Thanks to Dr. Gartner for contributing the Milk Club cases for discussion.
What a great idea.

I had a few thoughts on Case #1.  I'm interested in the hypertension sx.  If
this was treated with mag sulfate, that can sometimes delay lactogenesis.
Also, was the mother's UTI treated with a sulfa drug? The bili count really
shot up there quickly.  With epidural anethesia and antibiotic and possibly
meds for hypertension, baby may have had a lot of drug exposure and had
difficulty clearing this.  In addition, feed freq. was low initially and
stayed low.  Mom is over-weight.  Sometimes this poses a problem in handling
the breasts and getting good latch, which sounds like at least part of the
problem.  The consult seemed to improve poor attachment to breast.

Case #3.  I've seen a baby just like this -- all the way to the facial palsy
and the uneven tongue.  The baby I worked with had very low tone in the
mouth.  I think the bottle teat works for these babies  because it is a
'super sign stimulus' and  initiates a more definate palatal stimulation.
The softer breast may not be sensed in the mouth.  Without sufficient
palatal stimulation, the baby I worked with would fall asleep and not
continue to feed. Additionally, when tongue is up on the palate, baby may
simply be "confused" about where to hold it, in which case, the bottle teat
is rigid enough to push it down and into the correct position.  However, the
low oral tone may extend to the soft palate and other structures which
protect baby's airways, causing baby to defend them with the elevated
tongue.  I think that Baby # 3 is not using elevated tongue to defend
airways because coordination of swallowing was noted during bottle feeding.
This was the case in the baby I worked with.  I used a thin silicone nipple
shield with an SNS threaded under it.  The rationale was to stimulate the
palate and keep delivering a rapid flow of milk to keep baby awake and
swallowing.  Mother did post-feed pumping 4-5 a day for about 10 min with
fully automatic pump.  Baby was referred on for more eval. of the facial
palsy. I made the case to all that breastfeeding -- even if it needed
assistance -- provided excellent physical therapy for a baby with such
notable oral-motor problems.  Why wait until baby is old enough for PT when
nursing provides such great exercise for the oral structures?  Since parents
were motivated to bfeed, this made sense to them, and they continued to make
every attempt to provide both breastmilk and the opportunity to feed at
breast.  Before too long, use of the SNS was discontinued in favor of just
using shield followed by post-feed pumping. This milk was used for relief
bottles and occassionally for topping off if baby seemed unsettled.  Baby
grew well.

Barbara Wilson-Clay, BSE, IBCLC
priv. pract. Austin, Tx