This is a situation where test weights come in very handy. I suggest 
doing them every 10 minutes to see what the pattern of milk removal is. 
I would do each breast twice, with test weights before, at ten minutes, 
and then ten minutes later or whenever baby pulls off. Sometimes I do 
each breast once with test weights and then go again to see when baby 
tires. And have mom pump with a rental quality pump afterwards, double, 
for 10 minutes and see what she can remove. I try to compare what baby 
is removing with his actual caloric needs as set forth in the BAB. If 
mom is willing, I might try an SNS type device and see if baby can 
remove milk better or goes to a more rhythmic pattern of sucking with 
supplementation at the breast. Oral motor problems can run in families, 
or tongue tie -- especially those sneaky posterior tongue ties. I like 
to watch the sucking pattern closely and then try to correlate the 
sucking with the intake. I have seen a baby be very disorganized at 
first, with poor intake, and then go into a very loud gulping sounding 
sucking with 3 ml intake. Mom is then instructed to stop nursing when 
baby starts getting to the ineffective pattern. I also like to see how 
baby sucks on a wide based slow flow bottle, how the lips grip, if there 
is spilling of milk out of the mouth, choking, etc. I would want a 
careful weight history so see if there was a time when weight gain was 
good. Some babies live on an abundant milk supply but it down regulates 
after a while when baby is not doing his part with proper sucking. If 
mom is on birth control, this could lower her supply.

Kathy Eng, BSW, IBCLC

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