Dear Wise Ones,
I'm hoping to find some suggestions for a new patient (who picked me after
we met at a LLL meeting!)  Mom is 44, this is her second baby, first is 7
1/2 now and was breastfed 1 1/2 years.  Baby was born by vaginal birth after
cesarean on 3/6/04 at a different hospital than the one where I work.  He
apparently latched the first time right after delivery, and has been feeding
fairly well since birth.  He was born at 37 1/2 weeks, though, and mom
reports the first few days he was hard to keep awake. Birth weight 7 lbs 6
oz.  Discharge weight on 3/8/04 was 6 lbs 14 1/2 oz.  Naked weight today (in
my office, on a different scale) was 6 lbs 13 oz.  Baby has at least 6 wet
diapers and at least 5  yellow, seedy stools a day in the last 2 days.  Mom
complains of severe pain at latch of both nipples, which improves after baby
nurses a few minutes.  On exam, I noted one of those minimal, tight lingual
frenulums we've talked about her recently, and baby sucked on my finger with
a rather chomping motion with tongue back and forth over the lower gums.
The most notable thing, though, was that mom's nipples are very large in
diameter, at least quarter size.  Baby was at the breast when I came in the
exam room, and when he came off the breast the nipple was flattened, and
even larger in diameter appearing.  It looked like baby had obtained a deep,
enough latch based on how much breast came out of his mouth when he opened
his mouth.  Remarkably, though, there was no obvious nipple damage other
than mild redness on both sides.  Baby opens wide to latch on, but his
little mouth is small enough that the nipple doesn't clear the opening, even
when he's wide open.  (Does that make sense?)  As a result, baby tends to
slurp up the nipple until he obtains a deeper latch.  Mom about levitates
off the chair during this process, but is comfortable once he's settled on.
 Although his weight was a little worrisome, he is not even slightly
jaundiced, is very vigorous, and with his current output I'm guessing he's
going to start gaining.  (Will of course weigh him again, soon.)  I went
ahead and clipped the frenulum although I wasn't sure it was causing a
problem.  Baby then latched at breast again readily for me, but again just
can't open wide enough to get around these nipples in one fell swoop.  WE
tried again in football hold, and had a little better result as mom could
see the breast and his mouth better, but still it was hard to avoid scraping
the nipple along his gums as he latched on.  The baby is very agressive at
latching on.  I'm guessing a less aggressive baby would not be able to latch
at all.  Mom also tried once to pump at home with an Avent Isis and found
the pump very painful, I'm guessing because the diameter of the shield is
too small.  Finding any better pump around here is an ordeal, and mom is
willing to continue at breast so will not pump for now.
She doesn't remember having this hard of a time latching her older child.
I'm guessing that this might improve as baby grows, but is there anything
else I can suggest to her in the meantime?  She's going to try some
ibuprofen, the football or cross cradle hold to help her guide the latch a
little better, and deep breathing until baby is on well.  Maybe also, the
frenulum being clipped will help a little?
What else can I tell her?
Jennifer Tieman
Family Physician
Mom to 4, including nursling Caroline Rose born 5/31/03

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