Phyllis Adamson, thanks for sharing your experience and knowledge about
thalassemia.  While anemia has been linked to low early milk production, I
was struck by one phrase in your post, which I thinks bears scrutiny with
regard to Tracy's question about how the mother in her case could have best
protected her (now very low) milk supply.
Phyillis states:  "Personally, I had no problem producing milk. I had more
than I needed because my babies were voracious nursers."  Note the part
about the VORACIOUS NURSERS.  This means the baby was capable of handling
the problem of the mother's potential risk for low production.

Whenever there are markers (like anemia) that are potential red flags for
early milk production problems, it becomes all the more impt. to also
identify through careful assessment, baby red flags that might coincide or
collide with the mother's, producing the dreaded "train wreck".  A train
wreck occurs when BOTH mom and baby have problems.  In Tracy's case, we see
another one of these tiny babies we were talking about earlier.

Tracy states that "Baby was 6 lb 8 oz at birth and 6 lb 2 oz at discharge.
Baby is now 5 lbs 14 ozs."  By my calculations, that is a 10% weight loss,
and the weight is still decreasing.  Such a baby is undependable in terms of
being able to re-stimulate a flagging milk supply.  Milk supply is
calibrated in the early postpartum. Neville describes this period as the
most critical time in the establishment of lactation, stating:
"breastfeeding failure usually occurs at approximately the first week
postpartum" (Neville, Anatomy and Physiology of Lactation, Ped Clinics of N
Amer 2001;48(1):13-34.)

Poor or weak early stimulation can cause delays in lactogenesis 2.  If the
milk supply is not protected by alternate stimulation, down-regulation is
inevitable.  We have literature that suggests what typical milk volumes look
like during lactogensis 2.  They seem to be around 500-600 ml/day (about 17
oz).  Vols rise still more out around the end of the first week pp in moms
of singletons if the baby is emptying the breast well.  So if the baby isn't
gaining there are only a few things that could be happening:
1) the milk is there but baby isn't transferring it
2) the milk never "came in"
3) the milk came in, but due to mis-management, has down-regulated.

Solutions:
1)Feed the baby (ideally pumped milk) via some method that guarantees the
baby gains back the lost weight/energy to feed
2)Protect the milk supply (by improving breastfeeding technique and by
stimulating with pump and  perhaps meds/herbs)
3)Keep baby skin-to-skin with lots of practice time at breast to protect the
orientation at breast (this will facilite an easy withdrawal of the
interventions)

Help the mother understand what she must do and WHY she must do it so that
she has a full understanding of her situation.

Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
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