Hyperemesis Gravidarum – The pregnancy Voms

Hyperemesis Gravidarum – The pregnancy Voms

“Aah Phoebes, you have that wonderful pregnancy glow. Glow … that is sweat! You throw all morning and see how you glow” – F.R.I.E.N.D.S

That unmistakable wave of nausea is commonly one of the earliest signs of pregnancy. It can be bitter sweet, as no one really likes to feel nauseous, but when pregnancy is your goal, it is really exciting. 70 -90% of women experience nausea and some vomiting in the first trimester. The cause of nausea in pregnancy is not completely understood, but does appear to be linked to the production of Human Chorionic Gonadotropin (HCG) hormone. Nausea usually starts at around 4-8 weeks and subsides around 12-14 weeks.

For around 5% and up to 20% of these women, this will continue throughout the pregnancy. Hyperemesis Gravidarum (HG) is the most severe form of nausea and vomiting in pregnancy, associated with ketosis, weightloss, dehydration, electrolyte and acid imbalances, and nutritional deficiencies. Severe cases may need hospitalisation. Women that are more likely to develop HG: developed symptoms in previous pregnancies; have menstrual migraines; develop similar symptoms taking oestrogen (birth control); experience motion sickness; and have GI problems such as ulcers or reflux.

Your obstetrician or midwife will usually start by trying natural nausea prevention methods such as Vitamin B6 and Ginger, eating smaller frequent meals, and dry food such as crackers. Drinking plenty of fluids to stay hydrated. Now, pregnant moms that I have given this advice to move from sarcastic, to nuclear, and then often to defeated. I asked some of my mom’s to tell me about their experience:

I have been pregnant twice and in both my pregnancies I have suffered terribly from nausea and vomiting. It started around 8 weeks and continued throughout the pregnancy. With my first I lost 10kg, and with the second it was 7kg. I felt nauseous all the time and certain smells and foods would set me running to the toilet. Nothing worked, I tried everything. My doctor even put me on medication but to no avail. I was open to all advice, I would have tried anything to stop it. Donna Matthews

Severe cases may require hospitalization. Pregnant women who are unable to keep fluids or food down due to constant nausea or vomiting will need to get them intravenously. Medication is necessary when vomiting is a threat to the mother or child. Majority of mothers try avoid medications at all costs during pregnancy, so usually if a pregnant mom is asking for medication, she really is desperate.

I was very excited when I found out I was pregnant with my first daughter, sadly that excitement was very soon replaced with nausea and vomiting which lasted all day. It started at about the same time that I began to suspect that I was pregnant and worsened as my pregnancy advanced.  I told my Gynae at time that I was suffering from severe morning sickness and could barely keep any food down. I was given Asic tablets and told to eat small meals regularly, this did not help one bit. The gynae would not give me anything stronger as she was unsure of what effect it may have on the baby. I was unable to go into any shop which stocked meat of any form as the smell made me vomit and I regularly had to leave a trolley full of groceries and run. My husband and I turned vegetarian for almost 6 months because I could not cook any meat.  My work was compromised, some days I only managed to get to work around midmorning and many days I had to call in sick. I vomited for a full 39 weeks and was totally exhausted and despondent by the time my C-section date arrived.  I suffered from exhaustion and postpartum depression for a long time after my daughter was born and I think a lot of it could be linked back to the hyperemesis. It took us 6 years to work up the courage to go through all of that again despite people telling me that the next time might be different. When I found out I was pregnant with my second daughter I made the Dr redo the blood test 3 times just to be sure as I was slightly nauseous, but not vomiting, however by week 7 the vomiting had set in again. When I was 10 weeks pregnant I was hospitalised for 4 days because I could not keep anything down and was becoming dehydrated. When I was discharged my Gynae prescribed Zofur which reduced the vomiting to mornings only, however the nausea remained. We finally got the vomiting under control around the 20^th week of my pregnancy, even though the nausea was never controlled and I struggled to eat many things. I felt a lot better and had far more energy going into the birth the second time around and am coping much better in the weeks following the birth. I had many people giving me advice about what worked to reduce their morning sickness, including ginger suckers, teas and small meals. None of this advice was helpful as none of it worked and I got progressively more frustrated and despondent. Hyperemesis is debilitating and frustrating and I don’t think that women who truly suffer from it are taken seriously, I mostly felt like a hypochondriac when I told people how terrible I was feeling. I will definitely not be having any more children as I cannot go through those months of vomiting again. Meagan Mansell

Medications that are commonly used:

Antihistamines such as Diphenhydramine or Meclizine, these commonly cause drowsiness.

Other anti-nausea medications such as promethazine and metoclopramide are available for use. Zofran (Ondansetron) is commonly used to help with HG. Zofran blocks the actions of chemicals in the body that can trigger nausea and vomiting.

The way that medications are used can improve efficacy.

-          Changing medications abruptly and frequently is counterproductive

-          Scheduled dosing improves response, rather than taking when needed.

-          Wean slowly after a few weeks of stability and adequate nutritional intake

-          Medication may be needed until delivery

Complementary treatments can be used such as acupuncture, acupressure, and hypnosis. These have been helpful for certain women.

Many of the moms worry how the HG will affect the baby. Although the pregnancy may be long and tedious, nausea and vomiting of pregnancy is typically not associated with adverse pregnancy outcomes in the absence of severe malnutrition or weight gain <7kg. There is strong evidence that women with nausea and vomiting in early pregnancy have a lower rate of miscarriage than women without these symptoms. Larger follow-up studies are needed to determine whether HG has long-term effects on offspring.

There are others that have HG and they are usually your best resource, even if it is just to know that you will survive it.

 

www.HelpHER.org

info@HelpHER.org

facebook.com/HERFoundation

twitter.com/HGmoms

I Don't Have Enough Milk

“I Don’t Have Enough Milk”

By Samantha Crompton BNURS SACLC

New mothers are often overwhelmed with the insecurity that they will not be a good mother, that they will not do everything right. Over the years our confidence in the ability of our bodies to grow, birth and nourish our babies has been stripped from us. I often hear mothers say that they don’t have enough milk, and I always try and find out why they are saying this.

“The first milk is not enough, I need to top up until my milk comes in”, the milk coming in is an unfortunate term as it implies that there was no milk to begin with which is untrue. Despite mothers knowing the many benefits of colostrum, when they hear that it is measured in teaspoons and not tens of mls, they often think that can’t be enough for my baby, surely I must top up.

 A newborn with a stomach capacity of around 20ml translates into a feeding interval of around 1 hour. This is in line with gastric emptying of human milk and neonatal sleep cycles. Larger feeding volumes at longer intervals may therefore be stressful and the cause of spitting up, reflux and hypoglycaemia. (Bergman 2013)

 

Colostrum is low in fat, and high in carbohydrates, proteins and antibodies. Natures first vaccine. It is easily digestable, and has a laxative effect on baby helping to pass early stools, which aids in the excretion of excess bilirubin and helps prevent jaundice. Colostrum has an important role to play in babies gastrointestinal tract. A newborns intestines are very permeable. Colostrum seals or paints the GI tract mostly preventing foreign objects from penetrating. Small frequent feeds are all your baby needs, and your breasts will begin to produce mature milk increasing in volume as your baby grows. It is often not that our baby is feeding too often and not getting enough in these early days, but more that our expectations of how often baby needs to be fed are misdirected.

“My baby feeds all the time, my milk must be low or not strong enough”

Firstly it is good to know that frequent nursing is normal and expected in the early months. Most newborns need to nurse 8-12 times a day. It is needed to reduce engorgement in early days, nourish growing baby with a small stomach capacity but needs to double weight by 5-6 months, and to establish a good milk supply.

 SUPPLY = DEMAND. (Every formula bottle decreases demand therefore supply leads to vicious cycle).

Nursing is not only about nutrition, safety & security are basic needs. They just need mom, lots of kangaroo care in the first 6 weeks.

Managing expectations, it helps when the parents understand growth spurts or frequency days. I usually get the crying phone call at 2 weeks old. This is good baby suddenly turned on you and the lack of sleep caught up. Nature designed these frequency days to increase our milk supply to keep up with the growing demands of our baby. Your baby can feed every hour for 2-3 days and then usually returns to normal feeding patterns. They are difficult but if you are prepared for it mentally and physically. Adjusting expectations is the best way to cope. Once you consider frequent nursing in this time to be the norm and not a problem it will make life easier. Prioritise your to do list – List things that have to be done in the week and list things that can wait.

“When I pump, I am only getting ..ml’s”

Pumping is a good way to see how much milk you can pump. A baby that breastfeeds well can get much more milk out than you could ever pump. How much milk you can pump out depends on many factors. It is not unusual to have to pump 2-3 sessions to get enough milk for 1 feed. Pumped milk while breastfeeding full time is extra milk. It is normal for output to vary from session to session and day to day. Other things to consider:

-          Are you using the appropriate pump for the stage of nursing and the amount of pumping that you are doing. It is extremely difficult to pump colostrum with an electric pump. In early days hand expression is much better than any pump on the market. If you are pumping for a full day away, you may need a double electric pump to keep up.

-          Is the flange on the pump the correct size. Sometimes switching to a larger flange or getting the correct sizing makes all the difference.

-          How old is your pump?

There is also the lost art of Hand Expression. It is extremely important to  learn how to hand express. No need for electricity or batteries, hands are always with you. A number of my mom’s that battle to express using pumps get much better results when using hand expression or manual pumps.

How do I know that I really have a low supply?

As moms we tend to stress ourselves more than we need to. We obsess about knowing how much milk baby is getting. Let baby tell you how much milk he is getting.

-          The number of wet nappies your baby produces.

-          Weight gain problems such as a flat or dipping growth trajectory.

-          Consult with qualified SACLC or IBCLC lactation consultant

There are many factors that can cause a low supply, but it is not all doom and gloom, and the answer is not always come in a tin or a pill / supplement. We need to find the cause of your low supply and address the problem. Discuss these technicalities with a skilled lactation consultant and together you can find the right solution for you.

Samantha Crompton

BNURS RN RM community psych

South African Certified Lactation Consultant

Certified Preggi Bellies Instructor

What date would baby choose?

I heard a sad story from one of my colleagues this week, her client requested to have a C-section at 37 weeks because she wanted her baby to be born on 3/3 for reasons I do not know. What was so disturbing about this was that the obstetrician agreed. The baby was born and ended up in NICU because of respiratory complications, and other factors related to be born too early.

The question is what date do you think that the baby would have chosen?

Let's first take a look at the due date. The way to work out a due date (EDD - estimated due date) has always been to take the first day of your last normal menstrual period plus 7 days, plus 9 months and you have your due date. LNMP + 7 days + 9months = Due date (Naegele's Rule 1812). This is not evidence based. The problem with this method is that our memories are not exactly great, unless tracking your menstruation cycles. First trimester bleeding may be mistaken as your last period but may have been an implantation bleed. It also assumes that all menstrual cycles are 28 days and all women ovulate on the 14th day of their cycle. (1) When I was trying to conceive, I started tracking my cycle and ovulation by checking my temperature and discovered that my cycle was around 38 days and that I was ovulating around day 22. I used this information to help conceive, it is just a pity that I didn't use this information to help fight to keep my baby in longer. When we know better we do better.

The more accurate way is to have a 1st trimester ultrasound. The ideal time is between 11 and 14 weeks. Accuracy declines after 20 weeks.

In a study published in 2001, Smith looked at the length of pregnancy in 1,514 healthy women whose estimated due dates, as calculated by the last menstrual period, were perfect matches with estimated due dates from their first trimester ultrasound. The researchers found that 50% of all women giving birth for the first time gave birth by 40 weeks and 5 days, while 75% gave birth by 41 weeks and 2 days. Meanwhile, 50% of all women who had given birth at least once before gave birth by 40 weeks and 3 days, while 75% gave birth by 41 weeks. This means that for both first-time and experienced mothers in Smith’s study, the traditional “estimated due date” of 40 weeks was wrong! The actual pregnancy was about 5 days longer than the traditional due date (using Naegele’s rule) in a first-time mother, and 3 days longer than the traditional due date in a mother who has given birth before.

Study finds that estimated due date should be closer to 40 weeks and 5 days. (2).

 

My clients laugh at me when I ask them how they like their roast chicken? But often the recommended time on the recipe is just a guideline. We take out the chicken, poke it, sometimes it is done, but at times it needs just 5 more minutes. Although we can't take out our babies, check and then put them back in to cook if not done, we should really give them a chance to cook. Staying pregnant for 40 weeks is the best way to give the baby enough time in the womb to grow and develop. being pregnant is hard, but having a sick baby is harder.

 

What is considered full term vs. premature baby? Preterm is when a baby is born before 37 weeks of pregnancy. An early term is when baby is born between 37 & 38 weeks. A full term baby is born from 39 - 40 weeks. A late term is born at 41 weeks. Post term is born at 42 weeks and beyond.

 

A baby's brain at 35 weeks weighs 2/3 of what it will weigh at 40 weeks. Preterm birth is a concern because babies born too early may not be fully developed. Some problems may be seen at birth, but other problems such as learning disabilities, may appear later in childhood. A baby born before 39 weeks has an increased risk of breathing problems, likely to experience low body temperature and low blood glucose, experience feeding problems. Babies born early have more learning and behavioural problems in childhood than those born at 40 weeks. Each week of pregnancy matters even those last few weeks. make every week count and give your baby the best start to life. (1)

Is it worth It? Take a look at this video for more information.

 

I was chatting about the parents & Dr that delivered the baby at 37 weeks with someone from medical aids. I was asking if they should pay for the baby to be in NICU, as it was a result of an elective procedure. They gave the best answer, they said that it was not the baby's fault, why should they deny care to their newest client based on actions of others.

 

The foetus initiates labour which marks the point of optimum functionality - including the brain. The absence of labour means that the foetus has had no time for a successful transition from intra to extra-uterine life.

 

Respect your baby's decision on when it is ready for the outside worls.

 

References:

1. Expectant Mothers Guide 2017. Did you know the latest evidence. p65-66.

2. https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date/

Sweat Marks not Stretch Marks

Stretch marks are often a topic of discussion during my antenatal courses and at baby group. I honestly have never weighed in much to the discussion, as skin care is really not one of my skill sets. I often have specialists in my group that are far better qualified to take the floor. During a CPD function, I was listening to presentation by one of the skin care specialist companies and I heard a fact that piqued my interest. Exercise can prevent stretch marks. Now pregnancy and post natal exercise I am quite passionate about, so I revved up the search engine and was reminded as ever that you can never stop learning, even about what you do on a daily basis.

So what are stretch marks anyway? When the body expands faster than the covering skin, the skin tears, forming a scar as it heals. These scars are visible on the surface of the skin as stretch marks.
The likelihood of developing stretch marks varies according to skin type, race, age, diet and hydration of the skin. Those most prone to stretch marks include pregnant women, body builders, adolescents undergoing sudden growth spurts and individuals who experience rapid weight gain.(1).
If you have them, you’re in good company. About 90% of women will get them sometime after their sixth or seventh month of pregnancy, according to the American Academy of Dermatology.

If your mother had stretch marks, then you're more likely to have them too, since genetics plays a role. (2).

Majority of the prevention and treatments involved Retin-A creams and lotions, laser and other things that medical aids definitely wouldn't cover. There are also the Tiger Stripes empowerment that I have always prescribed to that says just embrace them, you have earned them. But lets explore this exercise thing. So firstly, can you exercise during pregnancy and how much? The Centers for Disease Control and Prevention recommend that pregnant women get at least 150 minutes of moderate-intensity aerobic activity every week. An aerobic activity is one in which you move large muscles of the body (like those in the legs and arms) in a rhythmic way. Moderate intensity means you are moving enough to raise your heart rate and start sweating. You still can talk normally, but you cannot sing. (3). The moms in my class know that I encourage them to belt out a tune because helps us breath correctly during the higher intensity cardio times.

Apparently, no exercise can remove or reduce stretch marks, but regular, moderate exercise may help prevent stretch marks from developing. Regular exercise can reduce the unnecessary weight gain that often results in stretch marks. Exercise also improves circulation, which could help the skin remain elastic and allow it to stretch without tearing. (4). Stretch marks may appear anywhere on the body that experiences rapid tissue growth, and are mostly commonly found on the abdomen, hips, thighs, breasts and buttocks. I took a look at the types of exercise that we do during Preggi Bellies classes that I instruct.

 

Aerobic exercise promotes better circulation so more nutrients reach your skin's surface. I include at least 30 minutes of aerobic exercise per class so that is a thumbs up for the skin.
Sit-ups and crunches are helpful at preventing stretch marks on your abdomen. We do modified abdominal exercises that are safe in pregnancy and a lot of the focus is on core strengthening.

The moaning that occurs but push-ups help prevent the appearance of stretch marks around your breasts. Whoop whoop, now there is no excuse. And the ever present Squats, squats increase muscle tone in your hips, thighs and buttocks. (5).
Despite there being no double blind randomized controlled trial proving that exercise can prevent stretch marks in pregnancy, ACOG advises us on the health benefits of exercise in pregnancy, so hopefully we are preventing those stretch marks at the same time.

Sr Samantha Crompton RN RM SACLC
The Baby Lady


References:
1. http://www.bio-oil.com/en-us/application/stretch-marks.
2. The truth about pregnancy stretchmarks. Elizabeth Krieger. http://www.webmd.com/baby/features/stretch-marks#1. 5/2/2017.
3. Exercise during pregnancy. The American College of Obstetrics and Gynecologist. May 2016. http://www.acog.org/Patients/FAQs/Exercise-During-Pregnancy. 5/2/2017. 
4. Which exercises remove stretchmarks. http://healthyliving.azcentral.com/exercises-remove-stretch-marks-1279.html. 5/2/2017.
5. Exercises to Get Rid of Stretch Marks by Myrna st Roman. Jul 21, 2010.http://www.livestrong.com/article/181266-exercises-to-get-rid-of-stretch-marks/.  

The Boobifly Effect

It's a good day! It is not everyday that you get to see the small things that you do effect someone and can effect the larger community. The Butterfly Effect is the concept that small causes can have large effects. Initially, it was used with weather prediction but later the term became a metaphor used in and out of science. (1).

Going back to when I was breastfeeding my first son, I was unaware that public breastfeeding was a thing, I fed my baby whenever and wherever he needed me to. Similarly, I was not aware that pumping at work was such a big deal. I pumped while sitting in traffic jam on the way to work, I pumped in toilets, empty conference rooms, and during busy times at my desk in open plan office. I put my pumped breastmilk in storage bags in the company freezer in the communal kitchen. Once, I was asked about the time taking to pump, I equated it to my colleagues going for a 10 min smoke every 90 minutes and surely that was far less productive than what I was doing, never heard it again. It was only when I left the corporate environment and emerged myself in the lactation world that I discovered that potentially there may have been an issue with my actions at the office. I put it down to my lack of social awareness or that if you just do something with confidence, no one will question you.

Back to the present, I received a WhatsApp message from a client that over the years has become a good friend. For both of us it has been a journey of learning, through many BBM's (I am getting old), phone calls, visits, glasses of wine. Always willing to be a test subject for advice, techniques, and understanding what mothers go through.

So what does this have to do with a butterfly? As a lactation consultant, I am passionate about breastfeeding and more often than not feel like I am failing parents at changing the world. I scroll through social media and this reinforces failure. Pictures and pictures of friends, family, clients and strangers with their baby and the ever present bottle. I am only entering this professionally long into the challenge, mentors have been at this for a lot longer, and with slower results. But each day through various means; 1:1 consultations, group training, workshops, blogs, WhatsApp messages and groups, Facebook, Instagram, Twitter and every other media available we try and get our passion across.

The day that you hear that an article that you posted, assumed that was scrolled past, was actually READ, IMPLEMENTED, EVALUATED and SHARED. When you get an aerial view of how one small part, ripples to one mother, and she can see the value in what she has done and how it can make the way for everyone else easier.

It is a good day!

Samantha Crompton RN, RM, (general, community, psych), SACLC
BNURS (Wits)
SJC Consulting cc
Lactation Consultant SACLC, Childbirth educator, Post Natal support and Preggi bellies instructor



^{1. https://en.wikipedia.org/wiki/Butterfly_effect. 18/1/2017.}

Birth Planning for Future Health

Birth Planning for Future Health

There comes a point in your pregnancy when you realise that this baby actually has to come out. You might laugh thinking back, but often we are so excited to be pregnant that we haven’t thought further than being pregnant. When you type “Birth Plan” into your search engine, immediately there are 13 300 results. Each of these has excellent advice on preferences and options that you should think about in order to make a positive birth experience. Some are very practical in the sense of what to pack, who should be allowed into the labour ward and when should you have an enema so not to poop on the table; but what if some of these decisions could impact the long term health of your unborn baby. Suddenly, how scary that we not only have to plan for beyond the pregnancy, but the responsibility of decisions made at birth could have far reaching impact.

Recent terminology that is starting to filter into these plans is the Microbiome. "Two amazing events happen during childbirth. There's the obvious main event which is the emergence of a new human into the world. But then there's the non-human event that is taking place simultaneously, a crucial event that is not visible to the naked eye, an event that could determine the lifelong health of the baby. This is the seeding of the baby's microbiome.” (1). The human microbiome consists of trillions of microbes – bacteria and viruses—the balance of which largely determines our health and well-being throughout life. The largest microbiomes in women are located in the mouth the gut, the uterus, the vagina, and the skin. Breastmilk also provides a vital microbiome for the infant.(2). The microbiome is normally transferred from mother to baby via the placenta during pregnancy; the vaginal canal during birth; and the mother’s skin, breastmilk, and lips in the hours, days and weeks after birth. The microbes and their genetic material play an essential role in the child’s health, development, and metabolism. Disruption in the transfer of the microbiome in the perinatal period due to changes in the way  pregnancy and birth are managed in the hospital have led to the increase in many diseases, such as allergies, asthma, diabetes, gastrointestinal diseases, obesity, autoimmune disorders, and some mental disorders. Until the past few years, the connection between the altered microbiome and poor health was virtually unknown. With newer technologies that allow for the study of microbes that were previously impossible to study, these connections are beginning to be discovered. (3).

Let’s go back to looking at just a few things on our birth plans while keeping the maintenance of the microbiome as our heading:

Mode of delivery – Unfortunately cesarean delivery (CD) is no longer reserved for medical reasons, but the massive increase in elective CD sitting in the 80% in some private clinics, has put this on the list of birth planning. During vaginal delivery, the contact with the vaginal flora is an important start to the infants colonization, this is absent in CD. Studies are showing that babies born vaginally are colonised with lactobacillus, whereas cesarean delivery babies were colonized by a mixture of potentially pathogenic bacteria typically found on the skin and in hospitals, such as Staphylococcus and Acinetobacter. The effect of this appears to be most robust in the area of immune mediated diseases. CD has been associated with a significant increased rate of asthma and allergic rhinitis.(4).

Skin to skin (STS) – Placing the baby immediately on the mother’s chest and leaving the baby there is what is needed. Almost all necessary interventions can be performed with the baby on the mother’s chest. Wrapping the newly born baby in hospital blankets and placing in an incubator means the baby has no chance to acquire the skin microbiome of the mother, through direct contact, including skin to skin holding, licking and nuzzling. Instead the baby is exposed to the hospital microbiome via the blankets and the handling by the nurse. (5). Even if CD is necessary, immediate STS should be done.

Antibiotics, widely used for the mother during pregnancy and birth and for the infant afterwards, destroy helpful microbes. Even though this is not usually the choice of the mother, as prescribed, but by just discussing risk vs reward with prescribing physician can go a long way to avoiding unnecessary usage.

Breastfeeding / Formula feeding and the consistent use of the formula top up. Infant formula deprives the baby of the rich breastmilk microbiome, and impairs the normal development of the newborn’s immune system and maturation of the baby’s gut microbiome. (5). Exclusive breastfeeding has a protective role of breast-feeding against the development of diarrhoea and necrotizing enterocolitis in the newborn and allergic and autoimmune diseases in childhood, including coeliac disease type I diabetes and atopic dermatitis. Later in life, breast-feeding has been associated to a reduced risk of inflammatory bowel diseases, cardiovascular diseases, obesity, and type-2 diabetes. (7).

Many woman are exclusively breastfeeding, oh ja, except for that top up or 2 that baby received in the hospital, or some choose for various reasons to mix feed. Breastfed and formula fed infants have different gut flora. The science bit: Breastfed babies have a lower gut pH (acidic environment) of approximately 5.1-5.4 throughout the first six weeks that is dominated by bifidobacteria with reduced pathogenic (disease-causing) microbes such as E coli, bacteroides, clostridia, and streptococci. Babies fed formula have a high gut pH of approximately 5.9-7.3 with a variety of putrefactive bacterial species. When formula supplements are given to breastfed babies during the first seven days of life, the production of a strongly acidic environment is delayed and its full potential may never be reached. Breastfed infants who receive supplements, develop gut flora and behavior like formula-fed infants, the dominance of bifidobacteria during exclusive breastfeeding decreases when infant formula is added to the diet. (6). Exclusive and partial formula-feeding have been shown to alter the gut microbiome toward adult patterns, increase proinflammatory bacteria,  and increase gut permeability, and result in lower concentrations of fecal short-chain fatty acids compared with exclusive breastfeeding. (8).

Now you are thinking so what? What all this leads to is that just one bottle can have a long-term consequence on immune health as well as reduced protection against overweight and obesity.

These are just a few examples of how the microbiome can be altered at birth, and as research in this field expands, there will be an impact on our birth plans and how we are treated in maternity care facilities. You are the advocate for your baby, when you are putting together your birth plan, add microbiome to the google search, and insist that your health care team THINK GUT.

Samantha Crompton RN.RM.RCM.RP. SACLC

References

1.    http://articles.mercola.com/sites/articles/archive/2014/12/27/seeding-baby-microbiome.aspx. The Importance of Reducing Your Toxic Burden When Planning to Start a Family. December 27, 2014. Dr. Mercola

2.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340594/. The Human Microbiome and Its Potential Importance to Pediatrics Coreen L. Johnson, PhD^a and James Versalovic, MD, PhD^b

3.    https://healthfinder.gov/News/Article.aspx?id=711974. Antibiotics, Formula Feeding Might Change Baby's 'Microbiome'. C-section birth may also diminish diversity of these colonies of helpful microbes, study shows.

 

4.    Cesarean versus Vaginal Delivery: Long term infant outcomes and the Hygiene Hypothesis. Josef Neu, MD^a,b,a,b and Jona Rushing, MD^. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110651/

 

5.    How the 'Microbiome' Affects Your Baby's Birth and Health. https://www.bastyr.edu/news/health-tips-spotlight-1/2015/06/how-microbiome-affects-your-babys-birth-and-health. By Penny Simkin, PT, CCE, CD(DONA)

6.    Supplementation of the Breastfed Baby “Just One Bottle Won’t Hurt”---or Will It? Marsha Walker, RN, IBCLC. January 2014.

 

7.    Effect of Breast and Formula Feeding on Gut Microbiota Shaping in Newborns. Federica Guaraldi¹ and Guglielmo Salvatori², https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3472256/

 

Double Trouble: Tongue and Lip Tie Twin case study

Double Trouble: Tongue and Lip Tie Twin case study

Introduction

Ankyloglossia and shortened maxillary frenula (tongue and lip tie) often cause difficulty with breastfeeding. Poor latch with subsequent maternal nipple pain, poor milk transfer, failure to thrive and symptoms of reflux and colic have been described in the literature.

 

 

 

Ankyloglossia (tongue tie) is a congenital anomaly observed in newborns and children, and is characterised by an abnormally short lingual frenulum. The tight frenulum can cause decreased tongue mobility to varying degrees. (2). In order for a breastfeeding infant to properly latch onto the mother’s breast, the infants tongue must be able to thrust to the edge of the lower gum and cup around the areola and the mothers elongated nipple. The infants tongue movement may be restricted by an abnormal lingual frenulum. In breastfeeding the infant is unable to form an appropriate seal. This frequently results in sore nipples for the mother. Ineffective sucking in the newborn may also result in insufficient milk drainage in the mother, which in turn may lead to mastitis, decreased maternal milk supply, and eventually poor infant weight gain secondary to non-nutritive sucking. (3). A frenotomy, simple “snip” with a blunt-ended scissors is usually all that is needed and bleeding is minimal. It is less traumatic than ear piercing, and much less invasive and painful than circumcision. Immediately after the frenotomy is done, the infant is placed back on the breast, and the latch adjusted. There is usually immediate improvement in milk transfer and maternal comfort. (8).

During latching onto the breast, is also the importance of the upper lip flanging outward. The normal breastfeeding motion is best achieved when the baby can widely open the mouth. This wide opening is best achieved when the baby is able to flange the upper lip outward, allowing the mucous membrane portion of the lip (rather than the dry outer portion) to contact the breast. This allows for a better seal, which is the first step in generating the negative pressure for breastfeeding. (7). If the upper lip tie is tight enough the infant may also have trouble feeding from a bottle. Dr. O'Callahan and colleagues (2013) found that 37% of babies with tongue tie also had a current upper lip tie (ULT). Those ULTs were treated routinely as part of the study. While they were not specifically separated out and studied, it shows the importance of treating the baby to maximize breastfeeding outcomes. Many practitioners who routinely treat tongue-tied babies feel that this number likely underestimates the number of babies who would benefit from a lip tie revision. (7)
Reflux in infants poses many challenges for the parent/infant relationship. Aerophagia is a poorly studied but commonly seen phenomenon in breast and bottle fed infants. Aerophagia from the Greek “aerophagein” means “to eat air”. Post-feed aerophagia can be seen with higher rates in infants with tongue tie and possible lip tie. When the infant attempts to latch and has an ineffective flange/seal and dysmotility of the tongue on swallowing, there may be an increase in swallowing of air, leading to post-feeding gastric distention, colic and possible reflux. This is often seen clinically in infants with ankyloglossia and/or shortened maxillary labial frenula (tongue and lip tie). Aerophagia is often seen after feeds and is diagnosed by auscultation (examination with a stethoscope) during feeding, presence of colic-like symptoms after feeding, and gastric distention immediately after feed and can be seen on flat plate X-ray with enlarged gastric bubble. The increase in gastric pressure may overcome the lower esophageal sphincter pressure and gastric contents may reflux into the upper airway. This may be confused with other types of reflux disorders and result in misdiagnosis and improper treatment. (9).

Case Study

Kate and Patrick parents to 4 boys were referred to me for feeding concerns of their twin boys Dyson and Cadan by their chiropractor.

Dyson and Cadan mono di twins were born at 32 weeks weighing 1.8kg and 1.7kg. They were in the NICU for 4 weeks, on CPAP for 2 days. Kate expressed breastmilk for the boys for the duration of the NICU stay where they were tube fed initially then moved onto bottle. Exclusive pumping without the baby stimulating the breast, Kate started having some supply concerns. Kate had breastfed her previous 2 boys, but decided with the inconsistency of supply and there being 2, she decided not to continue breastfeeding.

Dyson was posseting and actually vomiting 2-3 of his feeds per day. The pediatrician diagnosed both boys as having reflux. They were put onto Gaviscon for a few days and then moved onto Nexium, which Kate was not very keen on. Kate and Patrick took the boys to a chiropractor for the reflux. The reflux did improve but still had concerns. The boys were having trouble latching onto the bottle. It was taking around 90min for the boys to drink a bottle, and it was getting worse. Chiro suggested that they contact me, to assist with feeding concerns.

On seeing the boys, they would fatigue quickly while drinking bottle. Battling to maintain latch onto the bottle. Examining their mouths, I suspected that they had posterior tongue ties and lip ties. This was potentially the reason for the feeding difficulties and reflux. I referred them to a paediatrician for evaluation. I discussed suck training exercises in order to increase the muscle tone, as well as different teats to use and paced bottle feeding techniques.
Parents took the boys to an ENT that their family has been seeing for many years. The ENT told the parents that there is no such thing as posterior tongue ties. Kate phoned me, as now having concerns. She can see that there is a problem, but the twins were seen 3 times per day in ICU for 4 weeks and the pediatrician seeing them never once said anything about tongue / lip tie. There trusted ENT says there is no such thing. Now she must trust the word of a nurse over 2 specialized Drs. I sent her all the information that I had on the topic, with my rationale for why I think that Dysan and Cadan have posterior tongue ties. Kate and Patrick were now sitting with 3 different diagnoses; reflux; tongue tie; and no tongue tie. An extremely stressful and confusing situation.  She decided to pursue it with an ENT at Parklane Clinic. In the 6 weeks between seeing me, and seeing the ENT, the twins only gained 300g.
This ENT confirmed and diagnosed posterior tongue tie and lip tie. He performed a frenotomy, lip revision and put in grommets. As the boys came around from the anaesthetic, she was advised to feed them immediately. Kate said that there was a definite difference already in how the boys latched onto the bottle. Over the next few weeks there was a dramatic improvement, they were different babies. Much more content, and they gained 400g in 1½ weeks. The twins’ weight gain has steadily improved; they are now “klapping” their bottles. Kate also describes the difference in feeding them, where previously not even wanting a bottle, to now getting excited when they see it coming. They have recently started solids and are doing well.

Discussion

Parents want to do the best for their children and prevent or fix anything that prevents them from thriving. In order to do this, they rely on health care professionals to assist them. If we look back through the case study, Dysan and Cadan were compensating, when this became too difficult, they started presenting with symptoms. The symptoms were treated, not the reason for the symptom. Kate and Patrick and other parents seek help from various health care professionals. Paediatrician may treat the reflux with PPI, chiropractors, physiotherapists, sleep trainers, dieticians, clinic sisters, pharmacists etc. each doing best to help the parents and the baby. This all comes at a financial cost, putting parents under strain as well.
Reliable information about how tongue tie truly disrupts latch quality wasn’t available until 2008, when an ultrasound study showed what the tongue does during breastfeeding. This information presented a paradigm shift in the understanding of infant anatomy and physiology with respect to breastfeeding and had a huge implication for how restriction of normal tongue movement could impact successful breastfeeding. (10).
Tongue ties are not always obvious, especially posterior tongue ties. It takes training, reading and practice in diagnosing tongue ties. Education of health care professionals on the signs of potential tongue and lip tie needs to be done. In twins case:

-          Reflux

-          Poor weight gain

-          Fatigue during feeding, taking long to feed.

-          “colic”, fussy babies, fussy eaters

As well as training more health care professionals on how to assess a baby for tongue tie, and if a health care professional has the knowledge, to actually be assessing for ankyloglossia routinely. Cadan and Dyson’s tongue & lip tie could have been picked up in the NICU. If more babies were diagnosed with tongue-tie properly, not only would moms who want to breastfeed have a better chance of succeeding, but the long term complications of tongue & lip ties could be prevented. (5).

Samantha Crompton RN.RM.RCM.RP. SACLC

References

1.     Guidelines to the writing of a case study. Dr. Brian Budgell, DC, PhD*.J Can Chiropr Assoc 2008; 52(4) 199.

2.     http://www.cps.ca/documents/position/ankyloglossia-breastfeeding. 20/9/2015. Ankyloglossia and breastfeeding. Anne Rowan-Legg MD, Canadian Paediatric Society , Community Paediatrics Committee. 2015;20(4):209-13.

3.     Newborn Tongue-tie: Prevalence and Effect on Breast-Feeding. Lori A. Submitted, revised, 15 October 2004.From the Regions Family and Community Medicine Residency Program (LAR, DJM-K), Department of Family Medicine and Community Health (NJB), University of Minnesota Medical School, St. Paul, and the HealthPartners Research Foundation (TAD), St. Paul, MN.

4.     Tongue-Tie and Breastfeeding: a review of the literature. Janet Edmunds. Breastfeeding Review 2011; 19(1): 19–26.

5.     http://www.bestforbabes.org/booby-trap-docs-who-wont-snip-tongue-tie-thousands-of-breastfeeding-moms-babies-suffer/. 22/9/2015. Booby Trap: Docs Who Won’t Snip Tongue-Tie, Thousands of Breastfeeding Moms & Babies.

6.     http://www.perioimplantadvisory.com/articles/2012/7/ankyloglossia-tongue-tie-release-using-dental-lasers.html. 12/10/2015. Ankyloglossia (tongue tie) release using dental lasers. Dr Laurie Kobler.

7.     http://www.drghaheri.com/blog/2014/3/6/how-does-an-upper-lip-tie-affect-breastfeeding. 7/9/2016. How does an upper lip tie affect breastfeeding. 16 march 2014.

8.        CONGENTIAL TONGUE-TIE AND ITS IMPACT ON BREASTFEEDING. Elizabeth Coryllos, MD, MSs, FAAP, FACS, FRCSc, IBCLC. American academy of paediatrics.

9.       Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and Lip Tie). Scott A Siegel. Int J Clin Pediatr. 2016;5(1):6-8.

10.   http://www.drghaheri.com/blog/. How the system can fail breastfeeding families. 8/9/2016.