Nina, in a previous post re:microprolactinoma you wrote about the mother:

"She had milk supply issues with her first baby who is now 2 1/2, and stopped BF after 1 week.  This time she wanted to be prepared so she received a lot of lactation support right from the beginning, but apparently still had significant milk supply issues and baby weight gain issues.  Baby's birth weight was 9.8 lbs and at a 1 week he was 8.6 lbs (11.8 % loss).  She also reported that she did feel her mature milk "come in", but soon realized that she was not producing enough for her son.  She was working with another LC until she called me, so I was not involved in the beginning. She called me to see if there was more she could do.  When I spoke with her a week ago ( 2 weeks postpartum) she was still breastfeeding, and pumping only 3-5 times/day b/c that was all she could manage.  She was supplementing mostly formula after every feeding, (which ended up being 2 ounces every feeding) until he was "full" , per pediatrician's rec's. "
	  
"(Although she was supplementing quite a bit, and wasn't pumping often, which could be another contributing factor that I don't want to rule out)."

This situation reminds me of my EMS training and my favorite instructor and deputy chief drilling our ABC's into us ( all you RN's and MD's know this well) Airway - Breathing- Circulation - If the airway isn't open - why are we checking for a radial pulse? Much more intense and has further reaching consequences to ignore the A when focusing on a possible C issue in emergency medicine - life and death consequences in fact ... but it applies here too and helps me to keep it in mind every time I meet a new mother. 

Since a milk supply takes time to establish, "milk supply issues" do not show up, as an entity,  in 1 week (correct me if I'm wrong) but rather, in so many cases, poor latch, sleepy baby due to drugs during labor, poor breastfeeding management through lack of skin to skin, separation, etc etc etc.. result in poor milk transfer = lack of stimulation to milk production network = supplementation = lack of stimulation  and the continuation of this cycle during the early days and weeks will lead to "milk supply issues". It is hard to tell, unless you saw the documentation from the first baby, what the actual problem(s) were... and, likewise, perhaps this baby, like the sibling had a "good" latch that actually wasn't a good latch at all..  

If this mother was supplementing 2 oz every feeding at 2 weeks, that's pretty much almost 100% formula fed and pumping 3-5 times a day at two weeks would not stimulate an adequate milk supply no matter how much Reglan she took or mother's milk tea or fenugreek... demand=supply, milk removal = milk production... I would not expect this mother to be making any more milk than she was given these circumstances regardless of any medical history.

Another question that comes to mind, in view of the baby's size and weight loss, is: did mother receive IV therapy during labor or even before as well? Knowing the circumstances surrounding the birth is always important. After reading Jean's recent excellent explanation of the importance of RPS for some moms to actually be able to get babies latched well enough to allow for good milk transfer and stimulation of MER and to also have any success to pump their milk - it strikes me that it is quite likely that this is an example of a breastfeeding management problem. We see it happen all the time with mothers who don't have diagnosed prolactinomas. IMHO by getting caught up in exploring possible pathalogical hormonal issues and their consequences while overlooking the simple picture ie: feeding frequently and effectively at the breast drives up prolactin levels and keeps them up which in turn increases milk production - we are in jeopardy of forgetting that breastfeeding is the biological norm for mother and baby first and foremost - if, after assessing A, B and C, there is still a problem, then we start digging for other answers.

We have all helped the mother who was told - you need to feed or pump 8-10x a day - who's supply was a continuing problem until they "got it".. then they have been amazed at how quickly their supply increases once they do it...likewise with latching - mom says baby is latched well but when she experiences a really good latch - there is that "aha" moment - I recently helped a mom who's baby was latched "well" - we had worked on it for a good 3-4 latches the previous time I had seen her and we had gone over positioning by email and over the phone -  I saw her a couple of weeks later to reassess the latch - her supply was not increasing, baby was eating for 45 min. and still hungry, etc. etc..  said "let's see what he's been doing at the breast"  Mom brought him to the breast and his chin wasn't anywhere near her breast , let alone her areola.. so much for the good latch! Mom had bottle fed her first baby, and kept slipping into the habit of holding this little guy the same way - so this time I took a photo of him well latched with her cell phone and said "this is what he should always look like at the breast" (he also has a more recessed chin than is usual) and sent a follow up email saying "chin deep in breast for every feeding - NO EXCEPTIONS" - the next day he took a 3 hour nap - first time in weeks! The milk was there, thanks to mother's pumping efforts, but he wasn't accessing enough of it even with great effort! 

Another example of this is my daughter's first child who had a "good" latch - i.e. it didn't hurt, but he wasn't transferring milk because he wasn't getting enough areola tissue in his mouth - 3 LC's saw him and didn't notice that he wasn't latched well, one said his latch was great but he was lazy... he was losing weight and was sleeping at the breast even though he started off sucking "well" (big red flag that his latch was not fine) - after a few days of feeding 2 oz supplement by bottle after every feeding and pumping a few times a day (but not nearly 8-10) my daughter's milk supply was almost non existent and it took a few weeks to turn things around..  - worst of all - her confidence in being able to breastfeed was shot and we've all seen what that can do to a breastfeeding relationship even if mom has abundant milk.. it doesn't take long for the damage to be done and then it takes a very long time, especially with a toddler to care for, to get back to square one. 

We could fill a 1,000 page book with these stories.. it is so tempting to look for zebras when they are possibly just plain horses thundering past us... 

Hope we all experience a wonderful and Happy New Year!

Celina, LLLL, IBCLC, grandmother to Alex and Olivia (who is still breastfeeding and loves her Oma because I play Elizabeth Mitchell cd's for her endlessly and carry her around in the moby wrap.. I LOVE being a grandmother but I am exhausted and really empathize with these moms.. at least I get my nights to myself!)

 

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