Dear Kristi:

A few others are missing something important in this picture that she should not only 
have her metformin levels well regulated, but because insulin resistance can sometimes 
coincide with hypothyroidism, she should also have her thyroid levels closely moniitored.  
With this sort of profile, I would not extrapolate to studies in breastfeeding friendly 
cultures of moms who may have either already had children already or not have had 
endocrinological problems.  On the other hand I would not discourage her in the least 
because it sounds like her main goal is bonding so she is an excellent candidate for that 
relaxed style of wanting bonding that is so often key to success with induced lactation.  If 
she lived in Manhattan, I would send her to our breastfeeding medicine specialist to 
thoroughly explore all issues that could impede her creating a supply!!  In lieu of that, 
maybe a good breastfeeding friendly endocrinologist could help her to create optimal 
conditions for building a supply.

Two things you did not mention are what size nipple shield you are using and where you 
are taping the SNS when you try without the shield.  I may be grasping at straws here 
because I am envisioning how tough this particular scenario is to work with.

I only ask about shield size because many moms come out of the hospitals here in 
Manhattan with the 16 mm nipple shield.  I have only seen one baby once able to transfer 
milk from a 16 mm nipple shield and he was under 4 pounds at birth.  The most dramatic 
difference I found in milk transfer was one baby who took 30 min to transfer 1 oz using a 
16 mm shield and then proceeded to down an additional 3 oz in 5 min using a 24 mm 
shield.  I have typically found that you can get more areola tissue into a larger shield.  
Even most 4 pounders I have met can take a 24 mm nipple shield.  Smaller shields tend 
to put the baby more on the tip of the nipple.   

If you are trying without the shield (or even with the shield) with the SNS, I find it much 
easier for mom to attach a baby (especially with those elastic areolas that need a lot of 
shaping) if the tube is taped to the breast so that it will be directly under the tongue.  
Them mom aims the lower lip deep into the areola with the tube perpendicular to the 
bottom lip.  It makes for a much nicer target than the tube in the corner of the mouth.  I 
have never actually used the tube the way the company recommends.  In this manner, it 
is easy to get the tube into the baby's mouth without a big struggle which is especially 
important with attachment issues.  It may even work better with the nipple shield too.

I had a flash of one technique that I'd like to try, but then I realized with the tube, it 
would definitely be a two-person affair --- or you'd need something to suspect the SNS 
from.  I've been having good luck with very elastic areolas with latching the baby while 
the baby is draped prone over mom, legs dangling off one side, baby diagonally coming 
across mom to latch to the other breast.  The chin seems to sink deeper into the areola 
--- and I've even had it work nicely with a shield to get that lower jaw in deep.  But 
pragmatically, I'm think this would not work well with tube.

Finally, I think one reason you are not showing milk transfer YET is that this mom may 
need time to build the supply.  You might start tracking milk transfer as she starts 
responding.

Good luck with this one.  It sounds interesting and challenging.

Best, Susan

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