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