Newborn Dehydration

“What a cute baby.  How old is he?”

“4 days.  We can’t wake him up.”

Some days, from nowhere this conversation echoes in my mind – I can see the ER counter in front of me and know exactly what position I was holding Pumpkin in when the nurse who commented on how very sweet looking he was plucked him from my arms.  No one at the ER cared about our names or if we had health insurance – they barely cared if Spouse and I could keep up with them.  We watched the very definition is “springing into action.”

Pumpkin had been born on a Friday and this was the following Tuesday.  He had been a normal active baby at his 10am check up that morning and by 5pm he had slipped into a coma-like state: unwilling to eat; limp as a ragdoll; unresponsive to pinches and other pain; and finally no eye movement.  At our check-up our doctor noted that he had lost too much weight and that Pumpkin needed to eat every 2 hours, no exception and we were to return the next day.  All he needed to do was gain an ounce.

But we didn’t make it that far.  We left the pediatrician at 11am and fed Pumpkin.  He didn’t want to eat at 1pm but he ate around 2pm.  At 4pm we tried to feed again and had trouble waking him.  He roused a little but no eating.  Within the hour we watched as he fell into a deep sleep and went limp – unresponsive to any noise, touch, light, anything.

The ER staff at St. Rose Siena was fantastic – covering all bases with us, testing and monitoring.  They have a pediatric ER so our doctors were there for children only and knew their stuff.  They assured us it was most likely dehydration but tested for everything else one can test for with blood samples and a spinal tap.  Though still largely unresponsive, Pumpkin did cry some for the spinal tap.  Heart-wrenching to know he was in pain; relieving to know he was still able to respond.  Though I thought the obvious thing was to tell us if he was going to survive no one mentioned that for a few hours.  That’s because all his vitals were fine so the medical staff didn’t see this as a risk, didn’t occur to them.  Regardless, it was all I could think of and once my baby left my arms, I started crying.  Not weeping or wailing just tears streaming down my face.  Not knowing, feeling failed, scared and helpless was intense and awful.  That feeling and the tears pretty much continued for 30 hours – when, after bags and bags of IV and routine every two hour feedings, Pumpkin let out a vicious cry all on his own.  It was, without doubt, the most beautiful sound I had ever heard.

In that time, Pumpkin’s test came back clean – no meningitis, no brain infection.  He had an EEG which determined that his brain had shut down everything but what was essential to stay alive.  Smart baby.  They had not ruled out metabolic disorders yet (though a few weeks later those were ruled out via test results).  The nursing staff focused on feeding him – we were still trying for every 2 hours.  I was breastfeeding and the hospital staff supported me 100%.  I had a Medela industrial pump in our room and I pumped every 2 hours while we fed Pumpkin Similac.  That revealed something important – I wasn’t producing but drops of milk.  After the colostrum, though I thought it had, my milk never came in.  Pumpkin hadn’t really been getting any food despite sucking for appropriate amounts of time and there being milky residue on my breast.  I was producing a small bit – but only about 1/6 of what was needed.  We were measuring in milliliters, like less than 10 ml per pumping (newborns go for 30-90 ml per feeding).

After a little over 24 hours of feeding the formula, Pumpkin started to come around.  The EEG was done by a pediatric neurologist on Wednesday and when he made his rounds on Thursday he thought he had the wrong baby – Pumpkin had revived!  The doctor called him a whole new baby.  And he was!  Crying, squirming, pooping…he was doing all the wonderful things that newborn babies do.

Once Pumpkin wailed of his own volition, we felt we were past the darkest period of this trauma, and our doctor diagnosed dehydration as the most likely culprit, my thoughts turned to “Why? How did we not see this coming?  Why doesn’t every piece of literature mention dehydration?”

I thought I had missed something – this had to be our fault.  For those of you who know me, you know I am a researcher.  I like to research, to know, to plan.  So I reviewed everything I had read (The Baby Book, What to Expect When You Are Expecting, Your Pregnancy Week by Week, What to Expect the First Year, The Nursing Mother’s Companion) – and I had a hard time finding anything in any of those books that address dehydration in the first days.  Yet the hospitalist told us that the see this in 4-5 day old infants fairly routinely.  Where is the information on newborn dehydration?

Even targeted internet searches reveal little information (and, of course, having to search is the problem – the info isn’t in the obvious, commonly accessed places) .  There are lists of symptoms.  Key symptoms are: lethargy; fussiness; sunken fontanels; more than 6 hours without a wet diaper; lack of bowel movements; cold, splotchy looking hands and feet; improper sucking and excess weight loss (>10% birth weight).  There are instructions on what to do: call your doctor or go to the ER.  The best resource I found at the time is a Le Leche League article that is defending breastfeeding as a “cause” of dehydration in the face of a TV new program that identified dehydration as a danger of breastfeeding.  But this isn’t part of their basic web-based literature (I did not read The Womanly Art of Breastfeeding, the main LLL publication, so there could be an extensive discussion there).  In a web search today I found an article from the European Journal of Pediatrics from July 2009 that shows 1 of 66 breastfed babies suffer dehydration (about 1.5%).  Hardly an epidemic, I understand that.  Still, overall, I found the parent-prep books and resources to be lacking on this topic.

As such I want to tell everyone our story – to make sure new parents know what to look for and what precautions to take.  Pumpkin went into this hibernation so quickly – about 6 hours – and we, luckily, took all the right steps but it would have been so easy not to.  I am certain that we would have avoided this all together if we had just known a few things – and how I wish all those books would dedicate the one page necessary help those of us in that small 1.5%!

Here is what I learned and what I want every new parent to know:

1. Key indicators to look for. The basics are weight gain/loss, wet diapers, and consistent milk intake.  These are all good individual indicators but really they all work together.  We relied heavily on one indicator – the diapers – and that was a mistake.
2. Breastfeeding is a wonderful, natural, nutritionally perfect system to feed babies.  But not every mom will produce milk and not every mom will know when or what support to get.  See a lactation consultant and be vigilant – but also know that it is ok to supplement.  A little formula is way better than a little coma.  I saw 7 lactation counselors and took a lot of supplements before we resigned ourselves to full-time  formula feeding. Many breastfeeding proponents will say that it is very, very rare for milk to not come in and while I can’t attest to the percentages, when I told my story to friends and family it was a fairly common occurrence.  Some women had even had their prolactin levels tested to find them off the bottom of the charts.  There is a real possibility that a mother won’t produce milk – pumping is a good way to see how much is being produced and alleviate any concerns.
3. Pumpkin-head had been producing wet diapers reliably.  But as it turns out because he had been delivered via C-Section there was a lot of fluid being flushed from his body (rather than having been squeezed out in the birth canal).  What we thought was a reliable indicator was not – and no one had clued us in (not nurses, doctors, books, lactation consultants, web-sites) that extra fluid is very common with C-Section and so diapers could not be as relied upon as an indicator as they could with a vaginally delivered baby.  The journal article referenced above indicates that C-Section babies have a 3.4 times higher risk of dehydration.
4. Pumpkin’s loss of weight revealed at the pediatrician’s office was a big indicator but because we had been having trouble waking Pumpkin-head for feeding from the start our doctor thought the increase in feeding for a day would correct the trend.  Perhaps because of all the drugs in my and Pumpkin’s system at the birth, he was very sleepy, very hard to wake.  Though for months after this event he remained hard to wake for feeding – we did it nonetheless.  In those first days we thought maybe he needed sleep and his system would know when he needed food.  Not true – the first of undoubtedly many times parents will have to guide kids to what is right and needed.  Another problem with this indicator is that very few people have a baby scale at home.  Those scales measure to the ounce and most adult scales are simply not that reliable.  An early check-up at the pediatrician will help remedy this (like a day or two after you arrive home).  Plus your doctor’s office should be happy to let you visit and weigh your baby in the days following his birth.  This really is the most fail safe indicator to track.  Here in Vegas we have the WomensCare Centers that all have breastfeeding support including free access scales – if we have a second child, you can bet I will be there for a weigh in each day until a pattern of weight gain is established.

As a new parent I was aware that dehydration was a possibility during illness or in the heat, but I didn’t understand the basic risk of dehydration in the early days of life.  And because I am a researcher, a planner, a woman who uses resources, I feel like if I missed this important topic in the literature others could easily be unaware as well.  So that is why I am posting this – I wouldn’t wish those 3 incredibly difficult days on anyone – parents, babies or the people who love them.

Below is a picture taken after Pumpkin revived – maybe midday on the Thursday.  It is one of the most cherished pictures I have of him.  In some ways it was like he was born right then – he had, at the very least, come back to life.  The sun on his precious face…it was a new beginning, a year ago today.  Maybe we are the only silly parents who were unaware of this real risk and how all the indicators work together, but in case not, please share this with anyone you know expecting a new baby.