advice re: nipple anatomy and supply

[Guest guest]

Hello wise ones,I'm hoping you might be able to offer some advice on a mom I was working with, who has given me permission to share. This situation is a couple of weeks old now, but I'm still trying to help this mom get a better handle on the big picture of anatomy and supply concerns...

Mom of twins delivered via c/s at 38 weeks. No history of infertility, uncomplicated pregnancy, mom reports breast changes during pregnancy.

I initially saw them when the babies were 9 days old to assist with latching and concerns about weight gain.  Both babies were receiving supplements of ABM via syringe/tube at the breast (40-60ml per feeding, q3hrs).  Mom was able to express some milk, and we were able to get babies to latch and suck at breast, with supplements. Neither baby was transferring much directly from the breast (based on pre/post feeding weights). Mom was pumping, though not regularly, and we discussed the importance of regular pumping to provide additional breast stimulation while the babies were developing their suck skills. A few days later, mom reported that her supply seemed to be dropping, especially in her right breast.

She has very interesting nipple anatomy. Her left nipple is large, and her right nipple appears to be two nipples side by side, or one bifurcated nipple. She has no other supernumerary nipples, though she had heard her right nipple described that way before.

When I was working with her, we ended up feeding both babies on the left breast (first baby started there, and second baby wouldn't latch to the right nipple) but she later reported that both babies would take the right breast at least some of the time.  She is able to express milk from both nipples on the right, so both are connected to a ductal system.  She is using a rented Symphony pump, with appropriately sized flanges (30mm on the right, 27 on the left, and they appear to fit well with no reported discomfort).  I'm wondering if the pump is not providing adequate breast stimulation - that even with an apparently good fit, I wonder if she's only getting nipple stimulation and not deeper breast stimulation (perhaps from the babies' suckling as well). The suckling situation is complicated by one baby who was not eager to open her mouth wide (I showed the parents some suck exercises, and they reported improvement in this baby's suck.)

Does this sound like anything you've seen? Any other ideas of what to try?

(And in light of the recent conversation on TT I'll note that I'm not at all an expert on assessing posterior tongue tie, but based on the infant's limited range of motion and cupping of her tongue it's possible that is a factor as well. I suggested that the parents ask the pediatrician to assess the tongue, but I don't know what came of that.)

Many many thanks!

Jona

JonaRose Feinberg, MA, CLEC (and anxiously awaiting exam results!!)Twins in Mind Consulting

info@...

www.breastfeedingtwins.org

[Guest guest]

Things that speak to me here are:

At 9 days close to 100% of feed volumes is from ABM

+

Mom is not regularly pumping

If you don't have frequent/effective milk removal from either a well feeding

baby or use of a quality/effective pump full supply will never be achieved (much

less full supply for 2).

What type of pump?

Did she have Lact II?

How often IS she really pumping, and what is the yield?

>

> Hello wise ones,

>

> I'm hoping you might be able to offer some advice on a mom I was working

> with, who has given me permission to share. This situation is a couple of

> weeks old now, but I'm still trying to help this mom get a better handle on

> the big picture of anatomy and supply concerns...

>

> Mom of twins delivered via c/s at 38 weeks. No history of infertility,

> uncomplicated pregnancy, mom reports breast changes during pregnancy.

>

> I initially saw them when the babies were 9 days old to assist with latching

> and concerns about weight gain. Both babies were receiving supplements of

> ABM via syringe/tube at the breast (40-60ml per feeding, q3hrs). Mom was

> able to express some milk, and we were able to get babies to latch and suck

> at breast, with supplements. Neither baby was transferring much directly

> from the breast (based on pre/post feeding weights). Mom was pumping, though

> not regularly, and we discussed the importance of regular pumping to provide

> additional breast stimulation while the babies were developing their suck

> skills. A few days later, mom reported that her supply seemed to be

> dropping, especially in her right breast.

>

> She has very interesting nipple anatomy. Her left nipple is large, and her

> right nipple appears to be two nipples side by side, or one bifurcated

> nipple. She has no other supernumerary nipples, though she had heard her

> right nipple described that way before.

>

> When I was working with her, we ended up feeding both babies on the left

> breast (first baby started there, and second baby wouldn't latch to the

> right nipple) but she later reported that both babies would take the right

> breast at least some of the time. She is able to express milk from both

> nipples on the right, so both are connected to a ductal system. She is

> using a rented Symphony pump, with appropriately sized flanges (30mm on the

> right, 27 on the left, and they appear to fit well with no reported

> discomfort). I'm wondering if the pump is not providing adequate breast

> stimulation - that even with an apparently good fit, I wonder if she's only

> getting nipple stimulation and not deeper breast stimulation (perhaps from

> the babies' suckling as well). The suckling situation is complicated by one

> baby who was not eager to open her mouth wide (I showed the parents some

> suck exercises, and they reported improvement in this baby's suck.)

>

> Does this sound like anything you've seen? Any other ideas of what to try?

>

> (And in light of the recent conversation on TT I'll note that I'm not at all

> an expert on assessing posterior tongue tie, but based on the infant's

> limited range of motion and cupping of her tongue it's possible that is a

> factor as well. I suggested that the parents ask the pediatrician to assess

> the tongue, but I don't know what came of that.)

>

> Many many thanks!

>

> Jona

>

> JonaRose Feinberg, MA, CLEC

> (and anxiously awaiting exam results!!)

> Twins in Mind Consulting

> info@...

> www.breastfeedingtwins.org

>

[Guest guest]

You have to stretch a nipple shield to get it to fit around a large nipple without pinching. Drop the nipple shield in boiling water for 2-3 minutes to soften it. Fish it out with tongs. As soon as you can safely handle it (but it is still very warm), place your thumb and pointer fingers on the inside and outside of the shield at the juncture of the shaft and "hat brim" and beginning strongly tugging and stretching that juncture by pulling your fingers around that "seam". As it begins to cool, quickly turn it inside out to cool completely. You MUST turn it inside out or it will pull itself back to its original shape. Depending on how large you have to make it, you may have to do this several times to stretch it enough, but, amazingly, it won't tear. I was taught this by a mother with perfectly flat nipples that

were so large even the 40mm flanges weren't big enough. But she could get enough of the nipple into the shield by stretching it this way that her twins could latch to the shield and get milk. (She did have to stretch it numerous times to get it big enough.)

Dee Kassing

Subject: Re: advice re: nipple anatomy and supplyTo: Date: Sunday, September 18, 2011, 10:45 PM

Jona, I once worked with a mom with 'double nipples'. Literally two functioning nipples so close together baby could not get on one and could not get on both at the same time. Mom ended up pumping with a very large flange from Medela..remember the glass ones...for about 4 months on that side. She breastfed on the other. When baby was big, like 4 months or so, she was able to latch the baby on the 'double nipple' side. The flow was fast too, but by then he didn't mind. I often wish digital was in back then! That and the one time I saw a nipple inside a 'fold' like an envelope she could peel back and out would pop a perfectly health functioning nipple. So interesting...Anyway, if nipples are large, mom may need to express and supplement. And since babies are 38 weeks, that is likely necessary anyway. Keep in mind size of nipples in relation to size of mouth and ability to remove milk.

Sometimes it is a difference of weeks, but I have seen plenty of times when it takes longer for a baby to grow enough to get a very large nipple completely in his mouth. And sorry, I cannot imagine the discomfort of squishing a size 36 mm nipple into a nipple shield so baby can breastfeed. Ouch ouch ouch. And yes, just because I read about it, I did have a couple of moms try it...and my imagination was right...they said "ouch!"Pam MazzellaDiBosco, IBCLC

[Guest guest]

I would think it would work great with flat nipples. It is the moms with very very large nipples being told to squeeze into a smaller nipple shield so they will fit that I had mommas say ouch to. The length was there too. Those little openongs do there own brand of damage on the face of a nipple too. PamPam MazzellaDiBosco. IBCLCSender: Date: Sun, 18 Sep 2011 20:56:47 -0700 (PDT)To: < >ReplyTo: Subject: Re: advice re: nipple anatomy and supply You have to stretch a nipple shield to get it to fit around a large nipple without pinching. Drop the nipple shield in boiling water for 2-3 minutes to soften it. Fish it out with tongs. As soon as you can safely handle it (but it is still very warm), place your thumb and pointer fingers on the inside and outside of the shield at the juncture of the shaft and "hat brim" and beginning strongly tugging and stretching that juncture by pulling your fingers around that "seam". As it begins to cool, quickly turn it inside out to cool completely. You MUST turn it inside out or it will pull itself back to its original shape. Depending on how large you have to make it, you may have to do this several times to stretch it enough, but, amazingly, it won't tear. I was taught this by a mother with perfectly flat nipples thatwere so large even the 40mm flanges weren't big enough. But she could get enough of the nipple into the shield by stretching it this way that her twins could latch to the shield and get milk. (She did have to stretch it numerous times to get it big enough.) Dee KassingSubject: Re: advice re: nipple anatomy and supplyTo: Date: Sunday, September 18, 2011, 10:45 PM Jona, I once worked with a mom with 'double nipples'. Literally two functioning nipples so close together baby could not get on one and could not get on both at the same time. Mom ended up pumping with a very large flange from Medela..remember the glass ones...for about 4 months on that side. She breastfed on the other. When baby was big, like 4 months or so, she was able to latch the baby on the 'double nipple' side. The flow was fast too, but by then he didn't mind. I often wish digital was in back then! That and the one time I saw a nipple inside a 'fold' like an envelope she could peel back and out would pop a perfectly health functioning nipple. So interesting...Anyway, if nipples are large, mom may need to express and supplement. And since babies are 38 weeks, that is likely necessary anyway. Keep in mind size of nipples in relation to size of mouth and ability to remove milk. Sometimes it is a difference of weeks, but I have seen plenty of times when it takes longer for a baby to grow enough to get a very large nipple completely in his mouth. And sorry, I cannot imagine the discomfort of squishing a size 36 mm nipple into a nipple shield so baby can breastfeed. Ouch ouch ouch. And yes, just because I read about it, I did have a couple of moms try it...and my imagination was right...they said "ouch!"Pam MazzellaDiBosco, IBCLC