I have a strange case on my hands.   Here are the details:

Mom delivers full term (41+ weeks) baby boy, birth weight is 6.15, D/c weight
on Day 2 (vag delivery--pitocin, no epidural) is 6.08.   Day 7 at ped's the
weight is 6.13.   Day 8 or 9 mom is seen by a colleague for positioning and
latch-on help and baby's weight fully clothed is 7.02.   Pre and post feed
weights show a 2.5 oz intake at breast with little stimulation.   Colleague reports
that mom had tons of milk, was very full and that she (the colleague, who is
usually pretty conservative in terms of pumping, i.e. will often have the mom
pump a bit in case the supply is carrying the baby) didn't have her pump at
all.   I should mention that my colleague is outstanding and very talented, but
is taking the Boards this summer so doesn't have all the "breasts" under her
belt that many of us do, but certainly is not inexperienced by any definition.
Anyhow, mom calls for the next week, several times a day, feeling like the
baby is not "filling out" in the face at all.   Urine and stools are adequate,
in fact, plentiful.   I see mom and baby at a support group on day 14 and
baby's weight is 6.13.6 or .9 (I don't recall).   Baby looks skinny, hungry--still
stools a lot.   Pre and post-feeding weights during support group show a 3 oz
intake after both breasts.   I advise her to supplement at every feed and
start pumping after every feed and see doctor for weight check.   I (briefly and
fleetingly) palpated her breasts at the group and they were full, firm, taut.
I hand expressed---again, quickly--and milk came fairly readily.   My sense
was that supply was holding out, but that she should get pumping before it
dips.   Mom goes home, panics about the bottle and the pumping, calls Dr., and he
tells her to make sure she feeds every three hours at least (really stay on
top of things, that is) and to come in for another weight check in a couple of
days.   She goes in about three days later, and the baby is at 7.00 or 7.01.
SHe goes in about five days later (still feeding every three hours and on top
of things) and the baby is 7.02 or 7.03.   Doctor has already called me (he's a
great ped here in NYC--very "good" with bf) and told me that the mom is in a
delicate mental state and may not be able to handle all the pumping.   He
tells her after the 7.03 weight that she needs to supplement after every feeding
with formula (or expressed bm if she can pump).   She has been doing that for a
couple of days and I go to see her for a follow-up yeaterday (day 25).   She
has been pumping for a couple of days, and the most she has ever yielded is
3/4 oz.

At my visit, the baby has gained weight (he has been supplemented with
formula and *some* exdpressed breastmilk after every feeding for a few days).   He
is 7.10.   He takes 1.2 oz after about 40 minutes of nursing both breasts, with
most of that intake at the beginning of the feeding (he is asleep when we go
to supplement him).   Her yields, as I said before, are low.   Her breasts
feel full, taut, firm.   When I hand express, it takes a few squeezes to get a
drop or two to bead up to the surface.   Soemthing else to note is that when I
hand express, she says it is very painful/uncomfortable.   She doesn't pull
away, but states that it feels painful.   Given her history (i.e. what my
colleague saw, what I briefly saw at the support group) I launch into an explanation
about how she was an overproducer by nature and that that flow carried the
baby skill-wise but then his poor stamina led supply to drop, etc., etc.   I said
that it was important to get pumping to get this back, all the standard
acquired low supply stuff.  As I'm talking ot her, though, something is bothering
me, which I realize is this:   her breasts feel exactly the same as they did a
week earlier when I quickly palpated them in the support group.   I *know* she
is in low supply now, on day 25, as her yields are low and the baby's intake
is low.   So about halfway through the conversation, I ask her again if I can
palpate her breast and I really feel them and again, they are so firm and
springy--almost like an implant in front of the muscle (but she has no implants--I
asked about prior breast surgery).   So then I go back and really ask
questions:   what was her primary engorgement like, was it all over the breast or
pockets of engorgement?   She said pockets but described herself as very
engorged.  I also looked at health history--10 periods/year, very heavy, with clotting
every time.   High cholesterol, 45 pound weight gain.   No fertility
problems, but it did take 3 months until she charted ovulation.   Gestational diabetes
test was a 116 (I don't know if that is accurate or not--she was unsure).
No skin tags, no acanthosis nigricans.   No frank signs of insulin resistance
except, perhaps, weight gain and longer cycles.

Basically, this is a weird case because for the longest time, we (in our LC
group) were all like, this is a unexplainable because her supply was "so good."
  I have felt all along that there is a piece missing here, so much so that I
was starting to think that this was a Munchausen-by-proxy mom and other weird
thoughts, but what I think now is that this is low supply, but with unusual,
hard-to-"read" breasts.   I think that the "full, taut" feeling is just her
breast.   My question to you all is this: have yoo seen breasts like these?   I
have seen one other set and a local doctor of breastfeeding medicine here in
NY got sky-high testosterone levels on that woman and she had these doughy,
firm, but non-lactating breasts.   I'm sending this same doctor to this recent
woman as well, so I'll see what happens.   Also, I think that the "pain" she
felt when I palpated was because I was "hand-expressing" regular breast tissue,
not tissue that was full of milk.   The only piece I can't make sense of is the
2.5 oz intake twice on the digital scale.   The only thing I can think of is
that some of these insufficient glandular women do sustain the baby for
awhile, which means that some of the intakes must be okay (I usually see them when
they are *not* okay).

A few more things:   I realized just now that I didn't ask her about her
bleeding, which I will do.   She had no edema after delivery.   Also, there is
nothing wrong with the baby metabolically--I mentioned the copious and frequent
stooling to the doctor and mentioned that the mom described them as "fizzy" so
the baby was fully checked out.   And one last thing:   if I'm right, don't
ask me how I'm going to "correct" my diagnosis from "former oversupplier" to
"pathological undersupplier!"

Heather Kelly, MA, IBCLC
NY, NY

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html