How an eight-week-old who had been unable to directly breastfeed had a long drink at the breast then fell asleep in our consultation
When Jemima's newborn wouldn't come onto the breast, she received a lot of unhelpful advice
"Let's say that the pump and I have become close friends," Jemima tells me, wryly. Her firstborn, Jamal, is eight weeks old.
"But he latched and stayed on the breast for a whole 20 seconds the other day," she exclaims, "the longest by far he's stayed on in his entire little life! We even took photos!" Her husband, sitting by her side on my two-seater couch, brings out his phone to show me.
Jemima has seen a number of lactation consultants, three from the hospital, one at a clinic, and one who home-visits. They've worked very closely with her, in appointments up to two hours long. She's tried every possible position. After breastfeeding assessments, each of the lactation consultants have told her there's no positioning problem.
Little Jamal had a scissors frenotomy on his third day of life. However, the problems with coming on to the breast persisted, and the lactation consultants explained that the initial snip wasn't deep enough. They advised a deep scissors frenotomy by a different doctor, which Jemima and her husband, in desperation, proceeded with in his third week of life. Jemima tells me that the lactation consultants also told her she had big breasts and flat nipples, and that her baby had a recessive chin.
When I first see her, Jemima is feeding Jamal expressed breast milk by the bottle, as well as 50 or 60 mls of formula every few days. The baby's weight gain, and urine and stool output are normal. Jemima still tries to offer him the breast directly at least two or three times a day. She says that a nipple shield doesn't help because he has to work too hard at the shield to get milk through - she's been told he is a lazy sucker. When she brings him close to the breast in my consulting room, he begins to cry.
Yet by the end of our consultation, this same little one has swallowed substantial amounts of milk directly from his mother (which I know because of the swallowing sounds we hear in tandem with his jaw movements) and is asleep at the breast. Jemima keeps looking up at her husband in amazement.
"I can't believe it," she murmurs, lightly caressing her little one's downy hair, gazing up at her husband, shaking her head just a little. "Can you believe it?" Her husband is tearing up.
How Jemima's baby was able to drink well from the breast and then fall asleep at the breast, for the very first time
| The problem | What I did or suggested | Why this worked |
|---|---|---|
| Landing pad encroachment | Semi-reclined positioning | Landing pad encroachment by the abdomen results in breast tissue drag; lying back at 45 degree angle helped expose the landing pad |
| Two rolled up facecloths to expose the landing pad | Landing pad encroachment by the abdomen results in breast tissue drag; facecloth use exposed the landing pad | |
| Conditioned dialling up at the breast - strategy used in consultation | Nipple shield use | Accustomed to silicon contours of bottle teat, so baby was more likely to come on and have positive experience at the breast |
| Conditioned dialling up at the breast - strategies for daily life | Enjoy time when he is sleeping at breast | Enjoy time when he is sleeping at breast |
| Grow positive experiences, never coerce if baby is dialing up | Avoids reinforcing negative associations | |
| Nipple and breast tissue drag | Held woman's forearm as she practiced dropping baby to level of nipple with vertical micromovement, experimented with angle control and horizontal micromovements | Eliminated breast tissue drag |
| Mother's upper arm shorter relative to breast fall, holds baby higher than nipple (even with landing pad exposure) | Baby's head rests on woman's wrist; paddle hand | Eliminated breast tissue drag, gives woman control of micro-movements |
| Baby's lower arm caught between baby and mother's body | Gently ease lower arm to wrap around mother's side | Helps the baby get low enough to avoid breast tissue drag. Otherwise eyes tend to be looking towards floor. Once arm is wrapped, baby's eyes looked up somewhat, towards ceiling |
| Breast falls out to the side | Ease breast forward before bringing baby on and stabilise forward with upper arm | Baby doesn't have to go so far out to the side, which tends to promote tilting head forward, which makes it hard for baby to drop jaw and swallow comfortably |
| Angle at face-breast interface causes breast tissue drag | 'Down and in and control the angle' | Baby's eyes looked at an angle that slopes up towards ceiling somewhat |
| Although Jemima didn't need to do this, some women in this situation find it easiest if they lift and shape the breast | Education about the high risk of breast tissue drag and how to avoid this if she uses this lift and shape technique | The woman lifts and shapes breast but minimises possibility of breast tissue drag, careful micromovements once baby is on, splinting the breast with the baby's face |