Hello wise ladies,

I would like to get some input on how to advise a BFAR mom (and dear friend) who had a baby 2 days ago. I have permission to post.

General history: 

Mom had breast reduction surgery many years ago (in her late teens). The surgeon told her he was doing the surgery so that she would still be able to breastfeed someday (of course without giving any additional info or real explanation). I don't know the specific method used; I would guess some sort of pedicle technique. Now she is P3G3. All three pregnancies have been difficult due to high blood pressure and severe edema; she is induced around 38-39 weeks and the babies are small. No trouble conceiving; with #1 and #3 she got pregnant almost immediately. It did take 10 months to get pregnant with #2, but he was conceived naturally. (As an aside, at one time, before children, the possibility of PCOS was explored, due to excessive facial hair and the results of some hormone tests, but I do not know the details and she was never officially diagnosed with PCOS.)

Lactation history:

Baby #1. Born at 5 lbs and mom was advised to give formula almost immediately, because the doctors were concerned about her history of breast surgery and told mom that if baby fell below 5 lbs she would have to go to the NICU. Mom did mixed feeding for 4 months and pumped sporadically with a hospital grade pump, but never really developed a pumping routine. Another complication was that mom had emergency back surgery around 3 weeks postpartum. She also went back to work full time around 8 weeks. Between the poor start and the other obstacles, mom gave up bf at 4 months. She believes that at her peak she made 40% of baby's needs, but I don't know how accurate this is--could have been more or less.

Baby #2. Also small, don't remember exact weight. Mom was very determined to "succeed" at bf this time. She pumped around the clock for several weeks after the birth. Baby made a clicking noise while bf, but LCs in hospital said latched "looked good." No nipple pain. Mom bf directly and supplemented with her pumped milk, but baby did not gain any weight between 4 and 6 weeks, so she began using formula. Baby did not nurse well; mom tried to use a Lact-Aid but baby did not suck strongly enough to get any supplement from the device. Baby would not nurse for comfort and choked a lot while bottlefeeding. Mom suspected tongue-tie but the LC and ENT she visited in her area "couldn't see anything". Finally, while visiting me in NY, baby was diagnosed with submucosal posterior tt. Mom couldn't find anyone to clip in her area so eventually she returned to NY when baby was 7 months old and Dr. Coryllos clipped him. By this time mom had given up bf and was bottlefeeding formula and peer-donated milk. (I had a baby the same age so I was pumping about 10-15 oz per day for her.) Despite already having weaned, mom was very happy with the clipping as it resolved the bottlefeeding problems. 

One big regret mom had with baby #2 is that she felt that she gave over care of the baby to the father and the babysitter while she spent most of her time pumping. She thought it was temporary and that the separation would be worth it once she had enough supply to fully bf. Now she feels that baby #2 is less attached to her than baby #1 and that he prefers his father (although I keep telling her that that's probably a toddler stage he's going through). She's very into babywearing and has been wearing this child for almost 3 years; I don't think it's possible that he's not attached to her, but of course she may be correct that he bonded more to his father.

Finally, baby #3, born Wednesday around 7 pm. 5 lbs, 8 oz. In light of her regrets with #2 and some things I read in Diana West's "Making More Milk" and heard her present in a conference, I advised mom not to use an electric pump for the first 4 days. I suggested STS and hand expression. Baby was weighed & swaddled after birth but returned to mom w/i 1/2 hour and mom unwrapped her and has been keeping her STS as much as possible. Baby is happy to hang out at breast, though mom does hear a clicking noise sometimes and is concerned about possible tt. Hospital LC said clicking caused by shallow latch. When mom feels baby "wants more" or is fussy, she expresses a little colostrum into a spoon and feeds it that way. Baby's poop turned from black to yellow within 36 hours and she lost only 5% of birthweight. Today (Friday), the pediatrician wanted baby to feed at a certain time and baby wouldn't wake up so mom started to express into the spoon and, in her words, "milk squirted everywhere!" She says this never happened with her first two. They are going home from the hospital today and baby has not received any formula so far. I think that things are going as well as possible up to this point.

Okay, so far so good, but how to proceed? Given her history, mom almost certainly will need to work to maximize her milk supply. At four days, should she start pumping 8x/day or more? What about domperidone or herbs? Both? Neither? Each time I read about an herb or technique in "Making More Milk," I think "Oh, I should tell mom to do that!" But I certainly don't want to overwhelm her or have her do too much work or have her take substances that will cancel each other out. As a new IBCLC, I'm just not sure how to advise her from this point on.

I also want to keep in mind the balance between working on milk supply and bonding/spending time with/enjoying the baby. Not to mention that she has two other children that need love and attention, too. And a husband, and a dog etc. etc. ;-)

Thanks in advance for any words of wisdom!

Jennifer Sokolow, IBCLC
Long Island, New York
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