I have been working on a challenging case for about 4 weeks and, to make a
long story short, have sort of hit a brick wall.  With the mother's
permission to post, and plea: We need help!

Baby W.  was born 4 May in a traumatic vaginal delivery with forceps that
left Mom with vaginal wall tears and a huge episiotomy.  He was badly bruised
at both temples and extremely tender about the head, neck and shoulders when
I first saw him 4 days postpartum.  Mother has congenital kidney disorder
which results in her kidney function being 40-50% of normal.  The baby has
been and will continue to be screened for the same disorder.  Right now, he
shows no signs.

Mother has flat nipples.  The L inverts slightly on manual compression, but
everts to about 1/8" after expressing or using the inverted syringe
technique.  The areolar tissue on the L side is quite thick and dense, and
difficult to compress.  R side is better.  W.  fed at both breasts
immediately after birth, but due to some subsequent rough handling by
hospital staff (according to Mom), started to refuse breast on day 1.

He had urate crystals and was still passing meconium on day 4.  I observed
that he was very mucosy (and remains so even now) and jaundiced to the point
of using a bili blanket days 4-7.  Putting him anywhere near the breast in
any position resulted in agitated behavior and lots of crying.  Mother was
dripping colostrum in his mouth by dropper when she could wake him, about
every 4 hours.

Mom had been an infertility patient and at day 4 was expressing about 5 ml of
colostrum q 4.

She increased pumping and feeding by syringe to 2 hourly.  We had to
supplement with ABM to get his energy level and output going, and he did pick
up.  Very gradually, he transitioned to breast, but could not attach without
a breast shield and modified positioning.  For a few days in hospital, he did
fairly well feeding at the breast, and Mom comped him with syringe feeds.
They were discharged on day 8.

Then Mom's episiotomy got infected, and she was put on antibiotics, resulting
in thrush for Mom and baby. She worked through that, but because things were
slow to improve, I suggested they see an osteopath who specializes in
infants.  He diagnosed significant palate problems, and is addressing those
as well as the misshapen head from the forceps (the poor child still has 1/4"
deep dents on his temples).

Mom's milk supply over this time has blossomed. W. is gaining weight at the
rate of more than 200 g per week and appears to be generally happy and
healthy.

Our current problem is that while he will attach both the bare breast and to
the nipple shield deeply and suck well for about 2 minutes, he then squeezes
his cheeks and moves the nipple to the front of his mouth.  (I should note
here that he doesn't usually prefer one over the other, oddly enough. There
are rare occasions when he will only latch with the shield, mostly at night.)
 Frequent reattaching does not help.  After the initial 2 minutes, he simply
refuses to have the breast deep enough to feed without causing Mom pinching
pain.  The osteopath says that the palate is much improved and should not be
causing him discomfort and thereby forcing a shallow latch.  W's swelling and
bruising is resolved, and he doesn't appear to have any pain.  Mom does not
have a particularly forceful MER, but no matter the position, W. does have
problem coordinating his suck, swallow, breathe pattern.

Pediatrician says there's nothing to be done about the mucous and snuffly
nose.  At my suggestion, Mom has eliminated dairy and is considering further
dietary interventions.  She hasn't seen great results, but thinks he is
slightly better.

So now what do we do?  This Mom is fabulous.  No whining, willing to try
anything, even to continue in pain, but that's not good enough.  I don't know
why W. is changing his sucking pattern after a few minutes.  I'm beginning to
wonder if there might be some neurological underlying problem, but getting
the pediatrician to address this is unlikely at best.

Looking forward to your input.  Thanks!
Barbara Ash, IBCLC
Canberra, Australia






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