Question
I am currently assisting a 38-year old first time mom with an 8-day old term infant. Baby was born in a Baby Friendly hospital facility and weighed 8 lb 3 oz (3712 g). On day 8, infant weighs 8 lb (3627 g).
The inability to lift the tongue to the upper gum ridge and distortion of the tongue tip are two visual indications of tongue-tie.
Answer
Here are the key details from the birth history:
Male infant born after 4 hrs pushing in an unmedicated delivery
Vacuum extractor left a giant cephalohemotoma
Baby developed jaundice (max level 17.2) that has gradually subsided
His tight frenulum was clipped on day 7
Suck evaluation last night revealed slight improvement in his ability to trough and extend his tongue. I still feel the frenulum.
The baby has been finger feeding (FF) successfully w/ a p-syringe. Attempts to transfer directly to breast have failed. Use of a nipple shield with tubing underneath failed as well.
I am wondering if bottle feeding would be an option at this point or if the tincture of time is still indicated. Mom is wonderful and patient and will try anything I suggest.
Additional details:
- Mom’s milk supply is about 2/3 of what baby needs – formula supplementation by FF has been added.
- Mom is double pumping 7 – 8 times/day for 15 min w/ hospt pump getting slightly over 15 oz (425 g) each day.
- Fenugreek has been started #3/ 3x/s / day yesterday.
- Domperidone being considered – info given.
- Skin-to-skin (s/s) is being practiced – she got a sling yesterday.
I’d love info on what to try next.
Karen Evon
Barbara’s Response:
This is a complicated case; one of those train wrecks where a difficult birth and significant birth trauma resulted in levels of jaundice. On top of that, there is a somewhat low milk supply and a tongue tie! All of these issues, in my experience, contribute to lethargic, ineffective feeding.
On day 8 the baby is still under birth weight. The baby is being fed measured amounts of milk. Either the volume being offered is insufficient, or the method of feeding is resulting in the baby not completing feeds. I suspect the baby fatigues and shuts down before taking a full feeding. The infant’s inability to breastfeed indicates he is still recovering from the traumatic effects on motor behavior of the cephalohematoma. I have seen such infants take weeks to recover. Thus, time management issues related to finger feeding become an issue. The baby’s tongue may also be sore from the frenotomy, and the tongue muscle may require strengthening before the baby can breastfeed. Suck and the stamina to sustain effective feeding are impacted in this case by multiple physiological issues.
The law of first things first suggests that feeding the baby for recovery of weight loss has to be the big priority. Until an infant recovers birth weight, my experience tells me he will continue to be a weak feeder. In the case of this baby, he may continue to be a weak feeder for even longer until all the physiological issues resolve. Finger feeding carries the risk of inadequate intake and can be very time consuming for new parents, who are unfamiliar with the skill.
My advice is to help this baby get better milk volumes by switching to a bottle. Because this is likely to be a disorganized baby, pacing techniques are critical so that the bottle flow rate dose not over-whelm him. Explain your rationale to the mom so she views the bottle as simply one more intervention, not an abandonment of breastfeeding. Research suggests that such counseling prevents fixation on the bottle. (Ekstrom A, Widstrom A, Nissen E. Duration of breastfeeding in Swedish primiparous and multiparous women. J Hum Lact 2003; 19(2):172-78.)
The mother is recovering from a traumatic delivery just like the baby. We know increased maternal stress during delivery results in delayed or depressed milk production. If the mom is freed from time consuming (and often inadequate) finger-feeding duties, she may have more time to pump. Given that her milk supply is below where it ought to be on day 8, this makes more sense in terms of time management. Capitalize on calibrating the milk supply with maximum pumping efforts now. If her prolactin levels are low domperidone would help, and fenugreek is unlikely to harm her. As they both recover, it should be possible to back away from the bottle and pumping interventions. In the meantime, skin-to-skin care protects “breast focus” and should facilitate normal breastfeeding once everyone recovers.
As an aside, feeding tubes were invented for use in term, healthy, adopted babies. They are not as useful for weak feeders who can’t suck normally. If you can increase the milk supply, a shield alone would probably be less work and just as effective as a transitioning strategy. Encourage the mom to practice breastfeeding many times every day (with and without the shield). More than anything, this will help rehabilitate the weak tongue. Do provide realistic expectations. Early breastfeeding attempts may be very weak. It often takes several weeks for full recovery in such cases. The good news is that I have seen many similar dyads need interventions such as these. Many of them recovered well and went on to experience happy breastfeeding experiences.
Note to Readers: Kay had a very different response to this case. Her comments point out that different LCs will have different approaches.
Kay’s Response:
As I read Karen’s case, I had a different take on the situation.
Most babies are back to birth weight by 5 to 10 days. We certainly want to see the birth weight re-gained by 14 days. This baby is 3 oz (85 g) below birth weight at 8 days. I am not concerned by that. If the baby is taking in appropriate amounts of milk, the baby should be back to birth weight by 11 days. That is fine. Since Karen has started the baby on supplements, the baby will gain appropriately if offered 20 oz (566 g) over 24 hours. I base this on the fact that an 8 lb baby requires 20 ounces over 24 hours to gain appropriately.
This mother seems to be making ¾ of what her baby needs. She should be able to get her milk volumes up to meet the 20 oz (566 g) target volume within the next 2 days. Power pumping may help. A woman in Philadelphia, whose case impressed many of us here, left her pump equipment set up and easily accessible. Twice a day, she pumped on and off over the course of 1 hour, pumping for 10 minutes, resting, and then pumping for 10 minutes, etc. She doubled her milk production in 2 days.
I also would encourage the woman to hold the baby skin-to-skin many hours each day. She should massage her breasts while pumping and hand express after pumping (Morton J, Hall JY, Wong RJ, et al. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 2009). She needs to nap and to sleep whenever the baby sleeps. Helpers should assist with meals, shopping, cleaning of pump parts, etc.
If finger feeding is going well, I would not discourage it. I have found finger feeding takes no more time than bottle feeding. Babies can take in appropriate amounts so long as appropriate amounts are offered. However, if the mother is the only one doing the feeding, and she is trying to manage pumping, baby care, housework, etc. then she may become over-whelmed. In my experience I have found that parents do not continue to use finger feeding for very long. I have not worked extensively with babies with cephalohemotomas. Therefore, if the baby’s recovery is prolonged, switching to a bottle may make feedings easier. The baby should be carefully observed to see how he does with a bottle.
