You're right that the milk production issues are such complex detective work, and our tool kit needs to be bigger.  The book, "Making More Milk" by Diana West and Lisa Marasco is a useful, step-by-step exploration of possible factors (and there's a new edition coming out).  What underpinned this mother's fertility issues?  Doctors are all over mothers with tests about getting pregnant and during the pregnancy, but it's uphill work to get anyone interested when the next ordinary step after pregnancy -- lactation-- is running into unusual difficulties.

I discuss with mothers that there is not enough research on the herbals, but, because we don't have any medications for lactation, they are certainly worth exploring.  Lisa Marasco is doing some inspiring research on milk production issues, including the role of insulin-resistance.  This mother had gestational diabetes, which suggests potential problems with her sugar metabolism.  Goat's rue, chemically akin to metformin, has a reputation for improving insulin resistance and encouraging tissue growth.  So that seems worth trying.  There are lots of other herbal galactogogues -- the aforementioned book, and the kellymom website offer some resources on that.

If we had a pill that would just make milk happen, we'd drop it by helicopter over the country -- her hard work with the frequent, effective milk removals is the most important factor.  You're giving her some tips on productive pumping -- is she using a rental pump?

For the long-term picture, getting the baby back to the breast, and loving the breast, for food and for comfort, is important.  She's right not to battle the baby about the breast -- offering it for "dessert" after the bottle is a good step. 

 If a baby is willing to latch at all, I'm starting to really encourage supplementing at the breast -- it  is a fiddly process, but has so many advantages. (She doesn't have to choose one method -- she can use a paced bottle at some feeds, and the tube device at as many feeds as she can manage).   While I don't want to return to the terror of "nipple confusion" as a permanent barrier to breastfeeding, I think we've become complacent about expecting babies to go back and forth between breast and bottle without problems.

 You can point out that supplementing at the breast time-efficiently combines the breastfeeding and supplementing; it keeps the baby exercising his/her breastfeeding muscles and ending up at the breast happy and settled; and it rewards baby sustaining a firm, jaw-dropping suck that removes milk from the breast, which  pushes the production -- mothers have a hormonal click with a cute baby that the pump doesn't provide.

A home-made supplementer, with a feeding tube in a bottle tucked in her bra, is sometimes the easiest way to introduce the idea -- she's already giving a bottle, so it doesn't seem like an alien piece of equipment -- it can be presented as a long straw in a bottle, or a bottle extension.  (And a 30 ml syringe to clean the tube).  The milk only siphons when the baby does a nice pulling suck.

https://www.youtube.com/watch?v=ezGIkIkhC_o

She may choose to move up to a manufactured unit, such as the LactAid (with its soft, less bulky bags that can be pre-filled for the day and the siphoning action, it seems preferred for long-term use -- here's a nice video from the trenches
https://www.youtube.com/watch?v=-mDeRb_iGD4

The SNS is bulkier, and more potentially gravity-fed, but is more readily available.  Mothers who use it tend to start tweaking how they use it  -- not taping it, just sticking it in their bra rather than using the cord, sticking the unused tube up through the hole at the top where the cord goes,  to use as a vent, etc.  I'm sure there are some good YouTube videos.

With any at-breast supplementer -- a cool trick is to weigh the baby with the full supplementer alongside, and then weigh the baby again with the emptied supplementer after the feeding.  The supplement just moved from the bottle to the baby's stomach -- and any net gain was the mother's milk the baby took from the breast with the sustained sucking.  It's good for her morale to see that some of her milk was taken too.

Morale is so important.  Milk production difficulties can be devastating.  So point out, that in a world where some babies never get a drop of their mother's milk, or a minute enjoying being at the breast, the six ounces she is currently making is more than some babies ever get.  We don't know where we can push the milk production to (and she needs an exit strategy out of the "triple duty" of breastfeeding/pumping/supplementing).  But it helps her to feel that breastfeeding doesn't have to be all or nothing.

Margaret Wills, IBCLC, Maryland, USA





> Date:    Thu, 4 May 2017 23:53:49 -0400
> From:    "Carol Tenneriello, RN, IBCLC" <[log in to unmask]>
> Subject: Low Milk Supply-Goat's Rue?
> 
> Dear Wise Women, 
> I have been on Lactnet for a few years now but I rarely post. I am in private practice in the Phila area,(after working many years primarily in the hospital as a nurse in L&D &MIU )I  am having a small run of mom's with low milk supply that isn't (mostly)from lack of milk removal. 
> 
> I want to know after frequent nursing/ pumping..how can I help a mom with low milk supply? 
> 
> Mom A: 1st baby, gestational diabetes, infertility,(but no PCOS) some breast growth during the first trimester but said her breasts were back to normal size when I saw her at 6 days. Her breasts were soft, but didn't appear abnormal. 
> She was already supplementing after a >10% weight loss in the hospital due to a poor/no latch. 
> Our initial plan was feed the baby and remove milk to build supply. 
> 
> We got the baby latching with a shield at the second visit but he gets easily frustrated ,so she only does it when he's not fussing, sometimes after feeding with the bottle. 
> 
> Her doctor said her Thyroid levels were normal during pregnancy but at my urging she did get tested again this past week and told me it was normal. (She didn't know if she got a panel but will look). I will ask about her bleeding. I thought about Domperidone but I think that with the heart rhythm controversy it's not prescribed around here anymore. I searched the archives about it but didn't see anything new, but I did see a mention of goat's rue. Mom is already taking Fenugeek on her own. At ~3wks she says she latches about 4x and pumps 8x (with hand expression before and after) and gets 6oz/day, up from 5oz 1 week ago.I recommended hands on pumping. Yesterday she told me she started power pumping. I will be seeing her again tomorrow. Thoughts?
> 
> Thank you in advance,
> Carol
> p.s.If anyone knows of a Breastfeeding Med doc (other than Penny Soppas who is not taking patients outside of her pediatric practice), please let me know.
> 
>             ***********************************************

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