Perhaps your first strategy is to do all you can to rachet down the mother's understandable anxiety -- she is worried about going down the same path she walked with her first child -- but this is a new baby, and she is already taking active steps.  This baby is only 9 days old! And already trying to figure out a newly released tongue! And thriving!  Full-time pumping is an option, but would be really hard and no fun to maintain long-term with two young children, and nothing you're describing seems to warrant such a drastic decision.  If she really felt that she needed to do that, perhaps you could discuss it as a strategy to buy time, catch her breath,  and then woo the baby back to the job.
In cultures where breastfeeding is ordinary, they often have traditions of a 40-day period/babymoon where the mother is really taken care of because they assume there will be a crazy learning curve with a new baby -- breastfeeding tends to work when people stay in the game and work through these ordinary adjustments.  

Yes, she has a copious milk supply, and probably a real head-start with a second baby.  But the baby's intake is going up, and if she if feeding one side at a time, the fullness on the unused side starts to send a message that inventory is sitting on the shelves, so the factory doesn't have to run that fast.  As the baby's intake goes up, and the body calms down, they're likely to meet at a reasonable balance point. 
 She should minimize the pumping -- maybe use some reverse pressure softening if needed to help the baby latch, and, as you described, hand-expressing a couple squirts off first, and laid back positions -- all strategies to help the baby handle the flow.   Yes, some people do battle with difficult oversupply and you will certainly pull out all the stops if this mother/baby team is continuing to have problem --  but at 9 days, it may be too early to assume that this will be a recalcitrant oversupply problem.
Given her history, she should stay in "preventative maintenance mode" for plugged ducts -- cold compresses after feeds -- great breast massage video here: http://bfmedneo.com/.  

And do whatever she needs to do to stay in the game and help the baby out -- perhaps the nipple shield as a temporary aid, a somewhat reclined position so gravity slows the milk, waiting for the baby to organize and seek the breast, before helping the baby get a nice big "sandwich" of breast.   And, if the baby is really refusing the breast, a slow-paced bottle of her milk, maybe with dessert at the breast-- and knowing that the baby will be back for the next meal in a couple of hours and that feed might go better-- newborns eat all the time -- she has *many* chances to work on breastfeeding.

I'm concerned that the expectation is becoming that there is *one answer* and that the LC walks in and *fixes* everything in one hour.  Sometimes that happens.  But perhaps we're losing this sense that breastfeeding, like many human activities, has a wide range of normal and each individual mother and baby team is working out their "fit" and their routines.  Breastfeeding is something that you have to mess around with -- as long as we have a baby that is peeing, pooping and gaining weight.  Have we really progressed if mothers used to stop breastfeeding because they didn't have help, and now they stop in a panic because breastfeeding isn't going perfectly according to their expectations.

Good luck to the whole team.  

Margaret Wills, IBCLC, Maryland



> Date:    Sun, 5 Jun 2016 14:03:22 -0400
> From:    Nancy Gray <[log in to unmask]>
> Subject: Serious oversupply and OAMER problems - 2nd baby
> 
> Please forgive cross posting. The archives have some good info, but I wanted to get current thoughts:
> PTP: Baby is 9 days old. Mom has significant oversupply issue and an overactive MER. With her first child she dealt with frequent mastitis and plugged ducts and the baby had lactose overload from the copious amounts of high lactose milk. A nipple shield helped with the OAMER and block feeding calmed things down eventually. 
> With the new baby, she initiated block feeding on day 2 of life. Baby had a lingual frenotomy on day 5 of life. This baby is a sleepy baby, which aggravates mom's engorgement. Mom is well aware of arousing strategies but they just don’t work well for her. Baby refuses to eat occasionally, and has taken a bottle once after extended refusal without problem (disheartening for mom, for sure). She expresses milk prior to feeding so that baby can latch and says that since the frenotomy there have been no problems with latch, although it’s painful at first (protection against the OAMER. She uses laid-back nursing, lets down into a cloth, and applies a nipple shield to help with flow. Mom has tried Full Drainage Block Feeding but hasn’t seen much benefit.
> Weight gain is good – baby is already 3 ounces over birth weight. Elimination is good. So far no mastitis or plugged ducts with this baby. Mom is considering full time pumping at this point.
> ANY tips would be appreciated!
> Nancy Gray, MS, RD, LDN, CLC


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