Episode 87  Premature and NICU  babies and breastfeeding  

When I tell the story of a mother I have personally worked with, I change so much of the information, that even the Mom herself would not know it was her story. I do this so I can protect the privacy of the mothers I work with, while I can do my best at educating the public about all things related to breastfeeding. So, I am not just changing the moms name or her babies name or age or year that her baby was born. I am also changing other information that is not relevant to the story, but that will mix things up so much that you will just never guess. I will give this mom a twin sister when there is no such thing. I will give her 2 other children when there is only one. I will say that she is a teacher when she is an accountant. I will say that her husband said things during the consult, when he, in fact was never here. I will make her baby a 7 pounder when in fact, he was 8 lbs 10 oz. So, don’t begin to even guess or think that this story is yours. If you spend your time trying to figure out if this is you I am talking about, you will lose sight of the story and its meaning. And I know that you might do this because….. well If I was a past local client, I would be distracted with trying to figute out who this might be….

There are other parts to the story, the ones that really count, that I keep intact as this is where the learning comes in. In each story, I hope that you find something of interest that you learned that you feel will be helpful in your own past or current experience or perhaps to share with another mother. If you are a lactation consultant or a student, my hope is that you will learn some new things or confirm some things that you already know.

I first met Cassandra when she was 3 weeks postpartum with her first baby, a girl named Korina. Cassandra brought her mom with her to the consult and as they sat down, I noticed that Cassandra was moving quite purposefully. She took her time to slowly lower herself into the chair and as she sat I thought to myself,, either she is healing very slowly from her cesarean section or she has had a pretty significant 3rd or 4th degree tear from a vaginal birth that is slowly healing. For the uninitiated to vaginal tearing, a 1st degree tear is a thin tear of the perineal skin with no muscles involved. a 2nd degree includes skin and muscle, a 3rd degree is quite significant with the tear going through the perineal muscles and includes a layer of muscle surrounding the anal canal, and a 4th degree tear goes all the way into the canal or rectum. As one could imagine, this is quite painful and the healing can be several months.

I offered her the donut to sit on and she accepted and appeared grateful. Now, one might wonder why I am even talking about this. Why would I need to know this as a lactation consultant. After all, I am not her medical dr. Well, the interesting thing about being an experienced lactation consultant is that you learn to be aware of many things. Breastfeeding is not just the mother, her breasts and the baby. It is so much more. For Cassandra, I am already making a mental note that I have to keep her sore bottom in mind as we proceed. This is because believe me, Cassandra is surely quite distracted with her sore bottom and this may very well impact how she is able to pay attention to me and incorporate what I will need to share with her.

Cassandra tells me that she got off to a rough start with breastfeeding. Her baby was born 3 weeks early, the birth was long and traumatic, and her daughter needed to spend 3 days in the NICU as her breathing was labored and they wanted to observe her. Cassandra started to cry as she continued on with her story. I notice that her mother, who is sitting next to her, lowers her head and seems to be studying the floor. As Cassandra continued telling her story she quickly came to the part where she says she was allowed to be in the NICU, but had to wait for someone to help her with breastfeeding. As she sat next to her daughter she could see and listen to other conversations that were happening in the NICU. All the talk about other babies and their health situation raised Cassandra’s anxiety about her own baby and when she was finally handed her baby, she could do nothing else but sit and cry as she held her baby. She told me: I felt so guilty because I knew I should be happy that my baby was going to be okay, but I didn’t really know she was going to be okay. And hearing all these unfamiliar noises in the nursery and seeing her baby hooked up to all these machines made her feel on edge. Cassandra then told me that she was so frightened to move her baby around so much that she did not even try to breastfeed that first time in the NICU. She felt that she was verbally pushed into trying and was asked several times and she kept saying no. She did try a few times before leaving the hospital but said that her baby just did not want to.

Her mom seemed uncomfortable in her chair as she turned and twisted and lifted her head up and then looked down. It was as if she could not bear to hear Cassandra tell her story. I asked her mom if she had been at the birth and tears seemed to come so fast and she began to tremble.

Now I know that my job here is to help Cassandra with breastfeeding. I am not a physican, nor am I a therapist. However, once you have been doing this job for a while, you realize that there are just certain things that need to happen, before you can help a mom with breastfeeding. This family was in a crisis as they clearly had not processed the birth.

Again, not being a therapist myself, but feeling like this family could use some help, I talked about how traumatic their experience was and how just because you have a healthy baby, does not take away the thoughts and feelings and experiences they went through during their hospital stay. This is certainly not the birth experience they were expecting. Her mom said that she was totally unprepared for the anxiety she still feels having witnessed the after birth chaos and being frightened for her daughter and granddaughter. Her husband was back at work. Since he seems to be doing okay, Cassandra does not want to rock the boat and talk to him about her feelings. And Cassandras mother sees that her daughter seems to be holding it together, so she does not talk about their experience either.

I lovingly suggested that they were a family who was all trying to watch out for the other person so much, that they were not allowing their feelings to come to the surface.

As an outside bystander, all I had to do was ask a few pertinent questions and the tears and the words flowed. But with each other, in the home, everyone was tight lipped. We spent about 15 minutes talking about her birth experience before I felt she was ready to work on the breastfeeding. I encouraged Cassandra to speak with a therapist and said that I would give her a number and of course, she will decide if that is a phone call she wants to make.

In case you are wondering, her baby was initially happy and calm in the car seat. Halfway through she began to fuss and Cassandra picked her up,put the pacifier back in her mouth and stood up and rocked her gently while we talked. I am not a fan of making babies wait to eat, however, if they can be easily calmed with little effort, I will keep doing what I need to do, until I feel like the mom is now ready to sit and feed her baby. Korina was easily pacified, so I just kept going.

What I learned was important for me to know coming from the perspective of being her lactation consultant as well as someone who was going to be spending time with her, up close and personal, helping her with breastfeeding. Often times the birth experience is a very important component to what happens during breastfeeding. The part that I want to share with you, that is the most important part as it relates to breastfeeding, is that Cassandra and her baby did not do well in the immediate hours after the birth. Her baby was taken out of the room within minutes of the birth and her husband went with the baby, her mother stayed in the room with Cassandra and she explained that things were quite chaotic for a bit. However, within about 5 hours both were stable. Korina was to stay in the NICU for 3 days. They spent 1 day together in the same room, before being discharged on the 5th day.

I learned that Korina was use to getting bottles in the NICU. Cassandra estimates that half her milk was formula and half her milk was her pumped milk. She is happy to say that since Korina turned a week old, she has been drinking only expressed breastmilk and is gaining well, sleeping well and thriving. Cassandra expressed that she really wanted to breastfeed. It never even occurred to her during pregnancy that she would feed her baby any other way. When I asked Cassandra what happens when she tries to breastfeed Korina, she tells me that she gets stiff, pushes away and quickly starts to cry. Cassandra just cannot stand to see her baby cry, even for a minute.

I wanted to start the consult off with a weight check and Cassandra wanted to change Korina’s diaper. As soon as Cassandra started to change her diaper and she let out just a bit of a cry, her mom held the pacifier in the babies mouth. Maybe Cassandra would have mothered her baby this way anyway, even had she not had not experience the birth trauma and had her baby in the NICU for 3 days, but I find that moms are more likely to not be able to handle their babies crying, even for a second, when they have had a birth trauma.

Knowing her birth history, really helps me as her Lactation Consultant, understand how to approach this feeding session. As she is preparing to sit down to feed the baby, wrap the pillow around her waist and take down the bra flap so she could offer her baby the breast, I use this time to explain to Cassandra what babies usually do when they are rooting, when they are getting ready to come onto the breast. I ask her if Korina ever cries before getting the bottle and Cassandra says that yes, but she does her best to get to her as quickly as possible. I explain to her that while noone wants to hear their baby cry, it is fairly normal for babies to cry during diaper changes and getting dressed. It is fairly normal for babies to cry while their moms are heating up bottles, putting them in car seats.

I told Cassandra that more than likely Korina is going to cry on and off as we work together orientating her to the breast and showing Cassandra some positioning techniques that will help. I asked her how long she felt it would be okay for Korina to cry before we should stop and calm her. She said 1 minute. So, I said okay.

At this point, I verbalized that Cassandra had quite a few things going in her favor. She had a great milk supply and I congratulated her on all the hard work she has done so far with keeping up a good pumping routine. She also had a baby that was well fed and thriving. From my evaluation, I could easily see that there was no reason why Korina should have a hard time latching as everything with her oral anatomy was quite normal and so was the breast and nipples.

I explained what things might be like on Korinas side and asked that Cassandra keep this in mind. I told her that Korina was use to a very different sensation in her mouth, the smell, the taste, the texture of the firm nipple teat was far different than her breast and nipple and did not fill up her mouth like a beautiful soft breast and different nipple texture. The mechanism for removing the milk from the breast was very different than it is from the bottle. How she is being held during the time she is getting food is very different and lastly, once Korina gives one tight nipple compression on the bottle nipple, she opens her mouth and gets a flood of milk right away.

So, I wanted Cassandra to try and get into the mindset of Korina and focus on understanding this, rather than focus on the fact that her baby cries each time she brings her to the breast, making her feel like she is hurting her. And I told her that anytime she wanted to stop, we would and take a break, or totally stop if that is what she wanted.

This made Cassandra feel better and I took the time to watch what she usually does when she tries to latch Korina on. I saw a few things that could be tweaked, explained what adjustments I was going to suggest, explained the reasoning behind it and thank goodness for the first 5 minutes or so Korina was fairly mellow.

Unfortunately, As Cassandra practiced this a few times herself, Korina began to cry and her cries escalated pretty quickly. We worked together for about another 30 minutes with Cassandra stopping whenever she felt she needed to calm Korina down. Korina would either not latch on, or latch on and nt suck, or latch on and give a few sucks and then cry and push off. At the halfway point, she said she wanted to give Korina her milk in a bottle, so I said of course. She fed her about what she would have, before stopping to burp her. I asked her if she would try her at the breast again and she was willing to do so. For the next 10 minutes Korina cried on and off and finally at some point, Korina latched on, began to suck, was a bit fussy, twisty turning, but she kept up the sucking and all of a sudden, I could see that she had a let down and pointed this out to Cassandra, who was making that connection between her milk letting down and baby calming down at breast.

She stayed on that breast until she was done. During this time, I was able to review with Cassandra normal newborn breastfeeding behavior, normal sucking rhythm, tips on how to tell when she was done. There were lots of tears in the room,, this time happy tears.. from Cassandra and her mother,, and yes, some from me too!

Once she was done with one side, it took about 15 minutes of on and off fussiness until she finally latched on and settled into a good rhythm. Cassandra kept stopping and calming, when she felt she needed to. When she finally latched onto the other side, I continued answering all of Cassandras questions and felt that by the time she left this consult, she knew how a good latch was suppose to feel, what it looked like, felt like, how Korina should respond, signs of a good feeding, etc.

I did give my schpiel about how the next feeding, it might be as if Korina had never done this before, but to just keep working at it. Yes, this consult was longer than some, I definitely pushed that envelope more than I would usually like to, but intuitively I felt that Korina was a well fed baby, and could stand a feeding that was not the best, that she cried for more than she was use to. I needed Cassandra to leave this consult with the confidence that they both could do this breastfeeding thing. I di talk about her having her work cut out for her. Korina may take to this quite easily or she might sqwalk a whole bunch, however, I had every confidence that if she was consistently working at it that Korina would pick it up and they would just go on from there.

It took about another week, until Korina was excursively breastfeeding and Cassandra no longer needed to pump and bottlefeed. I wanted to share this story because I know there are many other moms in similar positions. Your struggles with breastfeeding are real. They may not be the same as Cassandras, but they are real and you are frustrated. I want you to know that the first thing that will be helpful is to get together with an IBCLC. have you and your baby have a full evaluation so your IBCLC can figure out what the problem is, where your struggles are stemming from. Then you can work together on solving your challenges. Know that sometimes the fix is easy and quick. Lots of times it is not so quick. Many times the struggle continues after your visit with the IBCLC. But you have a greater understanding of why this is happening and what you need to do to resolve this. You have a care plan and you know that practice and time and consistency will help you get through your challenges.

Learning how to breastfeed takes time and it takes energy and patience and trust in the process. It takes having supportive people around you who will help you in whatever ways they can. Remove the burden of household tasks and help out with baby and diaper changes and rocking and soothing and feeding you, so you can work on breastfeeding. I think mothers do best when they know, that breastfeeding is a learned art for many of us and it takes time, even when babies latch on well from the beginning. There is still a huge learning curve. When we have a hard start, it is that much more filled with worry, concern, or anxiety or frustration. Given the right help and consistency and time, you will be pleasantly surprised as to what you can accomplish.

I will end this show with a quote that may not have had such an impact on you, until you became a mom – No other job requires as much heart and strength as being a mom