I will share "the end of the story" on an interesting case.

A month ago, I saw a 24 yr old primip with twins who had been tx for
infertility due to polycystic ovarian syndrome (PCOS).  She vaginally
delivered the babies at 38 wks weighing 6lb11oz and 5lb7 oz.  On Day 7, I
weighed them at 5lb12oz and 5lb3oz respectively (the smaller baby had a
little formula prior to my visit).  Mother had epidural and demerol for the
delivery.  Mom described lactogenesis II on Day 4, with  self-reported Level
5 engorgement (on Hill and Humenick's scale).  However, by the time of my
visit, her breasts were soft.  When well positioned at breast (one at a
time) twins manifested an immature suck pattern characterized by 1-3 jaw
sweeps before a lengthy pause.  No swallowing was observed. Babies nursed
with their eyes closed and depressed affect. Test weights confirmed my
impression of low intake.  Babies took in 3 ml and 1 ml at breast.  Since
stooling was scant and urine dark, formula supplementation was begun.  Mom
was directed to rent a hospt. grade pump and initiate pumping at q3hr
intervals and to cont. using her breasts to pacify babies at each of the
feeding times.  Daily phone calls revealed no improvements in pumped vols or
observable diff. in behavior at breast (mother had been taught to observe
the signs of nutritive sucking).  Pumping sessions yielded an average of 2
ml total in 15 min. of pumping.  Fenugreek 2-3 caps tid with meals produced
no discernable diff.  Reglan initiated on Day 10 with no discernable
improvement to milk supply.  Babies still willing to pacify skin-to-skin at
breast, but mostly formula feeding.  Mother recalls that family doctor told
her several years ago that her prolactin levels were "off" and an MRI was
ordered to look at her pituitary at that time, but she didn't receive any
information from that test other than the impression that her levels were
not normal.

I spoke with this mom today.  She never responded in any way to the Reglan
or herbs.  Pumping never yielded more than the levels we saw during the 2
weeks I worked directly with her.  She abandoned the effort on day 21.
There was no engorgement during weaning, and the flacidity of the breasts
that I observed on Day 7 never altered.  The babies are thriving on formula.
She plans another preg. in the future.  I suggested she discuss these events
with her fertility specialist to see if there is anything that he can do
(progesterone supplementation during preg?) to prime her breasts better.
Perhaps immed. prolactin stim. with metacloprimide.    I asked her to phone
me after her next delivery to describe her experience.  She agreed to do
this.


Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates, Austin, Texas
http://www.lactnews.com

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