Karen
The problems with this dyad are multifactorial, as indeed, most are.
1. breast augmentation - as you know the incision site and surgical
procedure are important, like where the areola and nipple area cut? also the
reason for the augmentation, were the breasts underdeveloped, hypoplastic,
markedly assymetric? I suspect this because you said more milk is produced
on one side.
2. c-section birth - was she hypertensive? induction?
3. 37 week gestation or near term infant
4. relatively small infant size, less than 6 lbs with the weight loss

It seems they are on the right track. I would encourage continuous skin to
skin holding, and continue expressing with hospital grade pump. I would
encourage her to use the Classic or Lact-E I think they are the best. What
are her nipples like? Was the shield used because of some nipple inversion
or very flat nipples, or just to help the baby latch (as is used with
premature infants)? Do they use reverse pressure softening prior to latching
or pumping? This will help, as you know, with nipple eversion, and letdown,
however caution should be used due to the implants. I believe RPS is not
sanctioned for use with implants, however if the implants were behind the
pectoral muscles I would feel comfortable using gentle reverse pressure.
It is possible that there is a compromised milk ejection reflex if there is
nerve disruption due to the surgery. How many days postpartum is she and
what is/was her engorgement like? I find moms with implants often suffer
increased engorgement and this can certainly compromise latch and supply. On
the other hand, she may not have had a good milk surge due to some primary
cause.
Have they tried a supplementer at breast? This may not work if the latch is
not great, but maybe would give more suckle time at breast. Can be used with
a shield as you know.
I am not really sure that the breastmilk is deficient in some way, I would
be hard pressed to believe that. It is more likely a volume thing, you did
not mention how much she was able to express. A baby that has been
underfeeding will often need to catch up and a baby with 6 lbs birthweight
needs about 45 ml in 10 feeds per day or about 38 mls in 12 feeds a day
minimum. Is she able to provide this amount? And can she do breast massage
to increase the fat content or just the letdown factor? Make sure she is
using an appropriate flange size, as has recently been discussed, and that
they have ruled out baby tongue-tie, recessed chin, or other such issue.
Hope some of this is helpful.
Laurie Wheeler, RN, MN, IBCLC
MISSISSIPPI USA

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