Dear Friends,
Please help, I am working with a mother and drawing a blank on where to go from here. 

Baby was born at 36 weeks weighing 3.186 kilos.  Gestational age was based on first ultrasound.  The mother was breastfeeding and not menstruating.  The last ultrasound done put baby at between 37-38 weeks but the doctors are still going with 36 at birth.  Baby seems older.

Mom went to the hospital since her water broke and asked to be induced when labor didn't start spontaneously.  She had an epidural and gave birth within a few hours.  Baby latched in the delivery room and sucked a few times.  He was then taken from the mother and given a bottle because of low blood sugar. (don't get me started about the policies at this one particular hospital).  Mom and baby were separated most of the time - except at "feeding times."  Mom says that baby would latch and suck a few times.  He was supplemented regularly in the hospital and mom was not pumping.  

Home from the hospital, Mom decided not to give any more ABM and only nurse.  Baby tried to eat all day but Mom says he only succeeded in really latching and eating twice the entire time.  Mom started pumping and bottle feeding.  

I saw him at 5 days.  He looked a bit yellow and Mom said that she was going for a bili test the next day.  Mom put him skin to skin and sure enough he started rooting but when he got to the breast he couldn't latch.  He tried and tried but couldn't do it.  Mom tried in cross cradle, asymmetrical latch, and football but nothing helped.  There wasn't anything about the Mom's anatomy that would have made latching difficult. I noticed that when the baby cried, his tongue did not go up to the roof of his mouth.  I finger fed him ebm.  His palate and suck felt fine.  (Ofcourse that doesn't mean that he can suck well with his mouth wide open)   After finger feeding, he latched on and ate well - suck swallow suck swallow, until he came off alone. The whole feed hurt a bit and nipple was slightly compressed. Mother woke him and offered the second side but he just fell back asleep.  Mom put him down and he kept sleeping.

Our plan was to try to feed him at earliest cues.  If he won't latch then put him skin to skin.  If he still won't latch, finger feed some ebm to calm him down and try again.  If baby still won't latch and is getting to upset, finger or bottle feed (paced feed) ebm and try again next time.  Lots of skin to skin.

The next day Mom kept him S2S and tried the above protocol but baby took an hour to latch.  She then went to the bili test and it was 23 so baby was put under lights for 12 hours and ordered off breastmilk for 24 hours in which Mom pumped and baby had bottles of ABM.

When Mom called me back she said that baby was back to breast but that he consistently took an hour to latch.  Once latched he would suck and swallow for about 7 minutes and come off asleep and apparently satisfied. Feeding doesn't hurt the mother and she didn't notice her nipple being squished.  Mom is at the end of her rope with how long it takes for baby to latch and how frustrated he is trying.

 They went back for another bili check and haven't called me since.

What else can I do to help this dyad?

Thank you so much for reading through this whole long letter - looking forward to your words of wisdom,
Chayn Fogelman IBCLC Israel

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