I have been following a well educated, mature first time mother closely
for the last 5 1/2 weeks. She was referred to me prenatally for
functional retraction of fairly large, everted appearing nipples Her
breasts had that "doughy" texture where everything inside the
nipple-areolar complex seemed to be thick connective tissue and no milk
reservoirs palpable, and no colostrum expressible. Even massage and
breast compression in the area of the "tail of Spence" evoked retraction
of the nipple.
I had given her breast shells and the BMJ article on the "so-so" results
of prenatal breast and nipple preparation, and let her decide what and
how much she wished to do. Essentially, nothing. I loaned her
"Bestfeeding" (Renfrew, Fisher,Arms).
Her midwife assisted birth of a 6# 9 oz boy (no circ) involved only a
few labor interventions, and she reported the baby "latched really well"
the first two days in the hospital. But because of the disproportion
between the baby's mouth and nipple, I was sceptical about any actual
milk transfer.
Tongue-tie was recognized, but a "wait and see" attitude was taken.
Unfortunately, the pediatrician, trying to be supportive and not order
formula, advised 5% GW to avoid dehydration, and the nurses chose to
give it by bottle. Also, a pacifier was provided, and from there on, the
baby refused to latch.
In retrospect, I regret that I failed to warn her to be adamant about "no
rubber nipples" because of her retraction and large nipples. When I saw
her Saturday, the first full day at home, there had been no wet diapers
or stools for 16 hours, and the baby had "been really good", sleeping 4-5
hours at a time!
Of course, I had to invoke Rule # 1 for over the weekend, and they had
the baby's frenulum clipped first thing Monday morning and saw the
pediatrician that p.m. for a weight check - 6# 6 oz. I spoke often about
interpreting the baby's cues, and spending as much time skin to skin as
possible, but I'm certain, from observing the household, that there was a
certain separation much of the time, with layers of clothes, swings,
pacifiers "for when in the car" etc.
I have since helped her run the gamut of "fiddly stuff" (Heather, are you
listening?) and a double electric pump and finger feeding while close to
the breast have maintained the situation for a month while baby's mouth
was growing. He has complained loudly and angrily at all attempts she
made to try to latch him directly to the breast, and only occasionally
deigned to latch with a breast shield.
I gave her large amounts of moral support, and was thankful for Diane
Wiessinger's paper, "The Labor of Nursing" that buoyed her spirits up and
gave her hope that it WOULD work out with time and patience.
Last week, she called and said she was growing very discouraged. We tried
rebirthing with dad pouring warm water over the baby while mom was in the
tub, and lo and behold, he latched immediately like a charm and stayed
there for 20 minutes.
We put them skin to skin in bed for the other side but he would have
absolutely none of it, and I saw that all 4 of us were getting really
upset. So I encouraged them to keep on with the finger feeding and try
the rebirthing twice a day for a few days.
She reports that he has latched and stayed nursing each time she tried
it, and has now accepted nursing at the breast with a shield, with the
tube from the fingerfeeder tucked inside so she can "prime" him with a
bolus of milk when he appears frustrated.
Today, I arrived while he was asleep, after eating well, as described
above, an hour before. She felt full enough to pump, and I specifically
wanted to see how far the nipples extend into the pump. Plenty, to the
naked eye. But it seems the milk sinuses on one side are not really being
reached by the pump, due to their depth, and her MER does not yet appear
to be very strong or rapid.
He began to fuss with a big bubble, but appeared willing to try to eat.
She was searching hastily for the shield, and had the finger feeder at
the ready, but I encouraged her that latching directly just after she had
softened the areola with the pump was surely worth a try, and that he
would get hindmilk, if not volume.
They "worked together" for just a moment, and suddenly, he latched,
firmly and well. I sat with them for a half hour or more, five feet away,
and admired how well they were doing. He drifted off into a light sleep,
and I could see he had slipped and was nipple sucking. But she was not
feeling any pain, and felt it "wasn't broke" enough to try to fix it.
We talked about inspecting the shape of the nipple for evidence of tne
"Nuk look" when he would eventually let go. I encouraged her to use
breast compression. While we talked, I heard him wake up and swallow
audibly for a few moments. As I let myself out the front door, I smiled
and waved to her as I left them in a prolactin haze! What a happy
transition to be witnessing!
I don't think we're "out of the woods" quite yet, but we can see a lot of
light at the end of the tunnel. I shored up her spirits both with my
admiration of her dedication, and to the fact that better milk transfer
would happen automatically as the baby's jaw grows and develops with the
increased nursing, and her further relaxation conditioning the MER.
In the process, I have learned a whole lot. I know the situation would
have been totally different with a larger, more vigorous eater. I am
hoping I can give better anticipatory guidance to the next mother, due in
2 weeks, with a prenatal situation almost the same. And there will be
phone calls between the 2 mothers for "been there, done that" support.
I wanted to share my adventure with any of you who might find it helpful.
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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