First, a quick re-intro, having not posted for quite a while.  My name is
Mary Coutts, I am a LLLL and new IBCLC.  I work part-time, mornings for 2
hrs. in a local hospital.  I have been given permission from my client to
post for help and information. I apologize for length of post and perhaps
lack of clarity of the whole story.  I'll do my best.

Mom delivered 4/26/02, girl, wt 7# 4 oz. Discharged 4/28/02, wt 6# 13 oz. On
4/30/02 6# 11 oz. and on 5/2/02 wt. 6# 14.

I was called to the hospital Sat. evening (4/27) because baby had not nursed
since 2 a.m.  Mom told me she was told that baby had "spit up quite a bit of
mucous in the nursery after the 2 a.m. feeding, even turning blue and baby
was not able to come out to mom for next feeding until 10:00 a.m. on Sunday
due to needing to be observed at this time".  Mom told me each time she
offered breast as of 10:00 a.m. baby would not latch.  When I arrived baby
was alert and showing signs of readiness to feed.  Mom proceded to position
the baby and offer her breast.  Baby would root and attempt to take the
breast, opening very wide, only to end up sucking her tongue and lower lip.
 Baby finally latched well lying face down across Mom's upper abdomen at an
angle with Mom's back only very slightly elevated.  Baby suckled well, both
breasts, same position, swallows heard.  Mom stated she would use this
position each time if others again through the night did not work.  Because
she would be discharged before I returned to the hospital on Monday for
work, I offered to make a follow-up phone call.  Mom stated she would call
me if she needed me.  I did not hear from Mom and assumed things were fine.

Tuesday evening a hospital ob nurse called me, having seen this Mom and baby
that afternoon for a weight check.  RN was concerned that baby had lost
another 2 oz and had not had a bm in the last 24 hrs. Baby had had 3 wets.
The nurse asked me to call her for further counseling.  She also told me the
Mom went home Sunday with a hospital-grade rental pump because she was
having difficulty latching baby at discharge and had a plan of attempting to
latch baby, if baby did not latch, mom would pump and bottle feed or finger
feed. The nurse also told me that she was told by Mom that when home, baby
was latching with much work and persistence, only to fall asleep within 3
minutes at breast once baby was what Mom thought - latched well.  Mom would
then attempt to wake baby, only to have her fall asleep each and every time
in same manner.  Mom then double pumped for 12-15 min. getting a tsp or less
from each breast. She would wake the baby and give the breastmilk with 1/2 -
3/4 oz formula at each feeding.  Nurse told her to increase amount of
formula given after each attempted feeding at breast and that she (rn) would
call me for further counseling.

I saw Mom and baby Wednesday (5/1/02) morning.  When baby was first offered
the breast, she seemed somewhat confused, and when she did latch it was very
shallow, taking in very little aerola.  I did not see tongue sucking at this
time like I did in hospital. (Mom has average sized breasts and nipples with
no out of the ordinary "design".)  Sandwiching the breast and moving quickly
when baby opened finally resulted with a good latch, good sucks and
swallows, however, we only heared swallows at the very beginning, maybe
first minute, minute and a half. Baby did stay awake and suckle for 15 min.
on one side and 10 minutes on the other with baby taking second breast much
easier on her own, but still hearing swallows for only maybe the first
minute or two.  Mom stated her breasts felt only a little different after
feeding. I then had Mom double pump for 12 minutes, getting 5 cc's from each
breast, seeing a little spraying of milk at start of pumping and then
turning to drips for the remainder of the pumping time. Pump seems to be
working fine. I then tried messaging Mom's back and applying warm towels
while pumping.  No difference. Any other suggestions?  (What you'll probably
want to know is, Mom was slightly engorged, not severe enough that I wanted
to jump in and use measures to relieve it, wanting to see what baby did
first with breast as is - which I beleived was doable for many babies and
moms, however when I saw Mom and baby struggling to get latched, we took
measures to relieve some of the "fullness" by using cold compresses followed
by warmth, breast message and pumping for 5 minutes, getting very little
milk. It was after this that the baby latched with "sandwich" hold, due to
in my opinion the cool compresses and sandwiching, not the pumping. Mom,
being very sleep deprived, was concerned about going through this routine to
get baby to latch each time, and even then, though latched, would only hear
swallows during the first minute or so and then still need to take time to
formula feed.  Having worked with this mom and baby for well over 2 1/2
hours, I definitely sensed she had had enough for the time being with me.  I
told her I would see her again if she would like.  We also discussed a
feeding plan which would be to breastfeed, offer formula after and pump
after feeding til we spoke or I saw her again. Suggesting an SNS crossed my
mind, but I admit I did not suggest it at this time for the simple reason I
felt she wouldn't "go there at this moment".  Perhaps poor judgment on my
part.

 She informed me she was having a home health visit on 5/2.  I suggested she
also go for a weight check, which as I mentioned above showed a weight
increase - more than likely in my mind because of formula. Still only 1 bm.
She called me last night to tell me this, feeling somewhat rested and ready
to try and resolve this.  She also told me that the baby as of 5/2, would
not stay awake as she did when I was there and suckle, but would fall asleep
within 3  minutes.  Mom would wake her, latch her and have her fall asleep
over and over again.  Then bottle feed. I'm considering discussing an sns at
this time till we figure things out. While she stated she'd really like to
breastfeed, taking any "drugs" does concern her and she isn't sure she'd
like to go that route....

My question - finally:  From what I describe, and I'm afraid quite poorly at
that - would you say there is a milk supply problem or a problem with MER?
Or both at this time? I'm leaning towards MER, but oxytocin intranasal spray
is no longer available - is that right?  What else would I suggest for MER
problem?  Would you take measures to at the same time increase milk supply
(domperidome or Reglan - fenugreek?) or wait and first resolve MER problem -
 if there is one and then see how supply is - which I'm worried about with
little to no emptying of the breast taking place at this time.

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