A mom I am seeing gave me permission to post.  She has an 11 day old
daughter who was born by C-Section at 36 weeks.  Mom was gestational
diabetic and also has a history of Cushings Disease.   She had radiation
treatment for a pituitary tumor associated with the Cushings Disease.  She
has been off all meds for the Cushing's Disease for the last 2 1/2 years.

Mom is Gravida 6, Para 6.  She breastfed her 8 year old for one year, at
which time she was told to wean due to Cushings meds.  She breastfed her 3
yo for two weeks, at which time she was instructed to switch to formula
when going on the "diabetes pill" for her Cushings disease.

Question # 1: is mom likely to get a full milk supply?  She pumped 35 cc
today, but that was the first time she had pumped since yesterday.  Could
the radiation and the pituitary tumor associated with Cushings have
compromised her ability to make milk?

Baby is currently in the hospital for dehydration and low temp and apnea.
The low temp and possibly the apnea spells are probably iatrogenic and
related to being undressed in ER for quite a while.  Baby was feeding only
5 minutes at a time and falling asleep when I saw her Thursday on an
outpatient visit at the hospital.    The last day before she was
hospitalized mom couldn't even wake her to feed.

Mom hasn't been  breastfeeding since her daughter was admitted Saturday, or
for at least the last day.  She pumped twice yesterday and just before I
saw her today.  She is feeding the breastmilk or formula (Enfamil) with a
volufeed and standard nipple.  First of all I suggested that if she wanted
to pump instead of feeding that she needed to pump at least every 3 hours.
Last Thursday I had mentioned using an SNS to give any supplement whether
EBM or formula.  Mom was not interested.  Today I mentioned that again
along with cup feeding as other possibilities.  Mom is not willing to do
either.

Her stated desire is to pump to maintain supply until her daughter can
nurse well.  She wants to give EBM or formula via bottle.  She wants to get
back to exclusive breastfeeding.  Since she had gestational diabetes and
was at the gestational diabetes conference we hold monthly for expectant
moms, she is sold on exclusive breastfeeding and continuing breastfeeding
for one year.

Next problem:  mom's nipple size is at least as big as the bottle nipple,
perhaps bigger.  I didn't have a ruler with me (and I'm sure it would have
been rude to say let me measure that huge nipple), but my guess is that it
is 3/8 to 1/2 inch in diameter and at least 3/4 inches long.  I believe
this has been called oroboobular disproportion in previous posts.  The baby
looks like a premie to me and can't open her moutth very far.  She was 5 #
1 ounce at birth and was down to 4 # 12 ounce last Thursday.  Don't know
her weight today.  I thought that perhaps once momentarily she might have
been latched on slightly more than the nipple, but sometimes she wasn't
even latching to the nipple base.  Mom says she has never taken more than
that much of the nipple and breast.  She sucked well, but I would assume if
this kind of sucking has been the norm for the 11 days that baby can't be
transferring much.  I am new enough at all of this that I don't have any
idea what to do for this combination of factors other than keep encouraging
her to pump regularly and keep attempting to get the baby latched on
better.

Any ideas that don't involve lots of extra time or equipment will be
welcome. I am willing to propose others but don't know if Mom can cope with
anything complicated.   Mom already will be taking home an apnea monitor.
With a preschooler and a complicated social situation and not lots of
support, I need ideas that will hopefully simplify rather than further
complicate her life.  I see her again in the morning and have stayed late
at work this evening to post this before going home.  Hoping for ideas in
the morning.

TIA

Sharon Jimenez, MS, RN
hopefully future IBCLC
Breastfeeding Specialist
White Mountain Apache Tribe
Whiteriver, AZ

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