This mother sounds so very dedicated! It must be hard to fit all this plus some rest for herself into each 24 hours!

<She is currently nursing and supplementing with bottles her pumped milk or formula.The main problem that I discovered is that she only gets a milk flow with MER, and NO milk flow in between. We see this with a hospital grade pump, and also the babies will only be active during a let down, with no sucking and swallowing in between.>


Lots of babies are "lazy at the breast" if they develop a flow-rate confustion. In what position and with what kind of pauses and speed are they being bottle fed? If family is helping, could the "culturally usual" bottle feeding position and resultant pace of milk delivery be partly at fault? What about reviewing the Kassing method with everyone to help change the infants' expectations of flow rate, pacing and pauses?


This post makes me curious about where the fingertips would need to be placed to get the best result with fingertip expression, maybe even different depths of lactiferous sinuses on each side? (If anyone is curious why I DO believe in them, e-mail me privately. Glad to share.). By palpation and/or fingertip expression, I have found some mothers have very deep sinuses, sometimes, not always, related to normal or large nipple size. (More moms with flat or "shallow" nipples seem to leak more easily, even during pregnancy, related to lack of resistance behind the nipple due to very short galactophores, compared with long galactophores, the name for the ducts within the nipple that extend inward to the squamo-columnar junction at the distal end of the sinuses.)  If sinuses are deep, perhaps using a 2/3-to-all-the-way laid back feeding position might help the weight of the nursing infant's head to help compress more deeply, because she may have long galactophores/deep sinuses.


<History of repeated clogged ducts and mastitis with all babies.> 


This too might be suggestive of deep sinuses and less than efficient milk removal??


<She gets more milk with letdowns if pumps one side while nursing.>


And once again, there are centuries of evidence that vacuum does not pull; other forces push. Smart to be taking advantage of natural let-downs stimulated by obviously fairly adequate nursing of the one twin. If at other times when she pumps, it would be interesting to see if she gets more total in 15 minutes of actual pumping time if 1) she first used RPS to stimulate MER within 1-2 minutes, then pumped till flow slows (5-7 minutes???), 2) takes a break to gently massage/push milk forward from Tail of Spence and all other upper areas, 3) does another application of RPS to get another MER within 1-2 minutes, then pumps another 5-7 minute session, 4) and if desired, repeat massage and RPS just one more time. Short pumpings but if necessary, a little more often, would be less time-consuming and tiring, and more likely to yield more periods of fast production right after emptying, than long pumpings at any one time. How I love Diane W's handout "How We Make Milk"! I share it with so many mothers!


<She is on lecithin 1200 mg 4x daily with no good results.>

But things might be worse without it???? 

If she misses pumping, or takes any galactagogue, rather tea, capsules lactation cookies or Reglan(which was only with her first baby 10 years ago) etc...she immediately ends up with clogged ducts and mastitis.>

Sounds like all the more reason to use frequent and extensive breast massage/breast compression during intervals between MER's at feedings and pumpings.  

<Mom has very large nipples. She can pump up to approx. 3-maybe more ounces by getting multiple letdowns. The one baby is rarely nursing up to 3 ounces at a feed.  The other baby still has a hard time latching due to large nipples, and becomes overwhelmed with fast MER. She is doing some tandem sessions. Why the off switch between letdowns and how to help?  I saw the post about trying a smaller breast shield.>

I learned something with that advice too. It's working for my granddaughter.

So at least, using alternate breast massage/compression, starting some minutes into the feeding after the MER has finished the height of its flow, would be one solution to keeping some flow going. Of course, not possible by herself with tandem sessions! Help nature push milk forward between MER's. This can be done while pumping if desired, maybe more easily with the help of a bustier or tight t-shirt with slits cut for flanges to free her  hands while pumping?? She sounds like one busy mom!


<The other baby still has a hard time latching due to large nipples, and becomes overwhelmed with fast MER.>


Again, about 2/3-to all the way laid back nursing is useful in slowing MER simply because of gravity's effect when the path of the milk is uphill, like a drinking fountain, rather than downhill, like being under Niagara Falls. Babe might not have to have the negative experience of having to protect respiration from choking sensation. 

Hope some of these musings help a little.

K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC   Dayton OH    

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