Not clear on how old the baby is now.  But if even the bottle's 
unnaturally firm oral signal also doesn't trigger the baby into active 
sucking, she could have some kind of primary feeding disfunction.  But 
it's also a real possibility that she's not getting enough calories to 
feed actively.  So watching diapers and general energy level, and 
getting calories into the baby, by whatever method, is important.  It 
buys time to figure out a situation that likely includes several 
variables (including the distinct possibility of an overwhelmed mother 
with some level of post-partum mood disorder --seven kids, likely 
minimal help in the current isolation, and another baby not feeding as 
expected -- it could be easy for anyone to feel hopeless).   Some babies 
do need to grow into a better fit with a mother with large nipples, so 
"feed the baby" as the first rule is especially important.

The initial engorgement is promising.  But when engorgement becomes 
rock-hard, it creates a "traffic jam" in the breast that makes it hard 
for milk to flow.  Has she tried "reverse pressure softening" before 
feeding and/or pumping and hand-expression, to open up the roadways to 
milk flow?

  You might point her toward good on-line videos for some techniques on 
hand-expression (which should work, regardless of the shape and size of 
the nipple).  You might suggest "videos for mothers" at 
globalhealthmedia.org or at bfmedneo.com.   And the latter organization 
includes LC Maya Bolman, and her work with "therapeutic breast massage" 
with cold and gentle outward massage while reclined, may also help 
relieve the congested breast.

Getting that milk moving and protecting the supply is another vital step 
in buying time. If the mother is temporarily running the whole show for 
a baby who isn't feeding, she needs a time-tested rental pump.  Point 
out that there wouldn't be 36mm flanges if they weren't needed by some 
mothers -- it always helps to feel some common ground!  Perhaps she has 
some wheezy old pump, used intensively for previous non-latching 
babies.  (I don't know the situation in other countries, but in the US, 
because many insurance plans are mandated (at least for now) to provide 
a pump, and employed mothers need these tools, there's been a 
proliferation of unknown. often cheap, pumps that parents feel are 
"hospital grade" because the advertising says so.)

The German company Mamivac had 28 mm nipple shields, including a "cherry 
top" version with a firmer ball-shaped tip that might give a stronger 
oral trigger to suck, particularly if there's a high-palate involved.  
Even if it's not perfect, using a shield to present a more compact teat, 
to get the baby doing something happy and rhythmic at the breast, could 
be a baby-step forward.

Anyway, a few ideas, which you've likely already considered. Good luck 
to all.

Margaret Wills, IBCLC, Maryland, USA


> Date:    Mon, 8 Jun 2020 13:29:26 -0400
> From:    Yael Edelstein <[log in to unmask]>
> Subject: large nipples
>
> Dear Lacnetters,
> I haven't posted in years. My practice is small, as I've moved on to 
> other things but I still keep up and see on average four clients a month.
> I have permission to post.
> This is a telephone client as I am (impatiently) waiting for a Corona 
> test. 7th child 4 days old, nursed the first four babies long term no 
> problem. Baby #5 was sleepy, didn't nurse well so she started pumping 
> and giving a bottle. The same with 6, and now 7. She called me a few 
> hours after getting home from the hospital with engorged breasts and 
> no milk coming. She called me again just now with the same problem. 
> She says she has unusually large nipples and they have been deformed 
> from pumping so much. When the baby latches on she just holds the 
> nipple in her mouth, does not really suck. She is not much livelier 
> with the bottle.
> The mother and the baby do not have health problems. The pregnancy was 
> normal and the birth normal. She did have an epidural.
> She has seen another BF counselor already; she said it was useless. I 
> suggested another but she heard she's not working because of Corona.
> I suggested the problem might be with the baby and perhaps she would 
> like to consult a CST. She said that all she wanted was to get milk 
> out. She says hand expression has also stopped working. So I told her 
> how to do the old fashioned warm-glass-jar-cools-down-into-a-vacuum 
> method. (ancient history!) And a glass of wine.
> She is convinced that her nipples are ruined for nursing.
> She does not have access to any device that could do Zoom/Skype/whatever.
> I also asked if she ever tried nipple shields and she says even the 
> largest are too small for her.
> I am really challenged by not being able to see her!
> In addition to wanting your cumulative wisdom, this is a shout out to 
> IBLC's in Jerusalem, Israel who are seeing clients now to send me 
> their phone numbers so I can pass them on!
> Thank you all,
> Stay well,
> Yael
>

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

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