I have a case that I want to toss out to you all. Last weekend it looked like
a "victory", and I thought that it was all done, but now the situation has
deteriorated. What makes it a little harder is the sketchiness of the data--
the mother is someone known to me personally, the "breastfeeding mentor" of
her church, and from her description, I really thought that it would be a
one-two-three fix. Since it originated on Memorial day weekend and I had
company but wanted to respond to her crisis, I squeezed her in and didn't do
paperwork, just hands-on. Those are the ones you wish you'd filled out, you
know?

This is baby #6, born at 10lbs 7oz full-term (all her babies were large). Mom
was diagnosed with high blood pressure and toxemia at admit, was put on
mag-sulfate during labor. Her weight gain was actually a little less than her
other pregnancies, 40 vs 50 lbs, and this is the only labor that she has
elected meds. She figured that after six babies she deserved a break on the
pain, and had an ITN (morphine) administered 4.5 hrs prior to delivery; said
it was great! Baby was born after an 8hr labor, no distress, with 8/9 apgar.
Did not show interest in the breast after delivery, and never really suckled
well at all during the first 4 days. Mom and baby d/c at 2 days pp, mom was
coaxed to give 1 bottle of glucose water before that which baby "gobbled down
like a hungry puppy".

I was called at 4 days pp; baby still not really going to breast and crying
with hunger. Mom has *very* large nipples, but her other 5 babies pretty much
fed with no problems except for #5, who took 4-5 weeks to really start to
gain weight. Breasts were full as milk was in, but baby cried and fussed when
put to breast; mother had been working hard for 4 days.  I started mom
pumping and taught her to syringe feed at breast, but within 24 hrs baby
became aversive to the breast entirely even with flow, so we changed to
finger feeding just to get her fed and start putting weight on her. Baby's
output picked up signficantly and she became a "different" baby, very content
after feeds; all looked well.

My first suck assessment showed a good suck once she got going; it was a bit
confused at first. At breast, baby would seem to get mad and push the nipple
forward; the nipple and associated tissue is bulbous and easily isolated. We
fingerfed for a week until her suck became consistent and the milk supply was
built up, then attempted to put her back to breast. Baby behaved very
aversively, and only after becoming exhausted and falling almost asleep did
she latch properly and begin to suck and draw and swallow on her own.  We
were greatly encouraged, and figured that all we had to do was coax her to
breast, and it would work.

However, it didn't go that way for mom, success was not repeated, so I added
additional flow at breast. SNS was necessary over syringe because of mother's
need to use two hands to hold breast and apply pressure behind the nipple to
keep baby from kicking it out; with SNS flow, she fought a little but finally
latched and started drawing, not from the SNS but from mom!  With the
incentive of a few squeezes from the SNS, she started sucking and swallowing
beautifully on her own; we turned off the SNS and watched her go!  Mom was
thrilled, and I felt strongly that baby would be on her own in a few days
once she learned to work for her milk.  Mom reports that initially going to
SNS was great, and mom even nursed several times a day successfully without
it for the first few days.

WRONG. That was last Monday; I visited on Friday, and did not like what I
saw. Mom mentioned nursings taking up to 2 hrs, and baby not taking much from
the SNS. She just wouldn't try hard, and would quickly "check out" (fall
asleep), only taking long draws when mom spontaneously ejected milk a couple
of times during the session. Baby was mostly doing lots of choppy nibble
sucks, getting very little. I transferred the SNS to my finger and fingerfed
her with it, and she woke up, opened her eyes and started gulping greedily. I
transfered her and the SNS back to breast and started really getting in
close, poked around, and yet everything seemed properly placed. I reattached
her several times, and finally got her on such that she was drawing milk from
the SNS and breast, but it was difficult to tell what was wrong with the
other latches.

On June 1, baby was 9-6 (about 2 wks of age, so 1 lb below birthweight). We
figured she had been lower but had come up.  At MD visit on June 4, she was
9-10. Today, she is 9-9.  The past three days mom feels that things have
"deteriorated", baby has been very fussy and hungry.

Weird additional facts: A week ago, after baby had fed well and fallen asleep
in mom's arms in the football hold, I noticed that she turned very dark
red/purple in the face and extremities. I checked carefully to see that she
was breathing, and she was.  I have noticed that her skin often blanches to a
pasty white, and then I have seen these darkenings of color, quite a
contrast, *after* feeds and when she has fallen asleep. Mom reports that it
happened in bed after a feed this morning, and also has happened in the baby
swing.  Her eyelids at times have been very red-purple as if she had "black
eyes", and while her lips are ruby red, the skin *around* her lips has a
pale, almost bluish tinge that comes and goes.  Not exactly classic for heart
problems, but I did flag it with mom, and she flagged it with the Ped, who
double-checked the baby on Tuesday but found nothing apparently wrong.

So now it's the end of a week when I thought we'd be all done, and we're
practically back to square one.  Why will this baby only suck with forced
flow, such as an MER, at breast, yet will take SNS on finger?  Why does she
do the nibble suck at breast? What else might be going on in her mouth that
we can't feel? Has she been taking less and less this week and deteriorating
because she is fatiguing and there is a health problem?  Today's suck
assessment showed no cupping of the tongue, but in the beginning I did detect
cupping, so that has gone downhill. Suction breaks have increased. Due to
weakness from insufficient feeds? But she was strong enough and coordinated
enough when we first put her back to breast!

Could the ITN be a factor? Could she be affected by the narcotic, and will
she be one of those babies who won't organize well until 4-6 weeks?

I have suggested to mom that she get a polaroid camera and take pictures of
the different color changes in the baby to show the doctor. I have also
recommended that if the ped wants to "assess the suck", that she insist it be
at breast or with finger, and not allow the bottle to be the criteria.  Since
Ped said to bring baby back if any blue were observed (I noted it more than
mom did, it's subtle), she will be returning tomorrow for another check.

Does this ring a bell for anyone?  What started off as a "sleepy, lazy" baby
situation with a friend that I didn't take as being too serious has
definitely deteriorated into something more worrisome, and I wish I had full
documentation now.  I would appreciate any input on this mystery!

-Lisa Marasco, LLLL, IBCLC
Santa Maria, CA