I'd like the quick input of lactnetters on this one.

I saw my mom with the "no oxytocin" today.  She felt cramping everytime
she put baby to breast, though it is diminishing; baby is now 6 days old.

Problem:  her mature milk has just "dribbled in" as of yesterday, not as
strongly as with the others. Baby is *very* jaundiced but alert, active
and vigorous, and mom has been supplementing with a few ounces of ABM
each day from day 3/4.  This is my first opportunity to assess mom
physically, and now with a baby. Mom has very large nipples, probably 1/2
' diameter and 5/8" in length, almost bulbous. I asked her if they were
always this size, or if they've grown with each pregnancy; she wasn't
sure, but later thought perhaps they are a bit larger this time around
(baby #3).  This little guy also has an issue---- gulp---- he's
tongue-tied. Definitely. The other two children are definitely not, but
this guy's got a frenulum that at full stretch is less than 1 cm,
attaches near the tip of the tongue and at the base of the lower alveolar
ridge, and a mild heart forms when he tries to raise his tongue. Moderate
elasticity of frenulum, frequent breaks in suction/cupping at finger.   I
would say that the combination of long nipples and tight frenulum make
for an interesting match.

Baby roots zealously and goes to town, but tended of course to mostly
nipple feed. I gave him a little help to get more onto the areola and mom
reported that he was doing more swallowing than she had previously seen.
It looked really good, but..........  total intake at "full" breast was
12cc after 10-15 min of vigorous suckling and lots of jaw action and
swallowing sounds.  Jaw excursions exaggerated, probably compensatory.
Put baby to second breast that he had been on before I came, less
swallowing noted but scales reported -0- intake. Sigh.

When I had arrived and checked mom's breasts, the "used" side expressed
drops immediately when I compressed, and the "full" side immediately
squirted me.  After our bfg attempts on both sides, I tried pumping mom
on "used" side for residual milk and got only a few drops.  Couldn't hand
express anything at that point either.

I don't think oxytocin/let-down is an issue at all, though I did discover
that mom smokes (not during pregnancy, and only 10 cigarettes in past 6
days).  I'm wondering why milk supply is less than expected at this
point; has the frenulum impacted stimulation? No soreness in mom.

Because of all of this mom's previous problems, I lean towards a more
aggressive treatment: immediate clipping of frenulum.  I am afraid to
take the "wait and see" approach because mom has lost milk supply twice
before.  I encouraged her to discuss the bfg/frenulum issue with her ped,
who "of course" said that frenulums grow and not to worry.  She is open
to seeking a clipping elsewhere *if* I strongly urge it.  In the
meantime, I'm having her put baby to breast first with our modified
positioning 8+ times a day, then topping off with supplement. I'm having
her take "More milk" about five times a day, and massage-pump-breast
compression afterwards to collect anything left. I'm not sure if we
didn't get anything because baby took it all and/or because her supply is
really low, or if the pump has difficulty reaching the sinuses. I sure
didn't have any trouble getting milk to squirt before the feeding, just
had trouble after having had baby at breast.  Saw mom at 2pm, she called
at 6:30 to report on ped visit and tell me that she is again "leaking all
over the place."

My question--- would you "push" for a frenotomy in this situation as I
feel inclined?  I used Alison Hazelbaker's assessment and came up with
scores of 11.5 on function (had difficulty assessing 2 items, gave baby
benefit of the doubt) and 3.5 on appearance.

-Lisa Marasco, BA, IBCLC