Yes, getting off the nipple shield will be a big step forward for the team -- using a feeding tube *and* the shield is just too much stuff to manage.  To compete with the strong oral signal of the bottle and shield, it helps to exaggerate the deep, wide sandwich of breast tissue -- filling up the baby's mouth to trigger the suck.  And compressing like crazy to reward the baby's learning.

The shield is often a useful tool, but it needs to be introduced as a temporary measure, with the mother practicing slipping it off mid-feed a couple times a day right from the start, to ease the transition.  No battles about it-- but even if the baby just sniffs and licks, the practice keeps the breast familiar. I deal with so many mother and baby teams, six weeks out, who got a shield in the hospital (which worked ok in the initial engorgement, but now transfer and gain are slipping) who have never fed without it. 

She does need an exit strategy out of the transitional "triple duty" with breastfeeding/supplementing/pumping. (Otherwise people just stop breastfeeding, because that is not a sustainable lifestyle.) Changing the rate of milk production takes intense demand, to get the thrifty body to make more -- that's why the early weeks of the "babymoon" when the baby's intake goes up quickly, are relentless, with the baby cluster-feeding and up all night.  Maintaining the supply -- just running the factory instead of building it -- will be calmer.  Families get past the crazy of the "babymoon."

Right now she is using the pump (and a rental pump is certainly worth trying) and the baby's improving efforts, as "twins" to put intense demand on the system.  The formula can't be dropped abruptly (and the overall intake is likely still going up)-- weight gain is very important for making the baby an effective feeder.  But as the baby feeds more effectively, with audible swallows, is he taking a little less of the freely offered supplement?  Is more of the supplement coming from the pumping?  She is chipping away at the formula from both sides.  Individual feeds and pumping sessions can be very up and down, so it helps to keep the 24 hour totals.  

You're right that only she can decide how long she can stay on the supply-building campaign with the "twins."  The goal is to give the job back to the baby -- the pumping and supplements are tools to buy time for the baby to gain skills.  Anne Englash has written some thoughtful posts on helping mothers get past the "madness of pumping."

Is the baby getting as good as, or better than the pump at getting milk out?  When she looks at the 24 hour totals, where has she chipped the formula down to?  When she starts to shift gears to maintaining supply -- if she starts to drop out pumping sessions, and keep the baby close and feeds frequently (with switch nursing and compressions to help the baby focus), does the amount of formula being patched in across the day stay the same, or maybe even go down.  She'll want to watch the weight gain and diapers during the transition.

Probably a lot of this note is review, but you're right to be helping her think of the long term -- Barbara Robertson's post had good thoughts on trying to make this sustainable enough to keep the team in the game.

Margaret Wills, IBCLC, Maryland, USA


> Date:    Sun, 7 May 2017 00:38:03 -0400
> From:    Carol Tenneriello <[log in to unmask]>
> Subject: Low Milk Supply-Goat's Rue?
> 
>> Thank you so much Margaret,
>> (I had to copy and resend this message)
> 
>> I had a copy of that book but can’t seem to find it. I wanted to wait for the new edition before buying a new one.
>> 
>> Yesterday at the consult the baby transferred 12cc’s which is way better than 0 first week, and 4 (2nd) week. When I first went they were using a nipple shield with a feeding tube inside it from hospital. It was very cumbersome and the baby wasn’t really latching and the baby was hungry and refusing the  breast so, I had them focus on feeding, and milk removal any way possible, and putting baby to breast only if they both wanted. I showed them paced bottle feeding and finger feeding and gave them the choice.
>> At second visit, baby was gaining, We tried the "cherry" nipple shield put baby to breast after  some supplement. Baby latched much better with that shield, and transferred 4cc’s. One issue was baby keeping tongue up in a way that blocked the breast. I gave her a few tongue exercises which they’ve been doing.. Mom has been putting baby to breast 4x/day with shield, but because the supplementer had been so cumbersome before, was reluctant to use it. 
>> This visit, after initial breast feeding,I encouraged mom to put baby back to breast as he was still hungry. I encouraged her to just slip the homemade supplementer in and it worked well. She also was able to latch him directly to the breast without the shield, so I am encouraging that. I tend to give families a menu of choices , because it can be so overwhelming especially after a C-section. Power pumping was in the menu and she is doing it 10 minutes on and 10 off daily and didn’t report it being more difficult than anything else.   
>> She is doing hands on pumping but as her breasts are not large she can mainly massage the axilla area without disturbing the pump flange.
>> While mom is actively looking for solutions she is also asking when do you call it quits. I answered that everyone has to find their own level of success even tho it’s going slow the baby is gaining and there is progress with their milk supply.
>> 
>> She is not using a rental pump, I forgot to suggest that. The last mom with low milk production complained that it didn’t help. (But i have had other moms find it helpful) 
>> I was also sent this reccommendation by someone on this list for MotherLove brand  More Milk Special Blend because it has fenugreek, goat’s rue and blessed thistle, which she says work better when blended or ingested together. 
>> https://www.motherlove.com/product/more-milk-special-blend-capsules <https://www.motherlove.com/product/more-milk-special-blend-capsules>
>> 
>> I will be looking these up myself but also am interested in other’s experience/knowledge on this list.
>> 
>> In my practice, I’ve relied on milk removal to build supply. 
>> 
>> I have tried to read up on herbs in the past but haven’t really  reccomended them myself. 
>> 
>> Thanks again
> Carol Tenneriello RN,IBCLC
> [log in to unmask]
> 215.248.0197	
> 
>              

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