Hi All, I had an alarming consultation on Friday evening which is still in the works, but I wanted to hear from some of you as to what I should do next time this happens, as I'm sure it will. My Friday night 5:30PM consultation was a 5-day-old homebirthed boy who was being seen for weight loss and lack of stooling. When I heard the staff member talking to the parent on the phone, who said it hadn't stooled since d1, I said, "I don't want to see him until he sees a doctor." Then the staffer talked a little longer and the parents reassured her that he had stooled daily, so I agreed to see them. The parent hadn't specified that the stools were really only skid marks and were still meconium on d5 -- it wasn't that they were trying to withhold or alter information, it's more like they didn't know what to expect so they thought this was normal. The color of this baby was unnerving to say the least, but not as unnerving as seeing him undressed to a diaper. His skin and eyes were dark yellow, his skin hung off his thin little bony arms and legs, and I felt his little pelvic bones poking through his diaper. He was 6# 12oz at birth and was 6# 1oz five days later when I saw him. I kept poking his bony little legs trying to see if the jaundice was down to his legs (meaning a count of over 20, from what I recall) but there was nothing to poke into, it was just bone and muscles that felt like beef jerky. The parents said they were unable to wake him for a feeding for the past six hours but that he cried and slept on and off during the 60-minute drive from their home. He woke up, cried very weakly, but was aware and very responsive when I held and talked to him (whew!). Mom's nipples were all scabs but she said they didn't bother her in the least compared with the extensive tearing she had when she pushed him out. She refused to take any medication whatsoever for pain so she could hardly move without making a face. I helped the baby get latched on and he did so very eagerly, with surprising strength in this little scrawny body. He sucked eagerly for 15 minutes on the breast mom said felt like it had milk in it, while the mom and I tried using breast compression to help him. Baby transferred .1 ounce in 15 minutes -- eeeek! We had asked the parents to bring formula just in case, so they mixed a bottle, which was his first supplement ever. Here is my first question: When do you (LC) refuse to feed a baby because it is so malnourished, unless you have a HCP's OK? Isn't there a risk to feeding if it has been extremely undernourished for a period of time? I've been re-reading my lactation textbooks and I can't find any guidelines or explanation. We ended up giving him (very slowly, using paced bottle feeding) a total of two ounces over 30 minutes. I would have preferred not giving him so much in his first "real meal" but he didn't even burp. He dozed off happily and was still responsive as we carried him around, dressed him, and so on, so I know he wasn't "passed out." Here is my next question: Where can a family get a baby's bilirubin checked at 7:00 on a Friday night? Doctors' offices and urgent care were already closed, so the only facility open was of course the ER. I gave the parents directions to the nearest hospital (which, BTW, is known for its wonderful pediatric ER) to get a bili count before heading home, because I was so concerned about it continuing to rise and lead to complications. The dad told me the next day that the head nurse chewed them up one side and down the other for "bringing a newborn to a place full of sick people." She declared that the baby's heart rate, blood pressure, temperature, and oxygen levels were all within normal range and that they were negligent for bringing him there. What other options were there?!?!? Now on to the final question, and I'll try to make this as brief as possible. Where's the milk? The mom, age 38, is obviously producing very little milk, but she said she produced plenty of colostrum on the first few days. She fed the little guy constantly, day and night, so everything should have fallen into place. I know adrenaline can block oxytocin, but could her pain from the birth injuries restrict her milk that much? Background: She developed just like her sisters during puberty: maybe an A cup. She got silicone implants through axillary incision about 16 years ago, but she says she has lots of sensation in her areolae. She was a bodybuilder from ages 19 to 22, during which time her cycle was very irregular (I didn't ask if she took steroids). She said her hormones and cycle were "really screwed up" until she was 35, when she used dong quai, vitex, and progesterone cream to normalize them. When she decided to get pregnant, she had no problem conceiving. She reports having a dream pregnancy with no complications whatsoever, except her breasts did not change at all. She noted her L breast became hard and painful on d3 but quickly went away 1.5d later; R breast seems completely inactive. She had 2" long hair growing on and between her breasts (and she's Caucasian!). She was not overweight at all, even after pregnancy. Her lochia was bright red as of Friday night but she said as of yesterday it was much less and getting darker, so she suspected she may have been tearing her stitches when trying to do too much. Right now baby is getting hoers d'oeurves at the breast while they fix him a few ounces of formula, then mom tries pumping both for added stimulation. She's starting herbal and/or prescription galactogogues ASAP, which I hope kick in strongly because they despise formula. I suggested she have her thyroid checked and talk to her midwife about the possibility of a retained placenta. I also reassured her that most pain medications do not affect baby, and it's important that she is comfortable so she can be a good mommy. Any ideas/suggestions? Thanks in advance for reading this far, and for any wisdom you can share :) Debbie Gillespie, IBCLC Sunny Warm Tempe, AZ *********************************************** To temporarily stop your subscription: set lactnet nomail To start it again: set lactnet mail (or digest) To unsubscribe: unsubscribe lactnet All commands go to [log in to unmask] The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(R) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html