Need fresh eyes, and brains, for complex case -long-

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Permission to post. I have a repeat client that seems to be stuck at 50%

production, and I need a fresh set of eyes and brains to see if we can get her

production up.

First, the history. I first assisted this client almost three years ago when she

had an unfortunate stillbirth due to a cord accident associated with abnormal

cord insertion. She had been so busy making necessary arrangements and such,

that she hadn't even thought about her milk coming in, and she'd developed

engorgement and was miserable from that on top of everything else. After

reviewing the options, she opted to pump and donate her milk. She continued this

for about 6 months, and was able to pump 8 ounces four times a day, within a few

weeks of the birth. So, we know she has good tissue and responds to pumping.

Mom is rather classic PCOS type presentation, except her endocrine specialists

in two different states told her she wasn't PCOS. I'm not a doctor,

but....Mother has significant central obesity, very large breasts (cup size " F " )

that started developing very early in life. Significant insulin resistance (had

to be on metformin and insulin during pregnancies), hypothyroid, and possible

luteal phase defect treated with progesterone early in pregnancy, and

hypertensive. And yet, with all that and the unimaginable stress and grief, and

not even touching her breasts until day 5, she brought in and maintained a

normal supply of 36 ounces a day purely by pumping with a Medela PIS!

Here we are, almost three years later, she has a 36 6/7 week boy born via

elective c-section, per the recommendation of the Maternal Fetal Specialist

because this baby had the same cord insertion issue. She was seen frequently by

Lactation Consultants in the hospital and went home with a nipple shield because

mom's nipples were reportedly " flat " per her report of what she was told in the

hospital. Milk came in on day 5 (same as last time). Day one she had a great

supply going, baby feeding vigorously, swallowing lots, mom leaking lots during

feeding etc. The next day.... almost the opposite. Baby on and off the breast,

latch but won't suck or drink. Baby had only been supplemented up to this point

with colostrum via spoon feeding until her milk came in. Mom decided to pump,

and was getting maybe a couple of cc's and called me.

Mom's nipples weren't flat, but not particularly responsive to stimulation

either. The hospital had also given her a shield that was too small for her

nipples, and they hadn't shown her how to put it on, so only about 2/3 of her

nipple was getting in the cone, so we fixed that after trying quite a while to

entice him to latch without it. Baby was indeed acting as if he wasn't getting

anything except with an occasional let down. Tried breast compressions,

positioning changes, slipped him a little tube fed milk at the breast and he

sucked well then, but if I didn't push the milk, he didn't actively suck. Test

weights after all of that only showed the amounts I'd tubed. Then he fed

agressivly when offered expressed milk via spoon.

Baby looks good, no tongue tie, upper lip a little tight, but can be flipped out

during feeding. Suck assessment showed good tongue movement. Had some overriding

sutures despite being a section, so referred her to a wonderful chiro for that.

Got mom pumping every 2 hours, skin to skin, supplementing at the breast.

Had mom ask for labs since she is hypothyroid and her doctor order thyroid and

prolactin level at 1 week post partum, her prolactin level prefeed was 100.

Thyroid was not in her " sweet spot " . The doctor increased her thyroid, and gave

her some reglan, as baby was still losing weight.

In 24 hours, no weight gain in baby, and mom only getting 10cc total when

pumping. In trying to figure out what was different between last time and this

time, I asked what dose of metformin she was taking, and she gave me her dose,

but then mentioned the hospitalist who discharged her told her she probably

didn't need it anymore since she had delivered. (?!?!) She spoke to her doctor

again, who started her back on 1 gram of metformin.

The next day, day two of the reglan she had the WORST reaction I've ever seen!

It was like I suddenly had a weeping, sobbing, walking anxiety attack, who was

afraid to hold her baby, having muscle twitches all over, and begging to know

why anyone would want to go through this, having terrible anger everytime she

pumped. Well, as you can imagine, I was on the phone in a heart beat with the

doctor and he had her stop the Reglan immediately. Within 24 hours she was back

to herself, and her milk production was up to around 20 to 25 cc every two

hours. The local compounding pharmacy refused to dispense domperidone for

breastfeeding issues, so the doctor said keep doing what she doing and see if

things improved. Mom got some donor milk, and is supplementing, and baby started

gaining appropriately.

Here we are at three weeks, and she's making about about 30 to 45 cc every 2

hours if she pumps, and test weights show the same.

So now, I'm at a loss. We have her thyroid in the sweet spot. She's back on her

metformin, she's doing lots of skin to skin, regularly emptying the breast,

great positioning, baby is alert and has a great suck, and yet mom seems to have

maxed out at 12 to 16 ounces a day, when at this time almost three years ago,

with NO baby and same meds, she was making 24 ounces a day at this point.

Anyone have any ideas???

Hartfelder IBCLC, RLC