Today’s Podcast
166:  Preparing for breastfeeding series a case study

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Episode 166 Case study: Nancy and Adam

A couple of weeks ago, I provided a home visit for Nancy. I originally met Nancy with her first baby, about 6 years ago.

When I arrived at Nancy’s home, I was greeted by her sister, who walked be to Nancy’s bedroom. There I saw Nancy, sitting on the edge of the bed. I was glad to see her sitting in front of a food tray and eating lunch. I was also glad to see her in relaxed clothing. The delicious lunch she has tells me she is being well taken care of and her relaxed clothing tells me that she is doing exactly what I want her to be doing. Resting and not worrying about getting dressed for visitors.

I chatted with her about her birth, while she finished eating. I found out that her little boy, named Adam had been born 4 weeks early and weighed 5 lbs 1 oz at birth. He had some troubles initially breathing and so he spent some time in the NICU. While there, Nancy was told that his blood sugars were lower then expected. Since he was quite sleepy everytime she went to the nursery to breastfeed, and his weight was down to 4 bs. 9 oz, they advised 1 or 2 formula feedings just until his blood sugar levels were at a level they were more comfortable with.

So, Nancy spent the first 36 hours breastfeeding and for the next 3 days, Adam was formula fed. It seems he was having a bit of a problem breathing and was not thrilled with eating. This upset Nancy, however, she knew her baby needed to eat and hearing about low blood sugars had her and her husband absolutely frightened. They did what any good parent would do under those circumstances. Feed her baby. Nancy suffered from birth trauma having had a 4th degree tear and as she told me what happened, I thought that she was pretty lucky to be home with her baby, less then 3 weeks after the birth.

Even though this was her second baby, Nancy did not have these same challenges with her first baby. She suffered with pain and cracked and bleeding nipples. Nancy told me that it took her 3 weeks to ask for her with her first and by that time her pain level was excruciating.

While I was able to help her make latch adjustments, her pain level was too high and her nipple tissue had considerable damage. At that time, I suggested a specific nipple cream and to pump and bottle for 24 hours, before trying to breastfeed again. Nancy tells me that she does not remember all the details, but does know that within 5 days of our consult, she was breastfeeding in relative comfort, but it did take a couple of weeks for her nipples to fully heal.

With her new baby Adam, her challenges were quite different. She continued on with her story. She had no pain, and that was partly because her newborn was not at the breast doing much more than sleeping. With her baby in the NICU and Nancy discharged by Day 3, Nancy spent the next 2 days at home with her other child, being well cared for by her sister and mother and husband& trying hard to get back to the NICU once a day with pumped milk for Adam.

On Day 6, Nancy suffered a huge setback. She had begun to notice some pain in her belly and 2 days later, woke up from a nap in dire pain. After a phone call to her OB, she was told to go to the ER right. She did and tests showed her gallbladder needed to be removed and she would have surgery the next morning.

I listened to Nancy tell me this horrible story. I typically do a good job of keeping my emotions in check. I hear many beautiful stories as well as some shocking ones and it is important for me to keep my wits about me so I can show up and be there for the mom that I am working with. Becoming all emotional with moms vs. empathetic does not help me do my job well.

Perhaps it was just one of those days for me. I am far from perfect. Nancy freely let tears roll down her face and as she relayed to me her pp story and I listened, while I wiped my tears away. All I was thinking about was how hard it is to be separated from your baby. When they are in the nursery and you are in your own room, that is hard enough. But when you have to leave the hospital and see your baby only a few hours a day, for a new mother, that is heartbreaking.

And now, her baby is still in the NICU, breathing just fine now, but not the best eater. However, he had gained enough that he was ready to be discharged and this turned out to be the same day she was admitted into the hospital. With her mom and sister spending the day with her, her husband went to the hospital to bring Adam home.

The day Adam came home, she had her surgery. I know this show is listened to by thousands of moms and some who have had to leave their baby in the hospital when they were discharged. I have never had to do this but can only imagine the emotional pain this causes. Listeners who have been in this position, only you can know what it feels like to walk out those hospital doors empty handed. I just could not get past these emotions as Nancy continued on with her story.

Thank goodness, the rest of her story was rather uplifting. Her surgery went so well and she was discharged and home in 24 hours. Her baby was well cared for by family members and Nancy said that her reunion with her baby just wiped out any sad feelings she had endured leading up to that point.

Okay, so now no more tears for Nancy or I. Now that I am up to speed, we have to work with her current situation. What do you think she is dealing with? I will give you a few seconds to contemplate her breastfeeding challenges?

Well, pumping on a regular routine ws hard for her, given all that was against her. Adam has been mostly bottlefed his first few weeks of life. Nancy has been trying to breastfeed, but between her bottom trauma and the gallbladder surgery, she needed some time to heal before requesting her home visit. Adam was 15 days old today and gaining really well and a very happy baby.

Nancy said she is feeling remarkable well with all that she has been through and is ready to work on breastfeeding.

By this time, I had jotted down all my notes, Nancy was done with her lunch, I had weighed Adam and evaluated his oral cavity and her breasts and nipples, we talked about her supply, which is actually fairely well, again, with all she has been through. It seems that with her pumping, she is providing about 60% of Adams needs and the rest he is fed formula. She feels he is doing fine with the formula, however, she just really want to exclusively breastfeed, at least for the next 2 months while she is able to stay at home.

I watch her and baby together and quickly notice that Adam pushes away, and sometimes pretty hard, he is strong little boy. Nancy says that he does this most of the time and only some of the times does he actually relax and just latch on. She looked to me for help and I suggested she pretend I was not there and to do whatever it is she would normally do. I watched Nancy spend the next 10 minutes working hard to get Adam to latch on. He fussed and he cried and he pushed away and each time he did so, Nancy just brought him back onto the breast. I guess that she put him back on about 15 times in this time period. When nothing worked, she gave him a pacifier to calm him down. The whole process was started all over again.

I asked Nancy how long she tries and what she does when he just won’t take to the breast. She gives it about a half hour and then she gives up and gives him the bottle.

She said that she keeps trying so hard and for so long, because there are times when he eventually gives in and breastfeeds.
I can totally understand her logical thinking. I did explain though that this way to go about it, may make him more aversive to trying and that my concern is that he will turn a corner in the opposite direction and just one day refuse the breast altogether.

Since her latch technique was really good and since everything with her breast and nipple anatomy as well as the babies anatomy all checked out to be normal, and after trying all my tricks for about 15 minutes, I felt that we just needed to find a way that Adam would consistently go to the breast and get use to being held close to her, in a calm and relaxed fashion and getting milk at the breast.

I settled on trying the nipple shield and for Adam it was like night and day. He latched onto the shield, fussed and whined for a minute or two, but nothing like the hard crying and fighting like he had been doing. Nancy gently sang to him and within a few minutes of some gentle sucking, he was able to get a let down and from that point on, he settled in and had a good feeding on that side. When switched to the second side, he fussed as if he had never done this before. Picking him up and calming him down before putting him back on again. This time, he took to the shield quite easily.

Now there were happy tears with Nancy. I talked to her about the suggested care plan and made sure she knew that this was going to be a work in progress. Adam clearly told us that his big issue was his preference to getting fed from the bottle. That teat was familiar to him, the reward was immediate and he could get tanked up pretty quickly!

Since she was not making enough milk for Adam, Nancy was still going to need to give him a bottle after most feedings. This was likely going to slow their progress, however, I imagine that each day it would become easier and easier.
The key here was to bring him to the breast for every single feeding, with the nipple shield in place. Once done, offer him the rest of his feeding from a bottle.
Once he was settled down, she needed to pump, both sides. If someone else could give Adam his bottle, she could be free to pump.

I walked her through a bottlefeeding where she learned how to hold Adam in a more upright position and I talked her through how to pace the feeding. All these little things help Adam be less fussier at the breast.

It took longer than I would have liked, but she did persevere and by the time he was a month old, Adam was exclusively breastfeeding and still using the nipple shield. Moms that I work with, hear me say that I am greedy about breastfeeding. I want it to be as easy and as normal as possible. Nursing full time with the nipple shield, with a baby that can bare breastfeed is not my ideal breastfeeding situation.

By the time she had a good supply and Adam could have a full feeding at the breast, Nancy did spend a few days trying to wean him froom the shield.
She told me that he cried so hard and she lacked the stamina and emotional ability to keep at it and decided she was okay to use the shield full time.
We talked about ways to ensure she keeps up a good supply and I left the conversation letting her know that she is the mom and this is her baby and she gets to choose how she wants to feed her baby. I fully support her decision, however, wanted her to know she was free to call me if she changed her mind and wanted to work to bring Adam to the bare breast.

I think it is okay that as an IBCLC, I fully support moms in their choices, I understand why she is okay with the shield FT, and I also want to let her know that I think it would be great if there comes a t ime she wants to wean him from the shield that I am here for her.

As a side note, I want to be sure that you know that all babies and moms should be evaluated to see if a nipple shield is appropriate for their situation, which size to use, be sure that baby is actually transferring milk and be followed up by an IBCLC. There are enough times when it is used for the wrong reasons and actually makes breastfeeding worse then better.

I like to share with you Nancy’s story so you can see some of the challenges that moms have with breastfeeding. Her story highlights the importance of having pp help and how important that is to the healing and recovery for moms. You just don’t know how your birth is going to go or if you are going to have struggles with your health or your babies health or breastfeeding afterwards.

I know that you hear from me and from my guests the importance of making sure you have all your ducks in a row before your baby is born. Who is going to help and support you & your partner after your baby is born? Do you have a third person in mind that loves you and gets along well with both you and your partner? Can they step in with household help, meals and a helping hand with newborn holding, cuddling and diaper changing, if need be. is there s omeone who can drive you to appointments if need be? Watch a toddler for an afternoon? Stay up with a well fed, but fussy baby so you can get some sleep? It helps to have a person that you know you don’t need to get dressed for, know you don’t need to entertain and that they can be a help not a hinderance.

For the pregnant moms listening, write down your person! Then go ahead and have a frank discussion with that person and let them know what you are thinking. Sometimes the communication falls short and that person who you are depending on to help you, well it turns out that you wind up taking care of and feeding them and cleaning up around them. They act more like a guest in your home and you really need to be able to let your hair down and have them help you.

If you have a smooth birth, with not much to write home about and you and your baby are in sync with breastfeeding right away, your helper can still make life easier for you by cooking a few meals, putting up a few loads of laundry and be good company for you.

I know that one of the biggest factors in Nancy doing so well with all her post birth hardships is the love and help of her husband and her sister who put her care as a top priority.

Lori J. Isenstadt, IBCLC
Lori j Isenstadt, IBCLCLori Jill Isenstadt, IBCLC is a huge breastfeeding supporter.  She has spent much  of her adult life working in the maternal health field. Once she became turned on to birth and became a childbirth educator, there was no stopping her love of working with families during their childbearing years.  Lori became a Birth doula and a Postpartum doula and soon became a lactation consultant.  She has been helping moms and babies with breastfeeding for over 25 years.  Lori founded her private practice, All About Breastfeeding where she meets with moms one on one to help solve their breastfeeding challenges.  She is an international speaker, book author and the host of the  popular itunes podcast, All About Breastfeeding, the place where the girls hang out.  You can reach Lori by email at: aabreastfeeding@hotmail.com or contact her via her website:  allaboutbreastfeeding.biz/contact

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