Hello,





I hope you are all well.  I have been following a full-term, almost 4 month old little boy since birth and am concerned that he has been refusing to latch for over 3 weeks now despite lots of skin to skin day and night, and very frequent baby wearing.  I’ll give you some background and would appreciate some advice on what else I can do for this family.





The baby was born via water-birth at a birthing center and went home on the same day. I saw them when the baby was 24hrs old because he hadn't latched.  At 24hrs he was jaundiced and jittery. I had them give formula because we were unable to hand express milk from the mother's breasts (only 2 drops on the right, none on the left after expressing for at least half an hour), and I had him go to the hospital for labs. He was admitted for hyperbilirubinemia (bili was 19) and some hypoglycemia. He was found to have ABO incompatability.   In the morning before he went to the hospital, I noticed he had an upper lip tie as well as a tongue tie.  I also suspected some glandular insufficiency of the mother’s left breast because it was much smaller than the right. She didn't notice breast changes during pregnancy. 



She was never diagnosed with PCOS but was told she “would likely not ever get pregnant.”





While in the hospital, she was able to express some milk after a couple of days using the hospital grade pump. No one addressed the lip and tongue ties. He was discharged after 5 days of IV and phototherapy.



The mother was struggling with latching the baby for 2 weeks after discharge and after talking to me again, decided to get the lip and tongue tie released.  After the procedure, I came to work with her to help get the baby to latch. At this point, he had such severe reflux that his entire body was very stiff, and he constantly arched his back and cried. He was so uncomfortable that he could not even sleep in his mother's arms. He also had a bit of laryngomalacia, which was heard when he swallowed. He has since outgrown that.





We called the pediatrician, and she put him on Zantac, which helped a little. For 3-4 more weeks I worked with the mother to try to see if there were foods in her diet causing allergies. It was impossible to get him to try to latch while he was so stiff and so uncomfortable from the reflux.  We saw a huge improvement when the dairy was eliminated, and he got off the Zantac. The rigidity went away. He began to improve and was able to latch on several times, but not consistently. He continued to fuss whenever placed in the cradle hold positions on either side. I encouraged her to feed him in upright positions with his head tilted slightly back;  in the sling, or laid back nursing.  Things seemed a bit better and the mother was able to nurse from both breasts during the times of day when he would latch. However, there were always times in the day when he would only take the bottle. She always had to supplement some milk since the days he was in the hospital.



4 weeks ago, she took the baby on a plane for a cross country trip for 2 weeks.  While there, he latched on and nursed frequently for 2-3 days straight.  Then they came back on the plane, and since then, it’s been over 3 weeks and he won’t latch (regardless of the position, and whether or not he's awake or drowsy). I thought it could be due to inner ear pressure from the trip or some other discomfort, but he is completely healthy, has no signs of reflux, no stiffness, yet still not wanting to latch. 



The mother has gotten tired and has not been consistent with pumping 8-12 times/day, so her supply is very low now. (1.5 form right, 0.5 oz. from left). 





Here's what I told her. Please correct me if I’m wrong or share other suggestions as well:





She has to go up to 10-12 pumpings in a day (8-9 times didn't make much difference for her).



It may be that her left breast has insufficient glandular tissue but it still is able to produce milk. If she keeps pumping as much as possible, she can build her supply at least somewhat. I couldn’t promise that she would ever be able to exclusively breastfeed at this point though considering the baby's age and that the supply has already been established to near what she’s producing now.





I recommended galactogogues: Mother’s milk tea and discussing metoclopramide with her doctor assuming she doesn't have a history of severe depression.





Keep baby skin to skin as often as possible, wet the nipple with milk and allow him to sleep with his lips touching her nipple. Only try to latch him on when he is comfortable and not too hungry (all attempts to keep time at the breast happy).





Begin using an SNS during feedings to get him on the breast because at this point i don't think it’s discomfort that's making him refuse the breast, but I think it's the slow flow. I thought the SNS could help with flow and her supply.





My hope is that if she is able to increase her supply a bit more and the baby is able to latch with the SNS, he may not be getting his usual 4-5 oz./feeding but may get 3 or 3.5 oz. or so and just feed more frequently.  



Any ideas?





Also one other thing. I have numerous mothers, who for various reasons, have not been able to exclusively breastfeed and have needed to supplement.  With each one, I could identify the reasons due to choices that they made or the particular circumstances, but I did not jump in and push them because I was trying to honor their level of commitment and willingness to follow my recommendations.  Any advice on balancing the respect for a parent's readiness and own pace versus advising them much more seriously as their consultant?  In retrospect I often feel like perhaps I could have done so much more. 





Thank you for your patience in reading this. I truly appreciate your guidance and experience.





Blessings,







Hoda















 



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