I would be glad to hear from anyone with suggestions about how to proceed in
this case.
I have mother's permission to post.
Baby is 12 weeks old, mother's second child.  First child was breastfed
unremarkably.  This one seemed to be feeding well from birth though mother
says she has never felt the strong suck she recalls from the first child.
Weight gain was reassuringly good for the first 4-6 weeks, baby had been
stooling abundantly and often, but mother was concerned over baby's hoarse
cry around that time and sought help.  Baby was admitted to pediatric ward
for observation and given mycostatin for suspected yeast laryngitis.  Mother
asymptomatic then, as she is now.  No results from mycostatin.  Baby then
given Gaviscon (an antacid liquid for heartburn) in case the hoarseness was
due to gastric juices refluxing, as he did occasionally spit up.  I suspect
the pediatricians were shooting in the dark, trying as best they could to
make the baby seem happier.

Around this time baby began showing signs of reluctance to feed at the
breast, and developed 'cement' stools.  Mother stopped the Gaviscon and
stooling became more normal.  At routine weight checks between 6 and 11
weeks (only 2 checks because mother felt things were going all right) baby
was found to be not gaining, and becoming more averse to taking the breast.
Mother began pumping and feeding baby by bottle 12 days ago.  Supply was low
at first but yields have since doubled, so that she now gets about 110 ml
per pumping, from both breasts combined.  Baby is being bottle-fed the
expressed milk, plus small amounts of formula top-ups as he has not been
satisfied after feeding and mother's production has not yet met his needs.
He uses a Nuk nipple, the only one he accepts, and is now hysterical on
being offered the breast.  He has gained 2 oz. per day for the last 12 days,
and is stooling more frequently.  If he takes more than about 5 oz. at a
time, he spits up, though this is improving now.
Mother is not observing any special dietary precautions and there is no
history of food allergies in the family.

Mother hopes she will be able to get baby back to the breast.  To that end,
I saw them today.  Baby was vigorous and impatient to be fed, not at all
relaxed or lethargic.  Did not really 'latch' on the bottle nipple but did
drink from it in a disorganized kind of way, taking a while to get started
even though he appeared hungry on arrival in the office.  Was very
distressed on the two occasions we tried to offer him the breast,
stiffening, turning away, and crying, then needing to be calmed for several
minutes before he was able to continue his bottle feed, which he seemed very
eager to do.  It was when I tried to assess his suck by offering him a
finger that I discovered his bubble palate.  Doh!  He got very upset at
having a finger in his mouth too, so we abandoned any thought of finger
feeding, as we had already abandoned the attempt to breastfeed with an SNS.
He was just too distressed.  He seems to have atypical tongue movements- no
cupping, a lot of fluttering, could not observe any thrusting.  He is not
tongue-tied and can extend his tongue beyond the gum line.  After finishing
the bottle he smiled and cooed and burped, and spit up a small amount of
milk.

After reading all the archived posts with 'bubble palate' in the subject
line, I think this baby thrived until lactogenesis 2 really set in.  Then,
his anatomy prevented him from effectively draining the breast and
stimulating supply, and the downward spiral began.  Now, he doesn't trust
the breast as a generous source of freely flowing milk, and he definitely
knows he wants to be fed, so he is rejecting the breast, for the time being.
When he gets fattened up some more and production is higher, he may be more
willing to come back to the breast.  Does this reasoning sound plausible?

So, if you have any suggestions about how to proceed, I'd be grateful to
hear them, privately as well as to the list.  So far I have encouraged her
to:
spend time in direct skin contact with him outside of feeds for both their
mental health, consider co-bathing for same reason

rent, for the next week or so, a hospital grade pump with double collection
set to give her more time to rest and possibly increase yield further (she
is already pumping about 8 times/day, incl. at night)

try a Haberman feeder to see whether it is any better for baby

hold off on 'challenging' him with the breast until he has gained still more
of the weight he is catching up on now and her production has increased even
more

wait and see what response I get from Lactnet about wise ways to go on from
here!
hope to hear something soon,
Rachel Myr
Kristiansand, Norway

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