Kathy,
The mother you write about sounded like her milk came in with her first
baby, but couldn't come out. You treated her for possible failure of milk
ejection but that was not successful, and you also treated her for milk
production issues. Is this time around so far exactly the same? Does she
seem to experience breast changes, with increased fullness,  heaviness, even
heat, around day 3-4? If she has milk coming in that cannot exit, I would
think that she might develop mastitis.

I am wondering if it is possible that her milk does indeed come in normally
but that she has anatomical obstructions that do not allow the milk to come
out. When the baby is put to the breast or the pump is started, she has
symptoms of oxytocin release and thus assumedly attempted milk ejection, ie
uterine cramping, correct? 

So either there isn't much milk there or there is an obstruction. So if it
is possible to closely monitor the quality of her breast tissue (and I know
she is now about 5 days pp) and make sure that fullness isn't fibrous breast
tissue) to figure out if there is milk making tissue that is responding,
that should give you some more clues. 

What was her history of breast changes during pregnancy?  I would also look
very closely at the thyroid and make sure her TSH is between .5 and 2.5, as
those numbers are now being tightened for reproduction. I have one research
article (Miyaki et al) noting that women who are "euthyroid due to
treatment" still had more problems with lactation, but given these new
guidelines on TSH I am hoping that tightening the range will help. 

~Lisa Marasco

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