Hello Lactnetters,

I have a case that I'm really having trouble with and hoping you can help me. I have a mother who is having a great deal of difficulty with breastfeeding and wondering if anyone has any thoughts or suggestions. This is a very nice couple who had planned a homebirth with their first baby, but then decided to switch to a hospital birth due to mother's having thromocytopenia. She had a natural birth in the hospital with her midwife as her doula, bleeding was minimal. I got to play nursery nurse, so made sure that the baby had immediate, continuous skin to skin contact. The baby was healthy at delivery, except seemed tired with poor tone. Light meconium but vigorous at birth. He enjoyed the skin to skin time and relaxed on mom's chest but never showed any pre-feeding behaviors. After 2 hours he fell asleep. I told the mother that it's fine, most likely he would wake up after a long sleep and begin searching for the breast, which he did about 4 hours later. I
 didn't work the next day, but called her. Over the next 24 hours he had 4 feeds, one of which was about 20 minutes, per the mother, I didn't observe. Which she said was his best feed. I reassured her that some babies are slow starters, but as long as they are improving it's fine. However, it can be a good idea to express some breastmilk into spoon or babies mouth, because it's also good for her milk supply. 

She did a little hand expression into a spoon that evening, a couple times and noticed that it was rust colored. I came in the next day, and saw her again. Explained that this can be normal. She has fibrocystic breasts and I think she has the "rusty-pipe" syndrome. But then during that day, about 36 hours old now the infant began to feed more poorly. Becoming fussier at the breast. No bottles or pacifiers given at this point. We watched Jane Morton's video about hand expression and hands on pumping. Tried skin to skin and laid back breastfeeding. Also, the mother does have flat nipples, which usually I don't consider to be much of a problem. I teach them to due hand expression to get milk flowing and draw the nipple out and usually the baby gets on easily. So then the mother was hands on pumping and following with hand expression, and we were giving EBM to baby in syringe, and trying to use EBM to entice baby to breast, but to no avail. So we continued
 EBM. Then that evening at the end of shift, her nurse checked bili and it was 12 at 48 hours, which is high range, but according to treatment nomogram it's below treatment level for phototherapy for a 40 week baby. However, this happened after I already left for the day, the Ped wanted double phototherapy as a precaution. I can see the wisdom of that since baby wasn't really feeding that well. But of course wanted mother to supplement with formula. By the time I came in the next day, she had supplemented with formula by cup feed x 1. And the parents were really trying no to do a pacifier, especially with mom's flat nipples, but in the middle of the night with the baby on phototherapy (which was in their room) they did end up doing a pacifier because baby was do distressed under the lights and not able to nurse at the breast for comfort. Then the mother said that after photolight therapy and pacifiers, she was unable to get baby to breast at all. I
 agree. Even when baby was calm and skin to skin and begins rooting, he will go to the breast and suck for a few seconds and then come off like he's unable to maintain suction. No tongue tie. But that's when I noticed he has a very high palate. It looks like what some describe as a bubble palate, I think it may be interfering with his ability to maintain suction at the breast. Infant's bilirubin improved under phototherapy and they were discharged home yesterday. Mom has pump and is pumping/hand expressing and using soft feeder to give to infant. I'm not sure how well this baby was ever able to do at the breast because that was the day that I wasn't there. I've only ever seen him get on for a minute, then lose suction and pull away distressed. Now he's very distressed and arches away whenever we bring him near the breast.

I'm finding little info on high/bubble palates, and very few suggestions other than getting the breast deeply into the mouth. Any other suggestions would be welcome. Parents are very committed to breastfeeding. Getting the breast in deeply may be especially problematic because mother has small, fibrocystic breasts. So to recap:

High bubble palate
Fibrocystic breasts
Rusty pipe syndrome
Flat nipples

Any thoughts or suggestions would be greatly appreciated. Thank you so much.

Tricia Shamblin, Rn, IBCLC

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