Dear Colleagues,
I am a newbie IBCLC (2005) in private practice. I could really use
some ideas about this mom I am working with, who presents with low
milk supply that is not improving at all. Here is the background:
She is a 41-year-old Caucasian woman (G2, P1) who had fertility
issues due to advanced maternal age. She indicated that she did not
have PCOS. She had a planned c-section due to placenta previa and
heavy bleeding due to cervical polyps at 36 weeks. She lost a lot of
blood and had low blood pressure, low hemoglobin, and low
temperature, so baby went to the normal nursery for 48 hours, during
which time she had some glucose water and several bottles of 20 mL
formula after she lost 10% of her weight. Mom initiated nursing on
Day 3. She did not pump in the hospital. She initiated pumping on
Day 5 when I saw her, with a Lactina and 30 mm breast shields. She
appeared weak, had shaky hands, could barely walk or sit up because
of dizziness. She had not nursed on her right breast for 15 hours,
and it was swollen, but not hard and taut. She was nursing
exclusively on the left side, which was also full, but not as much as
the right. Her nipples are small and short at rest, but have good
pliability and do not flatten or invert. Her breasts are very large
and pendulous.
Test weights showed a milk transfer of 0.2 oz from the left breast
after about 20 minutes of nursing with breast compressions. Suck
assessment seemed normal to me with strong, rhythmic suction. Latch
at the breast appeared fine; the nipple was undistorted after the
feeding, and baby's mouth was open wide on the areola with tongue
forward. Mom did a good job getting her on asymmetrically. Baby was
pretty sleepy at breast, which I attributed to slow milk flow, but
could occasionally be stimulated to suck more actively. She perked
up when given a bottle. We also tried a 16 mm nipple shield, but
there was NO milk transfer with this. Baby also had a good latch on
a Playtex Natural Latch bottle. Mom then pumped with the Lactina for
about 15 minutes and got a total of 15 mL, about 10 from the right
(fuller) breast and 5 from the breast she had nursed on. Her nipples
were undamaged, and she reported that her right breast was feeling
very sore and tender.
I saw her for a follow-up on Day 7. She feels much better, but still
not 100%. She reported that she had pumped 4 times and got a total
of 1.5 oz. Baby is currently taking about 1.5 oz of formula about
every 3 hours. She has also been breastfeeding at every other
feeding. Baby nursed and got 0.2 oz*. We then tried both the
lactina and the symphony pumps. We would get a minute of squirts,
then nothing. Her nipples filled the 30 mm flanges, so we then tried
the 40 mm glass flanges, and then back to the 24 mm. The pattern was
consistent -- a minute of squirts and drips, and then nothing. I
could not hand express anything after the minute of pumping, because
the nipple-areola complex was too swollen from the vacuum. We were
using high suction, but then I tried medium and low, and there was no
change.
Hand expression before pumping yielded consistent drips and
occasional squirts. After either waiting a few minutes or doing RPS,
drops and some squirts could be elicited with pumping, but again they
only lasted a minute and then nothing.
*the 0.2 transfer is hopefully accurate. Prefeed weight was 5 lb 1.2
oz. The dad changed the diaper without me noticing, so we weighed a
clean diaper and 2 wipes, the compared it with the dirty diaper, and
the difference was 0.2 oz. Postfeed weight was 5 lb 1.2 oz and the
stool weighed 0.2, so milk intake had to be 0.2 oz.
What is going on here? I suspect there is more milk in the breast
than is able to be extracted, because the pump keeps attracting fluid
into the nipple and closing it off. Hand expression and RPS help
start things again, but I really only got a few mL in 5 minutes of
hand-expressing. I just am at a total loss about what to do for this
mom. She will start on Fenugreek, but is cautious about domperidone,
and Reglan is out of the question due to a history of severe depression.
Thank you for any ideas you can give me.
Warmly,
Lynnette Hafken, MA, LLLL, IBCLC
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