Lynnette,
Take a deep breath. This is what is sometimes called a "train wreck." (I 
don't mean to be flip). I disagree that this is unexplained low supply, but 
rather many red flags, or we could say it's multi-factorial. Very often, 
cases of low supply have a combination of maternal and infant factors 
inter-playing, as this case seems to have.
Here are the risk factors: infertility history, blood loss (Sheehan's 
syndrome? - She lost a lot of
blood and had low blood pressure, low hemoglobin, and low temperature - this 
is pretty significant!), small, preterm infant, delayed initiation of 
breastfeeding and/or expressing (iniated nursing on Day 3; did not pump in 
the hospital; initiated pumping on Day 5 - but this was erratic at first it 
seems), possible ill-fitting breastshields and ineffective milk removal even 
with the pump - although you can't say you didn't try many sizes. (Her 
breasts are very large and pendulous).

It seems hand expressing is giving the best results and I think I would 
recommend that until perhaps a pump could be tried that might work. Perhaps 
some pump with a soft shield. I think this mother is a good candidate for 
galactagogues and perhaps domperidone would work for her. The baby of course 
may continue to understimulate the breasts and perhaps he cannot reach the 
"sweet spot" to elicit her MER due to his small size and her large breasts. 
She should be followed up by her hcp to check on how she is recovering and 
to check for anemia which is also a risk factor. It is imperative that 
continued followup be given to this dyad, alternate feedings for baby and 
milk transfer measurements until it is verified that baby is transferring 
milk and follow his weight gain.

Laurie Wheeler, IBCLC, MN, RN
Mississippi, s.e. USA

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