Riva wrote: 
I am working with a Mom and her 10 week old baby. Mom has improved the milk supply and her technique. Baby had a frenotomy two weeks ago. Baby still takes long meals (about an hour) with lots of stops and starts, occasional clamping down. Frenulum was checked after a week, by surgeon, who feels it was open enough. I still haven't seen it. Baby will not suck on finger to do any suck training and mom feels he "doesn't like it". After all, baby does get satisfied and is gaining weight normally. Mom is very concerned what will be when she goes back to work, when she will not be able to dedicate endless hours to feeds. I was thinking that the next step might be CST – though there were no birth interventions, no asymmetry or other reason that I would usually refer on. 
I would appreciate your input, I am not sure i have given enough details, what have I missed? What might be the next step? 

Hi Riva, 

I have read the previous responses with great interest and appreciate all the different ways to approach this topic. Here is another thought for your consideration. Perhaps "power nursing" would be helpful, especially if combined with breast compressions. It may be that the little one responds to flow, sucking more actively when flow is greatest and slacking off as the flow slows. Mothers I have worked with have found that the combination of power nursing and compressions can keep the baby more actively sucking and more efficiently transferring milk. It also reduces the "down time" where the mother is tickling, blowing, nudging, etc. to keep baby sucking. It's good that baby is aging normally, so whatever baby and mom are doing together is working but time consuming. 

As for when Mom returns to work, her pumping time would be what she needs it to be to fully express. How baby takes a bottle from the caregiver may take some practice to find the most effective way for baby to feed with control. If baby's active sucking is related to the flow, the positioning of baby and bottle will be key to get the right spot that's not too fast but yet not to slow that he loses interest. her time nursing at home may be pretty similar, although many mothers will reports increased frequency of feedings when they return to work because baby is missing the relationship. not just the food. 

Keep us posted on how this works out, please, 

Cindy Garrison BS IBCLC 
practicing in Pittsburgh, PA, USA 

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