Dear Colleagues,

I am a newbie IBCLC (2005) in private practice.  I could really use  
some ideas about this mom I am working with, who presents with low  
milk supply that is not improving at all.  Here is the background:

She is a 41-year-old Caucasian woman (G2, P1) who had fertility  
issues due to advanced maternal age.  She indicated that she did not  
have PCOS.  She had a planned c-section due to placenta previa and  
heavy bleeding due to cervical polyps at 36 weeks.  She lost a lot of  
blood and had low blood pressure, low hemoglobin, and low  
temperature, so  baby went to the normal nursery for 48 hours, during  
which time she had some glucose water and several bottles of 20 mL  
formula after she lost 10% of her weight.   Mom initiated nursing on  
Day 3.   She did not pump in the hospital.   She initiated pumping on  
Day 5 when I saw her, with a Lactina and 30 mm breast shields.  She  
appeared weak, had shaky hands, could barely walk or sit up because  
of dizziness.  She had not nursed on her right breast for 15 hours,  
and it was swollen, but not hard and taut.  She was nursing  
exclusively on the left side, which was also full, but not as much as  
the right.  Her nipples are small and short at rest, but have good  
pliability and do not flatten or invert.  Her breasts are very large  
and pendulous.

Test weights showed a milk transfer of 0.2 oz from the left breast  
after about 20 minutes of nursing with breast compressions.  Suck  
assessment seemed normal to me with strong, rhythmic suction.  Latch  
at the breast appeared fine; the nipple was undistorted after the  
feeding, and baby's mouth was open wide on the areola with tongue  
forward.  Mom did a good job getting her on asymmetrically.  Baby was  
pretty sleepy at breast, which I attributed to slow milk flow, but  
could occasionally be stimulated to suck more actively.  She perked  
up when given a bottle.  We also tried a 16 mm nipple shield, but  
there was NO milk transfer with this.  Baby also had a good latch on  
a Playtex Natural Latch bottle. Mom then pumped with the Lactina for  
about 15 minutes and got a total of 15 mL, about 10 from the right  
(fuller) breast and 5 from the breast she had nursed on.  Her nipples  
were undamaged, and she reported that her right breast was feeling  
very sore and tender.

I saw her for a follow-up on Day 7.  She feels much better, but still  
not 100%.  She reported that she had pumped 4 times and got a total  
of 1.5 oz.  Baby is currently taking about 1.5 oz of formula about  
every 3 hours.  She has also been breastfeeding at every other  
feeding.  Baby nursed and got 0.2 oz*.  We then tried both the  
lactina and the symphony pumps.  We would get a minute of squirts,  
then nothing.  Her nipples filled the 30 mm flanges, so we then tried  
the 40 mm glass flanges, and then back to the 24 mm.  The pattern was  
consistent -- a minute of squirts and drips, and then nothing.  I  
could not hand express anything after the minute of pumping, because  
the nipple-areola complex was too swollen from the vacuum.  We were  
using high suction, but then I tried medium and low, and there was no  
change.

Hand expression before pumping yielded consistent drips and  
occasional squirts.  After either waiting a few minutes or doing RPS,  
drops and some squirts could be elicited with pumping, but again they  
only lasted a minute and then nothing.



*the 0.2 transfer is hopefully accurate.  Prefeed weight was 5 lb 1.2  
oz.  The dad changed the diaper without me noticing, so we weighed a  
clean diaper and 2 wipes, the compared it with the dirty diaper, and  
the difference was 0.2 oz.  Postfeed weight was 5 lb 1.2 oz and the  
stool weighed 0.2, so milk intake had to be 0.2 oz.


What is going on here?  I suspect there is more milk in the breast  
than is able to be extracted, because the pump keeps attracting fluid  
into the nipple and closing it off.  Hand expression and RPS help  
start things again, but I really only got a few mL in 5 minutes of  
hand-expressing.	I just am at a total loss about what to do for this  
mom.  She will start on Fenugreek, but is cautious about domperidone,  
and Reglan is out of the question due to a history of severe depression.

Thank you for any ideas you can give me.

Warmly,
Lynnette Hafken, MA, LLLL, IBCLC

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