Case Study - How Birth Position Can Affect Latch, Feeding, Development

Just fix the latch. It sounds simple but is extremely complex. Just pump and bottle feed. Again, sounds simple but this does not address core issues when a baby really needs some more help. Everything in the body is connected, nothing is separate. A picture is worth a thousand words. I think these pictures alone will show you why some latches hurt and some can't function at all. This case study is being presented through the SBAR format: Situation, Background, Assessment, Recommendation. I also wrote about the outcome for Baby since I was able to work very closely with Mother and Baby for several months.

Situation

Baby at 4 weeks old

Meet Baby. I met Baby when he was three weeks old. The above picture was taken one week after our first visit. Mother scheduled a lactation consultation to address; latching, staying latched, and she wanted to talk about pumping. The first thing I noticed was Baby Bear's severe torticollis (#iamnotadoctor). His cheek was literally glued to his shoulder. I pretty much knew his feeding history just by his torticollis presentation. Restrictions throughout the body can cause severe and long term latching and feeding complications and can lead to developmental delays. Families are often told "that will work itself out" or "let's just wait and see". This would not have "worked itself out" with no intervention. When my client wants to breastfeed at the breast, proper intervention is critical. This is why I'm on the road searching proper training programs so I can help mothers meet their feeding goals and make sure babies get the care they need.

Background

Baby at birth

This is Baby's picture immediately after birth. He was in a breech position, delivered by cesarean section. Mother was breastfeeding in the hospital and her nipples were raw, cracked and bleeding. Baby breastfed the entire hospital stay - no bottles or pumping. Mother was given a prescription nipple ointment (all purpose nipple ointment) before leaving the hospital.

After being discharged from the hospital, Mother's milk transitioned (aka- came in). When milk transitions, breasts get really full and swollen. It can make latching more difficult for a baby that is already struggling. (This is also why latch may be fine in the hospital, then milk comes in and the baby can no longer latch well.) After being discharged, baby continued to struggle with the latch, he was popping on and off, rooting all the time, and Mother's nipples were still raw and bleeding. Mother started pumping and bottle feeding and scheduled a consultation with me three weeks postpartum. 

Assessment

When I met Mother and Baby for the first time, I reviewed medical history, feeding history, and we discussed everything that happened up until the consultation. I reviewed Mother's goals for the visit and for the future. Mother wanted to feed directly from breast 2-3x a day, and pump and bottle feed the rest of the time. Mother had a really good milk supply from pumping.

Since Mother wanted to latch a few times each day, I assessed the latch. I have already noticed severe torticollis and also suspected the baby had tethered oral tissue (tongue and lip tie). I watched Baby latch, and then I used hands on techniques to see if I could assist with positioning and helping Baby maintain a latch. He was popping on and off, not able to seal and stabilize at the breast to be able to remove milk. This is what was happening in the hospital and at home after being discharged. This is one of those situations where assessing the baby while using a nipple shield was appropriate. I added a nipple shield and the baby was then able to seal to the shield and stabilize to be able to suck. When babies are having trouble stabilizing on their own, they can not seal, hold all of that breast tissue in their mouth, and get milk to release on their own. The shield can help in some of these situations. It did help in this situation. Mother had been pumping for three weeks now (since Baby was struggling) and had a really good milk supply. Baby is now at the breast with the help of a nipple shield and a good hearty milk supply. He is set up for the best possible success under the circumstances. Now its time for him to practice latch. He did really well with the shield and drank and appropriate sized feeding for his age. 

We had a handle on the latch for now and I saw that Baby could get a full feeding. Mother wanted to latch 2-3x a day and pump and bottle feed the rest of the time, I was comfortable with her plan. We also discussed Mother's pumping plan for moving forward. If Mother wanted to latch full time, I would have needed to monitor the baby VERY CLOSELY to make sure that he could feed full time on his own and get enough milk. I would have scheduled frequent follow up appointments and also had "plan B" in the care plan. If he was not able to feed well at my visit, I would have suggested pumping full time and latching for practice until I can see him build his latch skills and nurse efficiently. One good feeding does not give me the full picture of his abilities.

Recommendations

Great - we had a plan to latch 2-3x a day and pump and bottle feed the rest of the time. Now how about that toriticollis? Seeing his severe torticollis and knowing that there was no plan of action to help this baby had me very concerned. Untreated torticollis can lead to (or is already be combined with) plagiocephaly (flat head) and possibly developmental delays over time. The sooner the baby gets treated, the better. The only plan was to "wait and see" and waiting can make it worse with no intervention. Babies are sleeping on their back all night, possibly being restricted by swaddling. If they don't sleep well on their back many babies end up sleeping in a "rock-n-play" which can enforce that preferred head position and exacerbate (or cause) torticollis and plagiocephaly. One of the top complaints I hear is how babies have reflux and need to be held upright for 20-45 minutes after feedings, then are on their back for sleep all night. Babies need to MOVE and be RE-POSITIONED in this situation. So my next recommendation for Mother and Baby was TummyTime!™ Method. 

Mother was all in on implementing TummyTime!™ Method (TTM)! I showed her how to get started with TTM, we reviewed how to simply re-position away from the preferred side. We discussed sleep positions, positioning in the car seat, positioning at home and the need for repetition, repetition, repetition, repetition, repetition, repetition, repetition (got the point?). I also highly encouraged Mother to attend my weekly TummyTime!™ Method class......so the journey begins.

Outcome

                           started TummyTime Method             5 weeks of TummyTime Method

                            one week before this picture

Mother and Baby were the most excellent students! Look at the progress they made in five weeks! Mother then realized she needed to seek further help and Baby started working with a physical therapist. He was diagnosed with torticollis and also ended up having severe plagiocephaly which was caught very early and corrected with a helmet. Early on I had also suspected that Baby had both a tongue and lip tie restrictions. There was so much happening so we focused on TummyTime!™ Method at first, then physical therapy. Mother did have the tongue and lip tie evaluated and decided to have the procedures done right before Baby was measured for his first helmet. I was amazed when Baby came to my office shortly after his tongue and lip release - one thing I noticed immediately was how his smile changed dramatically. He was much more "smiley" after the procedure. It was quite amazing to see. Another outcome I noticed from this great work - babies in this situation may have reflux and have trouble eating by bottle or breast. In my experience, I see these babies drinking very small volumes 20-24 oz per 24 hours and gain 1/2 oz per day. This was also the case with the baby in this story. He drank small volumes, gained 1/2 oz per day. After TummyTime!™ Method, physical therapy, tongue and lip release, he started eating much better. He started drinking up to 35 oz of milk per 24 hours (average is 28-30 oz per day). He started gaining much better since he was drinking more.

By seven months old, neck was fully functioning and head shape was corrected. This is called prevention! Instead of waiting for the baby to possibly have developmental delays and then getting treated, we rallied together to get this baby the help he needed. A lot of this progress was due to our weekly TummyTime!™ Method classes. There is power in the community and when we gather each week we all learn from each other and it gives us the information and power to take action. A few other babies in the class were experiencing the same challenges and we were all taking action in some way, gathering information and sharing and learning from each other.

Thanks Mother and Baby for such an amazing experience. Our work together will help so many other families! Thank you for letting me share your story!

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