Dear Wise Ones,

PTP. Baby is 30 days old. It is taking mom 1.5 hours to get in 10 minutes of nursing at each breast, and she is exhausted. Baby has been exclusively breastfed. Breast only, until today when mom tried giving baby a bottle with pumped milk.

Current problem appears to be forceful MER. This is why I think so:
-Baby starts nursing, but about 2 minutes into the feeding, she begins gulping, breathes faster, sometimes holds her breath so she can keep gulping, then releases and cries. 
-At beginning of feeding, baby nurses 2-3 minutes, sometimes up to 5 minutes, then takes 20 minutes to burp and settle. With each new attempt, baby nurses for a shorter and shorter time before releasing the breast and crying. Each time mom spends 20 minutes trying to burp baby, change diaper if needed, and then try again. Burping really helps; baby is much more content at the breast afterwards if she has burped. Baby sometimes won't resume nursing until burped.
-Breath sounds are sometimes wet and gurgly. No stridor.
-(Forceful MER didn't seem to start until week 3.)

What we have discussed and/or mom has tried so far:
-Laid-back breastfeeding position (gravity probably helps, but not enough)
-More frequent (smaller) feedings 
-Mom has tried taking baby off right before the first MER, but finds it hard to coordinate
-Pump to relieve pressure only, then nurse on softened breast (have discussed the risk of increasing mom's milk supply, and the alternative of donating breastmilk if she has a large supply)
-pressure with a flat hand to reduce flow (a la Carol Chamblin, IBCLC)
-tried using a nipple shield, baby refused to latch
-as an experiment, tried to feed baby pumped milk, baby refused bottle with Medela Calma nipple, second time, baby licked the nipple and sucked enough to get some breastmilk on her lips, not sure if she ingested any milk

History and more details (for those who want all the info):
Mom primipara. Baby born full term 8# 7oz., nursed within first 30 minutes. Minimum weight at 3 days = 8# 1 oz. At 14 days wt = 8# 10 oz. Early breastfeeding went well, baby passed meconium on day 1. But baby began to have clicking sounds by day 3, even when appearing deeply latched. Tongue had good extension, but restricted elevation, so tongue-tie release was requested. About 5-7mm of the anterior frenulum was clipped with scissors. Elevation improved somewhat, breastfeeding sounds also improved somewhat, mother's pain reduced and nipples healed, so we left it at that. Baby has good movement of her neck to both sides, ruling out torticollis. Baby still has 4+ poopy diapers and multiple wet diapers, suggesting overall good intake. It takes mom 15 minutes to pump 50ml from one breast using a Medela Pump in Style.

Thank you for any suggestions you can provide!

Carolyn Donohoe Mather, MAS, RDN, LD, IBCLC
Honolulu, Hawaii
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