Dear Lactnetters,
I would appreciate some input on two cases I have been working with.
The first is a mom who is 3wks pp with her 2nd baby. Baby is gaining very
well - 6lbs9oz at birth, 6lbs 13oz day 14, 7lbs4oz day 18. Breastfed first
baby 8mos with no problems, only mild engorgement when milk came in.
Current baby showed definite preference for right breast in hospital, little
nursing on left for first 3 days. Baby did finally begin to accept left
breast on day 4 and latches well on left. Mom began experiencing
engorgement day 3 pp. Engorgement subsided on left breast within 4 days but
continued on right for 2 more days. Mom reports some relief of engorgement
on right from days 6-8 but then engorgement returned day 9. I saw her day
18 and the right breast is significantly larger than the left and is full
and firm (not rock hard, but very firm). No lumps, knots or redness. Mom
reports constant throbbing pain in left breast that worsens throughout the
day. Baby latches well but clamps down at letdown with milk running out
corners of mouth. We massaged the breast during nursing and mom reported
feeling relief after nursing, but breast full and painful again within 1
hour. I advised massage and compression while nursing, pumping after the
first nursing of the day to empty the breast as much as possible, pumping in
between as necessary just to comfort, apply cabbage leaves for 1 hour at a
time 2-3x per day if other measures do not bring relief. Is this a simple
case of over-supply in one breast or am I missing something?. I have not
seen a case of engorgement that lasted almost 3 weeks, especially after
beginning to subside and only on one breast. Any thoughts?
As for the second case, this is also a mom of two. Breastfed first child 18
months with no problems, although first child had a slow weight gain pattern
after month 4 and fell in percentiles from 50% to 10%. Mom and dad are both
on the small, thin side. Baby #2 gained very well in the first 4 months
then began to slow. Mom had abundant milk supply (donated 200oz to milk
bank during 1st 4 months). At four months, baby had 2-3 nursing strikes
within a 1 month period - possibly due to teething, recovered from the
strikes but continued to be very distractable and not very interested in
nursing. Would nurse 3-5 min per breast. Around this same time he became
very mobile and was crawling at 5.5months. Mom noticed he didn't seem to be
gaining. We weighed him at 5 months and he had only gained 1oz since month
4. He gained just 2oz more between months 5 and 6. Mom began feeding more
frequently (he was only nursing 5-6 times per 24hrs) and taking fenugreek at
5 months. Baby is happy and meeting milestones. Mom had prolactin levels
tested and prolactin level was 11.6, which is in the normal range for a
non-lactating woman. I know prolactin levels fall, but according to
Riordan, they still stay slightly elevated at month six (I believe the mean
was around 44). Should we be concerned about this prolactin level? Would
domperidone be a better choice for her at this point than fenugreek?
Pediatrician advised supplementing with firmula but mom is reluctant to do
this unless absolutely necessary. Mom started baby on solids this week and
is feeding rice cereal (1-2 tablespoons) and she began giving him a few
bites of avocado for the fat. He is not overly interested in the solids.
Another note to toss in - mom was gone one night last week and dad gave a
4.5oz bottle. Mom reported that babies wet diaper was noticeably heavier
than usual. Thoughts?
Thanks for your wisom and input.
Mellanie Sheppard, IBCLC
Arlington, TX
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