Disclaimer: the case below is an amalgam of multiple cases that have presented to me, and is not derived from any specific or identifiable mother-baby pair who have seen me as patients. Needless to say, all names are fictional.

Baby Riku has difficulty coming on to the breast, and never stays on for long

Baby Riku had difficulty coming on to his mother's breast right from the start, due to breast tissue drag and positional instability. Riku was a term baby, and otherwise healthy.

I first meet him and his family when he is twenty-five days old. By the time they came to see me, his repeated experiences of breast tissue drag had also caused him to develop a conditioned dialing up at the breast, which was very distressing for his mother, Verity. Verity had been using an ill-fitting nipple shield, too, which she was given in hospital.

This is Verity and her baby's story.

Riku's first day of life

Verity is hoping her newborn, Riku, will come on to the breast today. He roused just as she was finishing breakfast, and she waits now in the beige vinyl arm-chair which is wedged into the room near her hospital bed.

Verity gave birth about this time yesterday. She remains in a haze of sleep deprivation, with a dull, slightly nauseous head-ache. She has slept for perhaps four or five hours in the past forty. Her perineum throbs from the episiotomy which she had prior to a vacuum extraction.

Verity knows how important skin-to-skin contact is, and snuggled Riku in against her bare breasts most of yesterday. If she wasn't holding him, he was in his father Hiromi's arms. Sometimes Riku sniffed and licked her nipple, or even placed his little lips over the nipple, without really taking it into his mouth.

During the night, a midwife helped Verity hand express a couple of millilitres of colostrum into a syringe. The midwife slid the syringe into Riku's mouth alongside her gloved finger, patiently squeezing colostrum in as he sucked.

This morning, Hiromi strips his precious little son down to the nappy, marveling at the contours of his bird-like bones, prominent under his skin. Then Verity reclines the chair back and snuggles Riku in, tummy down and high up on her bare chest.

Soon Riku bobs his head and turns his face from side to side against his mother, lunging down towards her left breast and nipple. Verity helps by carefully shifting his bottom to the right, until he lies diagonally across her tummy. She knew this was called 'baby-led' or 'laid-back' breastfeeding, and she saw it done in a video in one of the antenatal classes. But now Riku is bobbing and rooting and panting around her nipple and areolar, making distressed grunting sounds.

"He still won't latch!" Verity says in despair, glancing up at Hiromi, but she continues to try to help him with encouraging murmurs and calming caresses.

Hiromi reaches down and briefly strokes their baby's spikes of raven-black hair.

"Come on son, I know you can do it," he says quietly.

But black-haired black-eyed Riku dials up even more. He bobs about Verity's breast and nipple and areola, sometimes closing his mouth over the nipple and suckling briefly. Then he pulls off and arches his back so that his little tummy pokes out, crying. He returns to the breast over and over, panting and rooting and flailing with increasing desperation. Before long he is screaming again, face red, fists clenched, knees pulled up.

This is heart-breaking for Verity and Hiromi. In a while, Verity stops.

Two days after the birth

It's the same on the morning of Riku's third day of life. Verity sits in the chair trying to breastfeed. Hiromi hovers, trying to be useful. He offers a glass of water. Verity doesn't want water. He asks if she'd like anything to eat. Verity doesn't want to eat. (Eat? She looks at Hiromi in disbelief, as the baby cries.) Should he go and find a midwife?

"What are they going to do?" asks Verity, and tears slide down her cheeks. "I've had about six try to help so far." She isn't exaggerating. Each one says or shows her something different.

Finally, Hiromi offers a box of tissues and rubs her upper arm, gently. Verity is usually no-nonsense and competent. Hiromi is managing sky-rocketing anxiety himself, partly because the baby's screams are so distressing, and partly because it is painful to see how upset Verity is. It's been like this every couple of hours, day and night, since yesterday morning.

But Hiromi stays calm. "It's all going to be alright", he says softly.

Verity stands with Hiromi's help and manages to calm the baby. Then, when Riku is quiet, she settles into the chair again, moving carefully so as not to aggravate her peroneal pain, and tries again. This time she squeezes her breast into what the midwives call 'a sandwich' with her other hand cradling the back of Riku's head and neck. She tries brushing the nipple over his lower lip to stimulate a gape, as she'd been told. He does open up wide at times, and she quickly places his chin on her areolar, aiming nipple-to-his-nose, then brings him in. But he won't stay on. Other times she holds him with his mouth one or two centimetres away from the breast, waiting for a wide gape.

"How on earth does anyone do this!" she exclaims in frustration to Hiromi. "Each time I offer, it just seems to set him off again!"

At one point when he opens his mouth wide she pushes him onto the nipple and breast tissue which she has now squeezed up into a large teat. Riku makes muffled little crying sounds but then settles and suckles, desperately. Just when Verity thinks it might be going to work, he is off again, screaming.

Finally Verity hands the baby back to his father, tears streaming down her face. Hiromi cradles Riku against his shirt, rocking and jigging. He hums a little Japanese nursery rhyme which his own father used to sing when Hiromi was little, and suddenly Hiromi feels a stab of grief for that wise old man who died a few years ago. But Hiromi keeps on humming and attends very carefully to his song and to his little boy, who is hiccupping and shuddering, but settling. Time to be completely in the present moment, he tells himself firmly.

Verity covers her breasts with the stiff white cotton hospital gown. She feels ashamed that somehow her body is failing in this way, that her breasts are demonstrating such outrageous incompetence. She's always been, since adolescence, big-bodied and generous-breasted. In her twenties, she fluctuated wildly between desperately dieting, because she hated her body, and then binge-eating, because what did she care?

These days, in her early thirties, she eats mostly wholesome foods, exercises enough most weeks, and shows a gutsy refusal to be intimidated by the thin culture around her. When she goes into work as a well-respected and senior public relations manager in a large corporation in the city, her block-coloured suits fit snugly over her gorgeous generous curves.

Hiromi adores every centimeter of his lovely wife. But still, Verity can't help feeling embarrassed about her body, here, now, in hospital, with their precious newborn screaming at her each time she tries to feed him. Her exhausted mind starts telling her that her breasts are ridiculously enormous and useless, with their puffy areolars and broad, flat-looking nipples. She knows that these very early breastfeeds are important for developing a good supply, and she was all ready to offer as frequently as the baby wanted, but what do you do when your baby won't take the breast?

A midwife comes in, with a brisk air about her. She is hurrying to check on the last two new mothers in her ward before her shift ends. It's the first time Verity has seen this particular greying middle-aged woman in her crisp pale blue nurse's uniform, hair pulled back tight in a no-nonsense ponytail.

"Any luck?" the midwife asks matter-of-factly.

Verity can't stop the tears rolling down her cheeks. She blows her nose gently.

"Maybe my breasts are too big to breastfeed", she says to the nurse, in a while.

"Really?" asks the midwife kindly. "Do you think so? Can I check?"

Together they ease back the garment and the midwife looks for a moment at Verity's generous breasts. Hiromi rocks the baby, who has quietened down.

"It's probably more that your nipples are flat," the midwife suggests. "That makes it hard for the baby to grasp the nipple. Let's try again." She turns to Hiromi.

"Why don't you slip him into his onesie? It's quite cool in here."

Hiromi places the baby on the bed and dresses him slowly, easing one scrawny little limb after the next into the garment. The midwife hand expresses the colostrum, which is becoming less dense and more milk-like into a sterile plastic container from Verity's left breast. The midwife is adjusting mentally to yet another day home late, all unpaid overtime and it's not fair, but then it's not fair if these new mothers don't get the attention they need, either.

Hiromi zips up the onesie and hands Riku over with a careful loving father's hands. Riku is crying again. The midwife asks Verity to sit upright, and helps Verity shape her right breast with her right hand, holding her left hand and fingers on the baby's upper back and neck, Verity tries again to bring the little one on.

Both Hiromi and Verity are thinking that both the Australian Breastfeeding Association counsellors in the antenatal classes and the IBCLC they saw yesterday advised against using this approach, but at least the midwife is trying to help. Frankly, lying back and letting Riku self-attach hadn't worked, either.

This time, Riku stays on for a while, sucking desperately. Verity and Hiromi look at each other briefly, in hope. It's uncomfortable. Holding her breast up and squeezing it like that hurts Verity's shoulders. Her nipple hurts too. But she sits very still in the hope that Riku will stay on.

"He probably couldn't breathe before," comments the midwife, who'd been standing there watching. "Sometimes," the midwife says, wanting to be helpful, "you can press a finger against the breast to keep the nostrils clear." She writes notes into her iPad, and soon is gone to check on the other two women.

The minute Verity tries to take her hand away from squeezing her breast, Riku comes off and screams. In a while, another very young midwife with a blond bob comes in and they finger feed the baby more expressed colostrum by syringe.

After that, when Riku is calmer, they try a football hold, tucking the baby down the side of Verity's body so that he rests on the wide flat arms of the lounge-chair, coming up under her breast. Again, there is some initial success - but soon enough the baby is off and screaming. With Hiromi and the midwife's help, Verity again lifts her aching body out of the chair, holds Riku upright against her chest, and begins to rock him.

"Little boy, little boy," she murmurs, "shshsh shshsh shshsh shshsh..."

Hiromi takes the young blonde midwife aside in the corridor.

"Verity really wants to breastfeed," Hiromi says cautiously, "and I'll support her all the way, but is this a situation where we need to think about using formula?"

"Maybe, soon," the nurse says, "but her milk is coming in well and Riku is passing enough urine so let's send in the lactation consultant again."

Late that afternoon another IBCLC visits. This cheerful, humorous gray-haired woman spent an hour and a half with Verity. She had Verity lie on the bed in a semi-reclined position, breasts exposed and with the baby on top of her, his tummy facing in.

"What we need is called 'baby-led' or 'laid-back' breastfeeding," the kindly IBCLC explained, "It's best for turning on Riku's breastfeeding reflexes." Hiromi and Verity glanced at each other: they'd tried this often without success. And once again, even the IBCLC couldn't help Riku come on.

"It's your nipples," the IBCLC concluded. "They are too flat. And Riku has a high palate with some oral connective tissue tightness, though we'll just watch that for now. See how he has a preference to turn his head slightly to the right? I think this is from the vacuum delivery. Maybe he has a headache as well. I suggest you see a chiropracter as soon as you can."

In the end, the IBCLC also used a syringe to feed Riku colostrum again.

Three days after the birth

The next morning, when the same IBCLC returns, she tells Verity and Hiromi that Riku has lost more than ten percent of his birth weight, and isn't having as many wet nappies as expected. His stool is still a dark green. She tries to help Riku come on, again with the 'baby-led' approach and also a football hold. There seems to be some success with the football hold, if Verity also uses a nipple shield. Riku stays on for about five minutes but still pulls off crying.

The IBCLC recommends that Verity starts a regimen of three hourly offers of the breast, then pumping both breasts, then topping Riku up with sixty millilitres in total, of either expressed breast milk or formula.

"You're so lucky having the IBCLC visit you twice," another midwife remarks that evening. "Most of the time, women are lucky to see them at all, because there aren't enough positions funded in the hospital."

Verity and Riku are discharged later that day, with a nipple shield and instructions to rent a hospital grade pump with a double kit.

Four days after the birth

Overnight, home in their own bed at last, Verity's milk comes in and drenches the sheets. Once again, she doesn't sleep well.

Riku continues to either not take the breast, or to take it for a short period of time then come off crying, no matter what Verity tries. Every three hours, after arriving home, Verity offers both breasts, sometimes trying 'laid back breastfeeding', sometimes sitting upright and making a c-shape of the breast, sometimes trying a football hold with the baby on a pillow, sometimes with and sometimes without the nipple shield.

Although there are brief periods when Riku seems to suckle, mostly breastfeeds end with a screaming baby. Riku does take the breast better with the nipple shield, but still never stays on long. Afterwards, Verity pumps while Hiromi bottle-feeds Riku.

By the morning of the fourth day of Riku's life, Verity's breasts are like great rocks, twice their usual size, hot and swollen hard. The nipples seem to blend into the areolar. Verity remembers how to do reverse pressure softening before she offers Riku the breast.

"I'm not sure how long I can do this for," Verity confesses to Hiromi that night. Hiromi puts his arms around her, and she cries. She can't believe how often she's been crying since Riku was born!