Greetings,



 



I have been dealing with a
challenging case and need a fresh perspective, so any thoughts or suggestions
are welcome. The mother has given me permission to post. I will give her case
history below, but want to stress that HER main concern is repeated plugged
ducts.



 



This mother of twins is also
a physical therapist. She contacted me on 1/1/09, when the twins were 6 ½ weeks
old because she had been battling repeated plugged ducts. She had been treated
for a breast infection with Dicloxacillin for 4 days then switched to
Cephalexin for 10 days. 



These fraternal twin girls
were born on 11/17/08. Baby A weighed 6 lb. 12 oz., Baby B weighed 7 lbs. 4
oz.  



 



The
mother had a fibroadenoma removed in 2000 and her breasts have always been
tender, even before pregnancy. Baby A was born after 4 hrs. pushing, spontaneous
labor, no augmentation or pain medications, followed by Baby B, 13 minutes
later. Mother nursed Baby A immediately after birth. Baby B needed O2 at birth,
but the mother thought she also attempted to breastfeed her, too. The mother
had surgery 2 hours after birth for a cervical tear and received two
transfusions. Her hematocrit was 26. As of 1/2/09 her hemoglobin level was 13.
She has been eating iron rich foods, but no supplementary iron beyond her
prenatal vitamins. I suggested, but am not sure whether further testing has
been done. Lactogenesis II was delayed until Day 6. The mother developed20sore
nipples in the first week, which resolved after a visit from a local LLL Leader.



 



Baby
B had been gaining appropriately, although had recently slowed down, produced
2-3 large yellow BMs/day, along with smaller ones. She had begun hanging out at
the breast almost continuously, spending a lot of time sucking without much
swallowing. Baby A had a green BM after birth and did not stool again until day
5 when she passed meconium. After that, her BMs turned to green. When she was
still not up to birth weight at 4 weeks, supplementation of 2 oz. of formula
after each feeding was begun. She gained 8 oz. the first week of
supplementation, but only a couple oz. the next week. She was sleeping longer
and only feeding 6-7 times a day. I encouraged the mother to watch for feeding
cues, and feed at least every 3 hours.  



                               



Upon my arrival, Baby B
showed feeding cues, despite having been fed a short while ago. We put her to
breast where I demonstrated asymmetric latch along with breast compression.  After repeated attempts at both breasts, Baby
B appeared satiated.



 



We then woke Baby A. Since
starting bottle supplementation, Baby A would suck a short time at the breast
and then begin to fuss. Suspecting that mom’s milk supply was low and that Baby
A was having difficulty extracting the milk, I sugg
ested an SNS. Baby A nursed
contentedly while taking 2 ½ oz. of milk via the SNS.  



 



The mother had purchased
More Milk Plus tincture, but took it infrequently so I encouraged her to be
more diligent in taking it, and to find time to pump, as increasing her milk
supply would make it easier for both babies to nurse. Using the supplementer
with both babies would ensure they received adequate amounts of milk in a
reasonable amount of time. The mother tried the SNS for a short time, but then
reverted back to bottles for Baby A and allowing Baby B to hang out at the
breast, as that is the only way to keep her happy. Both babies sleep 5 hours at
and she is loathe to wake at night either to nurse or pump as she is so busy
during the day



 



Baby A ‘s tongue had little
extension and a pronounced upper labial frenulum. Baby B’s tongue extended, but
did not fully elevate. Both babies had frenotomies performed on 1/17. Mother
reported little change in breastfeeding habits for either girl. 



 



Mother and babies have been
prescribed Nystatin for thrush. Mother reports she has trouble applying it as
frequently as needed, as the babies keep her so busy and although tender, sore
nipples are the least of her concerns.



 



The doctor was comfortable with
their progress at their 2 mo. appt. last week, although baby A is below the
3%ile for weight and baby B is below the 10% ile. Mother and father are bo
th
long, lean people. Baby A is still receiving 2 oz. of formula after every
feeding. Mother reports that she has been very content. Baby B receives 3 oz. of
formula before bedtime. She is only happy while at the breast. 



 



Mother tried wearing baby B
in a sling yesterday, so she could keep her content at the breast and get
things done around the house. She believes that the pressure of the sling
during the ½ hour she was wearing the baby has caused her latest plugged duct.
She reports that any kind of pressure on her breast causes a plugged duct.
Manual therapy performed on her thorax by a physical therapist set off her first
plug.  Wearing any of her bras, no matter
how loose seems to encourage a plug. She will be returning to work next week
and feels the need to wear a bra, so she is in a quandary as to how to prevent
further plugged ducts. She is taking lecithin, and using heat, massage and
extra pumping to clear plugs as they occur. Your thoughts?



 



Thanks!



 



Kathy P.




 


Kathleen Fallon Pasakarnis, M.Ed., IBCLC
Nurturing Family Lactation and Parenting Services

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