I could use some secondopinions on a difficult case, since I'm all out of ideas at this point. I'vebeen seeing a new mother as an outpatient for a few visits now. She is a firsttime mother, no other pregnancies, otherwise healthy and no indications of othermedical conditions or history of problems with breast development or surgeries.She is not on any medications, except she has been taking a fenugreek teaoccasionally for the past month but not regularly. She does state that shetends to eat a low protein diet and she did have normal breast developmentduring pregnancy. Her daughter is 5 weeks old now and was born at 41 weeks at 6pounds and 8 ounces. Her labor was induced for post dates and she deliveredvaginally, had an epidural, and apgar scores were 8 and 9. The baby wasclassified as small for gestational age. The infant had normal blood sugarsafter delivery. It did not receive any formula in the hospital. 

 I have to say that at this point, I'm veryfrustrated with many hospitals in my area who give out nipple shields way toooften and too early. While I do think they can occasionally be helpful incertain situations, I'm beginning to seriously question their use at all duringthe colostral phase of lactation. I really do not think that infants cantransfer any substantial amount of colostrum across them. I would love to seehospitals begin to implement policies banning their use within the first 24 to48 hours. Is anyone else in agreement on this? I really feel hospitals shouldinstead implement a policy that if the infant doesn't latch by 6 to 12 hours ofage, the mother should begin to hand express her colostrum and feed it to theinfant, mainly to stimulate her milk production. What is the benefit of havingthe baby suck on an artificial nipple that it likely gets little or no milktransfer from? It goes back to the same idea that many healthcare workers stilldon't understand - that just because the baby has a breast in its mouth does notmean that it is breastfeeding!

 In my humble opinion, this mother wasunfortunately essentially sabotaged in the hospital by a nurse that gave her anipple shield when the baby was an hour old because the baby didn't latch onright away! The mother said that when the baby didn't latch on within the firsthour, the RN offered NO assistance in helping her latch the baby. Instead shegave her the choice between a nipple shield and a bottle of formula. The motherreally wanted to breastfeed and not use formula, so of course opted for theshield (which of course was not even the right size for her anyway). She hasnormal breast and nipple anatomy and I feel sure that if she was just given alittle support and guidance the infant more than likely would have been able tolatch without a shield within the first day. However, this unfortunately didn'thappen and she has been using the shield ever since. More than likely whathappened was that the infant continued to nurse for the next couple days withthe shield while transferring a minimal amount (if any) of colostrum and themothers breasts received little stimulation as a result. The parents reportedthat the infant became more and more sleepy and jaundice developed.

 The first time I saw her the baby was 14days old and 6 # 7 oz and was quite yellow and sleepy. Serum bili was 12.5. Iwatched her attempt to breastfeed and it was evident that the infant did notenjoy the experience at all. The feeding was almost aggressive in nature. I'mnot quite sure how to describe it. But what I saw was that she was sitting theinfant completely upright, using the shield and almost forcing the infant atthe breast, compressing her breast during the feed, and when a let-downoccurred, the infant would swallow weakly and then as soon as the let-down wasover the infant would go back to sleep. I was concerned that the infant woulddevelop a feeding aversion if she continued to feed in this manner. She saidthat a feeding like this would typically take 45 to 60 minutes. She was pumpingmaybe 2 to 3 times per day with medela advance breast pump, this pump was newfor her from her insurance company. She was storing the milk and not giving anysupplements to the baby for fear that the baby would get used to a bottle. Shestated also that she didn't have time to pump because she was spending so muchtime trying to get the baby to breastfeed. The baby had 7 wet diapers and 4yellow bowel movments in the previous 24 hours. The mother reported that herbreasts felt full around day 4 and she actually began to pump and store hermilk because she felt uncomfortable and overly full (another sign of poor milktransfer, I think).

 My initial recommendations were that weneeded to get more milk into the baby and protect her milk supply. Watching thebaby it transferred very little milk, I saw and heard swallowing only duringthe let-down and then no swallowing at all. I worried that her supply wouldbegin to drop even more. She was pumping approximately 6 to 8 ounces total fora 24 hour day at that point. I recommended she rent a hospital grade pump, pumpat least 8 times per day using hand massage during pumpings for 20 to 30 min.Give the baby expressed breastmilk. Also, if she is using an artificial nipplealready, I didn't see a benefit of not giving the milk in a bottle, especiallywith the infant suckling so weakly. We attempted breastfeeding without theshield, it had little interest - with or without the shield. Mostly it slept. Irecommended at that point to limit suckling at the shield because it reallyseemed to be exhausting the baby and sucking up a lot of her valuable time. Themother was also exhausted and sleep deprived from essentially breastfeedingnon-stop 24 hours per day with poor milk transfer. I suggested she give about16 to 18 oz per day of expressed breastmilk and limit suckling with the shieldto maybe 15 to 20 minutes or skip it altogether, pretty much just duringlet-downs when the infant was swallowing but don't agressively push infant intobreast. My thinking at this point was that it was more important to get milkinto the baby and protect her supply. So I told her that the more importantthing at this point was to pump, protect her supply and give the baby EBM.Suckling time with the shield was really not accomplishing much, if anything,considering the amount of time she was investing in it. 

 So then saw infant one week later at 3weeks. Parents did not follow some of the recommendations. They did rent aSymphony pump and she began pumping 8 times per day. Her milk production jumpedup to about 18 oz per day of EBM. But she did not feed any to the baby again.She kept baby at breast for long feeds again. Parents stated that they couldn'tget baby to take bottle it was too sleepy, so they just gave up on the bottles.The weight was now 6# 8 oz. Only one ounce gain in a week - yikes! The babyalso had only 4 dark colored wet diapers in previous 24 hours. Infant’s skinappears to be very yellow still. I’m nearly in panic mode, but try to bereal clear with the parents when I talk to them but not terrify them. However,I tell them that the MOST important thing at this point is that the baby getsfood. The baby is becoming dehydrated. Please stop putting baby to breast atall and supplement with EBM or formula in a bottle if you don’t have enoughEBM. Mom assures me she has enough stockpiled in freezer to last awhile. Irecommend she continue pumping, eat, rest, take care of herself, etc. Dad ishome and laid-off his job, so I said his job is to feed 2 to 3 oz ebm every 2to 3 hours for a total of 16 to 20 oz per day. I teach them how to bottle-feedby massaging gently with the bottle and I tell them that if they cannot get themilk into the baby we will need to hospitalize the baby in the next 24 to 48hours. I think that did it because they did follow this recommendation and thenin the next week the baby gained 8 oz. So now baby was 7# 0 oz at one month. Theinfant is waking a little more frequently, feeding better at the bottle andappears visibly less jaundiced. The parents report that the infant is gulpingdown the bottle and cries strongly when the bottle is empty and appears to wantmore milk. I encourage them to increase ebm to closer to 25 oz per day. Themother states that milk production has plateaued at about 18 oz per day, eventhough she continues to pump 8 x per day using breast massage. She is almostout of frozen breastmilk. They are uninterested in milk-sharing. 

 We discussed ways to furtherincrease milk production. I recommend she consider taking Reglan for 2 weeks.She declined at this point, but I would like to revisit this with her. I think it would be a good idea. She has no history of depression. Also, I didrecommend rather than the fenugreek tea, if we are going down that route, thatshe consider a capsule 3x per day like the Mother’s Love More Milk Plus. Also, I mentionedthat some women have found success with increasing protein intake, wholegrains, brewer’s yeast, rest, stress reduction, etc. She is a normal weight,looks athletic, tall, but not underweight. The baby is a month old now and Ifeel needs more milk. My recommendation is the baby should have about 25 oz perday of EBM or about 30 oz per day formula, somewhere in between for mixedfeeding. 

 Complicating matters further, I’mnot sure that the father of the baby is supportive of breastfeeding. He’sfrustrated (understandably) it’s been a very difficult month for them. Themother is very committed to breastfeeding. I think he is adding to her stressthough and makes frequent comments that she’s not going to be able to do it. He’slost his job recently, they are selling their house and moving, and she isgoing back to work in a couple weeks. I think that stress is another factorthat is complicating her milk production problems. In my conversations withthem, he does seem a bit domineering towards her and she seems as though she isbecoming resentful of his comments. I’m not a marriage counselor, but I didtell them that open, respectful communication is really important and I need tofocus on just providing information about lactation here. I can’t really get inthe middle of their disagreements. I think the dad was upset with me because heseemed to be trying to get me to tell her to just give up on breastfeeding.I told him I'm not going to do that and if he keeps telling her that she's going to run out of milk, she may end up resenting him. If that happens unfortunately, it will be apparent to her, he doesn't need to keep harping on it. I understand he's frustrated and he has reason to be. I do think the baby needs more milk, he's right. But I did feel as though I spent 90% of that visit reassuring him and it was hard for me to talk to the mom about lactation. Has anyone ever had a similar experience? How did you handle it? I almost feel like telling her not to bring him in the future, just because I'm having a hard time communicating with her.

 I’m wondering what othersuggestions people might have. Am I missing anything? I was hoping that if the infant gained moreweight it would be more vigorous at the breast, and also if the mother’s milkproduction increased the baby would have more interest. Also, I mentioned toher that many babies have increased interest in going back to the breast atabout 4 to 6 weeks of age if the mother has a decent milk supply. Through skinto skin contact and baby-led breastfeeding we are able to get many babies to goto breast without a shield at about 4 to 6 weeks. I was hoping to attempt soonwith an SNS, possibly. But her supply really hasn’t recovered and I don’t thinkthe baby is still getting enough to eat. It's still pretty sleepy. At the 4 week visit we did attemptbreastfeeding at the breast and the infant still appeared uninterested andsleepy, both with an SNS and with and without a shield. 

 The client also called a fewdays ago to state that she has been giving only about 18 oz per day by bottleagain. I recommended she come in again for a weight check and she should begiving closer to 25 oz per day. She declined the appointment and I documentedit. I’m pretty worried about both of them. The baby is 5 weeks old now and dueto come in for 6 week checkup next week.

  Tricia Shamblin, RN, IBCLC

 
 

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