I am sorry that this is so long.  I have a client who needs more ideas.  She has given me permission to ask for help at Lactnet.

I met with her a week and a half ago.  Her baby was having difficulty latching and transferring milk and was only two ounces over birth weight at three weeks.  She had pain on both sides but severe pain on the left side.  She fed her son about 7 times a day.  He would nurse with very little swallowing and then she would feed expressed milk by finger-feeding.  The whole process (nursing, finger-feeding, pumping) would take about 1-1/2 hours or longer.

After her three week appointment, her pediatrician asked her to supplement at every feed so she used about 40ml per day total of formula because she wasn’t able to pump that much.  The formula supplementation started at three weeks (one week before I visited).

Her pediatrician and a lactation consultant told her that her baby had a borderline tongue tie but that it probably did not affect baby.  After supplementing, baby gained 14 ounces in one week.  However, mom said that when she supplemented, baby would sleep for 3-4 hours and didn’t want to feed as often

When I saw them, I noted that mom has quite long (approx 1”) and somewhat large nipples and baby had obvious type 2 tongue tie.  He also has a thick labial frenulum attached to his gumline.  After feeding in both cradle and biological nurturing positions, mom experiences remarkable nipple compression and shaping.  Shaping was more pronounced after cradle hold, very, very pinched.  Baby did not do much swallowing so I recommended that she try using the supplementer at the breast.  He also falls asleep at the breast after just a couple of minutes without the supplementer.  I do not yet own a scale so I am unable to do before and after weighing.

Baby’s tongue stayed on the floor of his mouth when he cried.  When he suckled on a finger, I could feel the tongue snapping back.  I recommended that mom ask for an immediate referral to an ENT for frenotomy.  Her pediatrician was not in agreement and mom describes the conversation as, “not pleasant.”  Pediatrician did refer to ENT who performed laser frenotomy as soon as he saw the baby.  He didn’t even wait to schedule an appointment for the procedure, Yay!

Until the frenotomy, which was 1 week after my visit, I recommended that she feed her baby at the breast with a supplementer instead of finger feeding to save time and for extra breast stimulation.  I recommended skin-to-skin and laid back feeding as much as possible but she had a hard time with the SNS in a laid back position so used cross-cradle to supplement.  I showed her how to get a deeper latch but baby continued to resist and slip into a shallow latch.  I also showed her how to do hands-on pumping and recommended that she switch from a PIS to a hospital grade pump.  I recommended that she feed at least 8-10 times a day (and supplement at the breast for at least 5 of those feeds) and pump at least 5 times (more if she had time).  I showed her how to do breast compressions which did increase swallowing.

The amount of formula used quickly increased to almost 12 ounces a day.  When she pumps after a feed she gets 20-30 mls.  Baby does not seem to be removing much milk on his own.

Baby had a lingual frenotomy 4 days ago and visited an infant chiropractor the next day.  Chiro says that there is muscle tightness on baby’s left side and wants the baby to return for more work.  Mom is doing lifting exercises, gag desensitization and sucking exercises on my recommendation.  Mom says that baby’s suck is now worse.

Latch is not improving.  When mom is able to get a deeper latch, baby gags on her long nipples and slips into a shallow latch.  Because baby was feeding less frequently when supplemented would sometimes wait to pump for fear that she would remove the milk that baby would soon want.  This meant that she would sometimes go 3-4 hours in the daytime between some feeds/pumpings.  I encouraged her to pump if baby was not feeding every 2 hours in the daytime.  

Mom is so sore that she is taking a break from nursing.  She is now pumping and finger-feeding.  She is using the hospital grade pump and hands-on pumping every two hours during the day and once at night.  I also suggested trying to do some power pumping.  Mom is getting 20-50mls at a time.   No where near enough to satisfy her 8 lb baby.  Mom has also been taking an herbal tincture with Fenugreek, Blessed Thistle, Goat's Rue, Alfalfa and Anise.  I am personally very wary of pharmaceutical galactagogues and I don’t think they are indicated in this mom’s case as her problem seems to be lack of stimulation/removal of milk.

What else can I recommend for mom to increase her milk supply?  What else can she do to help baby take more breast?  She is very motivated but getting totally worn out.

-Laura Spitzfaden, LLLL, IBCLC
www.feedthebabyllc.com

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