Suzie writes: I realise that I have no experience.  However, it seems to me
that
- between the mother and the LC, the mother's supply came up really well,
weight and length gains show that the baby was indeed getting plenty of
milk.
- not following the "finish the first breast first" practice lead to a
foremilk/hindmilk imbalance which resulted in an unsettled baby, who had
"feeding
frenzies", and an exhausted mother
- by "finishing the first breast first" and using breast compression, skin
to
skin contact etc, perhaps with fenugreek the problems could have been solved
and allowed the mother to gradually withdraw the Reglan.

I would really appreciate comments as to whether the above summary seems
reasonable or if I am missing something.  Suggestions as to how to get the
baby breastfeeding again and what sort of time frame the mother would be
looking at would also be appreciated.  Although she certainly sees the
benefits of the breast she is very tired, dealing with a 2 year old as well
and only has limited capacity for going back to the breast (ie. if it gets
too hard she won't be able to continue).

I am fully aware that I am out of my depth in this situation and I feel bad
for asking you all.

Don't apologize for being out of your depth. You presented a very coherent
case history with all of the pertinent facts and I think you made a very good
assessment. Reglan may have thrown mom into oversupply and, as you noted, the
fussiness in the baby was due to this. Of note, is the fact that her supply so
quickly dropped when she stopped the Reglan. Since you are in Australia, I
assume patients have access to Domperidone. I think this baby will not be happy at
the breast until there is some milk there. I would advise the mother to start
a regimen of Domperidone, pumping and gently easing the baby back to breast.
Although she had a great response to Reglan my experience with its use long
term is that almost all of the mothers I've worked with who have taken it have
had unpleasant to dangerous side effects. And I have not noted any side effects
with Domperidone except some transient sleepiness and headaches. Since it
does not cross the blood brain barrier it is a much better drug for long term
use.

I would want to make sure that the very good wt. gain the second two weeks
was on exclusive breastfeeding without supplementation. I just re read your post
and am not sure that is clearly stated. If so then it appears this mother was
pretty dependent on Reglan and may have low prolactin levels. I recently
heard Tom Hale speak and he pointed out that Reglan and Domperidone do not work
when mother already has normal prolactin levels--the assumption in these cases
is that low supply is due to something other than low prolactin. In the case of
PCOS mother has hormonal reasons for low supply.

Another large issue in dealing with this mother is her frazzled, fragile
emotional state and a two year old in the house. This is where it is very
important to listen carefully to her and devise a plan with her that she can follow.
Your support is invaluable at this point. I have had patients I know who have
been able to continue to breastfeed only because there is a sympathetic voice
on the other end of the line every day  for as long as they need it. We need to
give  good, evidence based advice, but beyond that, understanding where a
mother is emotionally and understanding and validating her feelings of
disappointment and frustration are invaluable. I find sometimes that mothers who are
experiencing breastfeeding difficulties for the second time can be extremely
emotionally labile. Because they've educated themselves and  have tried to do
everything correctly this time and still things are not going as planned, the
disappointment is compounded. If supply comes up again and this baby is able to
get back to breast then, of course, as you've stated careful management--i.e.
finish first breast first and slow weaning of galactagogues if necessary will be
important.

Hang in there--this mother is lucky to have you helping her.

Kathy Boggs, RN, IBCLC
Mountain View, CA

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