I have been following a well educated, mature first time mother closely for the last 5 1/2 weeks. She was referred to me prenatally for functional retraction of fairly large, everted appearing nipples Her breasts had that "doughy" texture where everything inside the nipple-areolar complex seemed to be thick connective tissue and no milk reservoirs palpable, and no colostrum expressible. Even massage and breast compression in the area of the "tail of Spence" evoked retraction of the nipple. I had given her breast shells and the BMJ article on the "so-so" results of prenatal breast and nipple preparation, and let her decide what and how much she wished to do. Essentially, nothing. I loaned her "Bestfeeding" (Renfrew, Fisher,Arms). Her midwife assisted birth of a 6# 9 oz boy (no circ) involved only a few labor interventions, and she reported the baby "latched really well" the first two days in the hospital. But because of the disproportion between the baby's mouth and nipple, I was sceptical about any actual milk transfer. Tongue-tie was recognized, but a "wait and see" attitude was taken. Unfortunately, the pediatrician, trying to be supportive and not order formula, advised 5% GW to avoid dehydration, and the nurses chose to give it by bottle. Also, a pacifier was provided, and from there on, the baby refused to latch. In retrospect, I regret that I failed to warn her to be adamant about "no rubber nipples" because of her retraction and large nipples. When I saw her Saturday, the first full day at home, there had been no wet diapers or stools for 16 hours, and the baby had "been really good", sleeping 4-5 hours at a time! Of course, I had to invoke Rule # 1 for over the weekend, and they had the baby's frenulum clipped first thing Monday morning and saw the pediatrician that p.m. for a weight check - 6# 6 oz. I spoke often about interpreting the baby's cues, and spending as much time skin to skin as possible, but I'm certain, from observing the household, that there was a certain separation much of the time, with layers of clothes, swings, pacifiers "for when in the car" etc. I have since helped her run the gamut of "fiddly stuff" (Heather, are you listening?) and a double electric pump and finger feeding while close to the breast have maintained the situation for a month while baby's mouth was growing. He has complained loudly and angrily at all attempts she made to try to latch him directly to the breast, and only occasionally deigned to latch with a breast shield. I gave her large amounts of moral support, and was thankful for Diane Wiessinger's paper, "The Labor of Nursing" that buoyed her spirits up and gave her hope that it WOULD work out with time and patience. Last week, she called and said she was growing very discouraged. We tried rebirthing with dad pouring warm water over the baby while mom was in the tub, and lo and behold, he latched immediately like a charm and stayed there for 20 minutes. We put them skin to skin in bed for the other side but he would have absolutely none of it, and I saw that all 4 of us were getting really upset. So I encouraged them to keep on with the finger feeding and try the rebirthing twice a day for a few days. She reports that he has latched and stayed nursing each time she tried it, and has now accepted nursing at the breast with a shield, with the tube from the fingerfeeder tucked inside so she can "prime" him with a bolus of milk when he appears frustrated. Today, I arrived while he was asleep, after eating well, as described above, an hour before. She felt full enough to pump, and I specifically wanted to see how far the nipples extend into the pump. Plenty, to the naked eye. But it seems the milk sinuses on one side are not really being reached by the pump, due to their depth, and her MER does not yet appear to be very strong or rapid. He began to fuss with a big bubble, but appeared willing to try to eat. She was searching hastily for the shield, and had the finger feeder at the ready, but I encouraged her that latching directly just after she had softened the areola with the pump was surely worth a try, and that he would get hindmilk, if not volume. They "worked together" for just a moment, and suddenly, he latched, firmly and well. I sat with them for a half hour or more, five feet away, and admired how well they were doing. He drifted off into a light sleep, and I could see he had slipped and was nipple sucking. But she was not feeling any pain, and felt it "wasn't broke" enough to try to fix it. We talked about inspecting the shape of the nipple for evidence of tne "Nuk look" when he would eventually let go. I encouraged her to use breast compression. While we talked, I heard him wake up and swallow audibly for a few moments. As I let myself out the front door, I smiled and waved to her as I left them in a prolactin haze! What a happy transition to be witnessing! I don't think we're "out of the woods" quite yet, but we can see a lot of light at the end of the tunnel. I shored up her spirits both with my admiration of her dedication, and to the fact that better milk transfer would happen automatically as the baby's jaw grows and develops with the increased nursing, and her further relaxation conditioning the MER. In the process, I have learned a whole lot. I know the situation would have been totally different with a larger, more vigorous eater. I am hoping I can give better anticipatory guidance to the next mother, due in 2 weeks, with a prenatal situation almost the same. And there will be phone calls between the 2 mothers for "been there, done that" support. I wanted to share my adventure with any of you who might find it helpful. K. Jean Cotterman RNC, IBCLC Dayton, Ohio USA ___________________________________________________________________ Why pay more to get Web access? Try Juno for FREE -- then it's just $9.95/month if you act NOW! Get your free software today: http://dl.www.juno.com/dynoget/tagj. *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html