Oh, Kym, my heart just goes out to you and your work with this mom! This
sounds so very much like many women I've worked with at WIC - the multiple
stresses (chemical, environmental, psychosocial - if you'll pardon the
term), the houseful of kids, the wanting to have breastfeeding work but not
being able to do all the wonderful things we "know" they should to make it
happen! This mom sounds very much like a good example of something I think
is very common, particularly in the families we see at WIC who may not have
a lot of family experience and/or support for BF: she knows that "BF is best
but not quite how to make it work for her, given her own situation. Our
promo of BF outstrips our available support in our society. Thank heavens
you are there helping her - I know that even if she doesn't "succeed" in the
all-or-nothing ideal, she is a billion times better off because of your work
with her. By working with her so persistently and thoroughly, you are
helping to "empower" ( hate that term - too PC for me, but seems appropriate
here) her, and she will be a stronger, better parent for it. She may even
end up saying she "hated" breastfeeding, but at least she'll know that she
used all the tools at her command to do what she thought was best for her
baby!

There are lots of things to be said about what's going on with her milk
supply, and I'm sure greater minds than mine on this list will speak more
eloquently to them. But here are some of the off-the-top-of-my-head
thoughts:
Reglan (metoclopramide) + depression = probably not a real great idea here.
Reglan certainly can exacerbate depression. Also the Depo can make
depression much worse - I wouldn't have recommended it for someone with a
hx. of major depression.
heavy smoking - well, we all know what that can do to a milk supply! You
don't mention it, but I bet there's a lot of caffeine going into this mom
too (not that I'd blame her - I'd be doing a lot more than caffeine if I had
this poor soul's life!) The combo of smoking + hectic household + all the
other factors can't be helping!
low caloric & fluid intake - I'm willing to bet that by itself this probably
isn't a significant factor, but that piled on top of all the other stressors
in this woman's life, it sure isn't helping. Especially not drinking
enough - which in my experience translates into not just an insufficient #
of oz. of fluids, but is symptomatic of the more pervasive problem, which is
that this mom just doesn't feel that she can take the time to nourish
herself. I think she feels like she's at her wits' end, and this is one way
she expresses that stress and exhaustion.
her life - wow! Now I know, because I've read research studies, that
"stress" doesn't necessarily affect the amount of breastmilk a woman
produces, or the quality of it, but I also know from my own observations and
experience working with lots of families like this that in fact find
themselves unable to make enough milk to nurse exclusively. Depends on how
you define "unable" - in purest terms, I'm sure she's capable of making
plenty of milk, but given the life she's living right now, she is clearly
experiencing supply problems.
ambivalence! She wants to BF this baby, but she doesn't like what she is
hearing she "has" to do to get to exclusive BFing; she doesn't like sleeping
with the baby, she doesn't like the fenugreek, she continues to smoke
heavily, she's realistically not able to "go to bed with the baby", it's not
apparently feasible for her to slow down enough to eat and drink adequately,
she's got a houseful of other kids including a demanding older baby, she
doesn't like having the baby "constantly at the breast", she feels that
giving cereal at night is something she has to do, etc., etc........

Now, please don't all jump on me, but I think that if I were working with
this mom I would pour on the understanding support for where she is right
now, give her positive reinforcement for the BF she's done so far, and
oh-so-gently and lovingly help her figure out what she really truly is able
to do. I would NOT encourage the Reglan in her case, partly because of the
depression but also because I don't think it would help given the whole
picture here. I'd certainly encourage her to keep breastfeeding, but to do
so in a way that works better for her than the all-or-nothing style -
explore with her the times when breastfeeding does work for her & the baby
(and the rest of her busy family). (But remembering rule #1: FEED THE BABY!)
For example, she may really enjoy nursing 1st thing in the morning, or
during the night when the house is quieter, or when the other kids are
napping/at school/whatever, but it might be an utter disaster for her to be
trying to BF and get supper on the table and pick up the older kids and cope
with end-of-day crankiness. Or she might despise BF'ing at night, but enjoy
it before bed and during the middle of the day. In other words, help her
find what she is able to do AND feel good about, support her to keep going
with that, and reinforce whatever you can in the way she's managing to carry
on in a difficult situation. Some women I've worked with have been perfectly
content to carry on for months by "nursing" first at each feeding, then
following up with formula, cereal, whatever; wouldn't work for me, and it's
not how we BF purists would do it, but it gets some br.milk into the baby,
and I think even more important is what it does for the mom.

Don't want to tread into the area of the dreaded "psychobabble" here, but I
am 100% convinced that even women who are not compliant (for whatever
reason) with what the "experts" suggest strengthen themselves, their
parenting skills, their bonding, and, by extension, their children, by a
combination of unflagging support for them ("validation", etc.) and help
finding a realistic way of continuing to nurse. Even when it looks to us
like not "real" breastfeeding, even when the amount of breastmilk (yes, and
even loaded with smoking by-products, caffeine, etc.) is technically not a
substantial part of the baby's intake.

Sorry so long - I'm trying to do better on length - but this story really
touched my heart. Kym, I know you're doing this mom a world of good, don't
get discouraged when she doesn't do what we think she should! Know
something? Now that I'm not at WIC any more, I really miss these kinds of
scenarios - and they used to drive me to the end of my rope, daily!

Cathy Bargar, with tender heart and tough talk...