Dear Lactnetters

I am in need of your collective wisdom.  I have searched Lactnet and
checked Bf and Human Milk and the BAB.  I will try to be brief.

44 year old primup, 6 weeks postpartum. Breast augmentation surgery -
surgeon says should be no problem with breastfeeding.  Term baby
delivered by Caesarean and put to breast 4 hours after birth.
Thereafter fed 4 to 6 hourly while in hospital.  Baby sleepy first week
at home - weight gain 50g.  Mother told to supplement with formula.
Subsequent weight gain about 400g (12 oz) per week with 180mls (6oz) of
formula per day.

Original contacts by phone re milk supply.  Mother initiated lots of
skin-to-skin contact and spent week-end in bed feeding ad lib.  Felt she
had more milk although gave occasional bottle when baby became
frustrated at the breast.

On first home visit observed good latch, but let-down only occurred
after about 5 to 10 minutes.  Baby quite accommodating but
understandably frustrated and impatient.  Fighting and pulling the
nipple.

During second home visit observed baby at the breast for 20 to 30
minutes - *no* let-down.  Supplemented baby at the breast with no. 5
tube and syringe and still no let-down.

Mother reports good feeds at night with let-down and usually good during
the morning.  But about 12h00 to 20h00 there is a delayed let-down, or
more usually, none at all.  This problem seems to be getting worse and
the lack of milk removal is now impacting on the milk supply.

Have tried back massage (with knuckles from neck to shoulder blades).
Mother will continue with skin-to-skin contact, warm compresses and
massage before feeds.  Also pumping before and after feeds.  I phoned
her very supportive obstetrician and she will prescribe metaclopramide
and oxytocin nasal spray (if we can source some!)

What else can we try?  What am I missing?  Many TIA.

Jean Ridler  RN  RM  IBCLC
Cape Town, South Africa
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