It's been fun receiving the private responses to the complicated case I
presented, and bravo to the brave souls who went public with their
suggestions. I will share what I did, and keep you posted from time to time
on how it is working. I want to remind everyone that there is more than one
way to be right, so if you would have managed it differently, I think there
is room for other opinions. I'll risk being wrong in public by keeping you
informed of the outcomes of my interventions.
What I decided was that there were essentially 2 complicated cases: The
mother had very suspicious indicators in her health hx which make her high
risk for impaired production. She had the most invasive kind of breast
surgery -- reduction mammaplasty. Periareolar scars and reduced nipple
sensation indicate both ductal severing and nerve impairment. These cannot
be fixed by management, altho every attempt should be made to maximize her
production. Additionally, she had a progesterone imbalance which caused
infertility. Did she ever experience enough ductal and alveolar
proliferation to support full lactation? Her lack of breast changes during
preg. suggest she may not have. While she was only double pumping 6 times a
day by the time I saw her, she was nursing constantly, carrying baby
non-stop and feeding in a variety of positions with lots of rousing
techniques. I am not saying herbal galactagogues wouldn't help, and I've
started her on some, but I suspect it is not prolactin which she lacks, but
an intact nipple to brain pathway and sufficient glandular development. I
have done the expected things such as upping the number of pumpings, etc.
but I will be surprised it her milk supply comes up much.
The second set of issues surround this feeding-aversive infant. It took
several days in the hospt. to identify the broken clavicle, and by then baby
had been manipulated in feeding positions which I suspect caused her pain.
She is very "shut down" in terms of affect. Additionally, as some pointed
out, the 3 deep suctionings have probably created a very sore throat, and
perhaps some damage to swallowing ability. Baby has been fed with very fast
flowing nipples because everyone is so worried about her weight problem that
they are pouring milk into her, and I think this has added to her aversion.
She weighed about 7lb 8 oz at birth and is 7lb2 oz at 14 days -- the same
weight she presented with on Day 9. Remember, for a week she has been
OFFERED a full daily compliment of milk/formula by bottle. She should be
very hungry and yet won't eat what is provided. That suggests a swallowing
or a respiratory prob. Observing her bottle feed was the clue. She forgets
to breathe while feeding. She takes one swallow after another until she
runs out of air and starts to stress. She chokes, spits, arches, frowns,
and since mother holds this fast flowing bottle in with grim determination,
baby does the only thing she can to get mom to quit: she closes her eyes
and plays possum.
I got a slow flow teat, showed mom to pull bottle out to rest tip on lips
every 2 swallows to allow for catch-up breathing. In a few min. baby was
pacing her swallowing and breathing better. She opened her eyes, relaxed
her face and body language, and took 3 oz! When she fell asleep, she was
laid down in a supine position. In a few min. she made a terrible face and
spit up a bit and began to cry. I think she also has a reflux prob. So I
suspect pain, a swallowing prob. and reflux are contributing to her
reluctance to fully feed. Shoulder and throat pain will resolve with time,
pacing respirations with swallowing can be helped by better bottle-feeding
technique. Reflux can be treated. If we can do these things while still
keeping baby nursing for comfort, she will begin to breastfeed. Because
remember, she likes the breast now precisely because she can latch on and
NOT SUCK. She really hasn't liked anything with a flow rate, so we have to
work back from that point and make her confidant that swallowing doesn't
hurt before during and after feeding. In my opinion, cup feeding would be
risky for a baby such as this one with swallowing problems.
The plan will be to get her weight and energy up with pumped milk/formula in
a way that doesn't cause her more distress, restores her trust, and gets her
energy up.
I'll keep you posted on how efforts to increase milk prod. work.
Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates, Austin, Texas
http://www.jump.net/~bwc/lactnews.html
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