Hi Heather,

Thanks for your interest and ideas on this case.  I will respond to  
your questions below....

>> Baby is now 3 weeks old, and weighs 6 lb 6 oz clothed (from
>> birthweight of 5 lb 4 oz, naked).
>>
>
> What does she weigh naked?

I don't know, but I would estimate maybe 6 lb 3 oz.
>
>>  Mom has been breastfeeding both sides with breast compression, then
>> bottle-feeding approximately 2 oz of formula.  She estimates that
>> she breastfeeds 7 times/day, and her husband gives some bottles.
>> She has pumped sporadically with the Lactina.
>
> This  definitely sounds better, compared to a week and a half
> ago.....however, while I don't want to rain on the parade,  7 feeds
> topped up with formula, and bottles given by the father instead of
> breastfeeds won't protect the breastmilk supply.

She has been breastfeeding 7 times minimum a day.  While more would  
be better, certainly, we have thought that the baby was only getting  
a few milliliters, so in the interest of mom's time management, I  
think this was reasonable.  I was hoping she would do more pumping,  
but she does not usually follow my recommendations for pumping  
frequency, perhaps because the output was so low that she just lost  
the motivation.  Maybe now that will change.

> Maybe this mother is doing what she is willing to do, but her milk
> supply will dwindle - at my reckoning she is still getting 14 ounces
> of formula a day (7 breastfeeds plus a 2 oz top up) plus whatever
> formula dad gives.
>

I would also love to see it increase more quickly, and I would love  
for her to take domperidone, but how can she cut the formula down  
more when her milk supply has been so low up until now?  I have  
already recommended that she decrease the formula to no more than 1.5  
oz/feed.  Certainly if a mom had a full milk supply, as demonstrated  
by test weights, pumping, and infant behavior at breast, this amount  
of formula would be completely inappropriate, but rule #1 is feed the  
baby, THEN protect the milk supply and fix the breastfeeding.

Dad is not giving tons of formula randomly -- they both help the baby  
get latched on and breastfeed with compressions, then Dad gives the  
baby anywhere from 1.5-3 oz (but average is 2 oz), depending on what  
the baby wants.  They are using paced feeding.  But now, mom will be  
using the Lact-aid for most if not all feedings (yes!!!).  I have  
encouraged her to put the baby back to breast if she is still hungry  
after 1.5 oz supplement, and if the baby seems to need more  
supplement, to give it in increments of 1/4-1/2 oz at a time.

By the way, the mom was negative on the SNS idea, but I asked her if  
she would be willing to try an experiment -- so I rigged up the #5  
french tube and showed her how it worked, and it turned out that she  
hadn't really understood what the SNS system was, and now that she  
could see how easy and time-saving it was (one feeding, instead of  
breast, then bottle), she was a convert!!!  I think that I will be  
doing that a lot in the future, given how cheap the #5 french tubes  
are.  I think sometimes the idea of it is more scary and complicated  
sounding than the reality.
>>
>> I encouraged her to pump at least twice a day (of course more would
>> be better, but I'm afraid she won't do any pumping if it's too
>> overwhelming).  I also said she could experiment with keeping the
>> formula at 1.5 oz and just breastfeeding if the baby seemed to want
>> more, while watching the diaper output.

> I think this is very appropriate - this mother may not be ready,
> physically or emotionally, to cut down the formula any faster. If she
> is happy with 1.5 oz top up, then maybe next week she can go down to
> 1 oz and so on. My concern would be that the milk supply would
> dwindle too quickly, and there isn't time for this gradual approach.
>
> She is working very hard - she is pumping, she is giving formula, she
> is breastfeeding, she is using a nursing suppkementer, dad is giving
> bottles, she is taking herbal supplements.....it's all very
> complicated, and she would have an easier life if only she could get
> to full and direct breastfeeding!!
I agree completely!  I will definitely be calling her in a few days  
to get an update and encourage her to cut down the formula further if  
it is appropriate.  I am just blown away that we went from negligible  
milk transfer to a whole ounce.

Lynnette Hafken, IBCLC

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