A case for and you wise ones

[Guest guest]

Hello and all,

Last night I saw a BFAR mom who was 18 hours PP. She had her breast reduction surgery 10 years ago. The technique used by the surgeon left the nipple in place. She has a scar around the nipple but states she has regained sensitivity of the nipple. Her breast increased on size cup (from B to C) during pregnancy. She recalls her surgeon telling her she had 50/50 chance of breastfeeding. We will keep in close contact to see how the production goes within a few days. Breast are quite limp. I imagine it is the normal texture after reductions surgery and before milk comes in (or am I mistaking and that is a sign of not enough glandular tissue ???). I have directed the mother to the BFAR.org site and talked about West's book. She was impressed and surprised that such a specific reference existed. Of course, she had not heard of it previously.

What makes matters more complicated is that baby latches poorly even with correct techniques for body position and latch. Baby was deep suctioned for meconium aspiration as she was covered with meconium when she was born. Labor lasted 4 days. Baby was born at 40 weeks + 6/7. In the end, after a non-stress test, they found that there was not enough amniotic fluid left. They tried oxytocin to augment labor but had to stop rapidly as the baby's cardiac rythm was affected negatively by the augmentation of labor.

At the breast, baby opens wide, latches but then does not seem to appreciate such a big mouthful and backs away slightly, closing her mouth and pinching the nipple. The nipple comes out wedged in football and cross-craddle holds.

I left them cup feeding ABM as the mother had not yet extracted colostrum. I instructed her on hand expression (Marmet technique) and left her with the pamphlet explaining the technique.

I think I will now instruct her on protecting her milk supply by pumping regularly if baby is still not latching properly. I read the oral aversion from suctioning can last several days. In the meanwhile, do we keep on trying to latch and perhaps dammage mom's nipples or do we stick with cup feeding and pumping ?

I need your feedback on this case.

TIA.

Ghislaine Reid, IBCLC

[Guest guest]

if it were me, and the mom was willing, i would try an sns or lactaid at

the breast (start with a 5FR, $2 jack newman style supplementer).

this might keep baby better latched, stimulate mom's milk, *and* feed the

baby all at the same time. if it still hurts, or even if it does't,

i'd refer for pediatric chiropractic or cranial sacral evaluation.

have you seen this great article on the BFAR web site by Dee Kassing on

evaluating a baby for cranial sacral or chiropractic treatment?

http://www.bfar.org/craniosacral.shtml

with a traumatic delivery, long labor, and low amniotic fluid, i would

suspect that baby might be uncomfortable, and perhaps is backing off the

breast due to discomfort. i have had *great* success with

resolving both maternal pain, low weight gain, and non-latching

babies with either cst or ped. chiro (different treatment worked for

different moms).

if she is using an at-breast supplementer, then at least she is

breastfeeding, and she will see to what degree her milk comes in a lot

more effectively than if she is cup feeding and pumping.

good luck with this challenging case!

Lyla

At 10:36 AM 8/9/2003 -0400, you wrote:

Hello

and all,

Last night I saw a BFAR mom who was 18 hours

PP. She had her breast reduction surgery 10 years ago. The

technique used by the surgeon left the nipple in place. She has a

scar around the nipple but states she has regained sensitivity of the

nipple. Her breast increased on size cup (from B to C) during

pregnancy. She recalls her surgeon telling her she had 50/50 chance

of breastfeeding. We will keep in close contact to see how the production

goes within a few days. Breast are quite limp. I imagine it is the

normal texture after reductions surgery and before milk comes in

(or am I mistaking and that is a sign of not enough glandular tissue

???). I have directed the mother to the BFAR.org site and talked about

West's book. She was impressed and surprised that such a

specific reference existed. Of course, she had not heard of it

previously.

What makes matters more complicated is that

baby latches poorly even with correct techniques for body position and

latch. Baby was deep suctioned for meconium aspiration as she was

covered with meconium when she was born. Labor lasted 4 days. Baby

was born at 40 weeks + 6/7. In the end, after a non-stress test, they

found that there was not enough amniotic fluid left. They tried

oxytocin to augment labor but had to stop rapidly as the baby's cardiac

rythm was affected negatively by the augmentation of labor.

At the breast, baby opens wide, latches but

then does not seem to appreciate such a big mouthful and backs away

slightly, closing her mouth and pinching the nipple. The nipple comes out

wedged in football and cross-craddle holds.

I left them cup feeding ABM as the mother had

not yet extracted colostrum. I instructed her on hand expression

(Marmet technique) and left her with the pamphlet explaining the

technique.

I think I will now instruct her on protecting

her milk supply by pumping regularly if baby is still not latching

properly. I read the oral aversion from suctioning can last several

days. In the meanwhile, do we keep on trying to latch and perhaps

dammage mom's nipples or do we stick with cup feeding and pumping

?

I need your feedback on this case.

TIA.

Ghislaine Reid, IBCLC

[Guest guest]

Thanks Lyla. The mother already has a Medela SNS. Do you suspect the baby would pinch less if the flow was greater ? I have referred them to a cranio-sacral therapist. They will call Monday.

With oral aversion from deep suctioning, usually "tincture of time" will do the trick.

I have read the article on the bfar site. Thanks for pointing it out.

Ghislaine

Re: A case for and you wise ones

if it were me, and the mom was willing, i would try an sns or lactaid at the breast (start with a 5FR, $2 jack newman style supplementer). this might keep baby better latched, stimulate mom's milk, *and* feed the baby all at the same time. if it still hurts, or even if it does't, i'd refer for pediatric chiropractic or cranial sacral evaluation. have you seen this great article on the BFAR web site by Dee Kassing on evaluating a baby for cranial sacral or chiropractic treatment?http://www.bfar.org/craniosacral.shtmlwith a traumatic delivery, long labor, and low amniotic fluid, i would suspect that baby might be uncomfortable, and perhaps is backing off the breast due to discomfort. i have had *great* success with resolving both maternal pain, low weight gain, and non-latching babies with either cst or ped. chiro (different treatment worked for different moms).if she is using an at-breast supplementer, then at least she is breastfeeding, and she will see to what degree her milk comes in a lot more effectively than if she is cup feeding and pumping. good luck with this challenging case!LylaAt 10:36 AM 8/9/2003 -0400, you wrote:

Hello and all, Last night I saw a BFAR mom who was 18 hours PP. She had her breast reduction surgery 10 years ago. The technique used by the surgeon left the nipple in place. She has a scar around the nipple but states she has regained sensitivity of the nipple. Her breast increased on size cup (from B to C) during pregnancy. She recalls her surgeon telling her she had 50/50 chance of breastfeeding. We will keep in close contact to see how the production goes within a few days. Breast are quite limp. I imagine it is the normal texture after reductions surgery and before milk comes in (or am I mistaking and that is a sign of not enough glandular tissue ???). I have directed the mother to the BFAR.org site and talked about West's book. She was impressed and surprised that such a specific reference existed. Of course, she had not heard of it previously. What makes matters more complicated is that baby latches poorly even with correct techniques for body position and latch. Baby was deep suctioned for meconium aspiration as she was covered with meconium when she was born. Labor lasted 4 days. Baby was born at 40 weeks + 6/7. In the end, after a non-stress test, they found that there was not enough amniotic fluid left. They tried oxytocin to augment labor but had to stop rapidly as the baby's cardiac rythm was affected negatively by the augmentation of labor. At the breast, baby opens wide, latches but then does not seem to appreciate such a big mouthful and backs away slightly, closing her mouth and pinching the nipple. The nipple comes out wedged in football and cross-craddle holds. I left them cup feeding ABM as the mother had not yet extracted colostrum. I instructed her on hand expression (Marmet technique) and left her with the pamphlet explaining the technique. I think I will now instruct her on protecting her milk supply by pumping regularly if baby is still not latching properly. I read the oral aversion from suctioning can last several days. In the meanwhile, do we keep on trying to latch and perhaps dammage mom's nipples or do we stick with cup feeding and pumping ? I need your feedback on this case. TIA. Ghislaine Reid, IBCLC

[Guest guest]

At 06:32 PM 8/9/2003 -0400, you wrote:

Thanks

Lyla. The mother already has a Medela SNS. Do you suspect the

baby would pinch less if the flow was greater ?

yes a better latch often comes from a steady flow . ..

I have

referred them to a cranio-sacral therapist. They will call

Monday.

oh good!

With oral aversion from deep suctioning,

usually " tincture of time " will do the

trick.

yes but cst helps speed it! i forgot to mention lots of skin to

skin/rebirthing type stuff might help this baby and mom.

lyla

I have read the article on the bfar site.

Thanks for pointing it out.

Ghislaine

Re: A case for and you wise ones

if it were me, and the mom was willing, i would try an sns or lactaid at the breast (start with a 5FR, $2 jack newman style supplementer). this might keep baby better latched, stimulate mom's milk, *and* feed the baby all at the same time. if it still hurts, or even if it does't, i'd refer for pediatric chiropractic or cranial sacral evaluation. have you seen this great article on the BFAR web site by Dee Kassing on evaluating a baby for cranial sacral or chiropractic treatment?

http://www.bfar.org/craniosacral.shtml

with a traumatic delivery, long labor, and low amniotic fluid, i would suspect that baby might be uncomfortable, and perhaps is backing off the breast due to discomfort. i have had *great* success with resolving both maternal pain, low weight gain, and non-latching babies with either cst or ped. chiro (different treatment worked for different moms).

if she is using an at-breast supplementer, then at least she is breastfeeding, and she will see to what degree her milk comes in a lot more effectively than if she is cup feeding and pumping.

good luck with this challenging case!

Lyla

At 10:36 AM 8/9/2003 -0400, you wrote:

Hello and all,

Last night I saw a BFAR mom who was 18 hours PP. She had her breast reduction surgery 10 years ago. The technique used by the surgeon left the nipple in place. She has a scar around the nipple but states she has regained sensitivity of the nipple. Her breast increased on size cup (from B to C) during pregnancy. She recalls her surgeon telling her she had 50/50 chance of breastfeeding. We will keep in close contact to see how the production goes within a few days. Breast are quite limp. I imagine it is the normal texture after reductions surgery and before milk comes in (or am I mistaking and that is a sign of not enough glandular tissue ???). I have directed the mother to the BFAR.org site and talked about West's book. She was impressed and surprised that such a specific reference existed. Of course, she had not heard of it previously.

What makes matters more complicated is that baby latches poorly even with correct techniques for body position and latch. Baby was deep suctioned for meconium aspiration as she was covered with meconium when she was born. Labor lasted 4 days. Baby was born at 40 weeks + 6/7. In the end, after a non-stress test, they found that there was not enough amniotic fluid left. They tried oxytocin to augment labor but had to stop rapidly as the baby's cardiac rythm was affected negatively by the augmentation of labor.

At the breast, baby opens wide, latches but then does not seem to appreciate such a big mouthful and backs away slightly, closing her mouth and pinching the nipple. The nipple comes out wedged in football and cross-craddle holds.

I left them cup feeding ABM as the mother had not yet extracted colostrum. I instructed her on hand expression (Marmet technique) and left her with the pamphlet explaining the technique.

I think I will now instruct her on protecting her milk supply by pumping regularly if baby is still not latching properly. I read the oral aversion from suctioning can last several days. In the meanwhile, do we keep on trying to latch and perhaps dammage mom's nipples or do we stick with cup feeding and pumping ?

I need your feedback on this case.

TIA.

Ghislaine Reid, IBCLC

[Guest guest]

Hi, Ghislaine,

I'm so sorry I didn't respond to this sooner. I was offline for a

long weekend.

Breast

are quite limp. I imagine it is the normal texture after reductions

surgery and before milk comes in (or am I mistaking and that is a

sign of not enough glandular tissue ???).

I would look more to what is inside the breasts -- are there

glands? I find that many breasts are limp prior to LGII, but when

there are sufficient glands, it has no bearing on milk production

capability.

I have

directed the mother to the BFAR.org site and talked about West's

book. She was impressed and surprised that such a specific

reference existed. Of course, she had not heard of it

previously.

Thank you!

At the

breast, baby opens wide, latches but then does not seem to appreciate

such a big mouthful and backs away slightly, closing her mouth and

pinching the nipple. The nipple comes out wedged in football and

cross-craddle holds.

What a difficult birth and what a challenging baby. I have seen

this so often. At this point, what you are dealing with is a

suckling issue, rather than a supply issue, although the supply may

become an issue soon.

I think I

will now instruct her on protecting her milk supply by pumping regularly

if baby is still not latching properly. I read the oral aversion

from suctioning can last several days. In the meanwhile, do we keep

on trying to latch and perhaps dammage mom's nipples or do we stick with

cup feeding and pumping ?

In my opinion, the first thing to do is (as you suggested), feed the

baby. We all have different approaches and I probably would have

suggested fingerfeeding with a starter SNS. I rarely suggest cup

feeding. But the important thing is that the baby is fed regularly

(in appropriate amounts) after the first 24 hours. Then, yes, as

you suggested, pump frequently to protect the milk supply. I do

think it would be very good to have the mother try latching the baby

several times a day using the cross-cradle hold and the asymmetrical

latch technique. She should break the latch as soon as the baby

begins thrusting its tongue and pushing out the breast. My feeling

is that it is important to keep the mom trying to latch and for the baby

to remain accustomed to being brought to breast. If a dyad goes for

too long without nursing, I find it more difficult to get the baby back

to breast.

I would also suggest lots of skin-to-skin, as much of the day as

possible.

I agree that CST may be very beneficial.

It sounds like you are giving her excellent information and she is lucky

to have your help.

[Guest guest]

At 06:32 PM 8/9/2003, you wrote:

Thanks

Lyla. The mother already has a Medela SNS. Do you suspect the

baby would pinch less if the flow was greater ?

I'm sorry I didn't read this first. Yes, I agree with the others

that this can be very useful to reduce the clamping. You have

probably tried it by now. How did it go?

[Guest guest]

Thank you for the encouragement. I felt very challenged with this case. It was Friday night, the parents were tired and the grandparents and friends were visiting already ! :-(

I've started reading your book and I do browse through it at times. I especially liked the different surgery techniques being reviewed thoroughly. However, I will certainly feel more comfortable with BFAR once I've read your book entirely and once I've seen a few BFAR mothers.

How do you check for what's inside the breast before the milk comes in ? Or do you have to wait for LGII ?

I did not suggest cup feeding. The parents came home with cups and ABM from the hospital because Mom was a BFAR and they asked to be discharged early (after 18 hours). I did not mention this, but the maternal grandmother is a retired community nurse. She was very helpful and encouraging.

They have a Medela SNS but after a 2 1/2 hour visit, every body was tired (including me) from working on latch-on and positioning. I had planned on going over the details of using the SNS on the phone. However, the parents did not return my call so far.

Actually, what the baby does at the breast is not trusting the tongue out but rather sucking on the tip of the nipple. She goes on with a wide latch and slowly pulls away to end up with a smaller latch. I suspect, because the baby was deep suctioned, that there is an oral aversion issue here.

I hope they are doing well. I will try again to get in touch with them.

Ghislaine Reid

Re: A case for and you wise ones

Hi, Ghislaine,I'm so sorry I didn't respond to this sooner. I was offline for a long weekend.

Breast are quite limp. I imagine it is the normal texture after reductions surgery and before milk comes in (or am I mistaking and that is a sign of not enough glandular tissue ???). I would look more to what is inside the breasts -- are there glands? I find that many breasts are limp prior to LGII, but when there are sufficient glands, it has no bearing on milk production capability.

I have directed the mother to the BFAR.org site and talked about West's book. She was impressed and surprised that such a specific reference existed. Of course, she had not heard of it previously.Thank you!

At the breast, baby opens wide, latches but then does not seem to appreciate such a big mouthful and backs away slightly, closing her mouth and pinching the nipple. The nipple comes out wedged in football and cross-craddle holds.What a difficult birth and what a challenging baby. I have seen this so often. At this point, what you are dealing with is a suckling issue, rather than a supply issue, although the supply may become an issue soon.

I think I will now instruct her on protecting her milk supply by pumping regularly if baby is still not latching properly. I read the oral aversion from suctioning can last several days. In the meanwhile, do we keep on trying to latch and perhaps dammage mom's nipples or do we stick with cup feeding and pumping ?In my opinion, the first thing to do is (as you suggested), feed the baby. We all have different approaches and I probably would have suggested fingerfeeding with a starter SNS. I rarely suggest cup feeding. But the important thing is that the baby is fed regularly (in appropriate amounts) after the first 24 hours. Then, yes, as you suggested, pump frequently to protect the milk supply. I do think it would be very good to have the mother try latching the baby several times a day using the cross-cradle hold and the asymmetrical latch technique. She should break the latch as soon as the baby begins thrusting its tongue and pushing out the breast. My feeling is that it is important to keep the mom trying to latch and for the baby to remain accustomed to being brought to breast. If a dyad goes for too long without nursing, I find it more difficult to get the baby back to breast.I would also suggest lots of skin-to-skin, as much of the day as possible. I agree that CST may be very beneficial.It sounds like you are giving her excellent information and she is lucky to have your help.

[Guest guest]

How do

you check for what's inside the breast before the milk comes in ?

Or do you have to wait for LGII ?

I just feel the breast with thumb on top and fingers below for

counterpressure. Try it on your own breast first and then (assuming

you are not lactating) you will notice the difference when you feel the

hard large lumps in the breast that are the lobes.

I did not

suggest cup feeding. The parents came home with cups and ABM from

the hospital because Mom was a BFAR and they asked to be discharged early

(after 18 hours). I did not mention this, but the maternal grandmother is

a retired community nurse. She was very helpful and

encouraging.

Whatever works!

They have

a Medela SNS but after a 2 1/2 hour visit, every body was tired

(including me) from working on latch-on and positioning. I had

planned on going over the details of using the SNS on the phone.

However, the parents did not return my call so

far.

That can be discouraging.

Actually,

what the baby does at the breast is not trusting the tongue out but

rather sucking on the tip of the nipple. She goes on with a wide

latch and slowly pulls away to end up with a smaller latch. I

suspect, because the baby was deep suctioned, that there is an oral

aversion issue here.

It definitely could be.

I hope

they are doing well. I will try again to get in touch with

them.

I've had a few clients not call me for follow-up and not return my

call. I put the onus on the client to call me, although I usually

try to make one follow-up call. But with the heavy caseload that I

have now, I don't have time to keep calling clients. I really feel

that it is part of their responsibility to the outcome of their situation

to follow-up. Thinking of it this way has been a process for me --

it has helped me put the responsibility of the outcome with the parents

and not carry it myself. Just what's worked for me.