Mira - Just read your message about the baby born at 3300g, went down to
3000g and only up to 4000g at 2 months.  Hmmm, not a good situation.

" Any chance that the suck may still improve at this age - 2 mnths?"
Definitely, yes!  Once baby's weight gain begins to improve, she will become
stronger, and can then "milk" the breast more effectively.  I would go with
FEED THE BABY, (supplement after breastfeeding) and take it from there.

"- What can be done to improve the suck - maybe osteopathic tmt?"  I'd pay
meticulous attention to positioning, using breast compression, switchnursing
for maximum 30 minutes, then topping up with supplement.

"- Any ideas on making pumping more comfortable? Mom is very dedicated to
bf, and would at least like her baby to have EBM."  Could she try manual
expression?  This can be particularly effective when the supply is low and
the breasts are soft.  I would suggest manual expression *after* baby has
breastfed and received her top-ups, stressing to mom (at this point) that it
is not the volume of milk that is produced that is so important as the fact
that the breasts are really well drained (sometimes low gain babies *don't*
do a good job of drainage).  Obtaining even 5 ml of creamy hindmilk is good
at first (feed to the baby after the *next* breastfeed, before the formula).
If the mom is prepared to do this she should see the amount start to
increase after several days.  If she can drain the breasts really well
approx 10 times in each 24 hours her production should sloooowly increase.

"- Could Domperidone help the supply at this stage, assuming mom will be
able to pump, or baby's suck will improve? I think I read that this is
useful only in the first weeks."  I'm not familiar with this med, we use
sulpiride which does seem to give prolactin levels a boost and give the mom
quicker "results".  Sulpiride needs to be tailed off very slowly once the
mom is happy with the milk supply.  Perhaps others could comment on Domperidone.

"Any other ideas will be welcome."  I find that *a lot* depends on the mom's
motivation to continue.  I stress No Guarantees, and lots of perseverance
and patience, and enthuse about how wonderful mom's own milk is for the
baby, in any amount.  I've seen even very poor situations improve if the mom
will just keep on.  The main care plan is 1) Breastfeed first at least ever
3 hours for 30 mins, encourage active nursing, watch for swallowing.  2) Top
up with any previously expressed EBM.  3) Top up with formula supplements
(as much as the baby wants, but start with 75 ml every 3 hours) 4). Settle
the baby (at breast, if wished, but allow baby to doze and fall asleep). 5)
As soon as possible massage and express the breasts, save any EBM to be fed
after the next breastfeed.  6) Offer breast again any time baby wants to
suck, in between "feeds".

Pamela Morrison IBCLC, Zimbabwe (who was sent a baby by a paed last week,
3600g at birth, 3000g at one month - yes that's 16% *below* birthweight,
skin and bone!  Used above care plan, baby gained 400g in 5 days, mom now
expressing 30 ml after breastfeeding, so I'm hoping we're getting there and
she will carry on! And we didn't use sulpiride for this one. Sometimes you
have to have nerves of steel!)