Thank you for the comments I received overnight.  They are so helpful in giving me ideas and helping me explore ways of helping this mother/baby pair.

Rachel - to address your comments first.  I am confident in good milk transfer as it is very easy to see. Jack Newman would describe this as textbook milk transfer as per his video! I also had another LC with me at this home visit (she is an Ob  and the woman's LLL) so we were able to confer notes.  I should add that this mum is tandem feeding with her two year old boy.  He has the right side and baby has the left.  Mum can also  express easily at any time and produces copious amounts.  

It is important the tandem feeding does not become a red herring here as I am confident this mum can readily supply for both children.  But I am afraid when she gets into the medical system they will see red over the tandem feeding in combination with the poor weight gain.  That is why it will be so important for me to document  my findings well and report them in a very concise way for allied health professionals to read.

My golden rule is always to feed the baby first, but I can honestly say after observing several feedings, that the baby takes all she can in any one sitting.  The cycle seems to be: feed for 4 -5 minutes, fuss, come off, cry excessively for about 10 minutes, cue again, feed a little longer (fresh let down each time), pull off, fuss and cry some more and on this goes for 1 -2 hours until the baby falls into an exhausted sleep for about an hour before the cycle starts all over again. I think reflux may need to be considered here and I have advised mum to talk to her paediatrician about that soon.

I am thinking about some lacto-engineering though (as suggested).  Mum is going to scoop off the hindmilk after it has settled in the fridge and teaspoon that into the baby's mouth.  Certainly the baby needs to start enjoying oral stimulation more otherwise feeding is going to continue to be problematic.

Meanwhile, Mum is doing all the right things including sling wearing and lots of devotion!

Will keep you posted.

Karen Palmer
ILBCLC and midwife
Waikato Breastfeeding Collective
New Zealand

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