Permission to post!  Have a client (my favorite pediatrician and very supportive of breastfeeding!) who delivered her first child 4 weeks ago who has never been able to pump more than 2 oz total and her supply continues to dwindle.  Normal pregnancy. No PCOS or hypothyroid issues.  Bra size increased from 34A to 36 B/C and breast assessment normal. Term vaginal birth (OP position so pushed almost 3 hrs) and d/c'd after 36 hrs with normal assessment for exclusively breastfed infant.  I was not able to visualize infant latched in hospital (don't like this to happen but I'm the only LC!).  Staff/mom reported latching well.  No nipple discomfort. 

Mom started supplementing day 5 with EBM and formula(2X/day) for "breasts not filling yet, sl jaundice and pressure from my mom".  Infant reported "latching well, seems satisfied after 40 mins total of nursing but BMs still dark. Voiding normally."  Mom only able to pump 10 mls from one side and drops from the other.  Encouraged hands-on pumping after each nursing session and to hand express when done pumping for complete emptying and extra stimulation.  She has large nipples so had already ordered larger flange.  Offered outpt visit in next couple days if supply did not normalize through breast or pumping in order to evaluate latch. Declined.

At 2 weeks, infant nursing every 3-4 hrs for 1 hour total then taking 1-2 oz formula supplement after in order for infant not to be acting hungry.  Weight now 2 ozs above BW.  BMs now yellow.  Pumping 1-2 oz total twice a day.  OB put mom on Reglan.  I warned her of watching for side effects of depression and recommended nursing more frequently, less formula supplement and taking lactation vacation for lots of STS time.  This new parent couple has BOTH in-laws staying with them for 3 months!  They are visiting from outside US.  Just a little stress for mom and dad, right?  Also, encouraged trying herbals before Reglan but she had already started.  Drinking Mother's Milk tea.  Gave her info on Fenugreek, Moringa and Shatavari.  No meds, no peppermint, no signs of retained placenta.  

At 20 days old baby was nursing every 1.5 to 2 hours during day.  Supplementing only at night with formula after which baby sleeps 4 hrs.  Reviewed importance of night feeds but this mom is exhausted and has given up her one cup of coffee a day!  Finally agreed to outpt visit.

At 23 days I got to see the first latch.  Infant is basically sipping on a straw for 40 mins to an hour between both sides while in a drowsy state!  Mom said, "I just didn't know that wasn't normal".  Now I know why mom's nipples never got sore and why milk supply is so low!  Not able to achieve deep latch despite all my tricks of the trade.  No swallowing heard.  No suck/swallow pattern seen.  Refused nipple shield.  Mom pumped about 3/4 oz (after feeding) with hospital grade pump. I also checked her pump for vacuum.  That was normal. Pretty sure baby has all the signs of posterior TT.  I don't need to go in to those details for this group.  Think baby is exhausted from trying to get a good seal for the last 3 weeks and has just decided that the breast is for comfort but the bottle gives her nutrition!  She transferred about 1 oz during that hour at breast.  For 3 weeks this baby has NOT been emptying the breast and there hasn't been enough pump stimulation to keep supply going.  Sent mom home with a plan to exclusively pump to see if we could get her supply back. 

Mom not interested in following up with tongue tie eval even after I presented it alternatively as an OT eval for oral restriction possibly r/t her difficult OP delivery.  Mentioned CST as well.  She will be returning to work in 1 month and will be pumping most of the day so decided to stick with pumping only plan.  BTW, I observed her bottle feed the EBM and her lips curl in on the rubber nipple!  Mom said it seems like she "gums" the artificial nipple sometimes and she hears a jaw click now and then.  She'll need an eval at some point.

As of today (baby is 1 month), after 6 days of exclusively pumping, supply has decreased to 1/2-1 oz total every 3 hours.  She is weaning off Reglan after 14 days with no improvement.  Started moringa 3 days ago.  Was not taking therapeutic level of Fenugreek but is increasing dose today.  She is actually supplementing with the EBM of one of our nurses blessed with an abundant supply until she can increase her own.  She is VERY discouraged!  Her goal of exclusive breastfeeding is fading.  She said she wanted to be such a good example for her patients and their families.  Told her she can still be a great advocate for her families that the experience does not always go as planned and can be a challenge and, to ask for help early!!

Again, what am I missing?  Would appreciate any suggestions to help this mom improve her supply through pumping!  Stress is my only answer for her right now.  She is already anticipating crazy days back in the office in 1 month and how she is going to find time to pump.  Sending the in-laws back home is out of the question!  I told her to at least send them off to be tourists for a week!

Thanks!

Holly Prescott RN BSN IBCLC
Women and Children's Services
Carolina Pines Regional Medical Center
1304 W Bobo Newsom Hwy
Hartsville, SC  29550
843-676-5568 cell

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