Hello Wise Ones,

I am helping a friend with breastfeeding, always a tricky proposition. I just saw her today and would like some feedback about the advice I gave her.

Background: This is baby #4. With first three, mom never felt baby was getting enough at breast, so she supplemented with formula after every feed and stopped bf within the first 2-3 months. This time mom said that she really wanted to bf and make it work. Induced at 38 weeks due to low amniotic fluid. Typical US hospital medicated vaginal birth. Mom was offered to have baby on chest immediately after birth but refused until after baby was bathed & swaddled. We made plans for me to visit twice in the first weeks, but each time mom cancelled. She said baby was doing well. Last night, however, mom told me she had nipple soreness and asked if I could see her today.

I visited this afternoon. Baby is now 13 days old, but only one day adjusted, as her due date was yesterday. Birth weight was 7# 4 oz. At 1 week old, her weight at the ped's office was 6# 12 oz. Mom informed me that baby had regained her birthweight as of today (according to the bathroom scale trick: mom weighed herself with and without baby and subtracted). We know how accurate that is! On my Tanita neonatal scale, baby was 6# 10.4 oz. So in fact, baby had lost slightly or just maintained her weight for the last week and is NOT back to birthweight. This was concerning to me.

Baby has been sleeping long stretches and mom has to wake for feeds. Mom tends to wake her every 3-4 hours. She estimates that she has been feeding her 6-8 times per day. This afternoon, baby had fed at 2:30 pm and was sleeping upstairs. I had to encourage mom several times before she agreed at 4:45 to check on the baby and possibly wake her up. As soon as mom entered the room, the baby started moving and stretching, leading me to believe that had baby been close to mom, she would have woken sooner.

Once awake, baby was very active, not at all lethargic. She twisted and turned on my scale and began actively rooting, sucking hands, and showing other feeding cues. When initiating bf, mom put baby on a pillow in her lap, held her breast in a "cigarette" hold with two fingers very close to nipple, and then tipped baby's head down onto the nipple. Needless to say, this led to a fairly poor latch, with baby's chin against her chest and mom's fingers actively interfering with placement of baby's lips on the areola. I tried to show mom laid-back breastfeeding and to see if baby would self-attach, but mom expressed fear that baby might hurt her and continued to hold her breast in ways that interfered with latching, so we went back to a cradle/cross cradle hold. I figured if she's determined to do mother-led latching, let's give her the tools to make it better. So we practiced getting baby's head tipped slightly back, body in alignment, nipple pointing toward roof of mouth, etc. We were able to achieve a fairly deep latch, but baby was able to maintain it only a few minutes before slipping down into a shallow latch that was painful to mom. After numerous slips and re-latches, baby took about 1 oz on one breast and 1/2 oz on the other. 

Baby's palate had a slight bubble, not terrible, and on the underside of her tongue I felt an obstruction consistent with a tongue tie (I'm guessing Type III). I mentioned this to mom and suggested that she have baby checked for tongue-tie. She was open to the idea.

I told mom in no uncertain terms that she MUST feed baby AT LEAST 10 times per day until she regains birthweight and starts gaining 4-7 oz per week. I also told her to record # of feeds, pees & poops on a simple chart (the "wet" diaper baby had at my visit was just streaked with urine, although mom says she does have soaking ones as well). I also told her poops only count if they're bigger than a finger & thumb "OK" circle.

My question for all of you more experienced BF helpers is, is that enough? Can this active baby have a couple of days to see if more frequent feeding with a deeper latch will get her back on track, or should I have suggested that she immediately start to pump & supplement? Mom was proud to be exclusively BF for two weeks but also somewhat overwhelmed. I felt that any suggestion of supplementing (even with breastmilk) might discourage her enough to give up BF. But of course I would never want to endanger a baby, and now I'm second guessing myself. Certainly if baby doesn't gain in the next 24-48 hours I will absolutely tell her to start supplementing.

Sorry for the long post, I don't seem to be able to write a short one! Thanks for reading this and I'd love some other opinions.

Jennifer Sokolow, IBCLC
Long Island, NY

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