You are a nutritionist in a small rural WIC clinic. Kara, a 35 year old white postpartum woman, is your last appointment on a Friday afternoon. Kara's pre-pregnant weight was 115 pound and her height is 5'8. She gained 22 pounds with this pregnancy. Today she weights 120 pounds, Kara's new baby, Britta was 6 pounds 6 ounces at birth. Britta was born at 38 weeks after an apparently uneventful pregnancy at a hospital that is about 30 miles from her home. She and Britta were discharged home after 24 hours, and have had no follow up care since the hospital.
Kara is a 35 year old single mother. She has two other children ages 10 and 12. Her extended family lives on the east coast. She moved to this area 2 years ago and tells you that she hasn't met many people because she's been busy with her children and her small farm. Kara's boyfriend makes his living by fishing and is currently close to the end of a three month trip to Alaska. When he is not fishing they live in a house on 20 acres together. There they have a large vegetable garden and raise chickens and goats. Kara makes a modest income selling products from their small farm. Kara tells you that her boyfriend was sorry to miss the Britta's birth and that he plans to be an active presence in her life when he gets back.
Kara had early problems with breastfeeding her first two children and switched to formula with them in the first few days of life. This time, both she and her boyfriend are very committed to breastfeeding this baby because they feel that it will provide many health benefits.
Britta is now 10 days old. She lives in a non-fluoridated area and is being given no other foods or supplements other than breastmilk at this point. You weight Britta and find that she is 6 pounds 10 ounces and 18 inches long.
Kara tells you that Britta is a very quiet baby and is actually sleeping through the night. She has about 4 wet diapers a day and has had three bowel movements since her discharge from the hospital. Since it has been so hot, Kara has been giving Britta bottles of water, which she drinks without a problem. Kara has been trying to nurse Britta at least 6 times per day in between working in the garden and getting the older children off to school and fixing meals. Kara had a lot of trouble with sore nipples when she tried to nurse her first two children and now she says that she is so sore, she has to put ice on her nipples before each feeding. She says that she was very uncomfortable with engorgement at first, especially at night, but now her breasts seem to have a lot less milk.
Kara's Diet for the past 24 hours:
| Yesterday | Today |
| 5:00 - Baked chicken thigh 1 cup steamed green beans, 2/3 cup ice cream, 1 cup goat's milk Evening: 2 cups water while nursing |
6:00 - 12 ounce Blessed Thistle Tea 8:00 - 1 cup Cherrios, 1/2 cup goat's milk, 1/2 cup raspberries 11:30 - egg salad sandwich: 2 eggs, 1 T mayo, 2 large slices whole wheat bread, 16 oz iced tea (no sugar) 3:00 - 1 large plum and 1 oz goat's cheese During Day while nursing: about 5 cups water |
You are not a trained lactation consultant, but you ask Kara to nurse Britta while you watch. You notice that the baby's lower lip is folded in and that she appears to be mostly sucking on just the tip of the nipple. There is no regular suck swallow breath pattern that you can detect, indeed you notice very little swallowing. Britta pulls off the breast and Kara winces and tries to push her back onto the nipple and when that doesn't work leans far over and tries to put her breast in Britta's mouth. Both mother and infant are clearly frustrated.
Kara is in tears and she says that she feels that she just can't do this anymore. Over the phone, Kara's mother has been advising Kara to give Britta some infant cereal and goat's milk. Kara is here today to ask for WIC coupons for formula.
A few weeks after this visit with Kara you are asked to serve on a county committee to look at ways to improve perinatal care.
REFERENCES
Pregnancy Weight Gain Grids: http://www.healthy-baby.org/pdf/WeightGainInstAndForm.pdf
The National Center for Complementary and Alternative Medicine (NCCAM) http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html
Lawrence, Ruth A and Lawrence Robert M. Breastfeeding : a guide for the medical profession. St. Louis : Mosby, 2005
Riodan, Jan (ed). Breastfeeding and Human Lactation. 2005 (on reserve in HS library)
Breastfeeding Triage Tool: http://www.metrokc.gov/health/breastfeeding/factsheets.htm
Pediatric Nutrition Handbook (on reserve in HS library)