Dear Lactnet friends & mentors:

First off all, thanks to all of you who advised me on my friend with the
disappearing supply. Her supply returned, as mysteriously as it left, after
a few days. And now to a new question...

Permission to post:

I am helping a mom who at day 13 has never felt her milk “come in” and
produced about 25 mls in a feeding/expression cycle during our visit -with
lots of help. She has some red flags for hormonally-driven low supply
and/or insufficient glandular tissue, despite normal-appearing breasts.

I am a new IBCLC, and I could use any advice you all have on lab tests to
request (and why), or appropriate galactagogues for the specific risk
factors she has.


And of course, if you have suggestions of any books or webinars that get
deep into the hormonal issues – I want to learn!

Thank you all in advance for your wisdom!

April

PREGNANCY/POSTPARTUM:

   -

   Still producing red blood intermittently at day 13 – sounds like
   spotting, not clots or soaking pads. [beta-hCG test / ultraound]
   -

   Docs told her she had an unusually shaped placenta – two distinct lobes,
   joined together by some placental tissue.
   -

   Baby was very large for gestational age – bordering on macrosomic – but
   she denies gestational diabetes or excessive maternal weight gain in
   pregnancy.
   -

   Her breast veining is faint – barely visible. Other than that, breasts
   appear normal: round in all quadrants and symmetrical, normal areolar
   appearance, spacing not too wide. I didn't palpate for glandular tissue
   because I've been trained to generally avoid touching womens' breasts, and
   am not sure I would recognize the feel of normal vs. abnormal glandular
   tissue. She has normal breast and nipple sensation.
   -

   Tenderness increased in pregnancy. Husband (but not mom herself) noticed
   breast growth.
   -

   Milk is white, thin, and flows easily – doesn't look like colostrum. [Is
   it still worthwhile to request tests for testosterone=GOTL cyst?]
   -

   There are no clinical signs of hyperandrogenism or androgenous body
   type; denies blood loss, diabetes, thyroid, hypertension or fertility
   problems. No surgery, spinal cord injury, etc. [Test TSH anyway?]

EARLY BREAST DEVELOPMENT:

   -

   She took hormonal birth control pills continuously from the age of 13
   until this pregnancy at 33, prescribed for very irregular periods (two
   weeks of bleeding, a two-week break between periods, etc.).
   -

   She feels she didn't notice significant breast growth after starting
   birth control pills in puberty. Started as an A-cup and was a B-cup by time
   of pregnancy, but she attributes that to weight gain in adulthood. She has
   a slim build. [Mom is taking an herbal blend with Goat's Rue.]

MANAGEMENT:

   -

   Daughter born at 40 weeks via C-section after long and arduous labor
   with lots of IV fluids. After separation for the first hour, mom began
   breastfeeding. She has fed around the clock on demand, with at least 10
   feedings in a typical day, sleeping no longer than 3-4 hours without
   emptying the breast. Breasts feel softer/looser after feedings/expression.
   Since day 3 mom pumps after most feedings with a rental-grade pump, at
   first with flanges too small but did get a size that fits. Mom did have
   lots of edema, throughout her whole legs, which has resolved.[Prolactin
   levels? And given her relatively good early stimulation, might domperidone
   help?]
   -

   Baby has a posterior tongue-tie which is relatively mild – by which I
   mean that compared to most PTT babies I see, she produces a better “pull”
   on mom's nipple, and causes less nipple compression. TT does cause skin
   irritation to the nipple face. [Mom will think over frenotomy.]
   -

   Mom had been using SNS for all supplementation but found it stressful
   and has just switched to bottle. I suggested breast for dessert, alternate
   massage before and after MER, switch nursing, hands-on pumping with hand
   expression, and paced bottle technique. We optimized latch and positioning.
   -

   Baby transferred 18 mls in a feeding with only one obvious MER despite
   lots of supportive techniques. Mom then expressed 7 mls. Baby was born at 8
   lbs 6 oz, dropped to 7 lbs 8 oz within 2 days (IV fluids?), and is 8 lbs
   1.9 oz per my scale at 13 days.

-- 
April Rosenblum, IBCLC

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