Agree this wt gain is not optimal esp in light of early weeks gaining. How
often does baby feed?
You say <mom reported pain and some scabbing early on that resolved
has had one bout of mastitis (rt breast) & 3 plugs, various locations
smallish nipples protruded, very slightly compressed after nursing>
This indicates to me less than ideal latch/ poor drainage of breasts which
may have led to gradually lower supply. Baby may nurse poorer w/ mastitis
(salty taste?).

<tongue somewhat heart-shaped but protrudes well over gums while nursing>
Maybe this needs further eval. May just need a change in positioning for
tongue to reach better. May even need to be clipped.

<mom refused consult until today and only pumped 1 - 2 times daily with
avent Isis, yielding about 2 ounces total>
I would recommend double hosp grade pump; the Isis I do not believe is
indicated in this situation, unless financially this is what she can afford.
I would recommend pump after each feeding (or as much as mother can manage)
and use this as supplement, make up the difference with donor milk or abm if
needed. Suppl. at breast w/ nursing supplementer device. make sure mom
understands the supply and demand system, breasts need to be well "drained".
  I believe these early weeks are very critical to ultimate capacity and
continued milk production. Of course, monitor wt gain closely.

Laurie Wheeler, RN, MN, IBCLC
Violet Louisiana, s.e. USA

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