for her friend,
who would take her to the island clinic.  I suggested she be there
before opening time to be the first patient seen.
The mother did not go to the clinic.  An aquaintance who was nursing
a 2-yr-old came by.  This woman saw the scrawny baby, now with sunken
fontanelle and wet nursed the infant.  She moved the mom and baby in
to her own home and nursed the baby throughout the weekend.  On
Monday they finally went to see the island doctor.  The doctor was
very concerned about the appearance of the baby.  She was now 6 lb 4
oz, a 6 oz gain from the PHN weight on Thursday.    On Teusday the
doctor did a home visit and got a gain of 11 oz  in one day!  He was
pretty sure that he had zeroed the scale.  Baby was still being fed
by the wetnurse with a lot of time also being spent on mothers
breast.  There had been a couple of stools of a lighter colour.
Friday morning we received a 3 week supply of breastmilk from the Vancouver
Milk Bank.  It was my day off, but I decided to accompany the PHN to
the island with the milk, and a breast-pump for the wetnurse.  We
arrived 11 AM.  The mom and baby were at the doctors.  The wetnurse
was upset that they had gone at that time as the baby had not fed
properly that morning.  She was having trouble feeding as the baby
feeds slowly, needs a lot of prodding, and the two-year-old was
having a difficult time with having a new nursling moved into their
home and onto mom's breast!  The babe's parents had been eager to go
to the village for their appointment rather than delay for a feed as
dad was out of cigarettes!  We instructed the wetnurse in the use of
the electric pump and transferred the milk to her freezer.  Mom,
mom's father, and partner arrived with baby.  Mom very upset because
baby had lost a couple of ounces since Teusday.  Mom felt doctor was
not listnening to her that they now had a plan to feed with banked
milk, and that he had suggested apprehension by social services.  She
had bolted from the office.  We told mom welfare of the baby was at
stake and had her bottle feed breastmilk immediately.  Baby took 4
1/2 oz.  Mom's breasts are very small, essentially flat chested with
a protruberant areolae, pale in colour and a protruding nipples. They
have been that way since she "got breasts", and have not changed in
pregnancy or post-partum.  She was able to express 8 drops (from 8
pores) of mature looking milk.  She claimed to feel her first ever
let-down after bottle feeding the baby.  She plans to keep the baby
at the breast as much as possible between bottles.
Doctor did talk to the child protection people and also made a home
visit before leaving town for the weekend.  Decided to leave baby in
present situation with feeding plan to feed 3-5 oz breastmilk by
bottle q 2-3 hrs round the clock and Sat & Sun weight checks at his
office with a nurse.
Today, Saturday, mom arrived 50 minutes late for the weight check but
the baby had gained 4 oz in a day and now weighs 7 1b 2 oz. She baby
and dad moved back into her own home with the frozen breastmilk.  The
wet-nurse phoned me this evenig concerned about having them on their
own.  She said that last night they slept through the alarm clock and
it was her own partner who on hearing a sound, went and fed the baby.
We decided on a night plan which is:  Mom is to feed the baby at
least every 3 hours by night.  She sets her alarm and if baby doesn't wake her
first she then feeds the baby and phones the maternity nurse at the
hospital to check in.  If the maternity nurse does not get a call at
the next feeding time (12:30 AM), she phones the mother to waken her.
If that does not work she phones the wet-nurse who lives on the
island who will then drive 40 minutes to the home.  All parties have
agreed on the plan.  I just phoned the home to confirm and got the
answering machine !!  I left a detailed message.

Are we overly anxious now that baby?  At 14 days baby is now 7-2 from
birthweight of 7-7.  I'd feel best if this dyad was hospitalized for
observation.

Mother today claims she can feel her milk coming in.  Is this likely?

Although I would have liked to try a supplementation at the breast
the caregivers felt that the baby needed to be fed as quickly as
possible, therefore by bottle.  Should we consider instituting
another feeding meathod?  Apparently baby is continuing to take the
breast.

Mom is considering domperidone.  Should this be encouraged, and if
not, what should be done first?

Mom seemed delighted at the prospect of me posting her story on
Lactnet when I asked for permission to do so.  It made me wonder
about Munschhausen by Proxy, but mammary hypoplasia is my foremost
thought.

Please copy replies to my address, as I am not sure I will have time
to read through all the posts.

Thank-you in advance for any thoughts on this case.  Naturally I am
keeping docummenting all conversations as there have been some discrepencies
in what various caregivers are hearing.

Hoping for a happy ending.

Suzanne McBride