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Subject:
From:
"Becky Engel, RN, IBCLC" <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sun, 24 Dec 1995 22:38:47 -0500
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Shirley,

I was just thinking of writing a note to Lactnet about a mom with flat
nipples. It is related to your case because I needed to offer interventions
for other staff nurses.  Although I am the lactation consultant, my primary
job is as a staff nurse. I am budgeted for 8 hours a week for strictly
lactation consultant time. I live close to the hospital and go in for short
periods of time. I also frequently receive calls at home.

This week, we had a mother with very large, soft breasts and flat, soft,
small, inverted nipples. The baby was small and, due to maternal antibodies,
was jaundiced. We work 12 hour shifts. At 7 a.m., the nurse reported that the
baby couldn't latch on. She had tried to use a breast pump to pull the nipple
out, but didn't have good results. The nurse had finally used a nipple shield
and got the baby to latch on and reported that she nursed well. The phrase,
nursed well, always makes me ill at ease. I've been charting the phrase,
audible swallow, and have done short inservices and provided articles, but
change is slow. The mother-baby pair were part of my assignment for the
shift. Colostrum could easily be hand-expressed. However, the colostrum just
sort of pooled in a little dimple of the mom's breast. The baby would latch
onto the breast, but her mouth was far too small to compress the collection
ducts.  When the baby sucked on the silicon nipple shield, she did not
stimulate the breast enough to obtain any colostrum.  The baby sucked
effectively enough at breast to obtain a supplement through a supplementing
device. Since the mother's breasts could not be effectively stimulated by the
baby, we ended up by having the mom put the baby to breast, then cup feed,
and use an electric pump. When the mom developed a better milk ejection
reflex, the baby received some milk at breast, but I expect that
supplementation (preferably with mom's milk) will be necessary for awhile.
(The jaundice makes adequate intake expecially important). I gave the mother
my telephone numbers and will also follow up by calling her. (I gave her
other resources, also)

Now I'll finally put in my general recommendations to nursing staff.

First, get the baby awake. Unwrap the kid, hold her upright. I tell moms that
babies are sometimes like those dolls that open their eyes when you hold them
up, and close them when they are lying down. Tell the baby (and mom) that
babies eat better when their eyes are open. Show the mom how to stimulate the
baby's lower lip to open the mouth and stick out the tongue. I also usually
unwrap the blanket and try skin-to-skin contact of mom and baby.

Next, get the mom in a comfortable, supported position. A lot of nurses don't
think about using bedspreads as armrests for the mom. For a baby that doesn't
stay on the breast, the football, crosshold, or sidelying positions allow the
mother to keep the baby close, because there is more support of the head. One
caution about the football or cross-hold is to avoid touching the occipital
area (back) of the head. If the mother's hand is at the base of the head (top
of the neck), she has good support, but won't be stimulating the baby to push
away. Also, if it has been a traumatic delivery, the baby's occipital area
may be tender and bruised.

The most effective ways I have found to get nipples out are the use of a
breast pump (we usually use a hand pump) or to make a "nipple puller" from a
syringe (as illustrated in an article in an issue of the Journal of Human
Lactation (that issue is at the hospital. Let me know if you haven't seen it
and I'll find the reference).

An even more important point is that most babies can latch onto flat nipples.
I remind nurses and moms that they are BREASTfeeding, not nipplefeeding. The
main problem in the hospital is that the baby won't wake up. People
concentrate on the fact that mom's nipples don't look and feel like the
rubber ones that can be forced into a baby's mouth.

After the baby's mouth is open and the tongue is extended, make sure the baby
is held close and the lips are everted. I do a lot of "flipping the lips" and
gently pulling downward on the chin.  If the baby has been sucking on a
rubber nipple, it is quite possible that the lips are tucked in and the
tongue is bunched up so that the baby is pushing the breast out of the mouth.

It's nice to hear that the hospital nurses are interested enough to ask for
suggestions. A big part of consulting for me is to praise the mother and
praise the nurses. It can be so frustrating to get breastfeeding established
and so nice when people can be persistent enough to get things working.

That's enough writing. My husband wants the computer.

Becky

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