I saw a mom tonight with a 5wk old baby girl.  Baby born at 38wks (induced -
mom states because she was "tired" and first baby weighed 9lbs and she
didn't want this baby to get too big.) Labor was 3hrs, mom states 3 pushes
and baby was born.  Birth weight 7lbs7oz, discharge weight 7lbs3oz, weight
at 2wks 8lbs 4oz, current weight is 10lbs 2oz.  Mom originally contacted me
2 weeks ago (baby was 3wks at the time) because she had very sore nipples.
She described stabbing, burning pain, very bright red nipples, stinging
right after feedings.  Mom reported soreness in the first week due to poor
latch but felt baby had been nursing bettter and she had not been feeling
much soreness until the onset of this new pain 2 days earlier.  Mom reported
just finishing a 10-day course of antibiotics due to mastitis.  I suggested
to mom that she be examined for thrush.  Her ob saw her and prescribed 1
dose of diflucan and the pediatrician prescribed oral nystatin for the
infant.  I did not talk to the mom again (she did not return my follow-up
call) until she called today.  She reported that she and baby just finished
treatment for thrush, she had stopped nursing at the breast last week due to
extreme pain, had been pumping only with a Pump in Style and only pumping
every 4-6hrs.  Mom had developed plugged ducts in the left breast, she
reported feeling achy, like she had the flu, sweating profusely but no
fever, red, inflamed patches on the breast.  She was trying to put the baby
to the breast again, but baby is "clicking", will nurse for 4-5min then pull
off and fuss or cry.  I went for an in-home consultation this evening.  Mom
reports baby takes 45min to 1hr to take a bottle, she feels that baby is
pulling off and fussing due to over-active MER.  Upon examining the baby I
noticed that baby still has thrush (white patches on roof of mouth and back
of tongue), baby has a high palate and face appears assymetrical - left eye
is slightly higher than right eye, nose crooks a little to the left, left
side of the mouth higher than the right, when laid on back tongue is on the
roof of the mouth and baby's mouth is open.  Mom reports baby always sleeps
with mouth open if sleeping on back (however, baby mostly tummy-sleeps).
Baby opens wide at the breast and moms latch technique is pretty good, but
baby clicks and constantly looses suction at the breast.  Mom reports that
baby had been latching well and able to maintain suction until the thrush
occured.  She said that baby was clicking some the first week, but it had
gotten better.  We were able to get baby in a pretty deep assymetrical latch
that was more comfortable for mom and decreased the clicking, but it was
still there (about every 5 to 6 sucks, as opposed to every 2nd or 3rd suck).
I was able to hear the baby gulping milk vigorously but baby did not pull
off during this feeding as mom reports she usually does.  However, baby only
nursed 3-4min on right breast and about 5min on left before falling into a
deep sleep.  (Baby had taken 4oz of expressed milk from a bottle 1.5hrs
earlier).

Mom's nipples are short and almost flat, nipples are bright pink/red, left
breast has inflamed patches and I was able to feel 1 lump in the upper,
outer quandrant and one in the lower outer quandrant.  Mom had been pumping
every 2hrs since I spoke with her earlier in the day, was applying warm,
moist compresses and massaging prior to pumping and she reported that the
lumps felt smaller but the breast is still very firm to the touch and mom
reports decrease in supply on left breast.  I suggested soaking the breast
in a bowl of warm water with epsom salts (leaning over the bowl) for 5-10min
at a time prior to pumping.  I also suggest that she call her dr back for a
14-day course of diflucan and I suggested gentian violet for baby because
mom reported nystatin upset baby's tummy.  This addresses two of the issues
but I think that the bigger issue may be baby's assymetry.  Mom is an
occupational therapist, but she refuses to see the assymetry, other than the
"crooked" nose that she attributes to being "smooshed" in the womb and she
was a little defensive about that.  Mom says she only gained 15lbs during
the pregnancy and feels baby didn't have much room to grow.  Mom said she
has not worked with many breastfed babies in her practice as an OT.  She
states that she realizes that it should not take baby 45min to 1hr to finish
a bottle and mom has been supporting baby's chin when taking the bottle and
massaging her jaw and face.  I mentioned CST or chripractic treatment and
mom was adamantly against it.  She stated that she believes in
evidence-based practice and she doesn't believe that either CST or
chiropractic therapy is evidence-based.  It seems that route is closed for
now.  I'm not sure what other route to go. I thought about seeing if she was
open to seeking treatment from another OT.   Mom is leaving for vacation
tomorrow and will be gone until Friday.  We decided that she would
concentrate on treating the thrush and work on the assymetrical latch for
now.  She said that she may just continue to pump the left breast because it
was so painful to have the baby on that breast.  She did at least agree to
pumping at least every 2hrs until the plugged milk ducts were cleared.  I
advised her to call her dr if the inflammation got worse or she began
running a fever or feeling "fluish" again.  She said she would call me while
on her vacation and I would like to have some other things to suggest to
her.  Any suggestions?  Feel free to aks questions if I am leaving something
out.  There were so many issues that I am sure I forgot something.

With thanks,
Mellanie Sheppard, CBE
Lactation Connection
Arlington, TX
waiting (not so patiently) for the results of THE EXAM

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