Kirsten, thank you for recognizing that what may really good interventions/
strategies may also be too overwhelming for any given situation -- including
coping with multiple preterm infants! Does this mother have physical and
emotional support at home? Husband travels but is there other family or
friends helping out> It simply isn't realistic for someone who's just had
twice as many babies, and premies at that, to think she can do it all --
it's hard enough for a new mother of a singleton!

Lots of questions! The biggest question is what do you think is
interfering with adequate milk production for this mother?
I'm assuming she's using a rental pump with flange (breast cup) size that
fits her. (Obviously, the current routine of 4-6x/24 hr pumping is not
enough to result in adequate production even with Reglan, but she wasn't
making all that much with 8x/24 hrs. Also, mothers of twins are at higher
risk for postpartum depression and so are mothers who've given birth
preterm, so the potential for depressed mood should always be considered re:
Reglan use for these mothers.)

Also, were you saying the babies are now 40 wks 5 days gestational age? What
is each baby's current oral development/behavior as compared with a baby
actually born at the full-term gestational age they've just reached? Does
either/both have any ongoing health issues -- related or unrelated to the
preterm birth?

Don't know if you read the 1998 case study in JHL re: C Auer and K Gromada
about a mom of quads who were born at about 32 weeks. She had poor milk
production and babies did poorly with latching, but then one developed
sensitivity to all formulas tried at about 3-3.5 months chronological age.
She transitioned this baby to breast (somehow -- did it on her own), and
then within another 1-2 weeks had all 4 at breast for many feedings. Milk
production went way up. If I hadn't been involved with that case and seen
the changes for myself, I'd never have believed it.

Since then, I've spoken with a couple of mothers of twins who had similar
experiences with transitioning babies to breast and/or increases in
production at 9-12 weeks. (Actually, I've talked to mothers of preterm
multiples who had 1/both/all transition to breast as late as 7 months
chronological age.) Wish I could pinpoint some magic "something" that
suddenly made the difference, but there seems no consistent factor.

If this MOT cannot keep it up re: pumping and working on a transition to BF
(or one/both babies have an ongoing feeding difficulty), I'd encourage a lot
of skin2skin with both or one at a time to enjoy some of the kinesthetic
advantages similar to BF). I sometimes encourage MOT (but usually those with
signs there is the potential for decent production) to play "hookie" for a
few days from breastfeeding "attempts" and pump more often (with massage and
RPS and/or per http://newborns.stanford.edu/Breastfeeding/MaxProduction.html)
to increase production. This MOT can always pump as able to keep options
(and milk bar) open a bit longer...

Good luck to her. She may want to join other MOT/MOM, many who've had
experiences such as hers, on the Yahoo group APMultiples, There a link at
LINKS on my web site...

K



> Hi all,
> I had a tough case yesterday - a mom of twins born at 32 weeks, now
> adjusted age 5 days. Babies in NICU for 2 weeks with only 2x/day contact
> w mom. Most mom ever pumped (pumping 8x/day) was 6oz in the whole day.
> Babies now refusing breast (have only ever fed with shield), mom pumping
> 4-6x/day w total output 3-5oz/day. I asked her what her goals were, and
> she said she'd like the 3am feeding to be at the breast, not having to
> get up and deal with bottles in the middle of the night. Currently
> babies are getting 80ccs formula every 3-4 hours. Mom moved to the area
> 2 weeks ago, husband travels 4 days/week for work, her mom is here
> helping, but she just doesn't have enough help or support. Ideal plan
> would be to get babies to breast with SNS, mom pumping more, doing
> skin-to-skin - but she's overwhelmed. Worked with one baby yesterday to
> feed at breast, had some success with feeding tube under nipple shield -
> but feed was very slow and leaky.
> Mom is going to try this week to do one or two feedings per day per baby
> at breast with tube, keep pumping, and do the remaining feeds with
> bottles. I see her again in one week.
> Honestly, I feel like with her current resources, any more than this is
> too much to ask. Her postpartum care did not support breastfeeding
> adequately, she never has established a milk supply. I'm not sure how to
> tell her that her goal is not achievable with her current efforts and
> resources. She is already on Reglan as well. She just never got the
> right information about what it would take to make breastfeeding these
> babies realistic and has been limping along for 8 weeks.
> I don't need info on treatment plans for her, these I can figure out.
> But any ideas about how to have a frank discussion with her about the
> likelihood of any real breastfeeding with these babies would be
> appreciated.
> The goal for right now is to get the babies a few positive experiences
> at the breast with the feeding tube, and go from there.
>
> Thanks,
> Kirsten Berggren, PhD, RN, IBCLC
>
>





-- 
Karen Gromada
www.karengromada.com/

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