Part I – Goldi-Nurse and the Three Babies: What if Milk Supply isn’t Just Right?
Gloria Dudney, RN, BSN, IBLC, RLC
Gloria has been practicing maternal/child nursing for 30 years. She has experience in levels 1 & 2 newborn nurseries in Texas and Tennessee. She served 24 years at a private pediatric practice, where she launched the region’s first primary care lactation clinic. She now serves as director of lactation for East Tennessee State University Health.
Rachel and Conner – The Story of “Not Enough Milk”
Rachel is a 36-year-old G1P1 with a history of PCOS*, class II obesity, and diet-controlled gestational diabetes who was delivered via CD following failed induction at 37 weeks for elevated blood pressure and suspected LGA. Her newborn son, Connor, weighed 8 lbs. 15 oz and had Apgar scores of 7 and 8.
Rachel stated upon hospital admission that, even though no one in her family had ever breastfed before, she strongly desired exclusive breastfeeding. Connor’s first feeding was delayed due to an episode of TTN*, but at 2.5 hours post-delivery, he was stable enough to go to the breast. Rachel struggled with positioning after surgical delivery and was tearful as she expressed disappointment that she could not deliver vaginally.
After trying multiple positions and bobbing on and off the breast for several minutes, Connor could attach and nurse from each breast. He did not struggle to attach to the breast during subsequent feedings, but by 36 hours of age, he began to “fall asleep” after a few minutes at the breast. Rachel struggled to keep him actively sucking during his feedings, but if she took him off the breast, he would cry, so she put him back to the breast for additional time. She reported that most of his breastfeeding sessions were at least 45 minutes in duration, and he was still acting hungry afterward. At the time of discharge at 48 hours, Connor had lost 7.5% of his birth weight, and his TSB was 12. She was encouraged to continue breastfeeding and ensure he went to the breast at least eight times every 24 hours.
Rachel continued breastfeeding frequently but noticed Connor was very sleepy and not nursing very vigorously. When his pediatrician examined him at the outpatient clinic at 72 hours of age, Connor had lost 10.5% of his birth weight, his stools were not yet transitioning, and his TSB was 18. Connor’s pediatrician ordered home phototherapy and recommended formula supplementation. The pediatrician encouraged Rachel to continue breastfeeding and ensure she breastfed before offering the supplement.
The family complied with this plan of care, and by day 6 of age, Connor was gaining weight well, and his jaundice was resolving. However, Rachel was concerned about her breast milk production. Connor remained interested in breastfeeding, but she could only hear him swallow for a minute or two on each side. If she encouraged him to stay on the breast longer, he would begin to fuss and push against the breast. However, Rachel continued formula supplementation due to continued hunger cues exhibited after nursing. Around three weeks post-delivery, Rachel felt like her breasts were as soft as they were before she became pregnant, and Connor began to refuse to breastfeed.
She expressed continued sadness that neither her delivery nor her breastfeeding experience was going as planned. Her pediatrician and her family were supportive and encouraging, but she sensed that somehow this could have gone differently.
Could Rachel and Connor’s story have had a different ending?
*PCOS: Polycystic Ovary Syndrome; TTN: Transient Tachypnea of the Newborn
Look for Gloria’s next blog as she explores the breastfeeding dyad of Rachel and Conner further.
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