Hey, Anna Thanks for bringing this one up. I've got a lot to say because I
come to this as an RD, not an RN---just a different perspective.
You ask whether we recommend a PCOS work up in the case of supply/wt gain
difficulties after the usual bfdg mgmt has been considered.
I have seen sooooo many mothers heartbroken by this that NO! I DON'T
recommend a PCOS work up in cases of supply/wt gain problems . . . .(keep
reading!). I want to do everything I can to avert the heartbreak.
So this is one I try to catch proactively while we still have the help of
whatever immediate post-birth hormones she's got working and long BEFORE
there are supply/wt gain problems. Therefore, I notice every mother's pre-
preg height & weight & age & how many babies she has with every chart I
open on the post partum floor.
If she's a disproportionate weight for height and "old" and it's her first baby, I
ask if she had trouble getting pregnant. If so, that lets me go further and ask
if she's got PCOS or insulin insensitivity/metabolic syndrome/syndrome X
(google those). If she says "no," we're good. If she says "yes," it opens the
door to the rest of the conversation. And it's probably going to be a long
conversation as I combine the necessary information with the emotional
support. Sometimes the weight for height also becomes important when a
mom tells me she had supply trouble with her first and that's why she wanted
to see me. It alerts me right away to ask about PCOS. Her response is
often "How did you know!" To her it was unrelated so she didn't think to
mention it.
As you've probably read, some of these moms also have noticeably small,
widely-spaced breasts with little growth during pregnancy. Even if a mom
says "no" to PCOS/insulin insensitivity, etc, and got pregnant fairly easily, if
she has small, widely-spaced breasts with little growth during pregnancy,
much of the rest might apply to her. Is she one of the undiagnosed women
with PCOS? I don't know. IBCLCs don't diagnose, but we can certainly offer
information that will help her max-out whatever her own capability is.
(Can I assume you've read Lisa Marasco's JHL article? Her work has gone well
beyond that now, and if you google Lisa, you'll probably find several more
recent conference sessions for which you can purchase the CD. We're all
eagerly awaiting the publication of her book with Diana West called "Making
More Milk.")
Because it's going to be a long discussion and I want to be supportive, not
lecturing, I sit down with the mom. I explain that our current understanding is
like a closet with a light inside and the door is just open a crack so a sliver of
light shines out. Right now we know there's a connection among all these
things. Per Lisa's work there are nearly a dozen places along the hormonal
process where insulin metabolism, PCOS, and milk-making intersect. But we're
not entirely positive about all of it yet. Researchers are working hard on it
and we hope to know soon. We hope that in the near future that closet door
will swing all the way open and we'll see the full spectrum of what's going on
inside, but we're just not there yet.
In the meantime, we want to help her max-out her milk-making capabilites
because we don't know if she's someone who is going to be affected by this
or not. Some moms with PCOS don't have any trouble, but we want her to
understand so she can avert supply problems as much as possible if she was
going to have them. The other thing this does is eliminate the feelings of "I'm
not doing something right. How come everyone else can make milk and I do
the same things and it doesn't work for me?" If she understands from the
beginning that there's a difference in her body, she can accept the outcome
more easily, just like if she had to make special accommodations for a breast
reduction. (It's a very similar situation in that we just can't predict her milk-
making capability.) Knowledge is POWER, the opposite of heartbreak. When
we approach it from this angle, we help her celebrate what she gave her baby-
-how ever much that was. In the words of Diana West's book title we help
her "define her own success." (The book is "Defining Our Own Success.")
After we go through all this slowly and gently with a positive attitude, we talk
about what she can do to max-out her capability from the outset.
The first is if she used to be on glucagon, I refer her back to her
endocrinologist. Normalizing her own insulin metabolism is an important
aspect. She'll often ask, "What about my OB?" I have to remind her that her
OB's job is to help her carry and birth a healthy baby, but once that baby is
here, the OB isn't paying attention to the rest. The OB moves on to help the
next mother carry and birth. OBs aren't often reading lactation research. Her
endocrinologist is going to be her best help.
The second thing I do is to share a story/case study of a mom who had bad
enough PCOS that she'd given up conceiving and adopted two children.
Those kids were now 10 and 12. But knowledge of PCOS, conception, and
maintaining the pregnancy improved, so the mom tried again these many years
down the road.
This mom happened to be Orthodox Jewish. It was highly suspected that
she'd be giving birth during the High Holy Days when no work is allowed to be
done. Using electricity counts as work. (Maybe someone with a better
understanding of the Scriptural Law can explain that further.) So the mom had
arranged to be given a room near the nurses' station because she couldn't use
the call button. She was given a dinner bell to ring. The staff would use
flashlights to check on her during the night. This Catholic hospital is all about
respecting religious traditions.
Mom was 42. Sometimes it's said that older moms have trouble making milk.
She had a cesarian birth. Sometimes it's said that moms who have surgical
births have their milk come in slower. She had serious PCOS.
The pediatrician ordered that the baby be bfd q 2 h. The nursery RNs thought
he was nuts. The mom thought he was just old-fashioned. I thought he was
brilliant because he was doing all he could to get mom's milk in soon and
strong.
Mom did give birth during the High Holy Days. She kept her baby in her arms
or on her chest. She couldn't watch TV, she couldn't listen to music, she
couldn't read once it got dark in her room. No visitors came because they
were all observing the Holy Days. She truly did breastfeed her baby q 2 h and
sometimes more often. Her words were, "There's nothing I rather do! We are
so blessed to have this child!"
This mom's milk was in by day 3 and the baby just thrived! She had every
conceivable strike against her! But an "old-fashioned"--- or brilliant---doctor
and the Holy Days combined to stimulate/protect her supply.
After telling the story, I explain that we can't be sure what the mom I'm
talking to's situation will be, but we do know that her best chances are if she
copies the Jewish mom's mothering style. "Keep your baby with you. Bfd at
the slightest cue that he's willing. Let the rest of the world go on around
you. Focus on the baby."
Then we talk about monitoring output to be sure baby's doing okay.
I refer her to www.bfar.org for after she goes home because, again, her
situation is similar to a mom who has breast reduction.
I give her the info from the San Diego Bfdg Coalition newsletter to share with
her doctor if she hasn't been on glucagon in the past.
And I remind her that mammary tissue proliferates during each pregnancy and
with suckling during the first few weeks after birth, so that whatever happens
with this baby, it'll be a bit better for his baby sister, and even better for their
baby brother!
Of course I make sure she's got numbers for follow-up.
Debbi Heffern RD, IBCLC
St. Louis, MO
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