Yes that is all pretty complicated, and I wouldn't want to suggest too many
things that might overwhelm mom. The good news is she is making 16 oz per
day. As far as priority, since a tongue tie was not seen and a lip tie is
"iffy", I would suggest the CST if mom is open to that and her budget
allows. She has large pendulous breasts, with slow letdown, and it seems
the best flange size has not been determined exactly. So I would
encourage massage and hand expression to elicit letdown (before bf or
pumping) and hand expression at end of pumping, and experiment a little
further as to flange fit. When I am working with a mom with bf or supply
problems, I always like using a hospital-grade pump if that is financially
feasible. Even though reflux seems to be "overdiagnosed" the baby may
indeed have this, as he seems to be limiting feed volume most of the time,
and crying and arching. Anti-reflux tactics could be used: upright in
kangaroo care after feeds, smaller frequent feeds, possibly meds. I hope
this helps you sort this out, somewhat.
Laurie Wheeler RN MN IBCLC
Mississippi USA

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