Dear Kathy:
My empathy with this case. The combination of low supply and a poor suck is
a difficult one. And often the poor supply had led to the low supply. It
sounds like she really missed the critical window for establishing those
prolactin receptors and is going to need some significant interventions to
boost her supply. I was trained in Manhattan by supervisors who primarily
use the SNS as their intervention of choice so I feel I know it well. I
had the good fortune to just drop into a job at the Elizabeth Seton
Childbearing Center where I was introduced to a breastfeeding medicine
specialist and other lactation consultants who have revolutionized how I
work with the SNS.
I. SUPPLY
One of the key issues that I have found is that you MUST address the supply
or this poor woman is in for a long haul of hard work and may not only not
achieve her goal - but may not even come close.
A. CURRENT RATIO
In terms of the ratio of breast milk to formula, you've given the following
information:
"I have done 3 visits, and each time baby took about 1 oz from mom's
breasts and 3-4 oz. in supplement from an SNS"
"She nursed yesterday 12 times with SNS and used 20 oz. formula the entire
time" "Baby continues to take 20 oz in 24 hours. I believe baby takes
about 30 oz total per day."
"Never more than 1 oz total from PNS use." and "She used her PNS twice
yesterday."
From this is sounds like to me that the maximum the woman is producing is
about 14 oz (~1oz each time with the SNS x 12 = 12 oz and ~1oz with the SNS
x 2 = 2 oz) and the baby is consistently taking 20 oz of formula after two
weeks of using the SNS.
It sounds like the woman is only at one third supply. We have seen many
women limp along with no progress when the supply is low, especially when
there is a suck problem. Even with a baby who has a great suck - we seldom
see progress in moving towards breast alone without getting the supply up.
And it doesn't sound like the past two weeks have done the trick.
B: GALACTOGOGUES:
Then you stated that:
"I have suggested galactagogues, rental pump,................" and " She is
willing to try fenugreek and blessed thistle today."
I remember reading about domperidone on Lactnet and wondering how it would
help my clients - but I had no contact with anyone who had used it.
Finding a breastfeeding medicine specialist who prescribes galactogogues
has been wondeful for these cases. The poor woman is 8 weeks in, missed a
critical window of stimulation of her prolactin receptors, and her supply
is extremely low. In my experience, fenugreek and blessed thistle won't
cut it. I would highly recommend you explore your community for a
sympathetic MD who can prescribe some domperidone. This poor woman needs
all the help she can get.
C: PUMPING
Then you stated that:
"She used her PNS twice yesterday.". and "I have suggested galactagogues,
rental pump,................"
So this means that the woman is barely pumping. It's great you recommended
the hospital grade pump which may increase her yield so she gets more from
the pump. I doubt that twice a day pumping going to cut it if she's going
to build her supply. We usually recommend 5-8x per day.
II: PRIORITIZING THE WORK LOAD
The pumping regimen I suggested poses a huge dilemma because you stated
that:
A. FEEDING FREQUENCY
"She nursed yesterday 12 times with SNS and used 20 oz. formula the entire
time" and "Sometimes will nurse without SNS after finishing all the formula
that was in it to begin with."
The first thing I would do is explore why she is needing to nurse 12x/day
with the SNS. Usually with the SNS, infants only need to nurse 8x/day.
Having worked with many women and the SNS, I have NEVER known a woman who
could manage to use the thing 12x/day. No wonder the woman is asking how
long this will last. The questions that come to mind are:
1) Is trying to limit the supplement in the hopes that the baby will start
taking more from the breast? Who could possibly blame her for hoping that
would happen, but I guarantee that this approach has NEVER worked and often
backfired. If the baby isn't finishing a feeding, then the baby would be
waking sooner and the mom is only succeeding in exhausting herself and
possibly the baby.
2) Is the baby tiring out on the breast, when the mother puts the baby back
to the breast without the SNS? Again, who can blame her when she puts the
SNS on 12x/day, finds that it is drained and doesn't have the energy to
refill it. We find that babies typically do their less effective feeding at
the end when they're tired and actually need MORE supply. Letting the baby
tired out on the breast by ineffectively sucking, can lead to the baby
waking up earlier.
Now, I'm all for frequent feeding in more normal breastfeeding
circumstances, but this woman needs all the help she can get to simplify
her routine and cut out the unnecessary steps. I would HIGHLY recommend
that she put in MORE formula than she thinks the baby needs. We typically
find that limiting supplement in any way limits progress because the baby
usually is less vigorous at the breast at the next feeding.
B. TRANSFER OF MILK WITH SNS VS PUMPING:
You stated that:
"I have done 3 visits, and each time baby took about 1 oz from mom's
breasts and 3-4 oz. in supplement from an SNS" and "Never more than 1 oz
total from PNS use."
So it sounds like the ratios for draining the breast using the SNS and the
Pump N Style are equivalent and using the hospital grade pump may tip the
balance in favor of pumping. In an ideal world, the mother would get
maximum stimulation by doing both. However, it is clear this is going to
be a long term process. I would highly recommend a more realistic
scenario. This is an endurance contest, so I would explore some
alternatives to the SNS for at least some feedings of the day. I would work
with her to determine what's reasonable.
The key questions are:
1) Which is more stressful for the mother, pumping or using the SNS? Some
women detest pumping. This poor woman is working so hard she probably has
no time to pump, so who knows how she may feel about it if she has enough
time to do it more regularly. She may also be feeling pretty overwhelmed
with the SNS.
2) Which is more time consuming for the mother, pumping or using the SNS?
Some women love having the baby at the breast and feel that it saves time
because they don't have to stop and use some other device. Other women
really need a break and like to have an easier method, especially for the
nighttime feedings. The pumping sometimes takes less time than using the
SNS.
Again, my best regards to you and to this mom. Sorry for getting carried
away here. It's because I want it to work for the mom and you because I've
been there myself.
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