Dear Wise Ones,
I am a hospital based LC and I had an outpatient consult this weekend that
left me feeling stumped. I have Mom's permission to post.
Full-term, 1st baby, unmedicated vaginal delivery (as in no pain meds., no
epidural because Mom thought that would be better for breastfeeding!!) that
took place at another hospital; no vacuum, no forceps; birth weight 8lb.
8oz.; no antibiotic use; baby had 4 or 5 meconium stools; discharged at 24
hours; hospital LC said baby going off and on the breast because he really
didn't feel like nursing.
Weight check at 5 days at pediatrician's office, baby down to 7lb. 9oz.;
baby had not stooled since hospital discharge; did stool with rectal stim.;
nurse recommends Mom purchase a nipple shield because of cracked, bleeding
nipples; baby accepted nipple shield but still squirms, pulls off the
breast throughout feeding; diagnosed with reflux at 2 weeks and put on
Zantac; stools 2-3 times/day but baby fusses, strains, stiffens for about 30
prior to stooling; one day last week baby went ~16hrs without stooling and
Mom states baby fussed and strained for an hour or two before finally
stooling.
At 3 1/2 weeks baby is up to 8lb. 6oz. with nipple shield use; Mom states
baby looks uncomfortable most of the time. Gives an occasional bottle of
EBM. Baby roots ~every 1 1/2 hrs.; either baby comes off the breast or Mom
takes him off after 10-15 minutes and then puts him on the other breast
until he falls asleep 5 mins. later. He'll sleep about 15 mins., then he's
up and fussing again. Mom says the only place he'll sleep is on her chest
or Dad's. Mom's only dairy consumption is 5-10 cracker sized pieces of
cheese a day. Doesn't drink milk, eat yogurt or ice cream. She eliminated
onion and garlic thinking that might be the problem. Mom takes no meds. and
has no significant medical history. Baby nursing fine with shield but did
latch on once before Mom able to get shield in place so she decides to nurse
without the shield. But then, nipples become very sore again.
Mom comes to our office at 6 weeks. Baby weighs 9lb. 6.3oz. (has gained 1
lb. in a little more than 2 weeks) prior to nursing. He is obviously ready
for a feeding and latches widely without the shield, in the cross-cradle
position. He coughs and sputters at the letdown. For the next 20 minutes
or so he squirms, fidgets, fusses, pops on and off the breast; sometimes Mom
is very uncomfortable with re-latching, OK at other times. Her nipples are
red and are sloughing some skin. Baby has had no signs of oral thrush or
diaper rash. Mom has had no symptoms of a yeast infection. Baby fed for ~
15 minutes on the first breast while Mom says it feels like sandpaper
rubbing under nipple. Baby's tongue is cupping the nipple. On digital exam
baby reluctantly sucked on my finger, moving his tongue back and forth.
Oral anatomy appeared normal. I tried to get him to go back on that same
breast rather than putting him to the other one, thinking maybe it was
overactive letdown/oversupply, but he wouldn't stop fussing until Mom put
him on the second breast. We tried variations of the football hold but he
would have nothing of it. I did have Mom use the shield on the second
breast thinking that the shield may be easier for him to reduce the flow if
reflux is his main problem. He sucked for about 5 min., then fell asleep.
He woke up 15 min. later and fussed and fussed while Mom danced with him,
trying to calm him. Post-fdg. wt. was 9lb. 8.3oz. He appeared to be very
uncomfortable. This mom was very loving and patient with this very unhappy
little guy. I was very impressed with the way she handled him...most moms
would have been in tears. I asked if he had started smiling yet and she
said only in his sleep and that he looks uncomfortable a lot of the time.
I suggested trying to keep him on one breast for a 3 or 4 hour period, but
he clearly was unhappy with just one breast in the office. If she continues
to use the shield to reduce the flow, should she pump to maintain supply, or
will that only aggravate a possible oversupply? We also talked about using
different positions to slow the flow. Would it help to see a chiropractor
or CST? They are military so it might have to come out of their pockets.
Is this reflux ( there's no spitting), disorganized suck, something else, a
combination of things? Where to go from here? She was happy just to be
reassured she was doing a good job. I sure wanted to have a magical cure
for them. Any help will be greatly appreciated!
Cherie Price, PA, LCCE, CD(DONA), LLLL(Reserve), IBCLC
Virginia Beach, VA
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