I have permission to post client's situation.

I spoke with a client at 38 weeks gest. She was unable to nurse first child
(3 yrs ago) because of severe weight loss in baby despite "constant
nursing." I asked her some questions and suspected tubular breasts.

Today baby girl is 4 days old. Approx 40 weeks gest (although OB claimed
baby was "due" 10 days before actual birth, mother has long cycles and she
says baby was 40 weeks.)  Born at 6 lb, 15 oz. lowest wgt. in hosp 6 lbs. 3
oz. Weight today before feeding (per Medela Baby Weigh) 6 lbs. 2 oz. After
feeding, 6 lbs. 2 oz.

Mother's breasts are pendulous, one noticably smaller than other. Deeply
pigmented large areolas (light skinned caucasian), large nipples. Mother
says they have "plumped up" in the past two days, "Rounder than ever
before." Mother developed breasts very late, did not start puberty and any
breast development until age 16.Said breasts had little growth during
either pregnancy, but a little more growth with this preg than the first.
On palpation, breasts very soft, I found one spot about the size of a small
flat plum on each breast, about a hand's width back from nipple. During
feeding, baby started swallowing when massage was applied to these areas.
Baby had four wet diapers last 24 hours and one medium, darkish stool,
baby's bili count was 10 on discharge. Mom saved last diaper for me and the
urine was concentrated and dark yellow, no odor. Advised mom to place
tissue in diaper to check for wetness and color. Ped will do an other Bili
count today. Baby's skin looked a bit wrinkled (and orange,) yet supple and
moist. No tenting on hand and good moist mucous membranes. Mother said baby
was "born wrinkled."

Baby happy to suck, doesn't seem to care if she gets milk or not. Open eyes
when swallowing, but falls asleep after a few minutes and I had to coerce
mom to wake her up. Had to correct both lip placement (curled inward) and
remove baby and reposition when baby jerked head back to place nipple in
front of mouth. More than 60 seconds of sucking before any swallowing could
be heard. Mom does not feel MER. After initial pain first 2 days mom says
nipples have little feeling. Baby swallowed for 60 to 120 seconds on each
breast then reverted to non-nurtritive sucking. Mother did not realize milk
transfer had stopped. We massaged and switched sides and got a few more
seconds of swallowing, about 30 seconds, then 10 sucks per each swallow,
then clicking began. I removed baby and mother said she had assumed the
clicking was a sucking pattern. No detectable weight gain during 15 minute
feeding. Most of feeding was teaching mom to recognise what the baby was
doing and how to determine nutritive sucking and maximise it. Gave mom
direction for old fashioned super switch nursing! Needs to keep baby awake
and swallowing.

On suck assesment baby refused offered finger at first (and gave me a
really cute look,) when she did take it (I try to be gentle and will give
up before I will force a baby) I noticed proper troughing of tongue, good
suck, but smaller than average oral cavity. The hard palate seemed low.

Mother became tearful as we discussed possible causes and treatments. She
had the same problem with her first child and said she "had to stop
breastfeeding because the baby wouldn't take the bottle while she was still
nursing. It was so sad. I can't go through that again. She was starving."
From the baby's weight pattern it appears she may have been. She had
discussed an SNS with her ped and the ped laughed at her. (!!!!) She is
willing to use SNS or cup, but thinks maybe the new ped may not suggest
supps. (I am all but certain he will.) Introduced SNS and will start her on
one after ped appt.

I have read conflicting reports on the success of galactogogues with
insufficient ductal tissue. Her OB didn't even notice obviously anomolous
breasts in two pregnancies, getting him to prescribe anything will be
nearly impossible. Does anyone think fenugreek might be worth a try? I
detected only one mass of ductal tissue in each breast, with the rest of
the breast very soft. That doesn't mean the ducts aren't there, just that I
couldn't feel them. Low supply, appearance of breasts and lack of weight
and hx with first child seem to indicate ductal problems.

We will be standing by with a pump and SNS for her return from her ped's
appt this afternoon.

Should I load her with Fenugreek too, or will she be overwelmed and not
helped enough to bother? I am thinking that if we can get those few ducts
she has to make the most milk possible, the better they will be. Am I
right?

Help.

Mary Jozwiak IBCLC Private Practice

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