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Initial Low Milk Supply: A Breastfeeding Story – Case Study

034     The History:

 One typical busy morning coming on shift, one of the couplets I received report on was a 3 day post-op C/S mom and baby who were scheduled for discharge this same morning.  She had been a long 3 or 4 day failed attempt to induce a vaginal delivery for fetal macrosomia (big baby) at 40 5/7 weeks before the C/S.  Lots of IV’s, lots of Pitocin… all before the birth.

Her baby weighed 10 lbs 4 oz at birth. We got in report that his glucose sticks had all been over 60 initially so they were stopped early on. His exams were normal.  His total bilirubin this AM was 11.3 at over 72 hours of age. He was “breastfeeding only”  (*sigh*from the nurse giving me report).  She then expressed a concern that  he was down 10% from birth weight weighing 9 lbs 4.5 oz today.  When I asked her about the feedings, she said he’s been nursing beautifully all the time but nobody’s had time to stay in the room and watch him feed. I asked about the output and she reported he’s been voiding, the last stool was a couple shifts ago.  Then the nurse added “We told her you were here today, Melissa, she has a lot of questions for you. ”

I was able to juggle some things around, have staff cover some of my other responsibilities temporarily to make this a priority. Since I am a general staff nurse, there are often more pressing situations. Fortunately, today I was able to manage the time to see her right away.

I went in and introduced myself to Meg*, Brad* and their son Mikey* (*names changed). They had indeed been waiting for me.  Breakfast was underway and Mikey was asleep in his crib. I asked her a few general questions in a relaxed manner about breastfeeding first to try to establish some background: Mikey’s energy level, drinking pattern, feeding frequency, and diaper checks.  It is important to gather information and observe the feeding  in the process of  a full evaluation to determine adequacy of feedings.  The information I got was concerning.  He spends a lot of time at the breast, falls asleep quickly, not very energetic with every feed, not much change in her breasts at this point and no stool since yesterday. I did not tell her I was concerned at this point, nor did I mention the weight yet. I asked if I could check him now and if  it would be alright if I observed the next feeding.. We determined that should be with in the next hour. I talked about feeding cues and asked her to get me if  Mikey seemed ready to eat before I came back.  His vital signs were normal, jaundice not too significant for his age, diaper contained a small amt concentrated urine, and Mikey went immediately back to sleep.  I felt he was OK at the moment and needed to go do a few other  things with other patients.
 
At this point I am feeling pulled in different directions because Meg’s situation could easily take hours of my already busy morning. I am upset that this has possibly been going on the last 3 days and hasn’t been evaluated properly, now it’s day of discharge! How do you do the proper evaluation, give the needed gentle support, make possible feeding plan arrangements in fragments of time? This is what I am trying to change…in my opinion, we the hospital, helped contribute to this situation of possible inadequate feeding and supply… we need to help her! I talk to the charge nurse and it’s cleared to keep my coverage the rest of the morning.. good thing L&D was quiet!
 
Mikey’s doctor comes in and thankfully it is a partner who is very pro breastfeeding and open minded to try options a mom may choose. I gave her report on his physical status, VS, weight, earlier glucoses, and the Bilirubin. I summed up my plan to evaluate feeding quality but suspected he has been ineffective at the breast & milk supply/production may be delayed. I added that I was going to check his glucose if he had low energy level, and encourage pumping or expression for the mom and get that milk into the baby as well as encouraging her to stay for a few feedings to work with me. The MD was happy with these ideas but requested he be supplemented (complemented) with formula at all feedings now until his weight came up. She supports the theory (as I do) that the birth weight can be somewhat inflated with all the pre-birth IV fluids mom rec’d and some of what he lost may be fluid.  The MD said that if things were better by afternoon, he could go home. She went out to examine him at mom’s bedside.
 
I went in for my feeding observation a little while later. Meg now knows his total weight loss and feels very upset. I give her a lot of support and agree with the doctor that some of that could be fluid. I then find out..Meg is an RN here at my hospital on another floor! It had not come up in conversation! So now I know she is even more worried because we nurses always think the worst! I do my best to think simple and encourage her to do the same… it is very early and we can turn this around quickly with a strong approach.
 
My Evaluation:
  • Good independent maternal positioning, holding and offering of the breast
  • Nipples erectile, breast tissue soft, pliable, small amts colostrum expressed–> mom reports her breasts were “swollen first 2 days”
  • Latch fairly adequate but not optimal-> improved greatly with football position and instruction on asymmetrical latch approach (I’d like to say here that I have a” if it’s not broke don’t fix it” attitude. I don’t correct a latch for a mom who has no pain and good milk transfer, we talk about it in case it may come up for though)
  • Mikey very sleepy at breast, difficult to maintain latch, no milk transfer observed–>breast massage during feed tried without improvement
  • Due to continued low energy level (suspected caloric deprived state causing sleepy ineffective feeding behaviors) a bedside glucose was checked. Result was 49.
  • Diaper dry–> the previous concentrated void was only his 2nd in last 24 hrs No stool last 20 hrs and that one was dark.
The mother’s feeding plan:
Many options and teaching points discussed with Meg including the need to boost caloric intake –>starting right now, methods to get her milk or formula into the baby avoiding bottles, a vigorous pumping plan to augment breast stimulation, alternate breast massage, how to observe for swallowing and milk transfer at the breast etc.. I also discussed with her how in my experience, sometimes it is like magic once the baby regains up to birth weight… they just take off!
She chose:
  • Cup feed formula now while she pumped –>Mikey would not cup feed so we used a syringe, 18 cc, repeat glucose 62
  • Pumping round the clock, double pumping –> Meg rented a hospital grade pump for home use
  • Keep close eye on feeding cues, put Mikey to breast in football w/ latch process discussed earlier
  • Closely watch signs for milk transfer, correct feeding activity while at breast, sucking rythym 1 or 2 sucks /swallow ( Brad was very involved in this process of learning the observation techniques)
  • Use breast massage/ compression while baby @ breast through feed to increase milk transfer
  • Goal of min 8 effective feeds in 24 hr..wanted to try for 10 –>agreed to feed expressed milk or formula 1/2 to 1 oz after each feed first 24 hrs until re-weighed next day
  • Have as 1st 24 hr goal:  to see 3 -4 increasingly wet/clearer diapers and at least 2-3 good sized stools
  • Return to MD for F/U bili and wgt check next day
  • Call IBCLC for eval in next few days if weight not adequate and not independently breastfeeding/output  within safe parameters for age

The follow up reports:

  • DAY 1 (In hospital) Mikey fed 3 more times in the hospital at 2 hour intervals.  Each time he had about 15 to 20 cc of formula by syringe. Each feed was improved but not adequate quality of milk transfer. Meg pumped 4 times before discharge not getting much first 3 times but 4th time she got almost 10 cc! Mikey had 1 conc wet diaper and a med sized dark stool. We re-weighed Mikey prior to discharge and he was 9 lbs 5.5 oz.  Meg left the hospital late that afternoon while I had been called to a STAT C/S. She was determined to go home after all the time she had been there! I called her later and she was on target with her plan.
  • DAY 2 (first 24 hrs home) Seen at Peds office. (reported to me from MD)  Bilirubin 10.6, weight–> 9 lbs 7.5 oz! Baby more energetic, better quality feeds reported. Meg still power pumping, now getting 1 -2 oz per pumping and giving to baby with syringe and only used formula occassionally if no breastmilk.  Had 3 wet and 2 stools since discharge, stools lighter in color. MD arranged F/U weight visit for 2 days, will arrange IBCLC if no strong improvement before 2 more days
  • AGE 6 1/2 days Seen at Peds office. (reported to me from MD) Weight–> 9 lbs 11 oz !!! Meg having fairly same routine but not always pumping if she feels Mikey had good milk transfer. She reported increased  breast fullness, 6 wetter, lighter urines and 4 mostly yellow stools in each of the previous 24 hr periods.
  • AGE 2 weeks  I don’t have MD office reports but Meg called me to tell me Mikey was 1o lbs 7 oz at his 2 week check up and nursing a lot better EVERY feeding!! She was still attached to her pump, gradually decreasing the sessions, just felt safer to keep going with that. If she gets milk she was still giving it to him. This was her security blanket and she was happy doing it. She was very proud of herself and crying happy tears! 🙂

Meg’s case was a beautiful example of HOW a situation can turn around quickly.  An individual mother’s determination coupled with a productive plan can produce these results. All situations are different.

Every mother and baby deserve our best!

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9 Comments Post a comment
  1. great post.. this is a common refrain i here from moms – meg was very lucky to have you give some extra time for her. a lot of other moms i know who raised this problem have been advised to supplement with formula, without being given tips how to boost milk production. This is certainly a post i will share with them. thank you.

    August 12, 2009
    • StorkStories #

      THANKS so much for sharing! 😉

      August 15, 2009
  2. Gayle #

    Everyone should be as lucky to have a great LC like you!

    August 12, 2009
    • StorkStories #

      Thanks ! *blush*

      August 15, 2009
  3. I’m so glad that mom (and baby) were able to turn it around. I think that if more women received better support, in and out of hospital, there would be more stories like this. It’s great that you were there, I think you made the difference to this nursing pair.

    August 12, 2009
    • StorkStories #

      Thanks Amber, I feel the same way. Correct information and early support is all some moms need for it to make a difference. Unfortunately, though, for every story like this there are several more that go the other way.. 😦 We still have work to do!

      August 15, 2009
  4. Susan #

    Does a baby need to feed at least 8 times a day during the first 2 days after birth (before milk comes in)? I did that with my first and I had problems with low milk supply (and almost no sleep) for weeks, while others I know took a 4-6 hour nap that first day and had no problems with milk supply. Also, can babies feed on demand once they surpass their birthweight or do we still need to wake up the baby every 3 hours? Thank you.

    August 14, 2009
    • StorkStories #

      Welcome! I am sorry for your issues with low supply. While I couldn’t say exactly what went on with your situation, the recommendation from the experts is a minium of 8 EFFECTIVE feeds per day even in the 1st couple days. There are some references that have said a minimum of 6 in 24 for first two days after the birth but the key would be not in the numbers but the quality.
      As far as feeding on demand, I like to use the phrase “feeding on cue”. If a baby is feeding well at each feeding with in the safe parameters described here in this post, and there are no other health concerns from the babies doctor, the answer is YES! Absolutley! Normal healthy newborns feed better when fed on cue and NOT on a schedule. Thank you!

      August 15, 2009
  5. Kick me in the butt for not replying to this sooner Melissa! I think this is a great example of appropriate hospital intervention for milk supply and weight issues for this specific family, even though it happened on day 3. Thank goodness you were there! I wonder what would have happened if you hadn’t been able to advise her??
    Anyhow, I’m glad she was able to turn it around. Now if all hospitals had a CLC or supportive breastfeeding peds and OB/Gyns and nurses, we’d likely hear more of these kinds of success stories.

    August 20, 2009

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