Nursing Challenges (Nipple Confusion?)

[@llli*maruchis18]

Hi,

I am (still!!) having a really hard time breastfeeding my daughter who was born prematurely. Here are a few facts about our situation:

- Born at 28.5 weeks
- She is now 4 months old / adjusted age is 6 weeks
- She spent 8 weeks in the NICU and has been home now for 9 weeks
- She is exclusively getting breast milk (always has) - first gavage feedings, then bottles, then I started nursing her here and there while still in the hospital (about 10 days before her discharge) for 10-15 minutes once a day, then topping her off with about an ounce - (NICU nurses said that nursing is more exhausting for her, so I should take it slow and initially only do a few minutes once a day)

When she got home mid-November, she still wouldn't nurse for more than 5-10 minutes and just fall asleep, so I continued topping her off after breastfeeding and mainly offering bottles. I got SO overwhelmed by the whole pumping every 2-3 hours / bottle feeding / nursing schedule, it felt like it was all I was doing, like I would spend my whole maternity leave doing these three things...I contacted a LC who came to our house early December - baby was latching and drinking, but her intake was rather slow (half an ounce in 20 minutes). LC recommended fenugreek and that I only pump every 4-5 hours, so that made it a bit more livable. She said that things were looking good and that may daughter would be able to breastfeed fairly soon. Then things got more difficult: my daughter started squirming and arching her back during feedings (breast and bottle), which made nursing basically impossible and really frustrating (she used to open her mouth and tried to latch, but would push herself away from my breast because she was squirming so much) - so we did mainly bottles. That way, at least I knew she was getting enough (essential when you bring home such a small baby) and also my husband was able to help me out, which was (still is) nice and allows me a break here and there. Because of her squirming, LC suspected reflux - so I cut out all dairy and soy - no improvement over the holidays. I tried nursing her here and there, but the few times she actually did latch she would drink for about 5 minutes and then stop (either falling asleep, not showing any more interest in drinking (even though still hungry) or crying from pain and/or frustration). Also, my in-laws stayed with us over the holidays and of course, everybody always wanted to feed her, so that gave me basically no opportunities to nurse her. After the holidays I called the pediatrician and she prescribed Zantac - no improvement (actually, thing got worse with added symptoms such as vomiting and diarrhea), so I discontinued it. Also, not all the feedings were bad and in between feedings she is the most happy and relaxed baby you can imagine, so I felt bad giving her meds. Now we're not sure if it's really reflux or maybe a milk allergy, so I am still not eating any dairy/soy and will probably start her on Nat Phos 6x (waiting to hear back re: dose). But actually, since I discontinued the Zantac, she has had one or two really painful feedings and ever since then she's mainly eating nicely (from the bottle, that is). Since things have gotten a bit better, I started nursing her again, but still the same behavior: sometimes latches nicely and drinks for 5-10 minutes, then 1) falls asleep, 2) doesn't want to latch again even though when I put her down she starts crying (=still hungry) or 3) gets frustrated and squirms. Sometimes I try to nurse her during a whole hour - she latches and drinks, then looses her latch and just sleeps in my arms, I try to get her interested again, after about 15 minutes she might latch again, drink another 5 minutes, etc. That way, we get to about 25 minutes of drinking in about one hour. Not ideal and not fun for neither of us. I read that babies can develop a breast aversion if you push them too much, so because I obviously want to avoid that, I usually give up and give her a bottle. It also makes me sad to see my otherwise so happy baby cry and fuss at my breast, but then with the bottle she drinks nicely, is done in 10 minutes and gets some time to play or cuddle with me.

After all this, finally my questions:

1) Does my daughter have what you call nipple confusion? If so, what can I do to "treat" her?
2) If it's not nipple confusion, what could be the problem?
3) After all this time, is it still worth trying to breastfeed or is it too late at this point? I have to add: My leave is over in 3 weeks, so she'll be getting more than 50% of her feedings by bottle anyways. I also only pump about 4 times a day which really isn't so bad anymore, but I would love to breastfeed because of the unique experience for the both of us.
4) Did I give up to soon, too fast? Should I have insisted more, despite the crying and fussing and frustration (on both ends)? I try to think that as long as she is getting breast milk, no matter how, it's fine and she's getting the benefits a breastfed baby gets, without the bonding and skin-to-skin with me, but at least she gets to bond with her daddy when he feeds her. And since pumping isn't such a struggle and time commitment anymore, is it really such a big deal? Is the romantic idea of me breastfeeding my baby really worth putting her through that ordeal? What do you think?

I know this post is really long, but I feel like I just had to get it out (today was a particularly frustrating day for me). I also think that, in order to give advice, whoever reads this and wants to help should have as much information as possible. So, thank you for reading it all and for any advice, suggestion or just kind word!!

[@llli*maddieb]

You only pump 4 times a day- but your baby is fed only your milk? How much milk do you get when pumping each day, and how much is baby eating? you may need to increase that pumping frequency...

Only you can decide if it is "worth" trying to breastfeed at this point. There are moms who adopted children well past this age- as one and two year olds - and worked very hard to establish a nursing relationship. Obviously they think it is worth it. And there are moms who prefer to pump and have their child be bottle fed from day one, and do so even when their child could and would nurse just fine. Obviously, they do not see nursing at the breast as all that important. That is the spectrum, so you can think about where you might fall in there. LLL as an organization certainly believes that the benefits of nursing at the breast are proven, but that does not mean you have to share that belief. Certainly the health benefits of your child getting your milk are immense on their own.

What is nipple confusion? No one really knows. You can read 10 different experts and get 10 different ideas about this. They are all probably right to some degree. What is known is that the more and longer a child gets food via something besides at the breast, the more likely it is the child will begin to refuse to nurse, or in the case that baby never nursed, the more difficult it is that the child will nurse.

But 4 months is not "too old" to get a child to nurse. Not at all. And while you may not think the sessions are going the way they should (I might disagree a bit there) at the very least your child WILL latch and nurse- at this point, you are not dealing with a child who never nursed or is having any breast aversion. These are very good signs. And the fact baby is exclusively fed your breastmilk and doing well makes you and your baby very strong contenders for getting baby nursing normally.

Here is what I suggest.
Take a longer leave if you can. Even one or two more weeks more would help- or consider going back to work part time at first. If that is not possible, make the most of the next 3 weeks.

so she'll be getting more than 50% of her feedings by bottle anyways

Why? will you be really be separated 50% of the time? Remember a normally nursing child of this age will nurse overnight, and of course weekends/days off can be all nursing. No bottles.


Did you like your LC? Can you see her again? Since things change frequently in these situations, it is really important to keep getting things tweaked as needed.
Keep (or continue to keep) a feeding diary. Note:
How much baby is getting in bottles, (per session and per day) and
Note every nursing session with approximate length of entire session. No need to break it up, if baby nurses 20 minutes total from 1 to 2 pm, note it that way, or whatever way makes sense to you.
Also figure out a way to accurately check weight gain about once a week. This means a very accurate scale, same scale every time, baby naked.

OK, so here is the hard part. In order to see if you can wean baby off supplements, you need to start weaning baby off supplements. You have to take a leap of faith here. Not a huge one, teeny tiny jumps at a time. But assuming gain is in good shape now, it is important to start reducing what baby gets in bottles, to see if baby is able to nurse well enough to transfer milk.
Because a baby is not going to want lots more milk than baby needs. One of the reasons baby might be nursing so ineffectually is because baby does not really need to nurse to get enough to eat. Baby is getting enough in bottles and is just not all that hungry. See what I mean?
I am not suggesting "starving" your baby into nursing. That is not going to work even if it were safe, and it isn't. But gradually decreasing the amount baby gets in supplements, ounce by ounce, while watching weight gain, is not going to starve any baby. But it may well increase baby's desire to nurse better.

As far as this:

sometimes latches nicely and drinks for 5-10 minutes, then 1) falls asleep, 2) doesn't want to latch again even though when I put her down she starts crying (=still hungry) or 3) gets frustrated and squirms. Sometimes I try to nurse her during a whole hour - she latches and drinks, then looses her latch and just sleeps in my arms, I try to get her interested again, after about 15 minutes she might latch again, drink another 5 minutes, etc. That way, we get to about 25 minutes of drinking in about one hour. Not ideal and not fun for neither of us.

It may not be fun, but this is just how nursing goes with young babies. (and some not so young babies, in fact this is how lots of entirely normally nursing 4 month olds nurse- very distracted and fussily) However, I think this is more due to your baby's prematurity and lack of practice than actual age. Some disorganization like this is 100% normal, in other words, and does not mean the baby cannot nurse well enough to get enough milk.

My other suggestion is to stop worrying about reflux, allergies, etc. at least for the time being. If baby is gaining normally, even if this is going on, it is not severe. I do not think those are likely since appropriate 'treatment' has not helped anyway. Instead, I suggest:
Hold baby most of the time, head above tummy, snuggled between your breasts. Do this either skin to skin or with very easy access so that whenever baby cues, baby can immediately nurse. Any time baby nurses is a win, it does not matter if it is 3 seconds. That is ok. If you are pumping or napping and cannot hold baby, have someone else hold baby this way. Skin to skin if they are comfortable doing so. Especially after feedings, hold baby in this position for at least 30-45 minutes.
Consider reducing the amount baby gets in each bottle, but feed baby more often. (if needed-it may not be needed if baby is nursing more.) Large feedings stress digestion, and many babies overeat when getting bottles.

Stop worrying about what you should have or could have done, and focus your energies on what you want to do now and what you can do now.

Protocol for weaning off supplements. Note this is weaning off formula supplements. If you are pumping enough for your baby each day, that is different. Weaning off formula is harder to do. But you can still use this as a conservative guideline. http://kellymom.com/ages/newborn/nb-...rease-formula/

[@llli*malwith2]

hey there,

I am having a very similar situation so instead of giving advice I'm just going to tell you what I am doing (as of today).

General details *31 weeker (now 14 weeks actual), 5 weeks in NICU, came home on a bottle, latched on boob if milk was flowing, fussy when it wasn't. I have plenty of milk and breastfed my 20 month old for 14 months with no problems.

For the last 14 weeks I have been pumping while trying to feed her a couple times a day. Every lactation consultant told me that she just needed time and at around 11 weeks old (2 weeks past due date) they finally referred me to an occupational therapist that could see that she was having suck issues and needed some exercises. Keeping in mind that I've been an emotional wreck since day 1, the mouth exercises gave me the extra push I needed to keep me pumping a few more weeks. Day in and day out her suck was not getting better and so continued our constant struggle of breastfeeding, crying, bottle feeding, frustration, guilt....

All i want to do is breastfeed this tiny little girl and give her the experience that my son and I had and yet each say the struggle seems more and more desperate. Finally today I met with her pediatrician. He could see the tears in my eyes when I told him she was still taking only the bottle. He told me that breastfeeding is just ONE part of raising a healthy baby and that I was clearly giving her everything she needed to thrive in other ways. He believed that 90% of breastfeeding benefits would be lost if it was a negative experience. After all, the bonding that I so longed for in breastfeeding turned into a traumatizing experience as I too watched her calm down with every bottle feed.

In the end, I've decided that today I will give up the dream of breastfeeding and move on to bonding with her in other ways. I will have to hold my head high when I'm bottle feeding in public, knowing perfectly well that some mothers might judge me (as I may even have judged) not knowing how hard I tried. Not knowing that I pumped for months, had endless lactation appointments, occupational therapy appointments, did mouth exercises every feeds, and cried with my baby as she tried and failed to suck on my nipple. I wish there was more support for mothers who's babies just can't breastfeed effectively, whether the reasons be biological or environmental (bottle feeding in the NICU, etc). It is an insanely hard decision to make but in the end do what's best for your baby, yourself and the bond that you share.

[@llli*maruchis18]

@maddieb:

Thank you so much for answering so promptly. Here are answers to your questions and some more information:

- My LC said that at this point my supply is well established and that pumping every 6 hours should be sufficient - I am doing this since mid-December and my supply has not decreased. I pump during 30 minutes each session and I get about 6.5 ounces a session (=about 25 ounces a day) and my daughter drinks just about this much. Doing this, my daily routine has become much easier and relaxed, which I believe is also important for adequate milk supply.

- I absolutely think it is worth to breastfeed my baby at the breast, I wouldn't have tried for 9 weeks and wouldn't still be trying and seeking help and support if not. I am just wondering if it's worth it under these circumstances (=baby upset / frustrated / crying sometimes when I try to nurse her).

- A longer leave or part time work is not an option - unfortunately. I would love to stay home with my baby a little longer.

- Initially I liked my LC, but when I called her for more advice about a week ago she didn't really offer her support at all anymore. She simply said that she couldn't tell me any more than she had back in December and that if we hadn't made much progress, it would be less likely by now that my daughter would successfully breastfeed in the future. I felt disappointed and left alone. i am going to reach out to another LC to come to our house hopefully this week.

- Weaning baby off supplements: I try to wait until she is hungry and then offer her my breast. If she doesn't latch at all or just for a really short time and then not anymore even after a few attempts, I give her a bottle. If she latches and drinks for longer, I then put her down to see how long she is satisfied and when she starts asking for more food again. If nursing turns out to be too complicated/frustrating, I tend to give her a bottle, because I am not comfortable leaving her without food for too long, but maybe that's what I will have to do. I keep an exact diary of how much she drinks when by bottle or at the breast. I am also getting a scale so I can weigh her after breastfeeding as well as once a day to assure weight gain.

Hopefully with a new LC helping us and having our own scale at home, we can get things going again and feel a bit more relaxed about it. I am confident that in the next 2.5 weeks until I go back to work, we can get baby to nurse efficiently and empty my breasts so I don't have to pump when I'm with her.


@malwith2:

Thanks so much for sharing your experience, and I am sorry that you had to go through all this.

He believed that 90% of breastfeeding benefits would be lost if it was a negative experience.

That's exactly what I mean by asking if it's worth pushing the issue and getting my daughter to breastfeed no matter what. We have a nice and beautiful relationship and she clearly feels comfortable with me, calms down when I hold her, smiles at me in the morning, etc. I think by focusing too much on breastfeeding, I might miss these moments and everything that is going so well.

I wish you and your baby girl all the best, and hopefully, now that you made your decision and are not trying any longer, you get to fully enjoy your little girl and focus on all the beautiful moments that you two have together!!

[@llli*maddieb]

My LC said that at this point my supply is well established and that pumping every 6 hours should be sufficient - I am doing this since mid-December and my supply has not decreased. I pump during 30 minutes each session and I get about 6.5 ounces a session (=about 25 ounces a day) and my daughter drinks just about this much. Doing this, my daily routine has become much easier and relaxed, which I believe is also important for adequate milk supply.

Ok, it is true that once milk production is established, many moms can reduce pumping from 8 to 10 times a day to 6 or 7. But I thought you said you pump 4 times a day, not 6? 4 might be fine of course, if baby is nursing well at least 2 or 3 a day as well...I think I was under the impression you are EPIng at this point so maybe I had that incorrect. Overall, The problem with reducing pumping frequency is that the adverse effect would not be immediate...milk production takes time to both increase and to decrease. So, you just want to keep an eye on that and increase pumping frequency if needed.

I am just wondering if it's worth it under these circumstances (=baby upset / frustrated / crying sometimes when I try to nurse her).

Ok, so you are wondering if the experience of trying to nurse is overly upsetting to your baby?
This is a hard one to say. Many of us who have struggled through breastfeeding issues have had to face a baby who seemed to be upset by our attempts to nurse them. It is confusing! I guess I would suggest that what is upsetting baby is not you or your breast, but that the situation is one where baby has been trained to eat differently than they otherwise would have, and baby is confused in the sense that baby is not sure what to do with the breast at this point. This can be counteracted, of course, but it can be a bit of a struggle. Jack Newman's thoughts about nipple confusion might be helpful to you here.

- Initially I liked my LC, but when I called her for more advice about a week ago she didn't really offer her support at all anymore. She simply said that she couldn't tell me any more than she had back in December and that if we hadn't made much progress, it would be less likely by now that my daughter would successfully breastfeed in the future. I felt disappointed and left alone.

That is too bad. At some point, I would suggest telling this LC how this conversation made you feel, in a letter or e-mail if you cannot do it verbally. This would be valuable feedback for her.

i am going to reach out to another LC to come to our house hopefully this week

Good.

Weaning baby off supplements: I try to wait until she is hungry and then offer her my breast. If she doesn't latch at all or just for a really short time and then not anymore even after a few attempts, I give her a bottle. If she latches and drinks for longer, I then put her down to see how long she is satisfied and when she starts asking for more food again. If nursing turns out to be too complicated/frustrating, I tend to give her a bottle, because I am not comfortable leaving her without food for too long, but maybe that's what I will have to do. I keep an exact diary of how much she drinks when by bottle or at the breast. I am also getting a scale so I can weigh her after breastfeeding as well as once a day to assure weight gain.

I would suggest do not wait until baby is hungry to offer to nurse. Try holding baby much of the time, skin to skin if you are comfortable, but just with easy access if not. Offer the breast whenever you like. Try instant reward techniques as explained in the linked kellymom article below. When encouraging a baby to nurse more or to nurse "better", often a calmer baby (non-hungry) latches better. Also, when trying to bring baby back to the breast, "comfort" nursing may come first.

I would also suggest, do not lay baby down to see how long baby goes without cueing as a test of whether baby got enough to eat. Babies expect to be held most of the time and require lots of comforting, and will cue and cry because they want to be held and comforted, and (hopefully) will root and seek the breast, not necessarily because they did not get enough to eat but because they are seeking to nurse for comfort. Using the scale should help you be sure baby is getting enough to eat, just don't let weight checks overtake your life or upset you. It is normal for baby to eat less at some nursing sessions than others, eat more some days than others, and weight gain is not typically steady.

Hopefully with a new LC helping us and having our own scale at home, we can get things going again and feel a bit more relaxed about it. I am confident that in the next 2.5 weeks until I go back to work, we can get baby to nurse efficiently and empty my breasts so I don't have to pump when I'm with her.

Great!

"Help, my baby won't nurse" - http://kellymom.com/ages/newborn/nb-...ack-to-breast/

[@llli*maruchis18]

Thanks a lot for all your helpful advice!

It is correct that I only pump 4 times a day - every 6 hours in a 24 hour period = 4 times. I keep track of how much I get each pumping session and write it down. Milk production has actually increased over the past week or so (abut 28 ounces). It is also correct that I am EPing at this point - we do get a few successful nursing sessions (~15 minutes) here and there, but not regularly and she definitely doesn't empty my breasts yet.

I guess I know that my baby is not rejecting me or my breast, but it can still be frustrating at times. Especially when I can see that she is opening her mouth and trying to latch, but for some reason doesn't get a good latch. I don't exactly know why this happens, but I have started using my nipple shield again (I didn't use it so much in the past few weeks because with my first LC, we noticed that baby actually transferred less milk than without the shield), and it makes it much easier for her. The only thing is I don't know how efficiently she actually nurses with the shield. Lately, she has done more comfort sucking at my breast, but you said that that's normal, so I am hoping it will slowly slowly bring her to actual drinking.

I got the scale to do weight checks before and after nursing sessions to get an idea of the intake. I find it really hard to know if she got enough and I wonder sometimes: how will I ever know...?

Tomorrow, my new LC will come to our house - I am hopeful that she will be able to help us.