Hi, all--
I just had a mom here yesterday who came for a pump rental. She is new to
our area, having just moved here 3 weeks ago, and her supply was down to
the point that baby is balking at the breast. She attributed it to the
hecticness of moving (they are in the military, of course) but was
concerned because her 4 mos old was starting to lose ground on the wt charts.

Well, I had her try the double pump set-up first to make sure that she
would be happy with it, and we hardly got anything out of her. Hmmmm. It
had been almost two hours since the last nursing, there should have been
more there. I also noted some scars peripherally on her areola. At ten
and five years ago, she had had breast lumps (benign) that were removed.
I was horrified to find that the lumps had occurred closer to the armpit
area but the surgeon had elected a peri-areolar cut to incise them, even
after she told him that she wanted to breastfeed eventually! So she's had
two identical surgeries in the same place on each breast.

Baby was 6-3# at birth, now around 12 lbs, but dropping from 25th to 10th
percentile. Mom says that baby began to balk at the breast, fuss, cry,
and even scream when offered the breast during the daytime about 3 weeks
ago, the same time as the move. Concidence? Her bfg managment and
positioning to date have been exemplary, and she is just wonderful with
this little girl. As I talked and watched and witnessed the tantrums of
this baby when offered the breast, I saw a little girl upset because mom
"wasn't giving her milk". Mom told me that she seems to have "quite a
temper", but when I questioned her further, it is only in these feeding
situations that her "temper" is displayed.

Because the pump did not elicit an MER, I tried hand expression on her.
This did not elicit an MER, either, but I noticed an interesting pattern:
it seemed that I was able to milk the sinuses, but they did not
automatically refill. I would get 4 or 5 streams, that would reduce to 2
or 1, in about 5 expressions, and then it would quit altogether. If I
stopped for 30 seconds or a minute, they would THEN refill, and I could
get some more. Obviously the intermittent automatic pump doesn't allow
for this refilling, but hand expression wasn't terribly efficient,
either. Mom has never been able to pump more than a 1/2 oz (or should I
say express?) at a time, but baby can get it out.

I later watched when baby finally attached, and she was swallowing 1:4; I
didn't see much evidence of MER, though mom says that she definitely does
still have them. I agree with mom; her supply is definitely diminishing,
despite good and normal management.

What would you do here?

How about herbs, such as fenugreek, or perhaps even the dreaded Reglan
(metoclopramide)?  Maybe baby did ok the first 3 mos because she was able
to manufacture enough milk, but now her body can no longer keep up, for
above reasons.

I ended up sending her home with an SNS to try (baby wasn't amenable by
the time we got down to that option to try it in front of me), and a
decision to poll you all. What do you think?

-Lisa

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Lisa Marasco, BA, LLLL, IBCLC
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