Help! PTP

I am working with a client who is 10 days PP and still no onset of copious milk supply.

G1P1, PIH (pregnancy induced hypertension), labetalol, low amniotic fluid, induction @ 38+3, epidural, more than 2L IV fluids, nuchal cord, long labor, immediate skin-to-skin contact, latched immediately, fluid aspiration, RD (respiratory distress), retractions, NICU (neonatal intenssive care unit) 3d, CPAP, NG tube to remove air from stomach, IV glucose, donor milk supplementation, formula supplementation, difficulty latching in NICU, frequent maternal milk expression, delayed onset of copious milk supply.

I saw this dyad at 6d PP. They were comfortably breastfeeding 8-10x daily and supplementing with a bottle every 3-4 hours @45ml. Baby transferred 0ml after 10 minutes of feeding at left breast during the consult. I helped them learn to supplement at-breast with tube and syringe and tube in a bottle. The baby did very well with supplementer and transferred a total of 58 ml in 25 minutes but removed only 4ml from the right breast and 0 from the left. Afterward, Mom did hands on pumping for 20 minutes and removed 9ml total.

Baby will be getting bodywork. He has good tongue mobility and lift and creates good vacuum while breastfeeding and does not pinch or cause pain while feeding.

Mom is taking nifedipine and continues to have high blood pressure. She has stretch marks on one breast but has no signs of tubular or hypoplasic breasts. They are round, symmetrical, and full in all quadrants.

She is now 10 d PP pumping with a Medela Symphony and properly fitting flanges. She was using too large flanges in the hospital and had switched to a Pump in Style when she came home. She is still only pumping a total of 1.5oz over 8 sessions.

All or most feeding is at-breast using a tube and syringe and supplemental formula. At 10 days, Baby is taking 45-60ml of formula per feed. He has a deep painless latch and good vacuum. He can even pull the milk through syringe without Mom pushing the plunger. It still appears that most of his nutrition is from the formula and milk supply is not yet increasing.

TSH came back at 1.38. No other thyroid testing was done. No unusual bleeding to suggest retained placenta. I have suggested more thyroid testing, A1C, fasting glucose and insulin. I have also suggested ultrasound in case there is retained placenta even though the placenta was inspected due to hypertension.

I have worked with one other client whose milk supply did not increase until day 11PP but she had mag sulfate at birth. What else??

Would myo-inositol supplementation be helpful here? It seems to be helpful for so many issues. Should she have full hormonal testing done or wait a few more days? She is becoming understandably worn out!

Laura Spitzfaden, IBCLC, LLLL

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