Sorry for the late reply, am catching up after a wonderful conference in
NH followed by a few blissful days visiting with Diane and Kathleen.

The "crying hoarsely" jumped out at me. This can be an indication of a
unilateral vocal fold paralysis. If this is the case, the baby will feed
much better with the working fold up if it's paralyzed open.

If the baby has the cord paralyzed closed, he might need more calories
because he's working harder to breathe. This could cause him to be
getting enough to stool and wet, but not enough to gain weight well. If
it weren't for the sore nipples, I'd think that might be it. But the
management we see in the visit is not always what mom does at home. If
the latch was suboptimal, the milk transfer will be as well. Even with a
nipple shield.

I'd take a really good look at the baby, and see if there's any evidence
of increased rate or effort of respiration at rest and during feeding,
see if the sucking bursts are short (3-5 sucks) and the respiratory
pauses are longer, and look to see if there are any oral anatomy issues,
they sometimes go along with airway issues. And of course, fix all the
positioning and latch issues first, babies with issues often manage to
breastfeed if we take care of basics and make some minor adjustments to
help them.

Catherine Watson Genna, IBCLC  NYC

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