Ok you all, I am feeling like I am missing something here so I am asking you
for you feedback on this particular case.  I cannot seem to figure out the
missing piece so I thought I'd ask 2000 of the greatest minds in lactation.

Mother:  Breasts:  both very soft, no evidence of filling, shape is
consistent with sufficient glandular development, some growth noted during
pregnancy, no filling postpartum.  Nipples:  both everted, small scab at tip
of left breast.  Birth:  scheduled cesarean at 39 weeks for transverse
presentation, lochia flow is decreasing.  Medications:  Ibuprofen for pain.
Mother reports no known history of hormonal problems.  No reported
difficulty achieving pregnancy.  Previously breastfed two older children but
weaned early due to excessive supplementation.  Mother has been pumping with
double pedal pump and after 1 0 - 15 minutes has not seen even drops of
milk.  Hand expression by LC yielded only dampness at the opening on one
duct.  Mother is heavy-set.

Infant:  Born 12/03/98.  Birth weight:  7# 5 oz.  Additional weights 12/5:
6# 6oz, 12/7/98 6# 8 oz, current 6# 11.7 oz wearing sleeper and diaper
before feed.  Circumcised at 2 days.  Urine:  yellow, 3/24h.  Stools: none
in 48 hours, last was dark brown.  Skin is yellowing and has little
elasticity.  Baby has been nursing at breast, about 5 times in the last 12
hours.  Given 2-oz formula at 9pm last night and 11 am yesterday.  Palate:
WNL.  Tongue: cups well and shows appropriate peristaltic action both on a
dry finger and on breast.  Position needed to be improved slightly to allow
more comfortable latch.  Baby opens wide and sucks well.  Baby nursed form
both breasts for 20 minutes.  Most sucks were non-nutritive (2/second), only
about 10 - 12 nutritive sucks were observed in the entire 20 minutes.  Baby
fell asleep after about 10 minutes on each breast but did not relax fists.
Test weights showed intake of >1/2 tsp.  A nursing supplementer was added to
the breast.  Mother had some difficulty coordinating SNS tube and baby but
eventually did get baby to take 1/2 oz formula at breast with SNS.  Mom
could not coordinate attempts to use SNS on second breast and I suggested
she give the baby more milk.   She opted to use a bottle and baby got a
total of 2-oz formula.

Suggestions:  Continue to nurse the baby at the breast using improved
positioning techniques.  Supplement as much formula as necessary to allow
the baby to have at least 5 heavy wet diapers and 2 stools per day.
Reconsider use of supplementer at the breast.  Contact obstetrician for
follow up.  Consider evaluation for retained placental fragments and thyroid
testing.

I have never had a mom with NO milk before where there was no obvious cause
like this one.  I contacted the OB office by telephone and by consult
report.  I tried to get them to understand that it is abnormal for a woman
not to produce any milk at all but the nurse did not seem to get it.

Linda Pohl, IBCLC
Phoenix AZ