Thanks so much for your response, Rachel.
>
> I have some thoughts about your choice of flanges.  You state that  
> the =
> mother's nipples are small (small in diameter?) and short.  Your  
> choice =
> of the 30mm, then the glass flanges and finally the 24mm flanges is  
> the =
> reverse order that I usually take.   I watch the mother closely  
> when she =
> pumps.  Occasionally I have been fooled in the past and I thought  
> that =
> the mother's nipple had widened, when in reality her areola was  
> sucking =
> into the tunnel of the flange.  These mothers actually need the 21mm =
> size flange.  I find many mothers need the 27 and the 30 mm flanges  
> to =
> accomodate their wider nipples.  I recommend the glass flanges to  
> the =
> uncommon mom with extremely wide nipples.

Interesting!  I will try the 21 mm flange.  I think I only have one  
in my whole inventory, because I have never used them, but maybe I  
need to try them more often!  I went larger because the mom  
complained of a rubbing sensation during pumping.  I also recommended  
that she lubricate the flanges with oil.


>
> I have watched many mothers, with low milk supply, drip and squirt  
> in =
> the manner that you mentioned.  They are having multiple "let- 
> downs" but =
> there isn't much milk to let-down. =20

The thing I don't understand is that when the milk stops coming, the  
areola feels very dense and swollen, and a minute of resting or RPS  
allows milk to start coming again.  So I feel that there must be more  
milk in there and the pump is somehow preventing it from coming,  
rather than helping it come.

>
> I rarely use a 16mm nipple shield.  The mother truly has to have a  
> tiny =
> nipple to comfortably use it.  If you "stuff" a nipple in a too- 
> small =
> nipple shield it compresses the ducts  and may completely occlude  
> them.  =
> 5 pound babies can comfortbly use a 20 mm nipple shield.  By your =
> description, I would not have recommended that you use a nipple  
> shield.  =

Yeah, I just wanted to try everything, and based on Paula Meier's  
research, I thought there was a chance that the firmness of the  
nipple shield would help keep the baby awake and sucking more  
actively.  But there was no milk transfer, so scratch that idea!

> This baby would probably be a good little breastfeeder if there was  
> some =
> more milk to drink.

Agreed :-(  I am going to just demo an at-breast supplementer next  
time and see if she warms up to the idea.


> You did not mention  the baby's birth weight.  =

5 lb 4 oz.

> Perhaps on your next update, you could also tell us if the mother  
> used =
> fertility drugs or in vitro fertilization to conceive.

Yes, she used fertility drugs.

Thanks again for your time in thinking about this case.

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