Dear Wise Ones,

I need some quick advice and please send it to me at [log in to unmask],
as I am nomail right now (vacation starts tomorrow!.)  Last evening I met
an 11 day old infant who was born at 36.5 wks gestation.  He had latched
very little in the hospital prior to discharge.  Sadly I hadn't gotten to
help them prior to their discharge and had met them only in passing.  They
left the hospital finger feeding and that is now the only way he gets his
expressed breast milk and some formula.  Mom is extremely stressed and has
been sleeping only 2-3 hrs/ night as she is worried that the baby will stop
breathing, etc.   She is a primip.  Her milk supply is faltering and she is
now pumping half as much (only 6 oz/day now) as she had been and needing to
use more and more formula.  She is heartbroken about using formula and
becoming totally discouraged with the dwindling amounts she is getting when
she pumps.  She reports that she hates pumping, finding it painful,
although I couldn't see any broken areas on the nipples.  She has nipples
that erect and pliable breast tissue.  Breasts don't exhibit any of the red
flags for insufficiency.

When the baby was brought to the breast, he instantly got very upset and
arched himself as far back from the breast as he could.  We teased him with
a taste without success.  We tried a nipple shield, with some ebm expressed
into it and still no success.  Next we taped a tube to her breast and we
had some slight success, in that he latched a couple of times and fitfully
got about a half ounce.  He was obviously not satisfied with feeding this
way.  He does have a small tongue tie and most often has his short tongue
curled up and back in his mouth.  Finally, we gave in and gave him the
finger and the tube and he relaxed and sucked down the rest of the 2
ounces.  He is gaining fine and was nearly back to BW at 8 days or so.

My advice to her was to make sleep a priority.  When I wasn't able to see
her the day before, I told her to take a babymoon, naked under the sheets
for the next day, which it sounds like she did some and that the baby
nursed a little at the breast, after he had already eaten from the finger,
once.  In fact she said he'd only nursed at the breast 7 times since
discharge and it was always after he had just eaten (she's dessert!)  My
feeling is that he developed an aversion to the breast and that she needs
to give him a break from it so that he can forget his aversion.  I wasn't
sure how long to tell her the break should be.  I also gave her advice to
keep the pump pressure comfortable (I think it was a Pump in Style) and how
to maximize her letdowns when she pumps. She is lucky to have a very
supportive, involved husband who is going to try harder to help her get the
sleep she so desperately needs. I suspect that her anxiety and sleep
deprivation are at the root of her diminishing milk supply, as she sounds
like she is pumping every two or three hours.  I'm not sure why I didn't
think of it, but maybe it would make more sense to transition the baby to a
bottle and then try to move him to the breast or a nipple shield.  Anyway,
I am very interested in hearing from anyone who has worked with a finger
addicted, breast averse baby and successfully transitioned them to the
breast.  I am hoping to call her later tonight from work with more
strategies.

Priscilla Tansley RN, BSN, IBCLC
(who has the pre-vacation jitters and hasn't slept very well herself, in
the past few days!)

             ***********************************************

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