Hello esteemed lactationsts;)

Mom is exceptionally motivated and interested in fixing whatever has
gone wrong.  She's extremely together, has excellent support from
husband.  I didn't know her prior to her breastfeeding difficulties, but
she's a close friend of a close friend.  Very ap oriented.  Very crunchy
etc.

unmedicated normal birth at a free standing birth center.  3 hour
pushing phase. compound presentation hand/head.  baby not interested in
nursing.  for three days.

7#5 at birth.  mom began pumping with a Hollister PY.  very little
response to the pump.  mom fed what colostrum she could get plus formula
via syringe/tube until baby latched at three days.  she doesn't know the
lowest weight but it checking for me.

He latches, she's relieved.  Baby nurses 10-20 times per day with
frequent fussing at the breast, continuing to try to nurse for long
periods of time, eventually screaming.  Maybe 2x per day he nurses
'well', seems satiated and falls asleep.  Generally difficult to settle,
unhappy.  Mom never gets 'engorged' in a manner that she hears discussed
amongst her friends.

She does feel a let down, there is milk transfer for a few seconds
before the frustration starts....

At 1 week pp, the plugged ducts start, then mastitis.  Various places in
both breasts.  It's constant.  So are the cracked and bleeding nipples.
At 6 weeks, she goes to the pediatrician and breaks down crying.  The
plugged ducts and mastitis, the ulcerated nipples, the unhappy baby.
Ped weighs the baby and says, 'well, his weight is fine'.   She didn't
have the weight handy but is checking into it for me.   Let's get you
some help...sends her to LLL.   Got moral support but deep down, mom
knew that it wasn't just a case of "keep going, it'll get better'.

She hears that there's a lactation center at one of the hospitals.  The
one that is probaly the farthest from her in metro Atlanta.  Probably an
hour from her [I wish someone would have mentioned that there's
lactation help at really all of the area hospitals!!! and Crawford Long
is very close to her]  at 8.5 weeks pp.  This is where she hears the bad
news....which in a way, is a relief.  She knows something is really
wrong and is glad to have someone say so.

They told her to nurse the baby every three hours, then give him a
supplement with a bottle, then pump.  The birth center had given her an
orthodontic nipple and said to use it if she *had* to use a bottle.   No
suck assesment was done, no imformation on improving latch; they
recommended she see the feeding specialist at a local children's
hospital. On her own she learned about fenugreek and was taking 8 caps
per day. She had been following the instructions for 10-12 days when I
first talked to her.

I called.  I told her that I might be able to help, and that I'd be
leaving to go out of town early 'tomorrow morning' - perhaps friday we
could get together.  Her sense of urgency was strong and we ended up
agreeing that I'd rearrange my morning and leave later for my trip.  She
fought rush hour traffic to get to my house Tuesday am.

Cutest baby on the planet.  Okay, jaw isn't exceptionally recessed.
Wow.   Highest arch in his palate that I've ever felt (though I haven't
felt many....maybe 15?)  It was like half of a kiwi scooped out.  He
latched right on....ooh, let's get those little lips flanged (showed her
how to just press on her breast tissue and see that little bottom lip
pop right out).   Textbook:  quick sucks...let down in a few seconds,
suck swallow suck swallow.  Great.  Lasted less than a minute...started
to kind of grunt/fuss at her breast...quick sucking again.  Showed her
breast compression - kept him going for a bit longer...switched to the
other side.  Tried this a few more times....he wasn't getting anymore
and was getting really upset.  She was going to feed him a bottle so I
gave her an evenflo elite which at least has a wider base on the nipple.

He drank the formula hungrily and cried for more. And cried.  And
cried.  She nursed him again, superswitching 4 times.  Stil crying.

I was torn......if it was a close friends baby, I'd nurse him.  After
all, I had nursed the babies of several close friends when mom had an
emergency dental appointment, a death in the family and a few other
circumstances.  And they'd nursed my babies...once when I was at a
birth, once when I was pregnant and couldn't nurse Alana for one more
second....and this mom was a friend of a close friend who wouldn't think
it at all strange to nurse one another's children....and Lynn had said,
"Katherine, she's like us..." after mulling it over for a few moments, I
decided that I'd ask her if she wanted me to nurse him.    I knew his
could be touchy.  If she gave any verbal or body language indicating
that she was uncomfortable I would artfully redirect the conversation.
She didn't...instead, "oh, would  you?  I can't stand to know that he's
so hungry.  I never would have asked you, but it was in the back of my
mind".       So I nursed him.  He did the same thing at first with me,
after the first let down slowed, he immediately started his
grunting/whining and eventually crying.  I experimented with an
*extremely* asymetrical latch that I'd done with my daughter at birth.
she had an extremely recessed lower jaw and it was hard for her to nurse
for months.   Bottom jaw fulll of breast tissue, positioned so that the
nipple just barely makes it in under the top gumline, pushing as much
tissue in as you can with your index finger.  It's hard to explain.
You're actually just flipping the nipple in.  I don't know how I
discovered that it worked, but it worked for lila and seemed to work for
this guy.  I also ended up practially laying him on my lap, doing 3
second breast compressions and was able to get him to nurse for about 5
minutes.....change any one of these factors and he'd stop nursing and
start fussing.

Mom and I talked alot.  She felt that at first, though her supply wasn't
over abundant, she felt that she actually did have enough milk, but b/c
of other factors, he wasn't able to transfer milk effectively.  Makes
sense...otherwise, why all the plugged ducts?  Anyone?;)  Then over
time, he supply dwindled b/c of lack of effective transfer (palate and
latch issues?) , then the three hour schedule (which simply isn't
frequent enough for most moms), a PY instead of a hospital grade pump
(which would make a difference for most moms but not all).    I keep
thinking about a true supply issue/ISGT  but then why the plugged ducts?

We talked about an SNS, practiced asymetrical latch, domperidone and
MoreMilk Plus tincture (instead of fenugreek) and Goat's Rue.    Mom was
interested in doing all of the above immediately.  Remember my friend
with the monoamniotic twins ?(who are now 4 mo old, huge and nursing
great:))  Since the tube they gave her at the birth center couldn't be
used correctly for supplementation (breast or finger)as it was very very
very large, I called my friend - she ended up having everything: medela
feeding cups, SNS, the video - everything.  Mom drove up to get the
stuff from Bronwyn and on the way stopped to get the goat's rue and MMPT.

As luck would have it, my friend is a SLP so she was able to second the
recommendation of the LC to see the feeding specialist SLP at the
Cranio-Facial disorders clinic.  Baby was asleep so bronwyn didn't have
a chance to check anything else....

I didn't ask if mom had had any breast surgeries, but I also didn't see
any indication of such (I know, I know)....she's getting the weights so
that we can see if weight gain really was adequate during the first six
weeks.

Mom was on the moving toward a very unhappy place.  She can hardly
remember anything since the baby was born.  The 3 hour, round the  clock
pumping schedule was tortuous.  I'm not a fan of pumping anyway if the
baby will actually nurse at the breast (ie baby is the pump).  since
this baby would, here's her new plan:

~offer breast often - at every early cue if he's up, not letting him
sleep longer than 3 h during the day or night....breast compression,
superswitching.  she's sleeping with him.
~mom is using the SNS every 3 hours - occasionally more based on his
requests, (always offering the breast first, super switching etc).
~taking MMPtincture and goats rue tincture.  waiting on domperidone from
NZ.
~she's seen breast and supply changes from the tinctures in just 48
hours.  however, she's already gotten one painful plugged duct.
has an appointment with the feeding specialist in 2 weeks.

Also, new and interesting, baby is refusing the larger (presumably more
productive) breast without the SNS.  Encouraged her to keep offering it
first, treating it kind of like a nursing strike:  offer it when he's
sleepy/sleeping, not so hungry etc.

I gave her my copy of Jack's book.  She's very interested in making a
plan to get off the SNS and formula (following some of the examples in
the book).  She's waiting on the domperidone though.  Wants to make sure
baby is gaining and thriving before she starts cutting back.  She does
have a gram scale, so she can assess intake more accurately.

I've got to find out about breast surgeries and weights of the baby all
along...and will be looking forward to hearing about the consult with
the specialist.

Interested in hearing anyone's theories....though I know that the
missing tidbits of info could complete the puzzle.  I'll keep you all
posted.  Anything else I should pass on to mom?

:)katherine in atl

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