I have permission to post. G1P1 delivered 8/6 by  c-section who came to me 
today for complaints of sore nipples. My coworkers  and I have worked on and 
off with this mom for the last 3 months. She  originally came to us because 
she was unsure about baby's intake. Baby's birth  weight was 7# 12oz and 2 
weeks ago she was 11# 5oz. At one month, pre and post  feed weights showed 
2-3 oz weight gain from one breast at a feed. We watched  baby's behavior and 
she would do all the classic behaviors of strong MER. At  that time, we 
suggested the posture feeding and/or expressing through the first  MER. She 
tried those without success. Baby would not feed in the reclining  position so 
I suggested that she try side lying. That she has been able to do  but not 
very often.
    Today I observed a beautiful 3month old feed. She gulped  from the 
first suck. Several minutes into the feed she began to slide down  nipple and 
occasionally would pop off the breast. She would relatch several  times 
throughout the feed. Mom has erect nipples that look intact but are red.  The 
nipple was not misshapen after the feed. Baby usually feeds from only one  
breast at a feed. Mom mentioned that she noted that her nipples look white  
before she gets into the shower, which is usually after 2 feeds into the  day.
    Mom stated that baby is a happy baby, not gassy and  fussy, has normal 
stools. Soon after our first visit baby was diagnosed with  GERD and put on 
Zantac. Mom said it has helped to some degree baby still has  periods of 
vomiting if she is laid down after a feed so she tries not to lay her  down 
after a feed, but the vomiting can occur one hour after the feed. She can  pump 
4oz from one breast in 10 minutes.
    We discussed: 1) trying to gradually recline more in her  positioning 
so eventually she reaches that 45 degree recline; 2) peppermint  Altoids to 
slowly decrease supply; 3) watch nipples over the next several days  to note 
if there is any other color changes that we might consider vasospasm tx  
with calcium/magnesium; 4) possible use of APNO. She will use a hydrogel pad 
now  for the tenderness. 
   My questions are what did I foget and what option should I  take to 
further assist her?
 
 
Thanks,
 
Allyson Michaels RN, IBCLC
Charlottesville, VA

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