I am hoping to obtain you collective wisdom on this case, expecially
Lisa Marasco if you're out there. Mom has given permission to post. I am
struggling to put this entire puzzle together.
Baby problem - I am working with a mother and her 12 week old son born at
36 weeks gestation, 7#10. Choking and difficulty breathing occurs during
feedings, both breast and bottle. He does alright for the first 3-5 minutes
takes in 2-3 oz in 5 min or less, but then starts to struggle. He comes off
and on the breast and feeding will then take 45 min to an hour to get
another 1-2oz in him. His latch is shallow as I would expect with the fast
flow - guarding. He normally takes 7 feeds in 24 h and sleeps 8 hour
straight at night. Weight gain has been continuous, though the last check he
was dropped from the 75 to 50% curve. The cookie swallow test was done
today, unfortunately it was done with bottles of formula. He hasn't had any
other formula since in the hospital. First bottle contained regular formula
and was fed with a slow flow, wide based nipple. Baby fed relatively well
for a bout 5 minutes and took in 1 oz. Second bottle contained formula
thickened with rice cereal and was fed through a standard bottle with a
cross cut nipple. The intake was 2 oz taken very quickly. He began choking.
There was some penetration of the bolus into his upper airway. This
information is according to the feeding specialist who is IBCLC at the
hospital. She sat in while th procedure was done. She is very concerned
about the possibility aspiration and hypoxic episodes. She taught mother to
observe the baby for respiratory distress and take him off the breast as
soon as he starts breathing fast or lips look blue. Clearly there is a suck
issue since this study was done with bottles. He has had no gastrointestinal
symptoms of oversupply. He is a fairly content baby. When this report gets
to the ped I am expecting they will reccomend pumping and feeding with slow
flow bottle. Mom says she is willing to do so if necessary, but would prefer
not to.
Mom problem - I believe she has hyperprolactinemia. She can pump 5 oz in 5
min. Milk just runs out everywhere even before baby gets to breast. Para 1
gravida 1, 30 y.o. premature labor at 32 weeks treated with terbutaline. Has
a history of menstrual problems. Painful menses as a teen. Birth control
pills age 18-26. Had to take the lowest does possible due to high blood
pressure, treated with Ziac. Possible PCOS, although the
fertility/endocrinology specialist she worked with did not formally diagnose
her as such. She has a history of elevated testosterone and insulin
resistance. Treatments she has undergone include prometrium when she was
amenorrheic, glucophage for insulin resistance, and clomid to achieve
ovulation and pregnancy. She did have elevated PRL 66.9 at age 20. MRI
revealed no pituitary tumor at that time. Old thyroid levels have alll been
normal. Became hypertensive 4-5 months into pregnancy and took methyldopa
250 mg bid. Was simultaneously taking Effexor. Discontinued both gradually
between 9 and 10 weeks postpartum. Was to her doctor last week for headaches
and dizziness. Blood work was normal, don't know yet what was tested, except
for a urinary tract infection. Took antibiotic for 7 days.
There are good days and bad days, good feedings and bad feedings. The first
am feeding is no better or worse than the others even though he hasn't fed
all night. I would have expected the flow to be more forceful and
problematic, but this isn't the case. I worked with her tonight. I think I
need to concentrate on slowing the flow and treating prolactinemia. I am
thinking we actually have 2 problems here, but maybe the baby has just
learned a poor feeding technique to protect himself. I am planning on
contacting her primary care doc tomorrow to ask for blood tests - Prolactin,
thyroid, should I ask for other hormone levels? Is it possible to check
oxytocin level? In the meantime we worked on feeding prone tonight and I
demonstrated sitting baby on her lap in front of her to get him approaching
from above the breast for feeding. We tried a nipple shield. I thought it
might help and seemed to in the first few minutes, but then he had a really
bad episode of losing his breath with it in place. I told her to put cabbage
on her breasts all day tomorrow. We discussed meds to reduce supply -
antihistamine, does anyone have actual research proving this I was thinking
long-acting loratadine?, Sudafed , birth control pills thought they might be
inadvisable due to history of blood pressure problems. Waiting for prolactin
levels for certain. If they're extremely high maybe cabergoline? Just read
some posts from Lisa on Vitex - maybe that?I greatly appreciate your reading
this and replies.
Judy Gutowski, BA, IBCLC, RLC
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