Thursday, March 15, 2007

Fear in the NICU

Image from Feebleminds

The day shift nurse is new. She doesn't know me and apparently doesn't listen much to gossip, so she was puzzled when I laughed at her question: "Do you mind helping breastfeeding moms?"

While I was trying to come up with an answer that wasn't sarcastic, she went on, "I can get L to help you if you're not comfortable with it." By this time, L was trying not to snicker too. She knows my reputation. She's watched me work. We both assured the day shift nurse that I could handle it.

They give me the hard cases - the ones where you simply cannot laugh while there are visitors in the NICU; the moms who need 3 people to get one baby latched and who bring ALL their visitors over to watch while they do it. I love taking care of the tiniest, most critical babies, but I enjoy the challenge of helping new moms learn to breastfeed too.

A NICU admission, even of a term baby, can create truly challenging circumstances for learning to breastfeed. That's especially true if mom lacks experience, has flat or inverted nipples, damage to one or both nipples prior to the NICU admission due to the baby's nursing style which in this case was Great White Shark.

Some babies have difficulty latching because the suck isn't strong enough. Others have such a strong suck that if they aren't latched perfectly, they can damage a new mom's nipples in a relatively short time. The hungrier and more frantic the baby, and the more inexperienced the mom, the greater the potential for damage. Issue mom a breast pump with inadequate instruction and you have a setup to absolutely sabotage breastfeeding.

Round 1:

Enter the Nipple Nazi: I'm usually not, but this case required extreme measures. The day shift nurse had phoned the mom while I was getting report on my other patient. She asked her to PUMP before coming to the NICU. Mom arrived with nipples tender from pumping, about 6 ml of colostrum in a bottle, and an entourage. I like to have mom's support person around when I'm helping a new mom learn to breastfeed, because I've found that the support person (often the baby's father) is able to quickly learn how to assist in positioning and evaluating the latch. Adding an audience tends to distract the mom and her partner and to add confusion. Especially when the audience wants to help. Double that when they have very little idea what they're talking about. At least this entourage was very pro-breastfeeding.

Step 1: Make the mom as comfortable as possible. Comfortable chair, check; footstool, check; screens, "No thank you, it's too hot in here." Mom strips to the waist. Uh-oh. Potential problem. Not for me, I've certainly seen enough breasts not to develop twitch when I see one, but there was another dad in the room and many of our ancillary personnel (housekeeping, laundry, etc) come through in the evening and they're not all comfortable with that much exposure. Fortunately, L heard the exchange and set up screens to give the other dad some privacy so he could pay attention to his own child instead of the performance across the room. Unfortunately, the screens weren't placed to do much for the gentleman from the laundry who entered the room eyes averted and one hand blocking out the view.

Step 2: Evaluate mom's technique: She requested (and was given) a syringe to feed the colostrum. She was concerned about nipple confusion, but apparently missed the point that ANYTHING which encourages the baby to suckle incorrectly will contribute. Give me a bottle any day over an incorrectly used syringe, finger, spoon, cup, etc.

Step 3: Try to get the baby to latch. 6ml of colostrum just wasn't taking the edge off the baby's hunger and every time the baby got close to the breast she lunged. And mom cringed and pulled away - making her nipples even more tender. The lactation consultant had been in earlier and left 2 different styles of nipple shields, so we tried those. And I spent a LOT of time repeating "Don't pull the nipple out, put your finger in the corner of the baby's mouth to break the suction."

Nipple shields can be helpful, but when the challenges include a tendency not to open the mouth wide enough, an incorrectly used nipple shield can make this much worse. We were eventually able to get the baby to latch and nurse on one side with the nipple shield. There was a lot of off and on behavior, though. Between the nipple shield, the fight to get a good latch, and the slow flow from the recent pumping, baby was getting more and more frustrated.

So we switched and the baby had a total meltdown. It was Shark Attack in the NICU on side 2. The baby lunged, missed the nipple and latched above it. This is quite painful and mom was becoming more anxious by the minute. Baby lunged, hitting closer to the target this time, but with her mouth not wide enough, so that she only got the tip of the nipple. Mom shrieked and pulled away, causing even more pain.

I showed her how to soothe the baby with a finger, making baby open WIDE before allowing her to suckle. By this time, mom was so gun-shy, she seriously asked if the baby wouldn't be satisfied with what she'd gotten so far and the finger.

Grandpa chimed in at this point, "She wants steak"

I had to laugh and responded, "Yes, and she's trying to get it from mom."

Mom looked at me and asked, "Don't you have some kind of nippley thing you can use to give her some formula?"

I said, "Yes, it's called a bottle."

Mom: "We didn't want to use bottles."

Me: "I don't want to give her a whole feeding, just give her enough to take the edge off so she stops acting like a shark."

Mom: Laughing (finally), "OK. Let's try that."

Out comes the orthodontic nipple and the formula. I take the baby and let her suck about 4 times, making sure that her mouth opens wide before I pop it in and making sure that her lips are turned out, not in. The baby relaxes and we're finally able to get her latched comfortably on side 2.

Baby sleeps for 4 hours. Hopefully so does mom.

Round 2

Baby is alert and rooting, but not crying. This is the point at which the NICU admission becomes a real problem. I call mom and 35 minutes later she makes her way to the NICU. By this time, baby is SCREAMING and frantic. Mom didn't pump before she came this time, but she had pumped after leaving the last time and her sore nipple is now cracked and bruised.

I ask mom's permission and we start with colostrum and 5 ml of formula by NUK again. Baby immediately latches strongly but not painfully on mom's less sore breast. We have a very long chat about breast pump use and how this is only about nipple stimulation and NOT a contest to see how much colostrum she can extract. I explain that "It didn't hurt that much" is NOT the goal and "It didn't hurt at all" is the only acceptable goal, so don't turn the vacuum up so high this time. Mom isn't able to offer the sore side at all at this feeding and baby isn't satisfied after nursing 20+ minutes on the available side, so we give 10 ml more of formula and tuck baby in. She sleeps for 3 hours. Mom pumps the sore side and sends 5 ml colostrum back with dad for later use.

Round 3

NICU interference again: Morning blood work gets baby totally frazzled so we need to use the bottle trick to soothe her, but this time she doesn't take more than 2-3 ml before she's calm enough to latch. 20 minutes on the not sore side and mom is off to pump the damaged side. Baby is satisfied with the 5 ml colostrum from the last pumping and the 20 minutes of nursing. She's still sleeping 1 1/2 hours later when I go home.

I have no idea why, but I also have a reputation of being "nice". Totally undeserved, really. Before the day shift arrives, I slip out to the nurses' station to talk to the day charge nurse. I make sure that our orientee has my assignment. I leave to the preceptor's sincere "Gee thanks!"

It's not so bad as all that, really. The lactation consultant will be available and mom should have all her visitors around to help too.


Student Nurse Nancy said...

Sigh...if only you were around when I had my babies. My poor nipples went through hell to breastfeed my first. He was a pull back and chomp his way back up the nipple kind of nurser. The second baby practically choked with each let down. Football hold and all. By the time #'s 3 and 4 came along, I gave up.

So glad you're out there helping the new moms.

Lilly White said...

Both of my big fat babies were savage eaters. They pulled their heads back and didn't maintain a latch for more than a few seconds. I didn't last with either for more than a few weeks. Thankfully they both thrived and and had zero issues with formula. I was so afraid of illness, earaches, allergies... and all the other bad things you hear of. Thankfully they turned out bright, healthy, and strong.

Medblog Addict said...

Thanks for stopping by and leaving a comment. I loved your “dirty socks” story. I have been enjoying your blog and will definitely come back and check out your archives.

Judy said...

Student Nurse Nancy,
I'm sorry you didn't get better help with breastfeeding. It can be hard work for the first few weeks. I worry about new moms who go home to a family who isn't keen on the idea of breastfeeding and who don't know about resources like LaLeche League. Lactation consultants are more widely available now than they used to be, but until WIC starts subsidizing them, the moms who can least afford them won't have access.

Judy said...

Lilly White,
The problems you describe could have been overcome with some help, but I'm glad your babies did well on formula. Breastfeeding decreases the problems you mention, but doesn't completely eliminate them.

Student Nurse Nancy said...

Hi Judy,
I was lucky in that my baby eventually settled into nursing well, at least every now and then (see first comment). I ended up nursing him for 14 months. My second I nursed until 9 months and then had health issues with dangerous medication that required me to bottle feed my last two babies. Overall, It's given me a good perspective of the nursing and formula side.
I agree with you though, that too many new moms go home with very little support AND information. If I had a nickle for every "milking the cow" comment I got from family, well, you know. A new mom has enough emotional upheavel without having to deal with poor breastfeeding support.

Judy said...

You must have been very determined to stick it out for as long as you did with the cow comments. Probably more destructive than the barbs, though, are the 'baby is starving' and the 'dad or grandma wants to help' sort of statements.

Dad and grandma can do plenty without interfering with breastfeeding, but sometimes they need a hand learning how they can help.

My mom was the one who pushed the envelope. She had to learn how to breastfeed in the 1950's when they took the baby away for 24 hours, gave mom serious drugs which made her and baby groggy, and generally treated her like she was nuts.

Fortunately, she happened to stumble across an "old fashioned" pediatrician and OB in a small town in NC who were both very pro breastfeeding. Turns out they were decades ahead of their time after all.

Denise said...

Hi Judy!

I am new to your blog, but I just had to say how much I enjoyed this post in particular. I myself gave birth to a Great White Shark (would that someone had given me some perspective about this and validated me then ... it would have made a world of difference). To boot, I am the palest of pale daughter of a long line of redheads.

I really didn't think I could imagine a more challenging breast feeding start until I read about this poor mom --at least we weren't coping with the NICU setting!

I had an unexpected c-section with #1 after a long labor (not an emergency ... her head was just stuck sideways after three hours of pushing). I was physically wiped out. Then, after the first 24 hours of breastfeeding, I had BLACK blisters on my nipples. My OB, who had breastfed her own children and was very supportive, said she'd never seen anything like it.

I had UMPTEEN people troubleshoot my latch, etc ... *including* two hospital lactaction consultants. The L&D RNs were kind and concerned ... they got me a pump and cheered me on, but with every change of shift came a new perspective and the inconsistent advice was very confusing and created some stress. The senior LC(in her pristine lab coat and super short skirt) was ice cold and just made me cry. She offered nothing helpful ... she implied that I was just exaggerating the discomfort. HA! That I was a whimp. HA! (when I delivered #2 in the same hospital, I FORBID them to let this woman near me. I could not be held responsible for what I might do at the sight of her).

The other LC, who taught the class that I took before birth, listened to me describe the situation and her only comment was in reply was, Well ... are you terribly disappointed that you won't be able to BF? ... Are you kidding me?

When my pediatrician heard that I was still pumping at an early well-baby check-up (it was a matter of survival -- as was supplementation -- in the early days. It was weeks before my nipples healed), he said that whenever he hears of women pumping beyond the first week or so, he wonders if they don't have anything better to do. !! And that Childbirth Educators (my mom was an L&D RN and Childbirth Educator for a good part of her career, btw) just make women feel guilty about BFing and that in his experience, there was *no* difference for the baby between breastmilk and formula. I suppose that remark might have been helpful if I was only putting myself through the start-up challenges out of simple-minded guilt ... but that was not the case. I'm not even a little bit simple minded.

The fact that I got such lousy, mixed-up, unhelpful feedback only made me more perversely determined to succeed. I could picture a long line of other moms and relatives who, upon inquiring and hearing that BFing was "too painful" ... would give me that same ignorant, pitiful judgement look that screams "pathetic" as that first LC had done. After a crazy labor, *that* would have just been too much to swallow. As I now know, not all experiences with these things are equal, but people judge you as though they are.

So I stuck it out. Persistence ... and ultimately my OB's angel of a nurse who had SOME clue what I was going through from her own experience ... and who was able to blessedly calm my frantic concerns (against *everything* else I ever read and was told) about pumping and supplementing until my nipples healed ... and my fears of starving my baby while I sorted this out ... these were the only reasons for my eventual success. I BF'ed for 14 months in the end. More or less exclusively.

Fortunately, my immediate family was supportive ... except my dad, who marched in on me in the first day or so at home while I was wide open, breasts exposed, in the bedroom ... still very much in the throes of this ordeal. I bit his head off (imagine that) for not knocking -- he *made fun* of my modesty (kicking me while I was down) and spit tacks at me and left town, taking my mother -- my only tactical help -- to return home, two states away. My mother (until she left) and my dh could only watch helplessly while I suffered ... while I made call after call to find a solution. I'm sure the whole thing looked perfectly masochistic. It certainly felt that way. But I was just so bent about the inability to find help for a topic where there seem to be *no* shortage of experts or books ... that I refused to give up. Then my in laws visited. LOL. I won't even go into my mother-in-law and her pathetic looks and her idea of "help." LOL.

They don't write about this stuff in the books are teach about it in the classes. It's always a miracle to me when I find someone who knows what I am talking about. I had similar nipple issues with #2, but having had the earlier experience ... it was just a matter or being patient and doing what worked. Which unfortunately I'd had to learn the hard way. God bless you for being able to help this mom and for being so savvy.


Judy said...

I am truly awed by your persistence. I don't think I could have done what you did!

Fortunately the LC who was working with this mom didn't have a problem with my slightly unorthodox practices. She put in more than a little time with the mom and sent her home with a pump to use until her blistered breast healed. I hope she sticks it out like you did.

One thing I always tell moms when the going is tough is that I started breastfeeding because it was "the right thing to do - best for mom and baby" but I continued because eventually it was the easy thing to do. I always let them know that the first weeks can be difficult, but that it nearly always gets better.