Whew! A lot of intervention here, too soon, IMO. You asked if Finger Feeding 
can cause Nipple Confusion/Preference. YES, it can! I never use this method in 
my practice and IMO a finger is not much thicker than a bottle nipple, is much 
firmer than a breast, (in fact, firmer than a bottle nipple)  and I see few 
advantages to using the method. IF supping is necessary, using a feeding cup, 
a syringe or an SNS are much preferable methods. 

It appears that sups were started before we were sure that this mom would 
*actually have* problems with supply, or how much of a problem. 7% of 
weight loss is well within the boundaries of normal newborn weight loss, and a 
more hands off Watchful Waiting approach is always a good idea. 

How much she can pump is no help in judging of her ability to transfer/produce 
milk or how much she can transfer to the baby, either is "a strong suck." ALL 
healthy newborns have a strong suck. It makes no difference in "sore nipples" 
at all. And even with an adequate "suck", the latch is what determines mostly, 
whether the baby can transfer milk and whether Mom will become sore. 

If she has sore nipples, something is wrong with the LATCH. Has a Digital-Oral 
exam been done by you? (Will the baby allow it?) What is this child doing with 
his tongue ect? What does his oral cavity feel like? He is clamping? A lot? Has 
Mom been taught how to UNLATCH him properly, if he does Clamp? (So many 
Moms tend to just PULL the baby off, due to the pain of the Clamp, and are 
not taught the proper finger "fish hook" delatching technique, which could 
save her a lot of pain.) Are there any problems with his tongue? (You said he 
had "good movement", but still check for Lingual Frenulum problems.) Is the 
baby orally defensive? Babies who are orally defensive tend to do better AT 
the breast, with as little disturbance of mouth to breast as possible, from what 
I have seen. If possible, supplements, if necessary, should probably be done 
AT the breast. 

I am a little confused at the delay in getting an SNS for this mom. It must 
have been understood that she had a reduction before the birth. (Not that the 
SNS was an absolute given, but to have one there in case of problems with 
supply, asap, before the birth, would have been helpful.)  I am also confused 
at the explanation of the tubes, ect. WHERE was the milk, and how was it 
transferred to the baby while these tubes were being used? I am not all that 
concerned at the size of the tubes or whether the parents knew what size 
they were using. 

I am also confused at the delay in getting this mother the proper sized flanges 
for her pump. These are usually readily available. Most hospitals and LCs who 
rent or sell pumps usually have them available. Is there difficulty with dialogue 
between hospital staff, midwife and LC?  IF she was destined to have a supply 
problem, Lactogensis I into II (thus ensuring good supply) could have been 
aided by use of the pump regularly ASAP. 

I have no idea whether the smaller flanges were inappropriate, or not, but my 
guess is a poor latch caused most of the soreness and cracks in the nipples. 
Of course, having the proper sized flanges immediately available would have let 
us know without delay if it was pump or latch which cause the sore nipples. 
(But, of course, a good latch assessment will also let you know if it is a latch 
problem, now, and I bet it is this.) 

If this were my case, I would do pre and post feed weighs after the fourth day 
of life on, regularly, before supps had been added (which is just Academic at 
this point.) Making sure to get in early morning pride and post weighs and 
some afternoon and evening weighs. Of course, daily weighs of this baby, if 
we are concerned about his intake are essential. 

It needs to be determined whether that 20 oz of AIM a day was actually 
necessary, (meaning Mom is not making much milk at all) or is an artifact of 
too early, too enthusiastic supplementing, and using WAY too many methods 
to get milk into this baby. I am not saying that this child will not need some 
sups, but 20 oz a day is virtually his entire intake! It appears that Mom's 
ability to make milk may have been sabotaged? (Not that it can't be remedied, 
though.) Mom tended to think this was too much supplement.(She is probably 
right.)  Is it known HOW this ballooned into such a large amount? (Too many 
people involved in feeding ect?) 

Who suggested the finger feeding? Is there more than one LC involved? I 
always ask my clients what books they are reading, what sites they are 
visiting on the net, if they are talking to someone from LLL, or "relatives" ect 
so I get an idea of where she may be getting her info, and whether it is 
appropriate. (LLL leaders are more than happy to be contacted, if they have 
also been involved.) Also, I prefer not  employ e mail about a case to or from 
Mom. Even if you can't see her due to illness (most moms don't want us 
coughing or sneezing on their babies, this is understood) I have found phone 
calls give one a much better idea of what exactly is going on. You can hear 
her voice, her tone, her demeanor, and questions you may ask are immediately 
answered, rather than waiting hours or days for a reply. (I only use E Mail with 
clients after a case if finished, to send her written info, Statements, and so 
she can send me pics of the baby.) 

I am pretty confused. (I can relate to the pre-migraine confusion, though. I 
hope you feel better. :) ) But, exact weights of baby at birth, release, and 
each day if possible would be helpful. This baby endured a 40 hour labor. Were 
there decels? Meconium staining? Device Assisted Delivery? Even if none of 
these were present, the baby may well have been stressed, and of course, 
that can often lead to Clamp Down Bite Reflex. This can be treated, and 
eventually most babies outgrow it, but there are strategies to treat it until the 
baby  can better organize neurologically. 

You said: "Okay, folks…lay it on me!  Why is this baby refusing the breast? Is 
it the finger feeding?  The No. 8 tube?  The chomping?   All of the above?" I'd 
say all of those but the No 8 tube, but I still don't know HOW that tube was 
used. (Was a Dr Newman type home made SNS, with tube placed into bottle 
system used?) My guess is this baby is as confused as I am. TOO much going 
on, too many devices being used, mom may even have too many people giving 
her advice at this point. No wonder the baby is frustrated and refusing breast, 
and Mom is in tears. (How many people are feeding baby at this point? And 
how? That alone could confuse him.) 

In the cases where I work with a mom with low supply (and we still don't know 
if this mom DID have low supply as it appears she was not given a chance to 
actually find out if she and the baby could bring in an adequate supply, before 
interventions were introduced.) I do not use the SNS for ALL feedings 
(exception being Tubular Breast with virtually nonexistent ductal structures) 

Using the SNS or other supp methods for every feed may often cause the 
baby to "wait" for the supp, and not actually develop his own potential for 
transferring milk on his own. Perhaps using the SNS for between 50% and 75% 
of feeds would better allow this baby to develop his ability and allow Mom to 
develop the greatest supply she is capable of making. The Tube can be placed 
so that the baby really doesn't see it, and not opened until he attains a proper 
latch, and we are sure he isn't getting much milk from Mom. (This could be 20 
seconds into the feed, or 10 minutes.) It could then be altered to fit the Mom 
and the Baby and their needs. 

We have all had cases where things spiralled out of control. The best thing to 
do is to talk to mom,  in person, find out exactly what is going on per Latch, 
need for supps, HOW supp will be given, Mom's preference (she sounds like she 
is reaching Burn Out, which means the least interventionist strategy, and lots 
of empathy is needed) and reliable weights on this baby. Take this case as if 
you just got it NOW. Start from where you are, and start by removing 
everything which does NOT need to be done. (Finger feeding, Dad "helping" 
with feeds etc) But, please, you NEED to be there to show her how to use the 
SNS. Moms at this stage of Burn Out are very vulnerable, and she will NOT be 
able to do figure it out, and properly use it on her own at this point. 

Remember, even an SNS is not a fix for a poor latch. 

I am sure you will get a lot of info and advice. But, at this point, try to keep 
the interventions to a minimum, an SNS may be necessary, but don't introduce 
anything else new, with the possible exception of maybe some Fenugreek IF 
the Mom is still open to dialogue. (My guess is she is at the end of her rope, 
here. She needs some success at this point, however small.) 

And lastly, if this seems to be too strained, or you or the Mom feels it would 
be best, on rare occasion, handing the reins to someone else is the answer. I 
am NOT saying this is true in this case, but to keep it in mind, if things 
continue to deteriorate, and Mom maybe starts to become more resentful of 
the Baby or her LC. (Or of breastfeeding in general.) 

Good Luck

Mary Jozwiak IBCLC, RLC, LLLL
Private Practice 

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