Jan

Your mom with the 4th low weight gain baby and the long nipples sounds like
an interesting (and frustrating?) case, and the replies and suggestions
from others sound very innovative.  Trying to visualize this from your
excellent description, and looking at the nipple shields I have (Pur,
silicone, ultra-fine) whose "teat" part is only 1.5 cm in length, I would
think that a nipple shield would probably not be so effective, unless the
length of mom's nipple was able to be telescoped into the shield.  If, as
you describe, baby is able to take as much as 3.5 cm of your finger into
his mouth, but slips down off the (slightly shorter) areola to chomp at the
base of the nipple during nursing, then I think I would try for a deeper
latch by using the 'flipple' technique.   Mom tips nipple *up* on latching,
by depressing her thumb in to the areola on top, placing the underside of
the areola on to the baby's tongue as he gapes, then releases the thumb,
allowing the nipple to fold/flip on to the tongue, (in a flipple!)  Mom
could also probably use her thumb to push *down* on the top length of the
nipple at the last second so as to depress the baby's lower jaw a little,
to keep him gaping long enough to get that long nipple (and a small portion
of the underside of the areola) all into his mouth.  She needs to remove
the thumb of course in time for the baby to close his mouth on the nipple
in the "latch".  The thumb goes depressinto the
breasttissue-release-pushdownonthenipple-withdraw.  Sorry!  hard to
describe this in words!  After the baby is latched, mom would need to
support/cup the breast very well to prevent gravity causing that areola to
pull back out of the mouth.

And, I would have mom continue with the breast compression, as she has
been, in order to increase baby's intake.  Yes, this must be a nuisance for
her, but it could be that this baby, who remained below birthweight at over
3 weeks, is just not very strong yet to breastfeed very "effectively", and
really needs Mom to keep triggering repeated let-downs for him until he has
the energy to stimulate them for himself. This might be nothing to do with
the long nipples - just a newborn who does what many of them do - dozes and
flutters unless the milk is flowing well.  Pumping for now will be good to
maximize drainage and maintain/increase milk production.  I can well
imagine that this mom despairs if this is the fourth baby to do this, but
she obviously goes on to breastfeed very successfully, and may need to be
patient, and persistent, just a little longer.  My experience is that many
low-gain babies just do not breastfeed well until their nutritional intake
is sufficient for them to achieve the gain they should have had if things
had gone well from the beginning.  That is, an initial loss of about 7%,
then a gain of 1 oz (30g) per day.  You don't mention his actual birth
weight, but I usually work out the weights on a chart for the mom, so that
she has something to aim for - using a blue line for the expected gain
(above) and a red line for what has actually happened.  If mom can re-build
her milk supply (drainage by any means) to replace the formula, and then
keep topping up until the baby gradually nurses stronger and longer to take
enough by himself, then she provides the best opportunity for this to come
right.

Pamela Morrison, IBCLC, Zimbabwe
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Jan wrote on Mon, 23 Dec 2002, "I have a mom with very large/long nipples
who is producing adequate amounts
of milk (thanks to Domperidone & pumping), but whose baby (4th son) is not
transferring adequate amounts. I know it is related to positioning and
latch. This is the fourth baby she has had problems with....she is majorly
discouraged, as you can imagine.
Her nipples are (at rest) 2.5 cm & 3 cm long; about 1.5 cm in diameter. I
didn't measure them after a nursing, but I suspect they are each at least 1
to 1.5 cm longer. She has nice squishy breast tissue, but the nipples are
much smaller in diameter at the base, so punky loves to slide down there
and just hang out. He gets more if she does breast compression constantly,
but that gets a bit wearing after awhile as you can well imagine. He can
handle (comfortably) my finger in his mouth up to 3.5 cm, so I don't think the
length is as much of a problem as getting him to STAY on the areola instead
of resting comfortably on the nipple as though it were a long pacifer with
a small base.
She's pumping at least 5 times a day, getting approximately 2 ounces each
time, breastfeeding 8 to 10 times a day in addition. She's now
supplementing with an average of 11 ounces/day -- mostly EBM, but over the
last 6 days gave him a total of 12 ounces of formula as well. With all
that, he's gained 5 ounces in the last 6 days, and at 3 1/2 weeks isn't up
to birth weight yet (if we can believe the birth weight which is suspect).
This has been the same problem with all 4 boys. I've worked with her with
all but the first. She ends up breastfeeding for at least a year with each
one, but the first 6 to 8 weeks are rounds of weight checks, pumping,
supplementing, and nursing. And she's tired. And has 3 other boys at home
this time.
Any suggestions to MAKE this adorable baby STAY where he is meant to be to
get the maximum amount of milk from the breast AT the breast? The most he
has taken at a visit here has been today with 36 ml from both breasts.
Merry Days to all of you,
Jan Barger, RN, MA, IBCLC, RLC
Wheaton, Illinois

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