Heather,
I think it is difficult to discern everything that is going on with the
mom you wrote about just by phone; she really needs to be seen in
person. The first question that needs to be answered is whether or not a
real milk supply deficit exists. If it does, all other potential factors
need to be ruled out. Three months is such a common time to start
hormonal birth control, for example. However, if she previously had a
good milk supply but then it truly dropped mysteriously, it could also
be hormonal on her side; in rare cases, some level just seems to decline
too low over time, and the bottom can fall out on a mom. I've seen this
a couple of times over the years. The hypothyroidism definitely needs to
be addressed, as it could play a role in low supply. BTW, it is not
uncommon to see hypothyroidism together with PCOS.

Thrush can certainly cause some babies to balk at the breast, and breast
refusal without compensatory stimulation and milk removal can certainly
lead to low supply. While one would think that the bottle would be more
uncomfortable than the breast, some babies can prefer it in these
instances. Certainly if the mother was amenable, cup feeding or
syringe/supplementer at breast would be ideal.

Whether or not PCOS pathology is involved in the perceived low supply
situation, if the mother was on metformin before, she should continue it
now. If a problem exists that is interfering with lactation, metformin
may help to correct this and allow for better milk production. But even
if it does nothing, metformin is good for mom's long-term health. Tom
Hale's article on metformin can be found on his website.

~Lisa Marasco MA IBCLC

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