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.