Brenda
I think you are quite on the right track with BFAR moms. I am working in a 
hosp setting, so only have a day or two to give info to the mom. 
Occassionally I get a prenatal consult for one. I do mention in bf class 
that any breast surgery should be discussed w/ the LC prior to the birth.
There is no surefire way to approach this. I believe in giving all the info. 
I believe in very close f/u of the dyad. Sometimes I recommend 
supplementation very early. This would depend on being able to express 
colostrum or not, size and gestation of baby, juandice, wt loss, baby cueing 
on hunger alot and no satiety at breast.
Others may even go home and not be on supplementation, but must have close 
f/u. I have personally never worked with any BFAR mom who did not need large 
amts of supplementation. However I have heard, read of cases where they did 
make alot of milk. I recently had a mom with very prominent keloids and she 
was quite reluctant to give the baby anything other than the breast, it was 
a 4 lb range baby who was losing. It was hard for me to get her to 
supplement.
I do discuss all methods of supplementing and usually use the supply line 
ala jack newman in hosp. I think it is the easiest to use.
You do have to have the best latch etc. I do inform the mother that, in my 
experience, lots of mothers develop low supplies very quickly (surprisingly 
quickly) if they are not doing optimal bf practices and techniques. So that 
is where you always start.

Gastric bypass: I think this is a new area and there is not enough cases to 
know what the ramifications are. Therefore, the dyad should be followed very 
closely. In the general population, it would be low volume that leads to 
poor gain or FTT. In gastric bypass pts, it *could* possibly be an 
alteration in milk composition, I don't know. I do think it is imperative 
for the mother to work with a nutritionist or dietician to maximize her 
nutrition. Even though it is true that normal moms do not have to worry much 
about their diets (IMO), absorption of nutrients and micronutrients 
apparently are affected w/ gb surgery and so this is not a normal situation.

Laurie Wheeler, IBCLC, MN, RN
New Orleans Louisiana, s.e. USA

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