Hi, Lynn,

>What a nice job of presenting the facts of this case!

Why thank you!

>I am confused about your recommendation to adequately drain the breasts,
>however.  If when you say *adequately* you mean *as well as possible with
>a pump* the this is contributing to the problem of over production.  Was
>this Mom being *encouraged* to take out 8-10oz per pumping session as
>reported above?

No.  It was a fine line.  Remember that the baby was not nursing at all, so
the next best means of milk removal was via pump.  The goal was to remove
the milk as effectively as possible -- and hopefully to move the milk in
the stagnated ducts -- without encouraging further production.  One of my
first recommendations was that she reduce the amount of time she was
pumping, but that she use a better pump.  I felt it was critical to use as
effective a device as possible to remove the milk.  A piston pump is more
effective than a diaphragm pump.

>In addition while compression will certainly help to open clogged ducts ,
>it will also,obviously, promote continued over production.  In other
>words, If you try to *cure* clogged ducts by employing a method that
>promotes or prolongs overproduction than you are putting the cart before
>the horse and you will never make progress.

Again, it is a fine line.  Massage and manual stripping of the ducts to
move plugs has been very effective in my experience.  I felt that the
overproduction was less of a problem (and more easily controlled) than the
plugged ducts.  I wanted to get the milk moving in order to eliminate the
plugs.  I felt that massage and the most effective suction/cycling possible
from a pump was the best chance of achieving that.

>Along the same lines, why the recommendation for the Medela classic when
>she was already pumping enough for a playgroup with the pump in style?

To more effectively remove the milk.  The Pump-in-Style may have been
yielding a good quantity of milk, but was it actually draining as many
ducts as possible?

>You mention later in your description that the issue of overproduction has
>resolved (totally or somewhat?)

Totally.

>but that she is left with severely clogged ducts. I hope she knows that
>relieving these ducts will be accomplished much more effectively with a
>nursing baby (sucking AND compression) vs. a machine that only exerts suction.

She understands this very well, but has firmly decided that she does not
have the physical and emotional energy to continue trying to get the baby
to latch.  As I said, I don't agree with her decision at all, but I have no
choice but to support it.  At least she is continuing to lactate.

>Did you try dripping milk onto the shield while the baby attempted to
>latch at all?

Yes, I sure did.  I spent nearly ten hours with this mom *just* trying to
get the baby to latch.  There were days when he would latch well, but he
did it so rarely that eventually the effort was too much for her.

>I find that an obstacle with moving an established bottle fdr to the
>shield is often the delay in milk transfer inherent to shield use ie. they
>need to suck rhythmically for several minutes before milk begins to flow
>and this is quite different from the immediate flow of the bottle nipple.

Yes, that is definitely a problem.

>As is most often the case with issues originating with overproduction,
>mismanagement by the breastfeeding help and/or misunderstanding of the
>teaching by the mother plays a big role and seems to have in this case as
>well as this mother's overproduction was sustained for many weeks post
>engorgement.

Yes, this mother is the first person to admit that her problems are
completely the result of lack of information and help in the early
days.  But I would never want her to feel the responsibility for this.  She
was released from the hospital with a baby who was not latching, even
though she had clearly stated that she intended to exclusively
breastfeed.  She did her best to get help: she called a volunteer support
organization and an IBCLC from the hospital and requested consults.  Both
individuals were only able to see her in isolated visits, which did not
allow them to understand the complexity of her problem.  Knowing she still
needed more help, she sought out a private practice IBCLC.  Because I was
able to spend a significant amount of time with her, I was able to peel
back the layers of her case to soft out the true problems and
causes.  Fortunately, her milk supply responded very well to methods to
reduce it so that we didn't have to contend with oversupply as a continuing
problem that may have resulted in even more plugged ducts.

I most sincerely appreciate your thorough analysis of this case and your
help in sorting out the cause and effects so that we can find a solution.

Diana West, IBCLC

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