Hello experts!

I don't know if you remember a case I had 3 weeks ago - baby had lost 25% of
birth weight at 3 weeks of age and when I came on, my job was (as I saw it)
to encourage feeding and pumping....

This is an experienced mom of 5 - and she has done everything right - baby
is now appropriate weight for age, gaining beautifully and mom is pumping 12
times a day, totally meeting infant's needs with her milk.  She also "wears"
her baby all day long with a carrier that allows skin to skin (older
children are MUCH older, so she's not dealing with 3 toddlers, here).  

BUT breastfeeding is still not occurring - some of my observations:

Mom's nipples are very large and meaty 
Mom's let-down is slow, but does come when pumping

However, what has me concerned are the observations on the baby:
Whenever she lies on her back, she turns her head to the left and then
extends her head way up (if it were me sitting up, I'd be looking up at the
ceiling over my left shoulder)

She has a strong tongue-thrust pushing everything out of the mouth - bottle,
fingers (her own), mom's nipple.

Supplementation had originally been started using an SNS at the breast, but
as she did not consume adequate amounts of food (at the time formula as
mom's milk supply was very compromised), and the weight loss was dangerously
great, she supplemented with a bottle and continues to do so.

I did use a nipple shield at the last visit (the nipple hardly fits in the
standard one) and observed no milk gathering in its tip or any milk
transfer.  I did teach mom how to position baby at the breast using her
favorite position rather than trying to use a traditional cradle hold or
cross-cradle hold - baby relaxed at the breast for the first time, but
sucking was ineffective.  Actually baby looked "kind of" like the position
in Glover's Follow Me Mum.

I do believe things will get better as baby's mouth grows up to the nipple,
but was wondering about the extension as a symptom of concern...

Besides continuing pumping, skin to skin, and trying to see if using an SNS
now will allow supplementation at the breast (our next visit on Monday we
will be working on that), what would be your recommendations?

I was thinking of referring her for a Physical, developmental and oral
assessment (Speech therapists, occupational therapists do this in our area),
but am sure that the MD will say that as long as she can bottle-feed, this
is unnecessary - and in order to have the costs covered, she would have to
have a Primary Care Provider make the referral (sorry, a U.S. "managed care"
problem).  

Thanks for your thoughts!

Jeanette Panchula, BSW, RN, PHN, IBCLC
California, USA

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