Saturday, May 30, 2009

breastfeeding difficulties in the first fortnight

Today I want to reflect on the journeys of two first time mothers and their babies. Although these 'cases' are based on two actual babies and their mothers, the situations are not uncommon, and I hope this account will assist readers in understanding better the complexity and the wonder of the natural processes in nourishing and nurturing newly born babies.

I will call the babies Baby Boy (BB) who weighed about 3.4 kilos, and Baby Girl (BG) who weighed about 4 kilos at birth. Both were born in public hospitals in Melbourne, receiving good midwifery care. Both mothers pushed their babies out under their own steam, so to speak - spontaneous vaginal births. The mother of BG had received an injection of a narcotic a few hours prior to the birth, and the mother of BB received several doses of an oral narcotic after the birth.

Both babies remained skin-to-skin with their mothers for their first hour or so, but neither breast fed in that period. BG's mother was taken to the operating theatre for removal of her placenta, and BB's mother was taken to the operating theatre for repair of a perineal tear. Both babies slept while separated from their mothers.

By 24 hours -
Baby BB had had a couple of brief breast feeds but was still quite sleepy most of the time.
Baby BG had been to the breast several times, without attaching well. She was sucking her lower lip when awake, and seemed content with that.

By 48 hours, second day -
Both mothers and babies had gone home from hospital. Neither of the babies was feeding effectively.

I was in contact with both mothers. I encouraged each to work on learning to express milk by hand, to 'reward' any effort made by her baby with expressed milk, and to give baby as much as she was able to express. This amounted to not much more than a few mililitres. The mother was encouraged to persevere with massaging and expressing her breasts every few hours until her baby's efforts at suckling became strong and effective.

Third day -
Baby BG was checked by hospital midwife. Although she had not yet breastfed effectively, she was receiving about 5 ml of expressed colostrum milk whenever she was awake. Both mother and baby were well. Mother was encouraged to continue, and to give BG access to her breast when ever she was awake.

Baby BB had not woken much, and his mother had kept to the plan of expressing her colostrum every 3-4 hours, and giving him the milk using a syringe or tea spoon. However, that evening the result of BB's serum bilirubin test indicated moderate jaundice, which was at the lower end of the range for which babies of his age are nursed in phototherapy. The hospital nurse called BB's mother, and asked her to bring him to the special care nursery, to be admitted. BB's mother asked if she would be able to stay to continue breastfeeding, and was told 'no'. There was no bed available. The hospital would use any expressed breast milk she provided, as well as artificial formula milk to feed BB while he was in their care.

At the same time, I was visiting BB and his mother. We worked at stimulating little BB, using olive oil to massage him, and co-bathing in the bath tub. We were delighted when he cooperated, and took both breasts better than he had done previously. The mother was not willing to be separated from BB without good reason, and we felt we had turned a corner. With my support the parents made the decision to stay at home, and have BB's jaundice checked again at the hospital the following day.

I had noted that BB was tongue tied, and arranged for the hospital breastfeeding support unit to review that too. BB did a lot of serious breastfeeding overnight, and when his serum bilirubin (jaundice) level was checked the next day he was out of the range requiring admission.

Fourth day -
Baby BG had found the breast, to the delight of her parents. However her mother's nipples were grazed and ridges were forming across the nipple when she nursed. When I visited them I guided mother with a few tips on improving the positioning and attachment - fine tuning the success that they had achieved on their own.

Baby BB also seemed to be progressing well. He and his mother spent the day with the breast feeding support midwife at the hospital. The frenulum (tongue tie) was snipped; the jaundice was settling; the number of wet and pooey nappies increased; and he was settling and sleeping between feeds.

Baby BB's mother was confident to cease expressing milk by about Day 5. However, over the next few days it became clear that his breastfeeding was not as effective as BB needed, as he did not gain any weight from the fourth to the tenth day. He was going to the breast frequently, but often unsettled after feeds. The Maternal and Child health nurse assessed him as dehydrated, considered that the tongue tie was continuing to interfere with BB's sucking, and insisted that he be given baby formula milk supplements. Attempts to express milk by hand and using an electric breast pump resulted in small amounts - about 10 ml.

That evening I visited baby BB and his mother, and once again we devised a plan. This included learning a more effective bi-manual compression of the breast, and regular expressing to stimulate milk production. All expressed milk was given to BB after he had worked at the breast. The record of feeds showed a steady increase in the volume of breastmilk that was given as a supplement to BB.

By about 12 days of age BB's efforts at the breast continue to be supplemented with expressed milk. The tongue tie is to be reviewed by another doctor who is expert in such matters. Mother continues to work consistently on increasing her milk supply. Her beautiful baby boy is responding well: the more milk she gives him, the more he wants.

As I reflect on these real life situations that real mothers and their babies face I am very pleased to record the stories. The issues in getting breastfeeding right are as multi-faceted as any other aspect of life. Each mother-baby pair have their own set of challenges; some expected, and some out of the blue. Each mother-baby pair who manage to overcome their challenges and make the best choices that are available at the time are learning about life and becoming more strongly bonded together. The resulting emotional attachment supports them in dealing with the life challenges that lie ahead.

1 comment:

Stitch Sista said...

Oh dear, I was almost tearing up at the thought there wasn't to be a happy ending here, but fortunately I was wrong.

Gosh I remember those nights with my first born, doggedly determined to feed him, with syringe in hand. It was easy for me to be insistent as I had an abundance of milk! But I also had a small, sleep, jaundiced baby who had trouble making a good attachment.

Anyway, here I am five years and 2 babies later and my poor breasts haven't stopped working in that time - and aren't I so glad I persisted. Feeding my babies has been such a wonderful thing!