----- Original Message -----
Celebrate that all her hard work with the pump is protecting the supply and buying the baby time to get bigger and stronger and learn about this. (And try to devise ways to make the pumping more practical) And that this is a difficult situation, but she's on some common ground -- all mothers in the early weeks are trying to figure out a comfortable "fit," and that it's just microns of difference between pain and a comfortable, effective mouthful. Focus on the fact that she and the baby have achieved that a few times, and that continuing these practice sessions will give her clues about what works for them. Some mother-baby teams really do have to exaggerate that big whomping assymetrical mouthful. The laid back positions might encourage the baby to stay sealed on and not lose milk. 

Discuss that the tongue isn't always a black/white situation, and that if the difficulties persist, it's common in many medical situations to get a second opinion. 

It might be worth revisiting the nipple shield (probably the biggest 24 mm size -- hospitals seem to frequently use the 16 mm size with newborns, which isn't usually comfortable or effective) since she now has a softer breast and a fabulous milk supply -- it might be a useful "training wheels" now. 

This Diane Weissinger hand-out has brought luck to lots of mothers working through initial latching difficulties -- it's good to feel some common ground: (LCs can buy a CD of Diane's hand-outs -- a good investment). 
http://www.normalfed.com/Help/babyget.html 

Empathize that it's hard to see your child having difficulty with something, but that's probably the baby who is going to gain the most if we can find ways to keep everyone in the game -- breastfeeding is the best oral exercise we can devise for a baby who is still gaining strength or coordination or patience. I always joke that if your child wasn't the Michael Phelps of swimming, you'd still be happy to have them out there in the water, learning stuff, getting stronger, having a good time. 

Feeding is such a complex orchestrated activity. If things aren't improving with the shield as a temporary aid, growth, practice, etc, then it's good to feel that enough other people have worked through these issues that there are oral motor therapists, SLP, occupational therapists, and body work specialists such as CST or infant chiropractic that we could consult as a next step. 

Good luck to all. 

Margaret Wills, IBCLC, Maryland 
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Date: Fri, 2 Nov 2012 12:04:14 -0400 
From: Samantha Slaughter <[log in to unmask]> 
Subject: Painful latch, baby not tranferring milk well 

Hello all, 
I have permission to post by a mother I have been working with, and I would welcome your suggestions. Her baby was born October 12th at 39 weeks. She was induced after her water broke. Reports hard labor but otherwise baby was said to be healthy. No additional interventions at birth. She is currently pumping and feeding only her ebm by bottle because breastfeeding has been painful since birth. A nipple shield was introduced on the baby's second day of life, but mother reports pain even with the shield. I saw her on DOL 5 but was unable to help her to resolve the nipple pain with latch (encouraging wide gape, trying laid back/biological nurturing, ridging breast). Nipples were cracked and painful so mother decided to take a break from direct breastfeeding and pump for a day to allow time for nipples to heal. When she resumed breastfeeding latch was still painful. She was able to achieve a comfortable latch only once at home, however she reports the baby couldn't keep milk in her mouth and milk went everywhere. She continued to focus on offering only the breast, and reports baby was fussy, seemed unsatisfied and wanted to nurse constantly. In addition she developed a plugged duct and mild fever. As a result she went back to just pumping and feeding and reports fussiness stopped and baby was eating and sleeping regularly. I was only able to examine the baby's mounth and tongue briefly, and I suspected she could have a short frenulum. The pediatrician (who is supportive of breastfeeding and will assess and clip frenulums if needed) said the tongue looked fine. I spoke to her on the phone recently and she states she tried again to only breastfeed, baby again was fussy constantly, latch uncomfortable, and breasts became engorged. 
Baby obviously has trouble latching and transferring milk on her own. Mother's milk supply is adequate and baby's intake is appropriate, and ouput and weight gain is normal. Mother is very frustrated, really wanted to and was looking forward to breastfeeding, but when we last spoke said she was just going to pump and feed. I am suspicious of the milk spilling out with the comfortable latch, and the engorged breasts and fussy baby when trying to only breastfeed, but am at a loss for what else to recommend she do/try. Any suggestions to help improve this relationship would be greatly appreciated. 
Thank you, 

Samantha Slaughter, IBCLC 
Yolo County WIC Program 
Northern California 
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