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I am currently working with a mom who is having some nursing issues and I need a new perspective on the case.

This is her second child, I performed nursing assessment on day 15; vaginal delivery 39 6/7.  Jaundice/hyperbilirubinemia diagnosed by pedi at day Day 5.  Infant received formula in hospital and 24 hours of formula only when jaundice diagnosed (I was not involved in the case until day 15), followed by pumped expressed breastmilk (EBM) and occasional formula via bottle.  Mom started to bring him back to breast with nipple shield she purchased (she had used a nipple shield with her first child after sustaining extensive nipple damage due to a poor latch; she nursed her first using the shield exclusively for 15 months).  When I met mom she had a couple of feedings at the breast with little success.  Oral anatomy withing normal limit (WNL) some tongue thrusting observed with finger assessment.

At assessment attempt made to latch infant without shield was met with resistance from mother and baby.  Mother requested shield be used for assessment (she has all information regarding proper use and weaning of shield). Infant unable to transfer milk appropriately at breast with shield during the assessment observed; for example, after 20 minutes of vigorous sucking but very little swallowing infant transferred 14 mL.  SNS introduced and mother stated she preferred to use the SNS with shield (again encouraged nursing without shield).  Weaning from supplement plan introduced with encouragement that all feedings and any supplementation be given at the breast.  

Weight check and reassessment 5 days later.  Infant gained appropriate weight and on track for supplement weaning (all supplements are EBM; mother has a good milk supply).  Feeding assessment preformed, encouraged latching at breast without shield; mother agreed.  Fed on right breast for 20 minutes, vigorous with 1:1 suck/swallow ratio, he found his nursing "groove"--transferred 2.8 oz.  Mother reported discomfort, but nipple was elongated and rounded using asymmetrical latch on right side, on the left side there was some compression of the nipple, but mom was able to re-latch using a deeper latch to resolve (their latching technique was very good).  Left side infant was sleepy but we did observe a 1:1 suck/swallow when vigorous.  He ended up with 3.2 oz.  We revised our feeding plan and felt very positive about his ability to transfer milk well.

Following information obtained via email and phone:

Mom worked on feeding without the shield; however, despite the good behavior observed when nursing (finding his "groove" and a considerable decrease in the amount of supplementation taken) found herself facing increasing pain.  The nipples remain intact bilaterally but are very tender.  Mom found herself using shield last 48 hours and supplements increased from 6.5 oz to 16oz.  Mom has decided to see how things go this weekend, but she was hesitant and very reluctant to try to feed at breast without the shield even when compromise encourage (every other--every third--a couple of feedings/day).  She is going to attempt some feedings at breast without shield this weekend, paying careful attention to latch and assessing the feeding for appropriate milk transfer as well as getting better descriptors of her pain (rating on a scale and describing location and feeling).  She will be attending my support group on Wednesday (where we hope to obtain pre-post weights using shield for feeding).   

My concern is that this little one is not transferring milk appropriately using the shield--can anyone offer suggestions, input or examples where you were faced with a similar scenario (not appropriate transfer of milk with shield and/or mother reluctant to nurse without it)?  I have always been comfortable using the shield as a temporary tool when appropriate, but I have never been faced with the fact that an infant may be unable to transfer with the shield when used correctly.  I am also concerned that this mom, although determined, if the shield is "off the table" may choose to exclusively pump and feed via bottle, which would be a disappointment to her--she wants to feed at the breast.

I need to address the pain she experiences when nursing without the shield, but during the feeding I observed the infant appeared to latch well, transfer milk well, and no tell tale signs of improper latching declared themselves.  The damage done to her right nipple when nursing her first left two areas of demarcation on her nipple 12 and 6 o'clock, white areas, approximately 1.5 mm in diameter best described as scarring.  Both infants seem to "prefer" the right side (larger production 3:1 when comparing pumping output to left and shape of right nipple is easier for infant to grasp).  Could the damage sustained with her first be causing an increased sensitivity?  If so, how to proceed or move forward?  The pain on the left side is most likely related to shallow latch on that side and mom is able to correct it by obtaining a deeper latch (she describes the pain on right to be more intense).

This mom is very determined and I am very determined to offer my support.  If you can offer any suggestions or input, please feel free to respond to this post or email me privately at [log in to unmask]

Thank you, 

Cassandra Leahy
BA, RN, MSN, LCCE, IBCLC
www.thelactationlady.com
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