I would appreciate your collective wisdom on a baffling case.  The mother
has granted permission to post her case.

This is a primipara 32 year old mom with a 7 week old baby.  She gave birth
vaginally (epidural/IV pitocin) in the hospital and was dismissed at Day 2
without the baby ever having latched, although she was clear that she
wanted to exclusively breastfeed.  When she couldn't latch him at home
despite her best efforts, she began using an Avent Isis manual pump every 2
hours and bottle-feeding.  Her colostrum output was copious and the baby
was large (full term), so no supplementation was needed.  She consulted an
experienced volunteer breastfeeding counselor, who was unable to get the
baby to latch, but recommended that she use a better pump, such as a Medela
Pump-in-Style, until her milk came in when she thought the baby would be
more interested in latching.   When Lactogenesis II occurred, vivid stretch
marks appeared radiating from both areolas (these are still every bit as
vivid 6 weeks later).  When the baby still would not latch, she consulted
an LC from the hospital, who came to her home and worked with her but was
also unable to achieve consistent latching.  I was consulted at 3 weeks
postpartum.   She was still pumping full time (8-10 ounces per pumping) and
bottle-feeding; the baby had not consistently latched.  In the interim
until we could get the baby to consistently latch, I suggested she rent a
Medela Classic.

After pulling back all the layers of her case, we discovered that there
were two problems, the first being dependent upon the second: The baby
would/could not latch because she had a severe oversupply, which had led to
a bilateral massive network of plugged ducts in the outer and lower
quadrants of her breasts.  She was distended, which made latching very
difficult. The plugged ducts (and possibly some galactoceles) would remain
hard when her breasts had been thoroughly drained by pumping with the
Classic.  Her MER was very strong.  I worked with her to make certain she
was adequately draining her breasts, using compression techniques, etc,
when she pumped.  But after each pumping session, her ducts refilled
quickly and were just as full 20 minutes later.  She used parsley and sage
to downregulate her milk supply and began taking lecithin for the plugged
ducts.  She also eventually decided to try an antibiotic (at the
recommendation of her midwife) as she was feeling some mastitis
symptoms.  The milk supply did seem to downregulate to an appropriate
level, but the plugged ducts remained.  The antibiotics didn't seem to help
at all and were discontinued after one course.  I suggested (after reading
Lactnet archives) using a vibrator and/or ultrasound to break up the
plugs.  She said she didn't know what a vibrator was and wasn't open to
trying it and she was very skeptical about ultrasound.  After working for
two weeks to resolve the plugs with every trick I could find in the
textbooks and Lactnet archives (with the exception of a vibrator or
ultrasound), she had experienced no relief and was just as miserable.

Of course, I felt the most important aspect was to get the baby to latch
deeply (asymmetrical) and transfer milk well.   The baby was willing, able,
and very goodnatured about trying, but just couldn't get enough tissue in
his mouth to stay on.  We tried pumping just enough to soften the areolas,
but the plugged ducts under them never softened.  We tried pumping until
her breasts were as empty as possible and supplementing with a starter SNS,
but we could only get her son to latch briefly.  We tried massage and
compressions until our hands were sore.  We tried using a nipple shield and
every other trick I could think of.  I was encouraged when on one occasion
of diligent work to latch him, a significant amount of stringy milk was
expressed.  But we couldn't seem to replicate it.   I worked diligently her
for two weeks, but although we could get the baby to latch occasionally,
the mom finally became overwhelmed and gave up, deciding to pump full time
and bottle-feed.  Accepting her decision and understanding the tremendous
frustration that had led to it, I nonetheless stressed to her that she
still needed to resolve the plugged ducts.  She was in tremendous pain from
them and readily agreed.  I recommended that she consult a breast
surgeon.  Her midwife referred her to one whom she believed to be
breastfeeding friendly.

The mom called me just now with great frustration.  She is just as
miserable and uncomfortable as ever.  She saw the surgeon and he told her
that she either had to wean (in which case he said the ducts would go away
on their own) or have him probe her ducts internally through the nipple
pores to clear them, but warned that he was nearly certain he couldn't do
such a procedure unless she had weaned anyway.  He said he had never heard
of ultrasound to resolve plugged ducts and thought that couldn't possibly help.

She does NOT want to wean and she is not at all sure that an invasive
procedure is appropriate.  Neither am I.  She really wants to give her milk
to her son.  But she is miserable.  She is very upbeat and cheerful, but
every time I talk to her, I hear her voice wearing just a bit thinner.  I
really want to get this poor mom some help, but at this point I feel that I
have exhausted my ideas.  Perhaps there is a better surgeon in this area
(US - Maryland/Washington, DC, suburb) who could help her, but neither I
nor the midwife know of such a person.

Ideas, thoughts, suggestions?

Diana West, IBCLC

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