Valerie,
 
Several things in your post jump out at me and will address them in  
sequence with your post.  However, I can't help but state first that if I  read 
your post correctly, this little one who is on the smallish size to begin  
with seems to be taking way too much per feed.  If,as you state, she takes  
80-100 ml of EBM then is given an additional 120 ml of formula, this is an  
enormous feeding of 6 2/3 to 7 1/3 oz.  Even if you meant to say baby takes  
80-100 ml of breastmilk and then take additional formula to equal 120 ml per  
feeding, 4 oz may be too much for this baby per feed.  With 3 oz or 100 ml  
per feed, baby could be sated and this would be mostly breastmilk and then  
likely baby would wake more often.  If in fact baby is being given 6-7- oz  
per feeding this is too much per feeding and in 24 hr.  So, Valerie,  
correct me if you've not written what you meant to say.
 
 
Date:    Tue, 1 Sep 2009 17:27:56 -0400
From:     Valerie Vanderlip <[log in to unmask]>
Subject: slipping  latch

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.  
~~~~~~~
no doubt, if intake you stated is accurate
 
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. 
~~~~~~~
30 min of latching attempts may be too long a time of frustration, just a  
few attempts are what I usually suggest and then feed the baby and try 
mid-feed;  a switch and bait method of bottle feeding may work.   Bottle next to  
bare breast and try breast every now and then quickly and only once-no  
battles.
 
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.
~~~~
Lots of skin-to-skin while asleep and again smaller feeds and teaching  
parents early feeding cues could help; some parents don't try the breast until  
baby is thoroughly awake (and she could be one of those babies who isn't  
regulating her states yet and goes from sleep to frantic in seconds and needs 
to  be encouraged to breastfeed sooner) or crying.

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. 
~~~~
good approach here
 
We tried every latch I could think of except side lying.
~~~~
side lying might help if mom is anxious and baby then is well supported by  
mattress; also, baby prone on mom for baby-led latch might work

She can find the breast showing normal newborn behavior but once latched  
she
slips off after 3 weak sucks.
~~~~
If mom has small breasts the tissue may be taut as well and babies have a  
harder time using their tongue to grasp.  An exaggerated  asymmetrical 
latch, with baby under the breast, and positioned nipple to  nose, waiting for 
tongue extrusion before bringing to breast.  Mom can try  to offer breast for 
comfort, too, and try to calm baby while walking or standing  to attach.  
I've found this works for some babies who are frantic.   Again, skin-to-skin 
when mom not pumping, so all the time when baby sleeps, let  it be on moms 
bare chest.

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.
~~~~
What do you mean about flanging lips with help?  This indicates baby  not 
being allowed to latch to bottle but bottle being put in baby's mouth and  
pulling her lips in while doing so.  Bottle nipple should be under her  nose, 
wait for gape, and then bring baby to bottle (Cathy Genna's book or  
Clay.Hoover's Breastfeeding Atlas show this beautifully).
Recessed chin makes it harder for baby to use tongue well and again very  
asymmetric latch with chin and cheeks touching breast can make a world of  
difference.
Perhaps, frenulum is posterior but short/tight.  Can baby elevate her  
tongue to mid mouth without the sides curling, even slightly?  Often babies  
with marginal posterior tongue ties have much more difficulty when mom's breast 
 tissue is inelastic and not soft and easily drawn in.  
 
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.
~~~~
absolutely necessary and if her milk is plentiful, baby may be more  
interested.  I'd suggest trying the above first but if baby and mom  continue with 
lack of success and frustration, the use of a nipple shield might  save 
this breastfeeding relationship.  This could help stabilize the breast  in 
baby's mouth, give baby a positive experience at breast and if need be,  
supplementing can easily be done at breast with tubing under the shield, and  being 
certain to have shield have milk in it before latch. (Cathy Genna's method  
of using a peridontal syringe to fill the nipple shield has gotten babies 
to  breastfeed as they are rewarded immediately).  The nipple shield of 
course  is temporary, but often prevents unnecessary weaning while supply is 
being  brought up and other suck issues addressed.
Hope this helps and know you're on the right track, just some fine tuning  
could be done.
 
Barbara Latterner, BSN, RN, IBCLC

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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