Christine,

These cases are a mystery. I suspect that she did not have "lots of milk
with her first" 7 yrs ago, but had short-term breast fullness (she did not
bf) which she interpreted as plenty of milk. Because she was not removing
the milk by expressing, nor bf, she felt very full for a day or so. I have
seen this many times, where the mother reports "her milk is in" but in fact
it is a short-lived event, and even with expressing and bf, the milk supply
remains very low. With her second child, who she did initiate bf, she "had
no milk come in."

There is so much to learn as far as the effects on lactation of premature
birth, delays in effective bf, or effective milk removal by expressing,
hormonal milieu, insulin resistance, increased body mass index or obesity,
etc. Several of these things could be affecting this mother, even in a
small way, but having an additive effect.

To counsel this mother, as you know, you will have to determine her goals
(milk volumes to bottle feed, feeding at breast, how many months, etc). If
she is mainly interested in providing ebm to the fullest, then you could
talk to her about rental pumps and nutrition and galactagogues. If she is
mainly interested in feeding at the breast, you could offer one of several
lactation aid devices. In my vast experience, when a mother with a very low
milk production attempts to breastfeed without a lactation aid and
supplement by bottle, the baby will soon reject the breast and become
completely bottlefed. On the other hand, a mother who tries to bf, pump
after each feeding, bottlefeed the supplement will soon become exhausted
and unhappy.

So I see the most practical choices are 1. feed at breast with lact aid, 2.
feed expressed milk and supplement by bottle. Of course it is the mother's
choice, even to do something other than these 2.

Laurie Wheeler RN MN IBCLC
MISSISSIPPI USA

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