Hello Friends,
Thank you for your answers to my question. 
Since seeing the mom and baby on Friday she did 24 hours of 30 minutes at
breast with the nipple shield, pumping 10 minutes after feeds, supplementing
with the pumped milk, and thrush treatment  - APNo for Mom and nystatin for
baby. She then reported no change in baby's output or behavior over 24 hours
from prior to starting this plan. Nipples slightly less painful with use of
shield. She felt overwhelmed by the process as Rachel expected. I mainly
wanted to supplement as much as he wanted to see if he had more output and
would be more content, but this did not occur. His output has been normal
despite not gaining much, but I think he works so hard at feeding he uses a
lot of energy. 
For the next 24 hours, from Saturday to Sunday mom pumped exclusively to
rest nipples and determine total milk production. She produced 19 oz of milk
in 7 pumpings and baby consumed 23.5 oz of EBM in 7 feedings all with a
bottle. Clearly the milk supply is low but it could be worse.  Her nipple
pain did not improve and is maybe worse. She can only tolerate pumping on
the lowest setting due to pain.  This tells me that thrush is more possible,
her nipples really look white and mushy in the middle. Even though she had
the Apno for a couple of weeks she only used it 3 or 4 times a day and then
was washing it off before feedings.   I still think there may be a thrush or
other kind of infection. I wanted the baby to be treated so thrush is
treated correctly and consistently. If the nipples still remain sore we can
at least  rule out that it was thrush.  She has been seen by 2 MD's for
this. One very knowledgeable about thrush.   

 Rachel says,
"  I've become more and more convinced that mothers whose supply suddenly
drops around two or three months, are actually mothers who were at risk from
the start due to suboptimal latch, and the hormonal boost to breastfeeding
in the early days camouflages the problem, everything looks great, and
everyone is mystified when the milk nearly disappears within a couple of
months.  This mother probably never has produced as much milk as she could
with effective suckling."  
   I totally agree with this. Ithink  that is exactly what is happening here
at 3 1/2 weeks the supply is starting to go down due to the ineffective suck
and was ok before because it was still under endocrine control.

Rachel also says,
" This baby likely has some oral anatomy problems, or possibly some tone
problems that could be helped by physical therapy, but in addition he may be
tense and clamping even more because he is simply not getting enough food.
A shield may be a good idea if it improves mother's comfort, but it
will not be enough to solve the food problem." 
I agree again. Several other have suggested a tongue-tie and the need for
craniosacral therapy.  I hope Cathy Genna will chime in here. I am just not
good at recognizing type 4 tongue tie, there is definitely not an obvious
tongue tie. Let's just say there are numerous health care professionals
involved in this case and all are skeptical of these two particular things.
My hands are tied as far as these treatments go, but I will continue
suggesting. 

 At least until tomorrow morning, or until the nipples feel significantly
better,  Mom will still pump and bottle feed. She hasn't mentioned problems
with feeding with a bottle and I did not observe bottlefeeding, but I will
ask. I certainly could give her a Haberman. He does suck a pacifier the same
as the breast - really hard work! After the nipples are feeling better we
discussed going back to unlimited feeding at breast with the nipple shield
and working on the chin down and deeper latch as he could tolerate it. I
cautioned Mom that it was probably hard for him and it would be slow
progress and maybe also needs the jaw to grow.  Pumping for 10 minutes after
daytime feeds only the increase the milk supply.I also suggested fenugreek,
but mom is reluctant.  All the while we will be watching the diapers and I
asked her to callin me with progress on Tuesday.

I this new information gives you all any more ideas please send them on.
Thanks again.
Judy 

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