On March 3, I posted about a mother who was very thin and who has a history
of feeding problems.  I'll include some of my post to remind you of the case.

>I have a client (first baby) who is *very* thin.  She is about 5'4" inches
and weighed >96# before pregnancy.

>I was called in due to insufficient output. I saw them on day 4 and baby
latched >better.  With a lot of breast compression baby did some
swallowing.  Breasts had grown >"lumpy" and fuller, but baby wasn't drawing
the milk out on his own.  His mouth was >dry even after his time at the
breast.  Mom began supplementing.

>It is now day 6 and no sign of more milk. Mom tried pumping, and in 15
minutes there >were about 3 drops on the flange of the pump.  Rescue Remedy
didn't stimulate a MER.  >She then tried hand expression and, after 10
minutes one breast was wet on the nipple >and the other had a few drops.

Baby is 2 months old now and at the 7 week mark, mom realized that she had
enough milk for him.  He has been gaining an ounce a day for over a month,
and the supplementing has decreased from 8 ounces at the most down to 2
ounces a day now (at bedtime). Hopefully, she will be able to let go of
that too.

She never could get more than a teaspoon of milk with any breast pump (
including the Classic.  Interestingly, the pump that did give her the
"most" was the Avent Isis hand pump. She used a supplementer from week 1
until week 7. She is now giving him the 2 ounces of abm in a bottle.

This woman deserves a medal for her hard work and determination, something
that I didn't think she would have.  She is a "socialite" type and had
little support from friends and family.  She seemed so emotionally fragile.
 But she *did* have the ongoing support of her husband and her
Pediatrician. One week, when the baby was gaining an ounce a day and was
taking about 6 ounces of abm a day, the Ped suggested that, since he was a
good weight, that mom could, for a week, feed without the supplementer and
see how he did. She did it and, with feeding every hour in the day and
every 2 at night, he did continue to gain. After that she went down to the
2 oz ob abm, where she has stayed.

The baby certainly has some suckling problems (or it could be location of
her sinuses) because mom squeezes the breast almost throughout the
feeding--has from the beginning.  I know that a supplementer doesn't
strengthen a suck, but I wanted baby to feed at the breast all of the time.
When the milk lets down, baby will feed without the breast compression, but
the rest of the time she is compressing.  I have suggested that baby be
seen by my OT/CS practitioner, but mom is so happy with things as they are
that she doesn't want to do anything else now. She can make milk for her
baby and that is GREAT!

I have tread delicately with this case, because of mom's seemingly
"fragile" demeanor.  This experience has certainly boosted her confidence.
She sees herself as successful and is very proud, so I don't want to stress
the OT idea, implying that things aren't good enough yet. I told her that
she could call if she wanted to look into the baby's suck. It may not be
the suck at all, of course.

A most interesting thing happened at 5 weeks.  One day she woke with
engorgement.  She was thrilled because of the anticipated gush of milk.
But there seemed to be "less" milk, even with cabbage and cold packs.  And
the next day the "engorgement" was gone and the milk supply seemed to be
the same. She had experienced initial engorgment also, with little "action"
following. I don't know what that was all about.

This has been a most challenging, and satisfying case.

So, if you have a client with delayed lactogenesis, you can now know that
it can come later--much later.

Pat Gima, IBCLC
Milwaukee, Wisconsin, USA

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