A Case of Breastfeeding Baby with Low Birth Weight (LBW) whose Mother had a History of Myxoma and Unusual Nipple Shape By: dr. Viranda P Mariska Mrs. H gave birth to her second child, Baby A, female, at a hospital in Depok through cesarean delivery at 37 weeks old of gestation. The indications for cesarean section, in this case, were impaired fetal growth and a maternal history of cardiac myxoma surgery three years ago. The baby’s birth weight was 2320 grams. In the early hours after birth, the baby had to underwent a monitoring in the perinatology room and finally be able to share a place with the mother after 24 hours. Mrs. H gave birth to her first child, now four years old, through spontaneous normal birth, and exclusively breastfed the first baby for six months. Due to the broad-shaped of the right nipple and its contribution on baby’s grasping difficulty, the mother only offers the left breast to the baby. The mother continues breastfeeding until the baby’s age of 1 year and two months when she had myxoma, a tumor of the heart. At that time, the mother experienced extreme tiredness, heart palpitations, hands, and lips became pale to bluish. Through echocardiography, the cardiologist diagnosed the mother with cardiac myxoma. The surgery was performed two weeks later due to the worsening maternal health condition. The cardiologist stopped breastfeeding because the mother had to take heart medication, namely bisoprolol, for 2.5 mg once a day. As the result, the mother consumed the drug. She stopped without medical advice due to the inconvenience of taking the medications daily. During her second pregnancy, the obstetrician consulted to the cardiologist and cardiac surgeon about the mother’s condition. They allow the mother to stop the consumption of bisoprolol. She was a mother who worked full time and was on maternity leave for three months. The breastfeeding counselor doctor visits Mrs. H and the baby A in the inpatient department during the early postpartum period. The mother complains about the difficulty in breastfeeding her second baby. The baby was struggle to catch the mother’s nipples. Physical examination showed a vertical scar in the middle of the mother’s chest measured 13 cm. Symmetrical medium-sized breasts and colostrum begin to appear. Mother’s nipples were large. On the right breast, areola was 3 cm in diameter and nipple with a diameter of 2 cm. The shape of the nipple was sloped on the upper side and seems to blend with the areola, while the lower side of the nipple was more prominent with a length of 1 cm. In the left breast, areola was 4 cm in diameter. The left nipple was more prominent, with a diameter of 1.5 cm and the length of the upper side of the nipple along the 1.5 cm and the bottom side of the nipple as long as 2 cm.BANNER 728 x 90 During the physical examination of the baby, it was showed that a medial tongue-tie and third-grade lip-tie was existed. The baby’s suction reflex was good. Breastfeeding observations were carried out and showed that the baby seems to have a shallow latch. After being helped to improve the position and attachment of the baby, babies were still having difficulties to suckle and tend to latch shallowly on the nipple. The lady doctor counseled the mother about the benefits of breastfeeding, the dangers of formula milk and artificial teats, tongue-tie and lip-tie as causes of breastfeeding difficulties, and the Kangaroo Care Method. Mothers and babies were also advised to visit the lactation clinic soon after being discharged from the hospital. At the baby’s age of two days, the mother and baby came to pediatrician and lactation clinic for further control. They met dr. A, a lactation consultant pediatrician. The baby weighed was 2210 grams, 5.1% of below her birth weight. The mother experienced beast engorgement and cracked nipples. The baby could barely suckle at the breast. The mother’s right nipple was wide and asymmetrical and disturbed the baby’s ability to suck. Mother’s breasts were swollen and hard even though the mother tried hard to breastfeed the baby. Mother offered the baby both her breasts, yet it was too difficult for the baby to latch on to the right nipple. The pediatrician performed the frenotomy. Afterward, the breastfeeding counselor doctor taught the mother how to use a nipple shield so that the baby can latch on the right breast. Mothers were advised to learn to breastfeed directly without a nipple shield. The mother also did tongue and lip exercise for up to 3 weeks and therapeutic breast massage in lactation (TBML). Kangaroo care method was continued routinely every day for 24 hours a day until the baby weighs 2500 g. At the next visit, at the baby ‘s age of nine days, the baby’s body weight increased to 2250 grams or increased by 14.3 g per day. Mother was using a nipple shield sometimes. At the clinic, the baby was able to suck well at both breasts without a nipple shield. The mother was advised to breastfeed the baby directly without a nipple shield and keep doing the kangaroo care method. At the age of 14 days, the baby’s weight fell 35 grams to 2215 grams. The mother had not done the kangaroo care method because she felt bothered by taking care of the child while taking care of his first child. The baby looks jaundiced, therefore the bilirubin was examined. Bilirubin test results were 15.7 g / dL. Dr. A re-educated the mother to routinely perform the kangaroo care method until the baby weight reached 2500 grams. At the end the mother agreed to continue the method. Nine days later, when the baby was 23 days old, the baby finally gained her weight well as much as 25 grams per day to 2440 grams. The nutritional status of the baby was still underweight. Kangaroo care method was carried out routinely every day. Mothers also feel improvements in the breastfeeding process. The baby’s bilirubin was re-checked, and the result showed 14.3 g / dL. Mothers were asked to continue the kangaroo care method. At the next visit, the baby was one month five days, gained weight 27 grams per day to 3316 grams. The mother was no longer required to do the kangaroo method because the baby weight was more than 2500 g. The nutritional status of the baby was still underweight. However, due to improved weight gain, exclusive breastfeeding was continued with close monitoring. The lactation consultant doctor told the mother to prepare on how to keep breastfeeding when she started working while the baby age was three months old. Moreover, the baby’s weight was reaching the normal range, or in other words, considered being an optimal nutritional status, when she was three months and 22 days old. At that time she weighed 5080 g. The baby’s weight continued to gain well through exclusive breastfeeding. The pediatrician suggested the mother give proper complementary feeding at the baby’s age of 6 months. Literature review Cardiac myxoma is a type of benign primary heart tumor. 1,2,3 The prevalence of heart tumors is between 0.001% to 0.3%, with 50% of benign tumors being myoma.1 These tumors generally do not predispose to genetic disorders. However, 7% of these tumors have genetic causes.1,2 Cardiac myxoma is most often found in adult women with a median age of 49 years. Patients with the age of lower than 20 years and above 90 years also had a chance to have myxoma. 2 Myxoma occurs two times more often in women than in men.3 Generally, myxoma occurs in the left atrium.2 Myxoma is globular in shape, has a soft consistency like gelatin, yellowish-green, and often has areas of bleeding and necrosis. Myxoma mostly has a large attachment but can also be localized. Symptoms and signs of cardiac myxoma can be shortness of breath, coughing, swelling, and fatigue. Symptoms can be severe with specific body positions, due to the movement of tumors in the atrium.1 On physical examination, a “plop” and murmur detected using auscultation, anemia, right heart failure signs, clubbing fingers, and Raynaud’s phenomenon. There are also nerve symptoms, such as weakness and paralysis.1,2 Complications of cardiac myxoma can include heart failure, regurgitation, arrhythmias, contractility disorders, heart block, pericardial effusion with or without tamponade, pulmonary symptoms, and embolization The primary non-invasive diagnosis for cardiac myxoma is echocardiography. Diagnosis can also be made by CT scan, MRI, and, very rarely, angiocardiography. 1,2 In 35% of patients, laboratory abnormalities. The management of cardiac myxoma is generally by open cardiac surgery with cardiopulmonary bypass. 2,5 Surgery must be performed immediately without delay because of the risk of complications. Local recurrence occurs in 3-4% of patients, especially young patients.2 Discussion In this case, Mrs. H had a history of open cardiac surgery with cardiopulmonary bypass three years before, due to myxoma. This condition happened when she breastfed her 14 months old first child. At that time, Mrs. H was asked to wean her child because of the consumption of the drug bisoprolol. The safety of bisoprolol during breastfeeding was on limited data, probably compatible. In a case report, there was no bisoprolol in expressed breastmilk of the mother who consumes this drug. There are no data yet on infants who breastfed by mothers who take bisoprolol.5 At present, Mrs. H has no cardiac complaints and has not taken heart medication. The mother gave birth to a child with LBW at 37 weeks of gestation. There are obstacles to breastfeeding in the form of large nipples and unusual shapes that made it difficult for mothers to breastfeed their babies on the right breast. The mothers kept trying to breastfeed the baby by visiting the pediatrician and lactation consultant routinely, aided with the nipple shield in the first days of breastfeeding with the guidance of a lactation consultant doctor, and performed the kangaroo care method. The mother successfully breastfeed her second child exclusively with both breasts and intends to continue breastfeeding until the age of two years. In this case, mothers with a history of cardiac surgery due to cardiac myxoma, unusual nipple forms, and LBW baby can be helped to continue breastfeeding with close and regular monitoring. Cohen R. Atrial myxoma: a case presentation and review. Cardiol res. 2012 Feb: 3 (1): 41-4. Mir IA, Ahangar AG. Atrial myxoma: a review. Int J Public Health Med Community. 2016 Jan: 3 (1): 23-9. Lee KS, et al. Surgical resection of cardiac myxoma — a 30-year single institutional experience. J Cardiothoracic Surg. 2017 Mar: 12:18. Samanidis G. Surgical treatment of primary intracardiac myxoma: 19 years of experience. Interactive cardiovascular and thoracic surgery. 2011 Dec: 13 (6): 597-600 Hale T, Rowe HE. Medications and mother’s milk. 17th ed. Springer publishing company. 2017.