Mary,
Take a look at the big picture first. Does the mother have any history of
reproductive or hormonal problems? Any evidence of hyperandrogenemia (too
much testosterone)? What about her mother, aunts, sisters, cousins? Any
problems in the family?  Then look at the breast shape, and feel the
interior gland. Is it soft, squishy, "smooth" in texture, or do you feel
feel the firmer gland underneath?

I have come to the conclusion that there really are two different things
that may be going on. The first is true insufficient glandular development,
which is more obvious by appearance and/or palpation. The second is an
apparently normal breast that has not responded to pregnancy hormones and/or
postpartum hormonal changes. While there is no standard test for glandular
development, there was an older study that utilized radiography, while
Marianne Neifert (80's) used diaphanography (light scanning-- ever put a
flashlight under your breast and observed how much light shows through when
in a pitch dark room? Lactating breasts are dense and let little
through.....) We have the technology, we just don't readily have the experts
to interpret what they see with an eye to lactation.

The "solution" to either of the above is not much of a known in our
profession at this time. You take the best history that you can and glean
whatever clues there may be. But the first line of treatment is pretty much
the same: lots of stimulation via pump or baby. It would seem, both from the
article Barbara cited as well as anecdotal information on this list, that
sometimes bleak-looking situations can begin to resolve after some weeks of
pumping. I think the Huggins article says that it can take up to 3 months.

In the first week or so, I encourage lots of stimulation, and I watch. If
results are not readily forthcoming, I speak to the mother about my
observations of her history and breasts and explain that sometimes it can
take a while, and that we may not know her full potential for several weeks.
They want to know right now what their potential is, and we really just
don't know. It is up to her as to how committed she is to keep working at
it. I do often recommend galactotogues, as I personally believe that the
worst thing that will happen is nothing, and the best thing is that they
might speed things up-- but again, it is her call.

I have been working the past 4 mos with a mom whose milk just did not come
in much. Her breasts otherwise look totally normal; she had pregnancy
growth, and her history is clean. We did test and find her prolactin to be a
bit below the range given by Lawrence for that day pp, which to me indicated
that prolactin-stimulating galactogogues would especially be appropriate.
Mother's supply is *almost* enough, but I think not quite. She has pumped,
she has breastfed, she has worked very hard and has been taking domperidone.
She is a hard worker; not all women will be willing to work this hard. We've
probably plateaued, and I still don't have an answer, only theories.

Lisa Marasco MA IBCLC

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