Lisa Marasco is on vacation, so is probably not reading lactnet this 
week. She needed a rest after finishing her and Diana West's new book on 
milk supply issues. (It's gonna be great!).

It seems that the two problems here are not related. Mom's hormonal 
issues are not keeping her from making milk, and baby does not have more 
difficulty with flow in the early morning. I would be hesitant to treat 
the hyperprolactinemia unless it is very high. Prolactin is only 
permissive of milk production, it is not linearly related to milk 
volume. Either one has enough prolactin to make milk, or not. Higher 
levels of prolactin are generally not associated with oversupply, though 
pushing prolactin by giving domperidone or very frequent pumping does 
help increase milk supply.

The big issue is the baby's poor endurance for feeding. Is mom willing 
to give short, frequent mini feeds, and not try to make the baby 
continue feeding once he is stressed? 2-3 oz 10-12 times a day should be 
enough. If feedings are more relaxed and pleasant, mom might be more 
rested feeding more often than struggling for a long time fewer times a day.

If mom's flow is fast, sometimes using a thin silicone nipple shield 
helps slow it a little, so the baby can have better control. Baby should 
be examined carefully for any cardiac or respiratory issues, or even a 
subtle posterior tongue tie, which has been responsible for difficulty 
with flow control in infants in my practice. I agree with ending the 
feeding as soon as the baby shows any signs of difficulty - rapid, harsh 
respirations in the pauses between sucking bursts, prolonged respiratory 
pauses and short sucking bursts, worried expression, mistimed swallows 
(isolated short stridorous sounds made when the vocal folds snap shut 
because liquid contacted them). Mom will get good at reading the baby's 
signals if she is shown what to look for.

Using positions that allow the baby to let go of the breast whenever he 
needs to can be helpful. Mom should keep her hands off the baby's head, 
just support his shoulders. This can also increase head extension while 
breastfeeding, which decreases airway resistence. Makes it easier to 
breathe.

Lynn Wolf and Robin Glass's Feeding and Swallowing Disorders in Infancy 
(Therapy Skill Builders) has a lot of great information on these topics. 
http://www.psychcorp.com (choose catalog- Therapy Skill Builders; then 
search for the title) I have no financial interest in this book, just 
recommend it highly.
Catherine Watson Genna, IBCLC  NYC

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