Valerie

What a very thorough description of a difficult latching scenario and 
what good recommendations you've already made. :-)

The only thing you haven't yet tried, it seems - and If this was my 
client I would now - is a nipple shield.  It it facilitates latching 
and sucking, I'd suggest the mother use it for every feed for a 
couple of weeks before making any attempt to try to wean off it - ie 
only when breastfeeding with it is really easy.

For the low milk supply I'd suggest that the mother express/pump 
between feedings if the baby won't wake often enough.  To stimulate 
the milk supply, the breasts need to be drained at least 8-10 times 
in each 24 hours.  Use any EBM obtained as the "supplement" after 
feeding, reserving ABM for top-ups only when all EBM is 
exhausted.   With more frequent drainage the quantity of EBM should 
gradually increase, so that ABM can be reduced.

If the baby has slept so long that she is frantic for food when she 
does wake, then yes - giving a little supplement to calm her before 
latching attempts would seem like the right thing to do.  Waking her 
to feed earlier would probably be appropriate too.  Hopefully the 
shield will work so that the mother will feel more confident about 
waking the baby earlier rather than leaving her to sleep so as to 
avoid the "fighting" that happens during attempts to feed her.

Please let us have feedback - I'm always interested to hear how these 
kinds of difficulties are resolved.

Pamela Morrison IBCLC
Rustington, England
------------------------------------------
Hello lactation friends,
I have permission to post from this baby's parents.
Baby M is 13 days old born at 37 weeks (6lb. 8 oz) after an induced labor
with failure to progress resulting in a C-Section.  She is her 34 year old
mother's first child.  Because of an inverted right nipple mom began using a
pump in the hospital on day 1 to draw the nipple out.  Both nipples are now
well everted.  Mom's breasts are very small yet rounded with clearly seen
veins and only 2 fingers between the breasts.  Areolas are also small.
(2.5cm)

   Baby M has never successfully latched for more than 3-4 sucks.  All
feedings of pumped milk and formula have been given by syringe until today.
Mom and Dad are both worn out and admitted to using a bottle for the first
time prior to our appointment.

Baby M has regained and surpassed her birth weight and is vigorous with no
health problems.  Parents have been unable to wake her more than once in
3.5- 4 hours.  She then tries to latch for 30 min. before being given
80-100ml of mom's pumped milk and 4 oz. formula. She is frantic when she
wakes and needs lots of soothing to get her calm enough to take her feeding.
Parents report that on two occasions they were able to wake her earlier and
she remained calm then.

They were in the office for 3 hours today.  I couldn't get this little one
to wake up either.  She was so frantic, crying hard, clawing the breast and
kicking that I suggested they give her part of the supplement and then try
to latch again.  We tried again to get her to breast after one and two oz.
with no success. We tried every latch I could think of except side lying.
She can find the breast showing normal newborn behavior but once latched she
slips off after 3 weak sucks.

She takes the bottle nipple deeply, flanges lips appropriately with help.
Her chin is somewhat recessed.  Her palate seems normal, no tight or
restrictive frenulum.

Mom's supply is low but she hasn't been pumping enough (3x in 24 hrs). I
hope that with improved pumping management and herbal galactagogues the
supply will increase.

What do you see in this scenario?  I must be missing something.  Thanks for
reading through this lengthy dissertation.

Valerie Vanderlip, IBCLC
GA-USA
  

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