Hi Pat!
A few things went through my head as I was reading your post.  First, (and I
think you know this), but to clarify for others who may be reading this
information and not fully understand the principles here.  The volume of milk
pumped/expressed per pump is not an indication of the volume of milk
tranferred at the breast by infant.  In evaluating the volume of milk
transfer at the breast, I agree that using the BabyWeigh Scale is necessary
to scientifically determine the milk intake and thus the need for
supplementation.  I prefer to speak in terms of grams of weight gain between
pre and post-feed weights, rather than in ounces.  The literature supports
the finding that though you would assume that 0.1 and 0.3 oz. are precisely
accurate, they are not as accurate as stating the weights in grams.
Furthermore, it is a lot less confusing language when teaching parents.  The
reliability and validity of the BabyWeigh Scale demonstrates that 1gm of
weight gain = 1 cc of milk intake each time that we weigh the infant.
2.)The history of the previous breastfeeding experience is helpful to us to
give us a broad picture.  It tells me I need to offer this mom emotional
support because I know from her perspective that this current difficulty is
emotionally being added to her past.  Therefore, I would intentionally plan
to reassure her that her difficulty with supply from her previous pumping is
no indication of her lack of ability to produce milk at this time.  Why?
Because she is saying to herself now "What's wrong with me?  Last time I
couldn't make enough milk and now I'm struggling with making enough milk
again."  I'd reinforce that the reason this is like comparing apples to
oranges is that her last baby was not latching to the breast, so we don't
know how much baby would have taken at the breast.  Again, amount pumped is
no indication of amount infant can transfer at the breast.  Overcoming this
emotional burden can really empower this mom to feel confident that she can
indeed produce enough milk for her present infant.
3.)  "Latch looks good" rules out a latch-on problem for us so that we aren't
sharing latch-on tips here.  So, thanks Pat for sharing that tidbit.
However, to move on from there, I'm thinking that I don't care how the latch
looks if I'm not hearing audible swallows and observing the suck-swallow
clusters accompanied by lower jaw movement.  The "some swallows heard" and
"doesn't want to stay awake" tells me that I've got an ineffective
suck-swallow pattern taking place.  Therefore, I agree with the OT referral
because I think the problem here stems from the infant's ineffective sucking
pattern and intervention needs to be prioritized here.  I'm wondering whether
an SNS was tried or not.  Sometimes an infant exhibiting an ineffective
sucking pattern and sleepy at the breast can indeed obtain the encouragement
via the SNS to get his act together and become coordinated with his
suck/swallow patterns.  I know sometimes it doesn't work because an SNS is
not going to correct a true dysfunctional suck.  I would also assume that
this is not a preterm infant, but a full term infant.  And, my other
intervention worth mentioning is a nipple shield.  I would not choose a
shield as my initial plan of care, but when all else fails, as it sounds like
has taken place in this situation, then I would attempt a nipple shield.  The
literature demonstrates that a nipple shield may facilitate proper latch-on
and the transfer of milk at the breast.  Until this infant's dysfunctional
suck is corrected, the shield may assist him to latch deeper onto the breast
tissue to further facilitate the transfer of milk.  Though we are warned to
assess for decreased milk volume with the use of shields, the literature
demonstrates that shields can indeed facilitate milk transfer at the breast.
With milk transfer being facilitated at the breast, perhaps we'll see more
ongoing jaw movements and hear more clustering of suck-swallows.
4.)  I would assess the infant's outer structures around his mouth.  Is he
tight?  Or is he placid?  If tight, I'd encourage mom to do some gentle
massaging around the mouth and temporomandibular junction (TMJ) to relax
these structures.  Lastly, I'd encourage kangaroo care, times licking at the
breast, etc.
I'm getting off now....this is long enough, sorry!  I'm witnessing a
thunderstorm, and though I have a surger on the computer, prefer not to be on
it when a storm is taking place.
Hope this helps!
Sincerely,
Carol Chamblin, RN, MS, IBCLC
Breast 'N Baby Lactation Services
Geneva, Il
e-mail:  [log in to unmask]

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