Hi Lisa,

It seems an obvious culprit would be the DOSE of nicotine interfering with
let-down.  It also would seem that perhaps the mom wasn't smoking for the
first 5 days then re-started?

Explaining to the mom that the DOSE of nicotine may be the main difficulty and
that it is with the MER, not supply as yet, may motivate her to cut back.  The
effects on the let-down could be lessened if she was to cut back to  say, 10
cigarettes/day?  Combined with relaxation, massage, et al.  she may see a
dramatic change in the let-down.  She probably won't hear about quitting if
she's smoking a pack and a half so soon after birth - that's a lot, even for
smokers, and so would guess that she's a "hard-core" smoker.

Suggesting that she ( and others in the house) smoke "up the chimney" or
outside, or at least in another room can greatly benefit her infant, and could
relieve some of the inevitable cognitive dissonance generated by smoking while
breastfeeding.  The point ( for you) of these suggestions is to show her steps
she CAN take to minimize the downside of smoking with her baby and thus lessen
the stress that she undoubtedly has put on herself for doing so ( which IS
only adding to the breastfeeding difficulty/pumping, perineal repair, etc...
stress).

After the MER is more established, the dose of nicotine may not be so critical
as in the first month or so.  ( Don't think there's any studies here ?).  Have
in mind that study with the surprise finding that babies of smokers are bigger
than the norm at 1 year - would be interesting to know how these successful
breastfeeding but smoking mothers were in the early weeks - I would intuit
that they didn't smoke so much or at all in the early weeks, but eventually
returned to their usual levels of smoking AFTER lactation was well-
established.

Studies of smokers overall show an impaired let-down but I think these studies
looked at immediate post-partum period, where perhaps high doses of nicotine
may impact lactation more dramatically.  Obviously smoking per se doesn't
always lead to breastfeeding failure through impaired let-down and that more
complex events are at work.

And that tight frenulum needs attention.  That's probably the main source of
difficulty with breastfeeding in the first place.  Have seen continuing
difficulties with breastfeeding when tight frenulum left intact and great
success when clipped.

Regards,
Sheila Humphrey