I have PTP and apologize for the long post.  This mom is 30 y/o G1P1 delivered via C/S at 39 5/7 weeks for unstable lie and eventual persistent breech (he was flipping constantly since 36 weeks, it sounds), was 8# 3oz at birth., now 9#12.9 oz with about 50% ABM.  While in hospital, received no lactation support until baby's weight dropped 10.5% which caused the staff great concern.  Mom had been breastfeeding q 2 hr, they watched her every 1.5 hr, which made her feel very stressed and incapable.  He often fell asleep at breast.  At that time, 2 LCs came in but never did test weights.  Once home, Mom's mother and grandmother have told her to "not worry about it, just breastfeed".  Dad works nights, mom has little support.  She has large pendulous breasts, no significant med/surg hx, not taking meds for any condition, not on BC.  She started fenugreek week 3, stopped last week when she had "stomach bug" and restarted 2 days ago.  She is taking 3 caps/3x day.  She was treated with antibiotics post delivery for infected incision site.  Family hx for 2 older brothers with speech and learning problems who breastfed 6 weeks and 4 months, respectively but her mother doesn't recall why she stopped.  Mom called for visit because her letdown takes 10 minutes, she is using an Ameda purely yours which was given to her brand new by the hospital.  The pump flanges are different sizes than Medela; the extra large (30.5 cc) is most comfortable but she gets no milk; the "standard" (I guess, 26.5) is too small, then next size is 28.5 which is an insert and this is only slightly uncomfortable but she gets more milk.  She describes if she pumps for 15 minutes she gets an ounce but if she pumps for an hour (!) she can get 4-6 oz. She is currently producing about 16 oz/day.  Baby eats 1-6 (!) oz/feed.  She also describes that double pumping is less suction and if she single pumps the suction is stronger, she can then massage which helps with letdown, which she doesn't feel.  Her nipples are sore and she is using APNO with good improvement

 I saw this dyad in the morning, he had fed 2 hrs prior and gotten 2 oz EBM. When she opened her bra, she had a bead of milk on each nipple, I thought good, she's wrong about her letdown.  I put them in BN and he latched well; mom said this was best latch ever but after sucking and compressions he only transferred 2 cc in about 10 minutes.  Latch was never uncomfortable.  We then gave 16 cc EBM and put him back to same breast, he transferred 12 cc.  He cries a lot, i noticed she used gripe water, and he was arching.   There is not an obvious TT and i didn't have gloves to do finger sweep for PTT, but lip is definitely appears moderately tied, though it flanges fine.  His tongue movements were asymmetric at times, and on bottle in paced bottle feeding position he "played" with nipple a lot before drinking.  He spit up a small amount on scale but mom says he only spits up if laid down; but then she said he has "reflux".  Mom uses a pacifier occasionally and seemingly appropriately and found only one he will "take"  (I think she called it a "nia?"  it had a mustache on it :) and slanted nipple).  He would become calm, I had him on my lap and he was alert, relaxed and even playful,  and a few minutes became stiff, tight and complaining.  When I was giving EBM while mom pumped, he didn't finish 15 ml, came off on his own, was very relaxed, and within few minutes was crying.  Mom took him, first let him suck her finger, ultimately topped him off with a little EBM, he relaxed again, fell asleep in her arms, she laid him down and he began crying again a few minutes later.  This is normal according to mom.  She can't just sit with him, has to stand and sway (which is what I was doing).  All said and done, he had just over 2 oz this feeding, over 1.5 hrs.  She pumped for me for 20 minutes, we stopped midway to massage and sure enough, she only got about 1/2 oz/side and said she knew if she kept going she could get 2-3 oz more each and I never saw actual letdown. She is young and patient and I give her a ton of credit, and she was a bit frustrated that I didn't have one solid answer {{I didn't have my magic wand OR my crystal ball with me :(}}, though I tried to explain the various weeding out we would have to do but that I thought it could be done. 

I have a lot of ideas about the various components of this situation but am finding it hard to prioritize what exactly to do first so we can get results to move things in right direction.  I saw a posting on delayed letdown suggesting Bach's Rescue Remedy, which i suggested.  I also suggested trying another pump to see if she could let down easier and to see if those other flange sizes fit better.  I suggested pumping more frequently and no longer than 20 minutes and using positive self talk.  (Just as an aside, with my 1st child, I purchased a brand new PIS after using Lactina for 3 months, and I could not let down to it, no matter what (can't drink wine at 530 am before going to work as RN); then I'd go to work and pump 12 oz!)   Im figuring that the stress from the very beginning that this poor mom has felt is what's really behind the slow letdown, but I don't know!  I suggested changing to combination galactogogue like More Milk Plus or Lactate Support.  I also see some "red flags" for cranial sacral (the unstable lie and birth story, the arching and rigidity, the tongue) and want her to get the tongue/lip evaluated but which should come first, the CST or the eval by a dentist?  Lastly, I thought afterward that maybe I should suggest an SNS, just to cut a step out, but she described wanting to just visit friends and be able to feed without having to prepare and bring a bottle or other "stuff", so I think this might overwhelm and disappoint her further.  Can anyone help sort through this complicated mess?

Laura Coulter, BSN, MS, IBCLC
Chicago
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