<<Weight gain was very poor and supplements were added after week one. Is 
now giving 1.5 ounce by cup- mom's choice,of  EBM if available or ABM. Mom 
pumps after every feed for better breast drainage and obtains between .5 - 1 
ounce EBM.  Maintaining a good gain with this and is now back to birth wt. 
 >>

I would NOT reduce supplements at this point.  I do not think the baby is 
removing milk well with the shield if it took 3 weeks to return to birth 
weight, AND only with mom giving 1 1/2 oz of supplement per feeding, 
including a significant amount of formula.  Unless gain is greater than an 
ounce/day I would not decrease supplements, because baby has not "caught up" 
to where it should be by now.  A baby with a posterior tongue tie can appear 
to have latch improved (based on improved maternal comfort) but still not be 
able to lift tongue high enough to effectively empty the breast.  I would 
also suggest the mom switch to a slow-flow bottle nipple at this 
point...cup-feeding is difficult over the long haul, and a lot of precious 
milk gets spilled down the front of the baby, and the baby thrusts the 
tongue forward to eat.

As for the Domperidone, in my experience if you have not seen an appreciable 
difference in a few days, it is not going to help.  This mom sounds like she 
may have had too much engorgement for too long to ever get a full milk 
supply.  Or, inadequate removal for too long.  Does she need larger pump 
flanges?

Those are my thoughts--good luck!

Kathy Leeper, MD, IBCLC
MilkWorks- Lincoln, NE

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