baby who won't latch

[Guest guest]

Hello everyone.  I have this mom's permission to post, and am hoping you all can help me with her case.

 

Baby born at 37 weeks gestation after a 6 hour labor.  First baby, unremarkable pregnancy, mother GBS positive.  Baby was mucousy at birth and vigorously suctioned then and repeatedly afterwards with bulb suction for first 48 hours by nervous parents who were advised to remove mucous frequently from baby’s mouth.  Birth weight was 6 lbs. 10 oz.  I first saw baby at day 3, when she had had 3 light wet diapers, but only 2 stools since birth.  She had not latched to the breast, and was discharged with a nipple shield, but the baby had not latched on with it either.  (When I spoke to the mother the evening before our consultation, I advised her to hand express and spoon feed colostrum, which she did during the night.)

 

At the consultation, baby appeared very jaundiced and sleepy. I don’t have a scale, but she was obviously lighter than 6-10.  (Mom didn’t know discharge weight.) She would not accept anything in her mouth; she wouldn’t latch on with or without nipple shield.  Mom had flat nipples and was engorged.  I did not do a digital exam considering the oral defensiveness issue.  Baby appeared somewhat hypotonic, but WNL for a baby of 37 weeks gestational age.  Because of baby’s degree of jaundice, output and sleepiness (very difficult to rouse for feeding), and gestational age, I suggested seeing pediatrician asap, that afternoon, which they did.

 

In the meantime, I suggested engorgement relief measures, skin-2-skin, manual expression, then pumping as desired/necessary, continue spoon feeding, and continue to offer breast.  We discussed various positioning techniques, asymmetrical latch, shaping breast tissue, positional stability, normal premature infant feeding behavior, self attachment, instructed cup feeding as an alternative, and giving the baby time to mature a bit before trying anything else.

 

The baby had lost about 13 ounces, and bili was 16.  Pediatrician wanted baby to use biliblanket and increase intake.  He was ok with spoon or cup feeding, and did not push formula supplement, but wanted daily weight checks for next 3 days.  She did gain weight slowly over the next few days, but not quickly enough with the cup, so pediatrician required bottle feeding with ebm, starting on day 7.  Mother continued with skin to skin and to offer the breast, but baby refused to latch.  Biliblanket was discontinued after 2 days.

 

I saw baby again today, 2 weeks after initial consultation. At last ped visit, 4 days ago, she was 4 ounces above birth weight, at 6 lbs 14 ounces.  Pediatrician is no longer concerned with weight gain, although I do not think she is out of the woods yet.  Mom’s breasts were quite full, and she had mastitis.  Nipples were still flattish, but more protruded than previous visit.  There was nipple damage on L nipple due to pump flange being too small, breasts too full and suction too high.   For baby, I was able to do an oral exam.  Baby has a type 4 tongue tie.  I believe she is hypotonic, although the pediatrician didn’t mention this to the mother.  She does not open her mouth widely, and has a poor lip seal on the bottle; she still shows little interest in feeding from any source.  During bottle feeds, baby has low tone in lips and cheeks, a very weak suck.  She flatly refuses to latch on at the breast, or even mouth or lick the nipple.  We tried a nipple shield unsuccessfully.  She will suck on a finger, but unenthusiastically and in a disorganized manner, and has trouble maintaining her suck.  She was too sleepy to try finger feeding, although I did talk the parents through the technique. 

 

My questions are how much of this behavior can, at this point, be attributed to her prematurity (her due date was October 30), and precipitous birth?  What else is going on here, besides the tongue tie?  Pediatrician has checked her out and finds her physical exam to be normal. (Although I’m beginning to wonder if there’s something subtly neurological happening. I've ruled out obvious facial/body asymmetry, torticollis, palate cleft, palpable ridges on head. )  Here is what I left the parents with in terms of my thoughts/recommendations as of today:

 

1.  address tongue tie problem.  Her tongue remains flat when crying; she cannot lift it from the floor of her mouth, it is humped in the back, and lateral movement is difficult. She has a very high narrow palate as well.  The pediatrician told her that the baby had a short tongue but didn’t know how/if that would affect breastfeeding. 

 

2.  consider various feeding options.  Does mom want to continue bottle feeding, or does she want to try finger feeding, with the hope that with finger feeding she will be able to at least try to train baby’s tongue a bit so that if she does eventually latch on, bf might be less painful?  Does she want to try bait and switch?  Start with the bottle, then try to latch on with (or without) the nipple shield?  (Although we did try this, and it was unsuccessful. We tried in various combinations--using dripped milk, with mom's let down, which is good, etc.)  I demonstrated some gentle exercises she can do with her daughter to stimulate oral muscles to try to get things going. Continue skin to skin.

 

3.  Explore craniosacral therapy option.  I gave her information and referral for CST who is also an OT.

 

4.  Re  mastitis, we discussed pumping more frequently (back to q 2-3 instead of q 4), and recommended care plan. Antibiotics from OB.  Recommended changing to larger flange size.

 

What else should I be doing? I’ve never seen a baby so disinterested in latching on. I was hoping as she got a little older she’d be a little more enthusiastic about latching on, but no luck.  She’s had lots of skin to skin with mother, who reports she shows no interest.  She literally just lays there at the breast.  Even if she’s hungry, or should be hungry, I’ve observed no rooting reflex. She doesn’t open her mouth; she just looks at the breast or her mother.  There’s no adverse behavior, no distress cues.  Mom says on the occasion when she is more active and hungry and she’s showing normal behavior of hands to mouth and moving head, she still won’t latch on.  She will take the bottle but, still, not enthusiastically.  When she is feeding, she can manage the flow well.  Mom is pacing the feed using a Natural Latch nipple and baby doesn’t seem overwhelmed by it at all.  But still, she’s not an enthusiastic feeder. 

 

Mom is thinking over her options. Any and all ideas will be much appreciated.

 

Barbara Ash, IBCLC

Burke, VA  

 

[Guest guest]

Barbara,

The only thing I can think of adding is that because of the suction the baby may have an oral aversion to anything in the mouth (it was probably uncomfortable/painful to baby and now baby doesn't want to let anything in her mouth - bottle nipple is stiff and can easily be pushed into mouth).

Other than what you are already doing is to really try to get baby to accept bottle before feeding. Meaning touching bottle nipple or finger with tube to baby's mouth to try to get rooting reflex before you put anything into baby's mouth for feeding.

I hope that helps a bit.

Felicia Henry, BCCE, IBCLC

Oxnard, CA

baby who won't latch

Hello everyone. I have this mom's permission to post, and am hoping you all can help me with her case.

Baby born at 37 weeks gestation after a 6 hour labor. First baby, unremarkable pregnancy, mother GBS positive. Baby was mucousy at birth and vigorously suctioned then and repeatedly afterwards with bulb suction for first 48 hours by nervous parents who were advised to remove mucous frequently from baby’s mouth. Birth weight was 6 lbs. 10 oz. I first saw baby at day 3, when she had had 3 light wet diapers, but only 2 stools since birth. She had not latched to the breast, and was discharged with a nipple shield, but the baby had not latched on with it either. (When I spoke to the mother the evening before our consultation, I advised her to hand express and spoon feed colostrum, which she did during the night.)

At the consultation, baby appeared very jaundiced and sleepy. I don’t have a scale, but she was obviously lighter than 6-10. (Mom didn’t know discharge weight.) She would not accept anything in her mouth; she wouldn’t latch on with or without nipple shield. Mom had flat nipples and was engorged. I did not do a digital exam considering the oral defensiveness issue. Baby appeared somewhat hypotonic, but WNL for a baby of 37 weeks gestational age. Because of baby’s degree of jaundice, output and sleepiness (very difficult to rouse for feeding), and gestational age, I suggested seeing pediatrician asap, that afternoon, which they did.

In the meantime, I suggested engorgement relief measures, skin-2-skin, manual expression, then pumping as desired/necessary, continue spoon feeding, and continue to offer breast. We discussed various positioning techniques, asymmetrical latch, shaping breast tissue, positional stability, normal premature infant feeding behavior, self attachment, instructed cup feeding as an alternative, and giving the baby time to mature a bit before trying anything else.

The baby had lost about 13 ounces, and bili was 16. Pediatrician wanted baby to use biliblanket and increase intake. He was ok with spoon or cup feeding, and did not push formula supplement, but wanted daily weight checks for next 3 days. She did gain weight slowly over the next few days, but not quickly enough with the cup, so pediatrician required bottle feeding with ebm, starting on day 7. Mother continued with skin to skin and to offer the breast, but baby refused to latch. Biliblanket was discontinued after 2 days.

I saw baby again today, 2 weeks after initial consultation. At last ped visit, 4 days ago, she was 4 ounces above birth weight, at 6 lbs 14 ounces. Pediatrician is no longer concerned with weight gain, although I do not think she is out of the woods yet. Mom’s breasts were quite full, and she had mastitis. Nipples were still flattish, but more protruded than previous visit. There was nipple damage on L nipple due to pump flange being too small, breasts too full and suction too high. For baby, I was able to do an oral exam. Baby has a type 4 tongue tie. I believe she is hypotonic, although the pediatrician didn’t mention this to the mother. She does not open her mouth widely, and has a poor lip seal on the bottle; she still shows little interest in feeding from any source. During bottle feeds, baby has low tone in lips and cheeks, a very weak suck. She flatly refuses to latch on at the breast, or even mouth or lick the nipple. We tried a nipple shield unsuccessfully. She will suck on a finger, but unenthusiastically and in a disorganized manner, and has trouble maintaining her suck. She was too sleepy to try finger feeding, although I did talk the parents through the technique.

My questions are how much of this behavior can, at this point, be attributed to her prematurity (her due date was October 30), and precipitous birth? What else is going on here, besides the tongue tie? Pediatrician has checked her out and finds her physical exam to be normal. (Although I’m beginning to wonder if there’s something subtly neurological happening. I've ruled out obvious facial/body asymmetry, torticollis, palate cleft, palpable ridges on head. ) Here is what I left the parents with in terms of my thoughts/recommendations as of today:

1. address tongue tie problem. Her tongue remains flat when crying; she cannot lift it from the floor of her mouth, it is humped in the back, and lateral movement is difficult. She has a very high narrow palate as well. The pediatrician told her that the baby had a short tongue but didn’t know how/if that would affect breastfeeding.

2. consider various feeding options. Does mom want to continue bottle feeding, or does she want to try finger feeding, with the hope that with finger feeding she will be able to at least try to train baby’s tongue a bit so that if she does eventually latch on, bf might be less painful? Does she want to try bait and switch? Start with the bottle, then try to latch on with (or without) the nipple shield? (Although we did try this, and it was unsuccessful. We tried in various combinations--using dripped milk, with mom's let down, which is good, etc.) I demonstrated some gentle exercises she can do with her daughter to stimulate oral muscles to try to get things going. Continue skin to skin.

3. Explore craniosacral therapy option. I gave her information and referral for CST who is also an OT.

4. Re mastitis, we discussed pumping more frequently (back to q 2-3 instead of q 4), and recommended care plan. Antibiotics from OB. Recommended changing to larger flange size.

What else should I be doing? I’ve never seen a baby so disinterested in latching on. I was hoping as she got a little older she’d be a little more enthusiastic about latching on, but no luck. She’s had lots of skin to skin with mother, who reports she shows no interest. She literally just lays there at the breast. Even if she’s hungry, or should be hungry, I’ve observed no rooting reflex. She doesn’t open her mouth; she just looks at the breast or her mother. There’s no adverse behavior, no distress cues. Mom says on the occasion when she is more active and hungry and she’s showing normal behavior of hands to mouth and moving head, she still won’t latch on. She will take the bottle but, still, not enthusiastically. When she is feeding, she can manage the flow well. Mom is pacing the feed using a Natural Latch nipple and baby doesn’t seem overwhelmed by it at all. But still, she’s not an enthusiastic feeder.

Mom is thinking over her options. Any and all ideas will be much appreciated.

Barbara Ash, IBCLC

Burke, VA

[Guest guest]

Hello, Barbara.

I am wondering if 48 hours of suctioning has just turned this baby off rather completely from having anything in her mouth. She may now be content to starve.

There is an aspect of craniosacral therapy called Somato-Emotional Release. Not all CST providers know this technique, or at least they are not all experts in it. But it may be very helpful in this situation. I would check www.upledger.com and put in the first three digits of the mother's zip code, then look for those who have taken SER classes.

Dee Kassing