Permission to Post…I need assistance thinking this one through.  (I apologize now that it is a long story…)

I am working with a mom (who just happens to be a P.A.).  She is now nursing her second child, age 5 weeks.  Her first child BF exclusively for 12 months after a long (about 7 days), slow and difficult beginning.  At that time, she began a sound pumping routine to protect her long-term milk supply as her body established successful lactation in light of many complications (hypothyroidism, prolonged labor, fractured coccyx bone, c-section delivery, delayed initial feeding, sleepy baby, jaundice, postpartum blues, prolonged hospitalization, etc.)  Throughout that year, it always remained her preference to almost always nurse first on only one side and then pump on the opposite side.  She produced well, rarely ever feeding this expressed milk.  First baby was diagnosed with reflux around age 2 months and remains on Prevacid now at age 20 months.  (I wonder if overproducing and unnatural nursing patterns = the reflux in that child…???)  (I think she reported having something like 30 gallons of excess milk remaining in the freezer when she weaned.)

We again met in hospital with this delivery and everything was going much differently (and better) for her this time – for about two days!  She had been highly anxious about every spit-up from birth so we had already begun upright nursing positions and spit-up logs to give her a sense of peace and control over the situation.  By the 3rd day, every classic abnormal newborn reflux symptom was being manifest, including dusky spells while latched. This led to pulse ox monitoring, which proved significant intermittent hypoxemia between feeds, while resting elevated.  An UGI was ordered and “severe reflux” was diagnosed. Prevacid was begun.  Maternal discharge and in-hospital phototherapy soon followed.  Mom faithfully trudged in to breastfeed 7 out of 8 SCHEDULED (Rrrrrr) feedings.  When spitting/desaturation spells did not dramatically improve after 36 hours of Prevacid, mom was told her baby was “allergic” to her milk proteins and a trial of Alimentum was ordered.  This mom stood her ground and challenged that she would do a food elimination diet herself before she would interrupt her breastfeeding.  (No family history of any food allergies.)  She went off of all dairy immediately and won her battle.  The result was discharge with a home pulse ox monitor.  

She contacted me recently as a private practice consult.  (A brand new adventure for me.  So new, that my test weight scale has not even arrived yet.)  Her pediatrician discarded the “maternal milk protein allergy” idea, she eats anything she wants, end of that part of the story.  Baby remains on Prevacid and wears the Pulse Ox monitor only when unattended (maternal choice to continue to have this tool in the home).  Baby still nurses in upright feeding positions and sleeps with head elevated per routine reflux precautions.  Mom’s only concern when she called me was “smacking” while latched and frequent latch interruptions.  An at-home visit revealed a robust baby who is steadily gaining weight and with adequate daily outputs.  Mom’s feeding log shows that all feedings are at the breast, from only one breast at each and every feeding with an average feeding time of 7-12 minutes.  By her choice, she pumps the opposite breast after each feeding (except for 1 or 2 night feedings) and averages 2.5 to 5.5 oz with each pumping (literally – 20 to 28 oz/day).  During this visit, I observed her pump 4.75 oz in less than 5 minutes.  She had great positioning but infant never establishes a tight seal at any point during the feeding.  Obviously, mom has active, rapid let-down and infant starts off, then nearly drowns with milk running out corners of her mouth. (No dusky spells.) Baby spontaneously pulls off to rest/recover and then re-latches, repeating entire process over and over again.  She does appear to be retracting her upper lip partially.  Bottom lip is flanged out nicely.  Visually, a deep latch appears to be established with each little “mini-latch”.  At any time or any point during a latch, the breast can be easily removed from the infants mouth without any audible interruption in vacuum.  (…pop…)  Rarely is there the slightest nipple distortion present.  (Mom has no nipple wounds nor complaints of pain.)  Having worked hands-on with this baby in hospital, both I and mom agree that this was not a problem initially. Mom reports that the “easily slipping off while latched” problem manifest about the second week and the “smacking” began about the 3rd week.  On manual assessment of baby’s suck, I feel a partially humped posterior tongue with nice “cradling” anteriorally. Tongue is moving to the bottom gum line, but not beyond. I am in my own learning curve with advanced assessment of tongue-tie issues, but I see no evidence of ankyloglossia. Baby can (and does) stick tongue out of mouth when not nursing as well.  There is a slight suck blister on baby’s upper lip and that frenulum may very well be the problem, although pediatrician blew this idea off. 

I know we have a multi-factorial situation here.  I do not understand the need to nurse and pump, nurse and pump, as baby is getting no milk from artificial method and mom intends to stay home for first year and breastfeed.  Overproduction cannot be healthy for the reflux.  Mom is terrified she will “dry up” without pumping and that baby is only getting “what she needs” because she is pumping often to keep her milk supply bountiful.  The baby is certainly safe and thriving.  Mom is emotional healthy and happy, but we all want to see her latch improve.  I intend to follow-up when my scale arrives to document some test weights… Help me!  What else am I missing?  Thank you all so much.  I have learned so much by reading these discussions.  

Shannon Sanford, BSN, RN, IBCLC
Buffalo, TX

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