Dear friends,

Thanks again to those who have sent suggestions and
reminders.

I saw the mom today whose nipples are denuded.  The right
one (the least sore one on which she continues to
breastfeed) has a small margin around the edge of the tip
and the raw area is covered with a very thin layer of
granuation tissue, showing that it is healing.  The baby, at
7 1/2 weeks, weighs 10 pounds, a gain of one pound in a
little less than 4 weeks.  The post-feed weight was 10 lb. 4
oz.  This probably represented about 2 oz. of milk obtained
directly from the breast.

He arrived acting very hungry, not having eaten for 3
hours.  Mom had originally done baby-led feedings, but
because of the nipple pain, has been giving the baby a
pacifier after feedings and feeding him when he is no longer
willing to take the pacifier.

When the expressed milk was warm enough, he was given the
bottle.  The nipple is very slow flow, and he became quite
frustrated after 10 ml.  I re-checked his mouth.  He is not
tongue-tied, although I think his tongue may be a little
short.  His palate is completely normal.  He sucks with a
tight mouth, and his tongue extension is not ideal.  It
feels more like he is biting most of the time.  I tried
finger feeding him with the two tubes of a starter SNS (the
new ones which are like the full-size SNS, but with only one
set of tubes).  His tongue movement did not improve, even
with gentle massage of the palate.  He became very
frustrated with the flow.  He was much happier and relaxed
when he was fed with a fast flow (standard formula company)
nipple.  After taking a little over an ounce and a half of
breast milk from the bottle, he was put to breast.

The latch would probably have been good enough for many
babies, but it was not ideal..The lower lip was too close to
the nipple, and the latch was slightly shallow.  On the
right breast, with a very deep, asymmetrical latch, mom was
more comfortable.  Mom said that she probably hadn't
bringing baby in fast enough because of the fear of the
stinging in her nipples.  On the left breast, mom tensed and
stomped her feeding to cope with the pain.  There was no
improvement with deep breathing, so feeding at that breast
was stopped after 2 minutes.

I think that when I had watched her latch during group last
Thursday, she may have been latching him better than she
usually did, knowing that I was watching.  I also know for
sure that being focused just on this mom and baby today, I
paid much more careful attention than I did in a group
situation where I watched briefly, and there were many
distractions.

Anyway, I think latch was still the primary problem.
However, a slightly short tongue combined with relatively
small and rather inelastic breasts probably has exacerbated
the problem.  Less than ideal maternal nutrition may also
have contributed to poor wound healing.  Mom told my intern
that she had gained no weight during pregnancy.  She said
she had not finished her prenatal vitamins and had not been
taking them, so we encouraged her to do so.  We also
encouraged her to take advantage of her mother's offer of
help so she could get more rest.  I called her back this
evening and suggested breast shells (sore nipple inserts).

We also worked on hand expression, especially careful
placement of the fingers over the lactiferous sinuses.  This
resulted in a somewhat improved milk flow.  She needs more
practice, but appeared to understand the principles.  I gave
her a log to record hand expression, feedings, voids, and
stools.  I encouraged her to hand express from both breasts
every 2 hours during the day and after every night feeding.

I discussed the possibility of short-term formula
supplementation.  Even though she understood that the baby
was not really ever completely satisfied, she did not want
to do this.  It was obvious to me that she was not
unconcerned about her baby's happiness; quite the
opposite--she was concerned about her baby's long-term
health and greatly values breast milk.  Given baby's good
general health and acceptable (though not ideal) weight
gain, I was comfortable with this decision, at least on a
short term basis.  She is to call me in two days.

When I called this evening, mom stated that baby wasn't
satisfied on the right breast, so she had given the left,
and it hadn't hurt nearly as much as before.  She felt
certain he had a good latch.

As I was rethinking this consult in preparation for my
report to all of you, I realized that we had not discussed
galactagogues.  I will plan to do that as soon as possible.

Bonnie Jones, RN, IBCLC from the sunny S.W. USA
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