Hello, wise ones.  I’m stumped and could really use some expertise.  It’s
been a long day for me and I’m battling a pre-migraine, so forgive me if
this comes out somewhat jumbled:

 

First time mom, first pregnancy.  Breast reduction 5 years ago.  Mom noticed
breast changes and growth during pregnancy and now can yield up to 1 oz when
pumping both sides when breasts at their fullest.

 

Baby boy is 14 days post partum.  Birth was long (40 hour labour with
midwives in hospital); epidural used.  Baby latched with midwife assistance
within a couple of hours of birth and lots of skin to skin was practiced
with some latching before baby slept.  LC (me) expressed 2 syringes .5ml of
colostrum for later use. 

 

Oral exam by LC noticed baby’s tendency to clamp the gums, but other wise
baby had excellent range of motion of tongue and a VERY strong suck.  Baby
very eager and alert.

 

Day one – first real feed at about 5 hours post partum.  Nurse-assisted
cradle hold.  Baby latched well and suckled for about 10 minutes.

 

Day two – LC and mom practice with the Medela Symphony pump.  Flanges
supplied by the hospital.  LC not comfortable with the fit of the flange and
counsels mom that they are too small and suggest that larger flanges be
found before the pump is employed.

 

Days two through 5 – regular feeding at breast, no nipple pain, no refusal,
everything going well.  Mom in high spirits.  Midwives doing post partum
home visits every day with weight checks.   LC counseled parents to add a
small bit of supplement (remember, this is a reduction protocol) at breast
once baby lost 7% of birth weight. Midwives counseled differently, and
supplement was not added until the 10 – 11% marker on Day 6.

 

Day 6 – Pump was used at midwives advice, with the original flanges.  LC
noticed nipple trauma immediately upon arrival and mother told her that
nipples had been sore since the pumping session.  LC counselled the mom not
to use the pump again, unless larger flanges could be found.

 

Day 6 – supplement added (via tube at breast but not with SNS) for the first
time after baby lost more than 10% of birth weight, but was still coming to
the breast and ‘feeding’ well.  Midwives supplied two supplement tubes to
parents, a No. 5 (which LC had counseled them to use) and a No.8.  Parents
mistakenly used the No. 8, but told the LC it was the No. 5, not realizing
that they had been given two sizes.  Baby took the supplement at the breast
with No. 8 tube for a few days until mistake was noticed, and then was
switched to the No. 5.  

 

Day 6 – 11 – everything seemed to be going well.  LC was down with a bad
cold and had minimal contact with parents during this time.  Email from mom
to LC indicated that baby was being overfed with supplement by end of week
one.  Approximately 20 oz (600ml) per day via tube at the breast as a top up
after about 10 minutes of sucking.  LC had suggested to parents that
supplementing with the tube in place for the whole feed and varying the flow
might be the best option.  Parents elected to stick with the top up method.

 

Day 11 – phone call to LC from mom.  Finger feeding had been added (LC
unsure why new method was employed).  Mother developed cracked, sore nipples
in the few days before.  Baby had been pulling and squirming at breast.  LC
and mother wonder if finger feeding had caused confusion (wise ones…have you
ever heard of finger feeding causing nipple confusion, or causing baby to
forget what to do at the breast?).  Baby doing a lot of clamping and
chomping at breast.  LC suggested APNO and mother was able to get
prescription same day.  Mother noticed a plugged duct and possible early
mastitis…massage, hot compresses, rest and frequent breastfeeding treated
all symptoms.  Mother told LC that milk production was increasing and baby
would gulp at full breasts from time to time.

 

Day 12 – phone call to LC from mother.  Baby refusing breast.  LC suggests
skin to skin, bathing together, self latching when ever possible.  LC
suggests feeding the baby and breastfeeding be viewed at two separate things
until no more refusal and no more nipple trauma.

 

Day 13 – LC able to attend at mother’s home once again.  Since the previous
day’s phone call, all had been well with baby latching well and supplement
added via tube as per standard practice.  Parents using BOTH the No. 5 and
the No. 8 tube depending on their or baby’s energy.  LC observed a feed with
a very content baby latching several times over the course of an hour.   LC
noticed that baby was chomping at breast, but was patient to keep trying
until getting it right.  Mother was very patient and in good spirits.
Supplement was added after latch on – LC noticed that baby would turn his
head toward the tube if he was able to see it.  1 oz of supplement
(expressed breastmilk) offered at breast with tube No. 5.  Happily sucking
baby was taking a long time to drain the supplement, and so after about one
hour, No. 8 tube was employed.  Once baby drank 1 oz of breast milk, he was
offered formula in a cup.  He took about ¼ of an oz and then refused more
and the feed was done.

 

Day 14 – LC gets frantic call from mother informing her that the feed at the
breast the happened when LC was with them was the last one.  Since then, no
other latches possible.  Mother was doing all the skin to skin and bathing
together like before.  She attempted finger feeding in the tub, but baby
refused that also.  Mother wondered if cup feeding was confusing baby.  Baby
took finger feeding via dad, when NOT in the tub.  Mother is frantic, in
tears, at wit’s end.  Confesses to becoming resentful of breastfeeding and
not wanting it to take up all of their time.  Parents now have an SNS, but
have not tried it yet.  Mother wants to know if adding bottles at this point
would be a good or bad idea.  LC suggests that it could go either way, but
that it might be best to avoid adding another element at this confusing
time, as baby does cup feed well.  LC suggests that mom and dad cup feed
baby for next 12 hours, and pump (mother now using a manual pump which is
draining the breast in 10 minutes and yielding 1 oz) regularly, then
offering the breast again in the morning when everyone is feeling more
energetic.  Mother agrees to try that and to call LC in the morning.

 

Okay, folks…lay it on me!  Why is this baby refusing the breast? Is it the
finger feeding?  The No. 8 tube?  The chomping?   All of the above?  Have I
missed something really important?  What do you think is the best supplement
protocol in this situation?  Our guess is that mom will only yield ¼ to ½ of
baby’s needs.

 

I look forward to your responses.

 

Blessings.

 

Karyn-grace Clarke, IBCLC, LLLL

Nanaimo, BC, Canada

 

 

 

 

 

 


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