I'm looking for suggestions and feedback for a family I worked with
tonight.  The file is in my office and I am home right now, so this is all
from memory.  I'll try to include as much info as I can remember.

Baby is 4 1/2 weeks old.  BW:  9lbs 4 oz.  Weight tonight:  10lbs 5.4oz
Born by planned C-Section at 39 weeks with Epidural.  Mother received
antibiotics in hospital (for C-section).  Mother has been taking
acidopholus since birth and another supplement (I can't remember what) to
prevent yeast.  She states she took a Diflucan right after birth to prevent
vaginal yeast.

Mother is G5,P5.  Breastfed 1st x14mo (10 years ago), 2nd x12mo, 3rd
x8weeks, 4th x3 weeks.  3rd and 4th discontinued bf due to pain while bf.

Mother is in to see me tonight because of pain when nursing and between
nursings.  She states that it is a "grating" type of pain, rather than
excruciating.  She states she does feel shooting type of pain between
feedings.  She states she often sees her nipple blanched after a feeding
and sometimes a pinch line.

She saw the IBCLC at the hospital she delivered at a week ago and she was
introduced to the asymmetrical latch, but states it hasn't helped
much.  She wonders if she might have a yeast infection.

She states that her baby fights at the breast.  She will root and act like
she wants to nurse, but after the first let-down (which is very forceful)
she will pull off and on and off and on and scream and fuss.  She states
that the middle of the night and early morning feeding are the best and
that as the day progresses, the feedings get more and more frustrating for
both mom and babe.

Baby has a very protruding abdominal hernia which the parents state they
were told not to worry about, that it would most likely heal itself by the
time she was 3-4 years old.  But they cautioned the parents not to let her
cry too much.  Which of course is causing a lot of worry because the baby
is crying so much during feedings.

Yesterday, it all seemed to crash in on the mom and she pumped and tried to
give the baby a bottle (or dad did) and the baby did the same  pattern with
the bottle.  She just didn't seem to know what to do according to the
parents.  The mom states that if her baby would be content at the breast,
she might be able to put up with the discomfort of nursing, but her baby
seems to be unhappy and that seems to make the pain worse, and she just
wants to put an end to everyone's misery.

Mom states that baby spits up copiously after every feeding and regularly
between feedings.

Feeding Observation:
At left breast in cradle position.  Mom latches baby very well
asymmetrically and baby goes on easily and starts sucking.  Within 30
seconds it is obvious that there is a let-down as baby sputters and chokes
and comes off breast.  Baby latches again well and stays.  Listening with
stethoscope, baby is sucking once, swallowing 1-2 times and breathing fast
4-5 breaths before sucking again.  The baby spent a lot of time getting her
breath back after each suck/swallow round.  After approx 5 minutes baby
pulls off and can't/won't stay latched.  Flails her arms and
squirms.  Total transfer 28ml.  Mother's nipple post feed is
rounded.  Mother states she still feels the "grating" type of pain while
nursing.  Baby spit up while still at breast.

Digital Suck assessment:
Baby has no organized suck at all.  She humps her tongue.  Roots her mouth
as if she wants to suck, but doesn't suck.  When touching the juncture of
the hard and soft palate repeatedly, she will close her mouth around
finger, but hump her tongue and not suck.  A little bit of EBM into mouth
causes her to swallow, but no suck, just crying.  No grooving of tongue.

Her tongue is flat at end, like a square.  Seems shorter than
average.  Very visible frenulum.  She is able to extend tongue past
gumline.  Mother states that some of her other children had tongue ties and
one had it clipped.  I don't think that is "the" issue here.  It doesn't
look as if this frenulum could be clipped anyway.

Baby doesn't have obvious signs of thrush.

Let dad calm baby while mom pumped.  In approx. 10 minutes she pumped
3oz.  We didn't empty her breasts at that point because we thought the baby
would go back on.  She didn't.  Mom states that her breasts felt pretty
soft.  Baby was generally inconsolable for the rest of the visit.  She
would not fingerfeed.  Parents state she is this way each night.

Mother is very tense and weepy throughout the visit.  Dad is
supportive.  Mom states she hunches her shoulders a lot when latching and
nursing.  Even when she consciously tries to relax her shoulders during
this visit, her shoulders remain rigid and raised.

Moms breasts are small (B-C) cup with small areola and small
nipples.  Nipples are everted.  Not shiny or red.  Breasts are symmetrical.


My impressions:
Possible reflux-type problem.  It really did appear as if feeding was
painful for this poor baby.
Possible oversupply.  I won't swear to this as I don't think it was proved
by the evidence at this feeding.  On the other hand, it was an evening
feeding, so this amount of pumped plus transferred may indeed be
excessive.  What do you think?
OALD. - I definitely think this is a problem.  I think the humping of the
tongue is to protect her airway.
Possible ductal yeast?  I doubt it myself, but it is a possibility.
Possible referred pain in breast from hunching shoulders?
Possible vasospasm due to pinching of nipples secondary to humping of tongue?

Interventions:
Worked on upright positioning, such as baby aligned vertically and lying
down with baby to the side but head up.
After pumping baby did nurse quietly at breast in vertical position for
approx 10 minutes.  Mother states she felt a let-down during that
time.  But no milk transfer per scale.
Showed parents how to work on suck with mom or dad's finger.  Discussed
pacifier "tug of war".

Immediate plan:
Try pumping past 1st let-down prior to latching.  Try latching in more
anti-gravity positions.
Call Peds clinic and make appointment on Tuesday to get baby checked for
feeding problems.

Anyway, I feel almost overwhelmed with this one.  There is no particular
ped involved, just the clinic where they will most likely see a NP at least
initially.  No problems with NP, don't get me wrong, just that I have no
one in particular to send a report to.  There is not any particular NP
assigned to this baby, just whoever happens to be there that day.  I want
to tell someone that I think there is something wrong with this baby but I
don't know who to tell.

I've worked with moms and babies who were diagnosed by Ped with reflux and
they could take a bottle fine or finger feed, so I don't think that even if
this baby has reflux, that it is the whole problem.  I think that this mom
probably does have a very good milk supply and a strong let-down, so that
this baby has been coasting and just latching to breast but not really
sucking well.  Her weight gain is adequate.

I don't like that this baby seemed to take all those breaths between each
suck.  Her mother states that she is all the time "pooped out" after
eating.  She eats 8-9x/24h.  Voids and stools are copious (at each diaper
change and each feeding).  Stools are yellow.

I'll give updates as I get more info.  Please let me know if you think of
anything I missed or misinterpreted.

Thanks,
Cindi Swisher, RN, IBCLC
Colorado Springs, CO

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html