Leslie,

Could it be that the milk ducts are further back in the breast, and the
newborn baby and pump are unable to reach the spots they need to stimulate
milk flow and milk production?  Since she has very large breasts, this part
of the ductal system may be beyond where the baby's mouth and/or pump flange
can reach to put pressure during the suck/release cycling that gets the milk
to flow.  Since she felt some engorgement when she stopped pumping, she was
able to make milk.  Maybe a larger flange while she waits for the baby to
grow into her breast size would work.  Maybe hand expression during
breastfeeding or pumping would work.

This may not be the answer, but it is a suggestion that you and she might
consider.

Barb Berges, BS, RN, IBCLC
near Cleveland, Ohil



Date:    Thu, 13 Oct 2011 20:24:10 -0400
From:    Leslie Cree <[log in to unmask]>
Subject: advice for a 2nd time mom who did not succeed breastfeeding her
first

Permission from mom to post this for ideas/suggestions: Mom has a two year
old son and is expecting baby #2 early November. When her son was born she
was told by nurses that her nipples were flat. She was given a nipple shield
to breastfeed and instructions to pump every three hours to build supply.
Mom faithfully fed baby at breast with the shield and pumped for two weeks.
At the end of that time her infant was 1 pound below birthweight.
Heartbroken, she switched to formula. Mom had no obvious signs of why she
didn't produce--no history of breast surgery, infertility, PCOS, breast
asymmetry, lack of adequate breast stimulation, postpartum trauma or
hemorrhage. She reported an uneventful birth, no unusual thyroid or other
labs.   I saw mom today for a pre-natal consult and noted the following:
large, symmetrical breasts (G cup), with large areolas (diameter of about 3
inches) that had a stretched appearance. The areaoler skin looked like it
had stretchmarks, although mom said her breasts/areolas have not
dramatically increased in size. The areolas also looked dry, but skin was
not flaky. Her nipples were flat and looked eroded. There was a small amount
of graspable tissue, and nipples everted slightly with stimulation.

I provided mom information on breastshells as an option prenatally if she
wanted to try them to evert her nipples. Mom wants to try to breastfeed this
baby, but doesn't want to go through all the steps (feed, pump, supplement)
and the anxiety she experienced last time. Mom reported that even with
faithful pumping she did not see an increase in milk supply. (Medela rental
pump)  She did not experience any fullness or engorgement early postpartum,
but did have two "uncomfortably full" days when she discontinued pumping
"cold turkey" at two weeks postpartum.

When mom comes in to deliver, nurses will be informed that she desires skin
to skin care and first breastfeeding within an hour of birth.Thankfully,
this is common practice at the hospital where I work, as is rooming in. Mom
is prepared to most likely need to use a nipple shield again, but is
desiring to have the first breastfeeds without one. She does not want to
pump again. We did not discuss herbs/galactagogues at this visit as I didn't
want to overwhelm her and supersede her need to tell her story by offering
more "plans". She was willing to exchange emails and is receptive to
links/resources she can explore.

Any suggestions or guidance on what I may have missed would be greatly
appreciated!

Leslie Cree, IBCLC, RLC
Harrisburg, PA USA area

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