Permission from mom to post this for ideas/suggestions: Mom has a two year old son and is expecting baby #2 early November. When her son was born she was told by nurses that her nipples were flat. She was given a nipple shield to breastfeed and instructions to pump every three hours to build supply. Mom faithfully fed baby at breast with the shield and pumped for two weeks. At the end of that time her infant was 1 pound below birthweight. Heartbroken, she switched to formula. Mom had no obvious signs of why she didn't produce--no history of breast surgery, infertility, PCOS, breast asymmetry, lack of adequate breast stimulation, postpartum trauma or hemorrhage. She reported an uneventful birth, no unusual thyroid or other labs.   I saw mom today for a pre-natal consult and noted the following: large, symmetrical breasts (G cup), with large areolas (diameter of about 3 inches) that had a stretched appearance. The areaoler skin looked like it had stretchmarks, although mom said her breasts/areolas have not dramatically increased in size. The areolas also looked dry, but skin was not flaky. Her nipples were flat and looked eroded. There was a small amount of graspable tissue, and nipples everted slightly with stimulation. 

I provided mom information on breastshells as an option prenatally if she wanted to try them to evert her nipples. Mom wants to try to breastfeed this baby, but doesn't want to go through all the steps (feed, pump, supplement) and the anxiety she experienced last time. Mom reported that even with faithful pumping she did not see an increase in milk supply. (Medela rental pump)  She did not experience any fullness or engorgement early postpartum, but did have two "uncomfortably full" days when she discontinued pumping "cold turkey" at two weeks postpartum. 

When mom comes in to deliver, nurses will be informed that she desires skin to skin care and first breastfeeding within an hour of birth.Thankfully, this is common practice at the hospital where I work, as is rooming in. Mom is prepared to most likely need to use a nipple shield again, but is desiring to have the first breastfeeds without one. She does not want to pump again. We did not discuss herbs/galactagogues at this visit as I didn't want to overwhelm her and supersede her need to tell her story by offering more "plans". She was willing to exchange emails and is receptive to links/resources she can explore. 

Any suggestions or guidance on what I may have missed would be greatly appreciated!

Leslie Cree, IBCLC, RLC
Harrisburg, PA USA area

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