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The Art of Medicine

Caring for a new mother

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: October 2017 - Volume 30 - Issue 10 - p 58
doi: 10.1097/01.JAA.0000524718.48213.1d
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Looking for goshawks is like looking for grace; it comes, but not often, and you don't get to say when or how.

—Helen Macdonald, H is for Hawk

I don't recognize the infant's name that appears on my mid-morning schedule. At 13 days of age, he's coming in for a weight and nutrition check.

I've never met this mother before, but I'm certain she's breastfeeding. In keeping with American Academy of Pediatrics guidelines, the practice where I now work encourages all mothers to breastfeed their infants. The challenge, of course, is to ensure that the infants are adapting well and surpassing their birth weight by 2 weeks of age.

The nurse steps out of the examination room, easing the door closed behind her. She's got a frown on her face. “He really hasn't gained any weight since last week—only half an ounce in 6 days.”

I open the chart to review the previous entries: birth weight, 9 lb 14 oz; discharge weight, 9-6; weight last week, 9-0.5; weight today, 9-1. This little fellow has dropped his birth weight by nearly 10% and seemingly plateaued from there.

Gently, I knock on the examination room door and turn the latch. The mother sits in a chair, nursing her infant. Slowly, he suckles at breast; but my clinical ear doesn't detect those small reassuring gulps and swallows.

I smile at the mother and introduce myself. “I don't believe we've met before,” I say. She shakes her head no. “So your little guy is almost 2 weeks old,” I say.

“He's not gaining any weight,” she intones flatly. “He hasn't lost, but he hasn't gained either.”

“I was just looking at the numbers. His weight is down about 10% from birth—normal for a breastfed baby—but you're right: he hasn't put on any appreciable weight since his last visit. Has your milk come in?”

She shrugs her shoulders. “I have some, but I certainly don't feel engorged. I put him to breast every 90 minutes. He feeds for about 20 minutes or so, then he falls asleep and I can't wake him up.”

“Can you express any milk?” I ask. “Do you leak milk when you take a hot shower?”

Again, she shakes her head no.

“Is he giving you wet diapers throughout the day?”

“Five or six,” she says.

“How often does he stool?”

“He had a good poop last Thursday, 5 days ago, then nothing until last night.”

Her eyes shimmer with tears.

Momentarily, I stand in silence, then decide to switch gears.

“First baby?” I ask.

“Second,” she says.

“Did you breastfeed your first child? How did that go?”

Tears cascade down her cheeks. “He was hospitalized at a month of age for failure to thrive,” she sobs.

I nod my head. “It sounds like, for whatever reason, your milk supply has dwindled. You've got enough to maintain him, but he isn't getting sufficient calories to grow. I'd like to add some supplemental feedings, 2 ounces of formula, after each breastfeeding. You could probably space out the feedings a bit, perhaps to 2.5 hours, to give yourself some additional rest in between.”

More tears. I pull a couple of tissues from the box on the windowsill and hand them over. She dabs the corners of her eyes, but now the flood gates have opened.

“Just because you're introducing formula doesn't mean you love your baby any less,” I say. “Many babies are bottle-fed over the first year of life and do just fine. The important thing at this point is to get some additional calories into him. Let's see him back in 2 days for another weight check. How does that sound?”

She flashes a smile through her tears and nods her head.

I rise from my stool, move toward the door, pause momentarily, then step over to where this mother continues to cuddle her baby. Quietly, I rest my hand on her shoulder. “Things will work out,” I say. “You'll see.”

Two days later my words are borne out. The baby has gained 3 oz; he's stooling several times a day. Those former maternal tears have been replaced with a soft smile.

Sometimes a few carefully chosen words coupled with a gentle touch is the best medicine indeed.

Copyright © 2017 American Academy of Physician Assistants