Hello Wise Ones,
I am posting this long and complicated case to get your collective input,
what worked, what cd have been done better, etc.  Please email to me direct
as well as to the list.
 This mom is a motivated and conscientious 34 year old primip, term
delivery.
 Baby was born (to unmedicated mom) at our out of hospital birth center
4/8/99.  Birth wt 8lbs 3 oz. Transferred to local hospital postpartum for
repair of 4th degree laceration.  I did home visit earlier than usual, at
36 hours postpartum, because parents were concerned that baby wasn't
latching on well.  Indeed, baby was very fussy/arching a lot, appeared to
have significant head and neck soreness that day.  Difficult latch, but we
did get her on during my visit, and she fed ok.   Weight loss at 36 hours
was 10% but no sx of clinical dehydration.  Phone followup over the weekend
sounded reassuring, w/ milk coming in, better feedings.
  At next wt check 3 days later (a monday), the baby had lost 5 more ounces,
and we began pumping 6-8x/day(lactina), and supplementing (ebm as much as
possible, formula to make up the balance); and fenugreek 3caps TID.  Parents
offered option to supplement with Haberman or SNS, they chose Haberman.
  Next day's wt check showed a gain of 4 oz.  Parents reported poor success
with haberman, given SNS, this worked well at breast.
  2 days later, baby had gained another 6 oz, and I estimated at that time
baby was getting about 50% of her total daily intake as breastmilk (pumped
and direct from mom added together).  All supplements at breast w/ SNS. Baby
latching better, much less fussy, archy.
 This pattern continued for the next two weeks, with mom's milk supply
eventually getting up to around 2/3 of baby's total intake, at a wt of 8lbs
8 oz.
  At around 3 weeks, mom developed thrush and the dyad was rxed with gentian
violet per Dr. jack's protocol.  Gentian violet x4 treatments was repeated,
as symptoms were still present.  discussed APNO.  Pt prefers to try
Nystatin.  Doing several feedings each day without SNS.
  At around 4 weeks, we discussed a course of Reglan,  mom's PCP did not
want to prescribe it because she said she needed more recent literature (our
oldest ref was from 88).  So we got the references, but by then this mom had
consulted LLL and begun doing shorter, more frequent pumping sessions..
Wanted to wait to start Reglan, since she had noticed some increase in her
milk supply.  Thrush symptoms worsened, so we started Fluconazole (150 BID
for 14 days). mom also began trying to wean baby from SNS during this time.

  At 5 weeks, wt check showed a gain of only 2 oz in 7 days, mom had
decreased pumping due to ductal pain.  Increased supplement volumes again.
4 days later mom called me in tears due to pain a/w thrush.  We prescribed
APNO, cont'd Fluconazole, and gentian violet. Also taking Ibuprofen for
pain.
  Baby had been fairly content and fed well at breast, esp with SNS, up to
now. Now she is restless, fussy during feeds (probably not thrush, we
re-treated her a couple more times during mom's long bout with thrush).
   At 6 weeks, we changed our protocol, and increased her Fluconazole to 200
mg/day for 14 additional days. Thrush symptoms improved somewhat, but
worsened whenever she wd increase pumping and have fuller breasts, more
pressure on the ducts. During this time, milk supply was at its best, with
baby weighing in at 9lbs 15 oz, and mom using average total 8 oz/ day per
SNS, and only 3 oz of this was formula.
  At 6.5 weeks, mom wants to start Reglan, her dose was 15 mg BID for 14
days, with a plan to begin tapering off at 9-10 days.
  At our most recent visit, around 8 weeks, baby had only gained 8oz in 15
days. (10 lbs 7 oz).   I recomended that she increase her supplement volumes
again.  During this time mom had been on Reglan (still is, tho tapering off
now), and pumping an average of 5 times/day, usually 1 hour after
breastfeedings.  Feeds 10-12x a day at breast.  By my reckoning, she has
been producing about 20 oz/ day for the past 2-3 weeks.  She seems to have
'hit the ceiling' interms of her ability to increase production. Am I giving
up too soon?  This has been such a long and complex case, i feel uncertain
of my bearings at this point.She has been symptom-free from thrush for about
a week now.
  Thanks in advance for reading through this long post and for sharing your
thoughts with me.
Martha johnson RN IBCLC
 Eugene, Oregon

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