Dear Readers,
Thank you for the several good suggestions offered for the mother I was helping who had problems with her first following her breast reduction and wanted to avoid the same "work" the second time. She is doing much better and finding that she can use the SNS more easily than she thought.
Now I come to you with the permission of an outpatient who has me mystified. english is mother's second language (she is Turkish) but she brought a friend with her who helped clarify if she or I misunderstood the other. (The friend is pregnant and asked very good questions.) Mother delivered her baby 6 weeks ago. Baby did well for the first month, going from 7 lbs, 9 oz to 9 lbs 14 oz in one month. Then baby started being very fussy at the breast, pulling off and crying. After several feedings like this mother tried to offer bottle but baby was too upset. Mother waited and pumped and offered bottle only and baby accepted the feeding. Most of feedings since have been expressed milk in bottle with slow flow nipple. Mother pumps with Avent hand pump and does very well keeping supply stable.
I observed this behavior in the consult. In adition to the behavior described above, I also observed baby pushing very hard against the back of the chair (in football hold - would not latch at all when cradled) and stiffen when fighting the breast. A suck assessment indicated a disorganized, thrusting approach. Mother showed me a healing section of the nipple where the baby had "bitten" her. It was obviously an open wound at one point. I tried to have baby accept milk from a sponn and the tongue thrust brought most of it back. Mother had also tried on advice of aunt who a pediatrician in Turkey without success. Baby was a "serious" baby, with frequent frowns and scowls. I could elicit no smiles but could calm baby with talking face-en-face and with firm pats on back while holding baby to my shoulder as if to burp.
Mother takes only prenatal vitamins with iron. Baby takes only vitamins. Father is out of the country until November so no birth control is used. Mother stated that previous to this behavior,when baby was latching well, there would sometimes be episodes of choking/coughing at the breast.
Here are my thoughts and what I suggested to mother. Since there has been evidence of strong milk release at breast, although that was not seen at consult, I am inclined to suspect some esophogeal irritation from reflux. I have seen other babies adapt a very unorthodox suck pattern in their attempt to manage the rapid milk flow. I encouraged the mother to see the pediatrician, who might prescribe something for the reflux. My other concern is that, since things began well and then changed and with the stiff body posture at breast, there may be an underlying problem that is now surfacing. I suggested to the mother that if the pediatrician did not feel that the baby suffered from reflux or if the treatment for reflux did not help change the baby's behavior that she might want to request a referral to see the OT at Children's Hospital to help with reorganizing the suck pattern.
I would appreciate hearing any ideas you may have. Do you feel reflux is the most logical cause? Am I over-reacting by suggesting the OT consult? Are there other possibilities? When I asked permission to seek your counsel, the mother expressed her hope that I would be able to call with some confirmation of our discussion or additional ideas. we are both looking forward to what you wise women have to offer.
Many thanks,
Cindy Garrison, BS, IBCLC
Magee-Womens Hospital
Pittsburgh, PA
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