Hi experts,
Permission to post. I have not seen this mother in person, but we had a
long discussion about her experiences and interactions. Baby is 6 weeks
old. Birth weight 7 lbs 11 oz at 41 weeks gestation. 30 hours labor without
medication, then pitocin and epidural (5 bags fluids, 3 bags IV
antibiotics, 3 bags pitocin drip, if I understood correctly) with 4 hours
labor, 2 hours pushing (someone told her baby's head was "coming
sideways"), and vacuum extraction due to fetal heart rate below 60. Lowest
recorded weight 6 lbs 14 oz Day 3 or 4.
Mother has been using a nipple shield given to her in hospital due to latch
problems with inverted nipples. Baby does not latch without shield but
latches quickly with shield. Mother senses 3-5 let-downs per 20 minutes
each side. According to mother, baby has at least 6 (usually more) ample
stools in 24 hours and is generally content. Spitting up is rare and scant.
Mother is taking More Milk Plus tincture 1-2 times a day and frequently
consuming oats as cereal or lactation cookies.
Baby had not regained birth weight by time of checkup at 5.5 weeks, when
she weighed 7 lb 9 oz. Length and head circumference appear to be
increasing normally. From our conversation, calorie *output* appears to be
a major factor. Baby was called "bizarrely active" by doctor observing
fetal ultrasounds, "just doesn't sleep" during the day, and continues to
have remarkably active arms and legs during waking hours, though she sleeps
soundly at night. Both parents are "lean", mother gained only 20 lbs during
pregnancy, athletic mother continued to run regularly until 8th month of
pregnancy, and I struggled to take notes fast enough during our phone call
;^).
Baby has been seen by a lactation consultant and two osteopathic
pediatricians at a local practice considered breastfeeding-friendly. Dr. #1
described baby's shoulders and neck as very tense when performing
osteopathic manipulative treatment (OMT) sometime during Week 4. Mother
noted baby starting to take a (short) daytime nap after that treatment.
Mother noted that baby was napping more or longer since 5.5 week OMT
treatment by Dr. #2. Dr. #2 noted a "shallow palate". Baby reacts to
pacifiers of any kind by gagging, but takes a bottle well. Mother notes
that her family reports she also gagged on pacifiers as an infant. Test
weight of intake with nipple shield at 5.5 weeks indicated a 1 oz intake
while feeding about half as long as usual. Dr. #2 recommended 6 oz
supplement daily of EBM and/or ABM in addition to BF at every hunger cue.
Mother has been managing to pump when baby sleeps longer and can get 1-1.5
ounces when baby has slept for an hour or longer.
I have not been able to find ideas to improve milk transfer or lower energy
expenditure particularly for a baby with a "shallow palate" (mother says it
is not high when she sees it) who gags on a pacifier, in my 2008 edition of
Genna's *Supporting Sucking Skills* or elsewhere.
My suggestions to the mother:
- Consider supplementing herself and baby with probiotics in case
intrapartum antibiotics have affected nutrient absorption.
- Nurse at every hunger cue to keep baby from expending energy from
crying and to maximize calorie density of milk output. Continue to pump
whenever baby takes a long nap. Look at videos of breast massage and
compression and use those techniques at every opportunity to maximize
volume and calorie density of baby's milk intake.
- Top off baby's feedings by bottle as directed by Dr. Consider pumping
in middle of night when baby appears to prefer sleeping and feeds less
effectively. Use that milk to top baby off well before bedtime, since baby
seems to keep large feedings down well and can be growing while inactive.
Encourage cluster feedings whenever baby is inclined, especially if baby is
due for a nap.
- Consider a comfortable rocking chair to offer baby lots of vestibular
stimulation without mother or baby expending many calories. (Mother reports
that rocking helps get baby to latch.) Continue to encourage baby to stay
latched for for many let-downs.
- Collect 24 hours worth of diapers to show lactation consultant and/or
Dr. in 4 days when going for weight check and to "try to get baby off the
shield".
- Continue to seek OMT for baby until baby is no longer described as
tense.
I suspect I may need to observe a feed and assess baby's mouth, but based
on this information so far, is there anything else I should tell this
mother about how to maximize calories in and minimize calorie expenditure?
Is the nipple shield really the problem the LC thinks it is? Is there
anything that clicks for you about this case from similar dyads you have
seen?
Thanks,
Ruth Piatak
--
Ruth Piatak, BA, MS, LLLL, IBCLC
Tulsa, Oklahoma
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