Pediatric Primary Care Case Studies (29 page)

You call her back and she reveals that Peter is eating five to six times per day for 20 to 30 minutes total and is sleeping most of the rest of the time. He has had four wet diapers in the last 24 hours and no stool in 72 hours. You ask her to bring Peter in for a status check.

Your criteria for adequate breastfeeding are as follows: At 8 days old, a baby should be feeding 8 to 12 times in 24 hours for a minimum of 10 to 15 minutes per side. In addition, he should be stooling three to four times daily and voiding light yellow urine at least six to eight times (see
Table 8-1
).

You are concerned so you fit them into the day’s schedule. She arrives one hour later with Peter and her husband. You do not have any information on this patient because this will be their first visit to your practice.

Breastfeeding Support

In addition to the indicators that Peter is not feeding adequately, there are also other reasons for bringing in the Jackson family at this point. The transition to successful lactation often requires providing support and information for families. Even in the absence of significant problems, a review of technique and expectations for breastfeeding and evaluation for maternal breast comfort are warranted. Among the most common reasons given for stopping breastfeeding are perception of inadequate milk production and sore nipples (Schwartz et al., 2002). The 3-day visit provides an important opportunity to address these issues. However, the Jackson family missed that appointment, so now is the time to assess the situation and provide needed support and/or intervention.

Professional healthcare organizations recommend exclusive breastfeeding for 6 months (American Academy of Pediatrics, 2005; National Association of Pediatric Nurse Practitioners, 2007); the Healthy People 2010 goal (Healthy People, 2000) is for 50% of babies to continue to be breastfed at 6 months of age.

First Visit

What information do you want to collect now?

The history-taking process for breastfeeding problems needs to include gathering key information about the baby, the mother, and breastfeeding activities in areas where problems may interfere with adequate weight gain.

The measurements were taken and the baby weighs 6 pounds 6 ounces today. You now enter the room and find a sleeping baby in the arms of a worried looking mother. Mr. Jackson also appears somewhat somber. Mrs. Jackson provides you with the following information.

Infant, Mother, and Breastfeeding History

Birth History
. The baby was born at 37 weeks and was a 6-pound 13-ounce male infant. There were no complications for mother or baby after a vaginal birth and an uneventful first pregnancy for this 27-year-old woman. Mother and baby were discharged together at 48 hours. The baby was sleepy during hospitalization, but nurses observed two feedings and did not report any problems. The discharge weight was 6 pounds 6 ounces (7% weight loss). The family was given a follow-up clinic appointment for 3 days after discharge but they did not attend.

Key information in this history:
Peter’s history to date has been uncomplicated by any notable problems. However, his birth at 37 weeks (near preterm) and his 7% weight loss, although within normal limits, are important to note. (See
Table 8-2
.)

Feeding history
. Mr. Jackson has been trying to help keep Peter awake during feeding attempts. They have to wake the baby for feedings and stimulate him to keep him awake. They are successful every 4+ hours. Peter generally feeds for 20–30 minutes but a lot of that time is spent in waking him up. Mrs. Jackson reaffirms that he has had four to five wet diapers (disposable) in the last 24 hours and no stool for 3 days. The last stool was green, pasty, and smooth in texture. She has seen him urinate during a diaper change and describes a strong stream. Mrs. Jackson thinks maybe she feels her let-down but does not hear any loud swallows from Peter during feeding. She has leaked breastmilk occasionally but not as much in the last 48 hours. On the second day home, she experienced some engorgement but Peter continued to nurse and her breasts became less hard. Her nipples are a little sore but she has not experienced any cracking or bleeding.

The parents have been grateful that Peter has been such a great sleeper for the past few days because they now are getting more sleep than they expected. However, in the last 2 days they have begun to worry that he may not be getting enough to eat. Peter’s maternal grandmother says he looks “skinny” and has recommended that they supplement with formula. They want to breastfeed and have resisted supplementation so far. Peter’s last feeding was 2.5 hours ago.

Key information in this history:
The infrequent and less than vigorous feedings are important to note. The lack of audible sounds of swallowing are also concerning. Finally, the absence of stool for 72 hours provides an indication that Peter is not getting enough breastmilk to gain weight. (See
Table 8-3
.)

Mother’s related history
. Mrs. Jackson has some allergies to pollens and dust but takes no prescription or over-the-counter medication on a regular basis. She denies any other chronic illnesses or conditions. She has not had any surgery other than an appendectomy at age 13 years. The pregnancy was uneventful and uncomplicated with routine prenatal care beginning in the first trimester. Her vaginal bleeding has stopped. She plans to use progestin-type birth control pills beginning at 6 weeks postpartum. She has been drinking lots of fluids and eating well in order to provide milk.

Key information in this history:
Mrs. Jackson is healthy by history. The lack of any chronic illnesses or surgery to the breasts or thorax is encouraging. In addition, she is not using any medications routinely and there is no evidence of hormonal influences from retained placenta or contraceptives. (See
Tables 8-4
and
8-5
.)

Other than the feeding concerns, Mr. and Mrs. Jackson have no other questions about Peter at this time.

What will you look for on the physical examination given the history to this point?

Physical Examination

You move on to the physical examination of Peter. Your examination reveals a baby with decreased fat distribution over his face, abdomen, and extremities but no evidence of dehydration. He is quietly alert at this time. He appears somewhat pale without any signs of jaundice. He weighs in at 6 pounds 6 ounces. His temperature taken in the axilla is 98°F. He has good tone and responds to light and sounds. His heart rate is regular, and no heart murmur is heard. Femoral pulses are palpable and equal. His lungs are clear. His mucous membranes are moist, his suck is strong, and his palate intact. His umbilical cord stump has fallen off, and the area is clean and dry. In addition, his circumcision is healing well. He has voided in his disposable diaper and the urine is a light golden color. There is no “brick dust,” an indicator that a baby is not getting enough milk. (“Brick dust” on the diaper results from uric acid crystals forming in concentrated urine). Otherwise his physical examination is unremarkable.

Mr. and Mrs. Jackson become very upset at his weight as they realize he has not gained any weight since discharge. They wonder if they should go and get some formula immediately.

What do you say at this point?

Peter’s exam is within normal limits with the exception of weight. In addition, there are indicators supporting inadequate weight gain but not the more serious failure to thrive. You share this information with the Jacksons in a supportive manner and urge them to stay calm while you proceed with the breastfeeding evaluation.

What will you look for on your breastfeeding evaluation?