I need some fairly expert advice on attachment issues, nipple refusal and subsequent supply problems.

[Olihan]

I think this may need someone with Tiktok's level of knowledge and experience but if anyone has any experience that could help I'd be grateful!

My Dsis has an 8 week old dd and has had major bf issues from birth. She was born by EmCS after a 54 hour labour, baby was stargazing and Dsis had every type of pain relief going. As a result both mum and baby were fairly out of it for 24 hours or so after birth.

Dsis had initial problems as her dd wouldn't latch on for more than a coupple of seconds. She saw a (supposed) bfc who worked on the PN ward who put her on nipple shields on Day 2 to help her latch but failed to mention that she shouldn't use them for more than a couple of days. Dsis went home on Day 6 still using the shields and whenever she tried to feed without them her dd refused to latch on.

When her dd was weighed on Day 10 she'd gone from birthweight of 7lbs 15oz to 6lbs 13oz but no one was overly worried as her milk hadn't come in until Day 5/6. However, she was still having no luck feeding without shields. By Day 16 she was up to 7lbs 7oz so it didn't appear to be a problem.

Since then though, she has had major weight gain issues - by week 6 she was still only 7lbs 9oz (that really is 2oz in 4 weeks) and her dd becomes absolutely hysterical if she tries to latch her on to a naked nipple. She was also feeding constantly, wouldn't be put down, was permanently unsettled, didn't sleep, etc, etc.

Dsis has been in touch with an NCT bfc who has been to see her, she's also just spent a fortnight with our step mum who is a retired mw. While she was with her they worked on increasing her supply by feeding at least every 3 hours using both breasts, expressing off both breasts for an hour after every feed, topping up with the expressed milk (using a syringe). After a week of that her dd had only gained 2 oz so she started topping her up with formula.

She's now cup feeding her with 1 - 1.5oz of formula after each feed and her dd is up to 8lbs 8oz. She's also continuing the expressing and bm top ups.

Obviously, this isn't sustainable and she is desperate to get her off the nipple shields and feeding properly but she is completely at a loss as to how to do it.

She's tried breastcrawl and her dd can get to the nipple but appears to have no idea what to do with it when she gets there. She's tried going cold turkey but her dd just becomes completely hysterical, our step mum managed to get her to latch on a couple of times using the old fashioned 'hold head, hold baby and force them together' but dsis can not do it by herself.

The bfc also helped her to latch her on for a couple of seconds but her dd would only stay attached for a couple of seconds.

So, where does she go now? Does any one have any tips on helping a baby to latch on? I suspect that her dd just doesn't know what a nipple feels like because she was on the shields from such an early point so how do we encourage her to recognise it as 'food' rather than the plastic?

Any advice would be so gratefully received, she is desperate not to have to fully ff but it seems inevitable if she can't get her off the shields.

You say she is expressing after each feed. So why is she topping up with formula and not ebm, since it is available?

I suggest lots of skin to skin contact without introducing the nipple, but maintain supply by expressing. Is she using an electric breastpump?

Am I right to assume she has ff by bottle rather than cup or other method?

She tops up with the ebm first, then the formula as her dd still wasn't gaining weight with just ebm top ups.

She's still expressing after each feed to keep supply up.

So far she hasn't introduced a bottle at all. All the top ups are via cup or syringe. I told her to avoid a bottle because of the nipple/nipple shield confusion - I didn't want to make it worse.

She's tried baby mooning, just letting her dd lie on her chest, etc, but her dd just doesn't seem to know what to do with a bare nipple.

Sorry, forgot to say she's using a double electric pump (Ameda Lactaline) to express with.

I've heard of people having success with the following -make the hole in the shield bigger with scissors - let babbe get used to it, then cut a sliver off the end of the shield so that the nipple is exposed at the end of it -let babe get used to it ,cut a slice more off, and so on untilthe whole end of the shield is off and by then babe should be used to the different feel of the nipple as opposed to the silicone. maybe combine it with taking to her bed for a day when ready to do without the shield to really give babe an intensive course in latching on - If poss I'd give up the formula top ups as well, just use EBM to make it a less complex situation

Thanks jamila, that sounds like a good plan to be starting with. Her latch is good with the shields, i just don't think she associates the feeling of skin with food. So a slowly, slowly approach may be good.

urgghh - I had to use one of them to give DD2 extra, i gave it up and got an avent pump as it really did not work for me -has dSis got larger or smaller nipples than usual? I found that the electric pump just pulled my nipples into the funnel rather than getting anything like a decent amount of milk out (30 minutes for 30ml IIRC) where straight away with the Isis I was getting 200 ml within 10 minutes

last message was about the pump Oli!

She started on the Isis but can barely get anything out of it, she borrowed a Medela Swing while she was with my step mum but couldn't get much with that either. She gets most out with the Ameda so far, and it's less time consuming .

Funny how different pumps work differently on different people, considering they all do pretty much the same thing.

S'ok, I realised!

Agree good plan to avoid using bottle.

My heart sank when I heard a retired mw was helping. sorry. Sure your stepmum only has baby's interests at heart but training of many mws, esp those of a generation ago, means that they are far more likely to set too much store by measuring. 2 oz gain in a week at that stage is no reason to panic and offer formula - if there is no other reason to suggest baby not getting enough eg signs of dehydration.

The breast refusal is another problem and needs patience and perseverence. Jamila's suggestions sound worth a try.

Message withdrawn

TBH, it wasn't my stepmum who suggested it. The HV had been putting pressure on, weighing every week , telling her she had to top up from about week 3 when she hadn't gained. Before DSis went away the HV ordered her to top up with 3oz formula, 3 times a day and said her dd had to have gained a lb in the fortnight she was away. Dsis just felt that she had no option. If I lived nearer I'd be fighting with her HV but I'm 150 miles away with 3 dcs of my own so it's hard.

AFAIK, there's no issue with dehydration and the baby was a lot more settled after they'd started the EBM top ups and expressing, so I'm guessing her supply did increase a bit. Bloody HV. Do you think it would be better to drop some of the formula top ups and see what happens?

Rather disloyally, I share your reservations about my stepmum's help. There were a few things that my dsis said they were doing that rang alarm bells for me but it's hard for me to correct her when I have no training at all (apart from MN!), even though I know what she's saying is wrong. Unfortunately, the holiday was booked before dsis was even pg (dsm lives in Singapore, it's an annual visit) and the bf issues were all too obvious.

Speaking a someone who used shields, the cutting thing is unlikely to work. It will create a jagged edge that a babe will not latch on to. Also, it is unlikely that the nipple with be near the end of the shield as the shield are quite big by comparison.

I use shields for 4-5 months absolutely fine, but then I had no supply issues - in fact I had oversupply. If she is using silicone shields (best are NUK/MAMS, then Avent) then they are very thin, so shouldn;t be having too much impact on her supply. Could there be another reason baby isn't gaining weight well?

As for weaning off shields, she could try feeding moving around (yes it can work!), but is tricky, or using the pump or a suction device to make the nipple as big as possible to mimic the size of the shield.

Do keep supporting her, but I have to say, long term use of shields is possible, even if every bfc I have met has been against them. I would be feeding with the shields as much as possible as this will get more milk than cup/spoon feeding, and then worry about the sheild issue.

X-posts, DA. That's possibly the best justication EVER for eating chocolate - I will be sure to tell her!

Oh, I was going to ask if those MOre Milk supplements or even Domperidone were worth a try or if it would be better to use them after she's got rid of the shields?

Have to get to bed so excuse brevity

• please - no cutting of shields. This is not safe or effective - could harm the baby's mouth

• she has had crap support at the beginning - when the dust settles, she needs to write and tell them

she needs to see someone in real life who knows what's what....the three hourly feeding was probably not enough as a plan to increase milk supply even with the expressing and giving of ebm with a syringe (what a palaver....) and I think the whole thing sounds a mess* now, what with the formula and the bossy HV

• if she is giving formula 3 x a day amd 3 oz at a time then she will not make enough breastmilk - just the maths tells you that, as the baby is taking in too much formula to leave room to stimulate the breastmilk. But simply cutting down/dropping the formula needs to be done with support and knowledgeable support

Sorry it's brief and brusque!

i don't think the supplements would work until she had more normal levels of stimulation , by then she probably wouldn't need them.BTW i shared the cutting of the shields (neatly) from a midwifery forum I'm a member of , it was used as a desperate last resort in a case very similar to your dsis !

Agree with you tiktok, its totally FUBAR

Lister, the only issue anyone can point to about the supply seems to be the shields. I think the reason most bfcs are against them is because they hinder the stimulation of the breasts and subsequently the supply/demand cycle is compromised. The expressing after every feed is definitely increasing her supply and the ebm top ups are helping to settle her dd more that just a bf does which is why it appears to be the shields that are the issue. If she just feeds then her dd will literally be feeding all day and only seems to take the edge off her hunger, rather than seeming full and satisfied, which she is after an eBM top up.

Elasticwoman, a quick question. Should breasts feel very full and painful in between feeds, DSM was telling Dsis that she ought to feel very full, almost painful, when her dd is due a feed, which seems wrong to me as I thought having very full breasts will send a signal to make less milk over time. Or am I getting my supply facts mixed up?

If they are full and painful, then it's a sign that she needs to feed ,however you may have hit on something there, it could be nothing to do with the shields as such -she may have a very forceful letdown, which the shields are calming down a bit and the cupfeeding gets around that one as well . that would also fit with the baby fighting the breast and seeming unsatisfied -maybe it's more to do with bellyache than hunger iyswim - Kelly mom might have something on that -I'll have a look here it is overactive letdown

Thanks Tiktok.

I won't mention the cutting down of the shield then .

I'm composing a letter in my head for her already! I am beyond furious that a woman employed for the sole purpose of helping mums to bf can f*$k it up so royally for her.

How often does she ideally need to be feeding? I told her to just feed as often as her dd wanted to, but dsm is of the schooling that you should feed 3 hourly. I did check that they weren't holding the baby off feeding until the 3 hours were up but dsis assured me she wasn't.

WRT top ups. I told her in no uncertain terms NOT to top up like that, so she's giving about 1 - 1.5oz after each daytime feed. So she's only giving about 8oz maximum a day. I thought (possibly wrongly) it would be less detrimental to supply and be easier to cut down if it was only a tiny amount each time. Is that right?

Would it be possible to cut out the formula top ups entirely, top up with the ebm and feed/express more regularly? Her dd will not settle on direct bfs alone, so some topping up seems inevitable until the shields are gone.

The only NCT counsellor in her area works full time so hands on support is limited, unfortunately.

X-posts again, jamila. I don't think, from what she says that she ever feels full or painful. She's worrying that that means her supply is poor, but I don't know if that is a reliable indicator or not.

I really, really, want to help her, I've failed to bf 2 of my dcs and I don't want her to feel like me, especially as she already feels down about the birth too .

BLOODY bfing woman at the hospital, I could swing for her .

Got to go to bed now but any more help would be much appreciated, thanks!

Here y'are Oli
Kellymom on nipple shields

Thank you, will forward her that link.

Olihan, full, uncomfortable breasts mean she needs to feed, for sure, and if she often has full, uncomfortable breasts then she could be i) over producing or ii) on the way to making less milk (or a combo of both - though some women who o/p continue with this uncomf. fullness for ages and ages, making 'less' milk but still more than their baby needs).It can also mean iii) the baby is not removing milk effectively.

No one should ever feed to a schedule - 3 hourly (or 7-8 times in 24 hours) is often not enough - and it's certainly not enough to build up a dodgy supply. She can move towards a schedule when she is confident all is well. If step mum is saying anything about needing the gap to replace the milk, then she is showing she doesn't know as much as she thinks she knows.

Honestly, the best 'remedy' is the simplest - skin to skin, all day/night close contact when baby is asleep as well as awake, quick response to feeding cues, frequent use of both breasts. Getting rid of the shields is less of a priority at the moment if the baby really does not feed and gets upset without them - though medium to long term, yes, she needs to get rid, as I suspect this is what lies behind the slow weight gain. OTOH, is she latching with the shield well enough to get milk through it....if not, and she is coasting with the top ups of formula and ebm and not really bf, then the shields are more of a priority. She needs to get someone to watch her feed - there are more people around than NCT and she may be in an area where NCT is not the only show in town. The counsellor, working or not, may still be able to come to see her if she is persuaded she needs to.