Dear Wise Ones,

Okay, Okay, I'm in over my head on this one without a nearby, available
today, resource and I need some help, suggestions, references to look
for, etc.

Today I saw a five week old infant who was born at 35-36 weeks, weighed
6#7oz, spent 10 days in ICN, 5 of them on a respirator, with lots of
suctioning, etc.  He's been at home for nearly 3 weeks now, on low flow
oxygen re: residual lung problems.  Mom, a 16 year old, has been
faithfully pumping since 24 hrs post delivery, and giving infant EBM via
bottle, with no need to supplement ABM since discharge.  She reports
pumping every two hours during the day and once at night.  Clarifying
that, I found she pumps and then waits two hours from when she finishes
til she starts again. :)

Grandma (very supportive of BF, did so herself) asked me to visit to
evaluate why mother could not get baby to take breast.  She also
reported that she was worried that mother's milk supply might be
deminishing.

Evaluation shows infant becomes very high muscle tone whenever he is
brought towards breast.  Clenches arms tightly against body, flailing
wildly, very little rooting behavior.  Much more relaxed when he is
lying on couch or in mom's lap.  Generally speaking he clenches his jaw
tightly shut when near breast, or when bottle nipple approaches his
mouth.  The report is that he has to be coaxed to take nipple for EBM.
I found that to be true when I attempted feeding EBM.

Suck evaluation shows very high negative pressure with a shallow grasp
of finger, and initial easily elicited gag when finger advanced toward
junction of hard/soft palate.  Gag was somewhat extinguishable with very
slow advancing of finger, but baby does a lot of tongue thrusting.
Grandma reports that he does that with bottle nipple also.

He has had almost constant "orthodontic" pacifier use since discharge
(family threw away the longer pacifier supplied by ICN because "it
gagged him").  I suggested that they do away with the pacifier.  We also
reviewed feeding cues, and discussed how quickly breastmilk is absorbed.

Since I felt the need for advise before I attempted to deal with getting
babe to breast, I spent most of today's visit on helping mom use pump
(hospital grade double set-up) more effectively.  I described and demo'd
breast massage/compression as she has multiple palpable ducts which were
not emptying as she pumped.  She reported getting little (20ml vs
previously getting 100ml each side) from one side in the last two days
when compared to earlier experience.  She did describe having had a
couple of days when she was unable to pump for 5-6 hour periods (been at
other homes for holiday activities and had not taken electric pump with
her!) and had noticed a decrease since that.  We discussed supply/demand
theory and went over some things to increase supply now.  By the time I
left this afternoon both breasts were soft with minimal palpable ducts
and she reported having gotten more this pumping than other recent times
(about 100ml from rt, 90 ml l).

I'm going back in am to see how things are and to talk about other
things that can be done.  I've worked with newborns who had difficulty
with sucking, but never one with this strongly reinforced a pattern of
problem behavior.  Any suggestions you can give me would be really
appreciated.

I left her with an infant carrier and suggested she just keep him close
and observe for early feeding cues so that she can respond right away to
those.  Both grandma and mother seemed to understand that.

Where do we start?
     infant massage, skin to skin, water bath,
     new feeding positions?  mom does well with cradle, cross-cradle and
football holds (that is she holds infant comfortably and easily moves
him around)
     attempt finger-feeding and suck retraining?

My visits are no cost to mom through a state funded program. (And are
supposed generally to be related to promoting infant
development/parenting behaviors.  I use this platform to provide as much
encouragement to newly breastfeeding moms as I can.)  Unfortunately I
don't have an experienced IBCLC to invite along with me.  Baby was born
at hospital 40 miles away, and local hospital's IBCLC apparently isn't
available this week.  Medicaid doesn't cover her charges so mom probably
wouldn't go for that level of care.  Baby has already amassed medical
costs in excess of $85,000!

Thanks for all the support you give to those of less experienced ones.

Melinda Hoskins, MS, RN, LC2B?
Visitation Supervisor, ISD#3
Family to Family Connection
Northern Nevada, where it felt like spring today as the snows melted
away in our 57 degree sunny day.