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Lactation Information and Discussion <[log in to unmask]>
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Sat, 21 Jul 2001 01:23:24 EDT
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I have the mother's permission to post her case on Lactnet.

Mother is 33, G1P1, after fertility treatments for polycystic ovary syndrome
(PCOS).  She is grossly overweight, and takes medication for high blood
pressure.  Mother reported prenatal breast growth, and a determination to
breastfeed.

Baby boy was born April 4, at 3.6 kg.  The birth was induced because of the
mother's blood pressure (although she reports she did not have preeclampsia).
 The induction began on April 1 and lasted 3 days.  After prostaglandin and
syntocin, and breaking her waters, she failed to progress beyond 2.5 cm and
the baby never engaged.  A cesarean was performed.  She had pethidine much of
that time. Mother and baby were hospitalized for 7 days after birth.   At
discharge, baby had a Staph infection of the diaper area, which was treated
at home.

Baby was born with 9/9 Apgars, but has markedly bulging fontanels, and droopy
eyelids.  Cranial ultrasound indicated no fluid in the bulging forehead area,
and opthamologist could find no reason for droopy lids.  Baby also has
undescended testicles.  He currently weighs 5.45 kg.  I observed him to be
somewhat hypertonic and disconnected from his surroundings.  He did not
interact with mother and me in a manner appropriate for a 3+ month old infant.

Digital suck exam revealed flat tongue, lack of proper suction, no suck,
inability to coordinate bolus for swallow (when syringe fed EBM), a very
sensitive gag reflex, and a poor seal of the lips, resulting in considerable
dribbling when feeding.

Baby usually attaches briefly to the R breast and audible swallows are heard
for about 3-4 minutes.  He will occasionally stay attached, but I did not
observe this and mother was unsure if there was swallowing occurring.  Mother
reports that he rarely attaches to the L breast.  Attachment is problematic
because of mother's very large breasts, nipple position (essentially on the
underside of the breast), flat nipples, and baby's tone.  After the first
MER, he refuses to reattach, and mother usually has to finish the feed by
bottle with EBM.  He demonstrates many signs of distress during breast and
bottle feeding:  finger splay, facial expression, gagging, pushing hands
toward breast or bottle.  He appears to be in pain when the palate, which is
a concave bubble-like shape, is touched.  Mother reports that it takes 1-1
1/2 hours to complete a feed of 30-80 ml.

Mother reports that the baby has never attached and breastfed well.  She has
never experienced sore nipples.  At 2 weeks, she was admitted to a community
tertiary care center for breastfeeding and "settling" help; she has also
spent a day during week 4 in a breastfeeding clinic. Interventions during
hospitalization and her two intensive bf stays have included nipple shields,
supply line (SNS), finger feeding, cup feeding, bottle feeding using EBM and
formula.  Nipple shields, supply line and cup feeding were not successful.
Finger feeding was during first few days only and she has not reattempted it.
 (Based on my digital exam, I don't think this is a realistic option now.)
During the two stays for bf help, she was also been taught the "controlled
crying" method of settling.  Mother stated that others theorized that the
infant's early feeding problems were due to his overtiredness and
overstimulation because he was staying with mother rather than sleeping in
his own cot.

Mother has been pumping 4-8 times daily and supply has been variable.  She
currently is expressing 90-120 mls every 3 hours.  She is now aware that PCOS
may be a complicating factor in the reduction of her supply.  She has
previously taken two courses of Maxalon (Reglan) and fenugreek.  She
supplements with formula as necessary.  Baby is a slow gainer, and has had at
least one episode of urine crystals about 3 weeks ago.  Mother also noted he
passed bloody, watery, mucous stools 2 days after first immunizations but
this passed and has not reoccurred.  At the recommendation of her GP, she
maintained a dairy free diet for approximately 3 weeks but has discontinued
it.

Mom would like to breastfeed exclusively for at least 6 months, and continue
indefinitely afterwards, but is discouraged.  After the initial visit, I
suggested minor adjustments to positioning and attachment techniques and
recommended the following care plan:

1.  consult an osteopath or CST for evaluation
2.  begin gentle suck training exercises (tapping, stroking lips and cheeks
only at first, then progressing to rubbing gums) as time and energy permit
3.  maintain expressing schedule and continue to supplement using the bottle
(Canon teat)
4.  continue to monitor milk production, weight gain, and baby's output.

The mother has consulted an osteopath, who noted several concerns including
the baby's palate, skull sutures, and baby's posture, and is working with the
family.  I have provided information on PCOS to mom's doctors as it relates
to her low milk supply, but the bigger issue now is, I believe, helping this
baby eat.  I have suggested she speak to the pediatrician and neonatologist
about naso-gastric tube to increase baby's intake while the osteopath works
on his issues.   While her supply isn't sufficient to nourish a normal baby,
she is producing more than her infant is willing to consume at this time.  I
have not yet been contacted by the physicians to whom I sent reports, and
plan to phone them this week.

OK?  I'm thinking a huge combination of issues--mother's issues related to
PCOS, difficult birth, physical anomalies, suck problems, possible gut or
absorption problems could all account for slow weight gain.  I don't know
what else to do for this dyad.  Mother is not willing to "give up", and I
want to support her by doing all I can.  We talk daily and she is willing to
consider everything.  Can you help?

Thanks,
Barbara Ash, IBCLC

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