Today we are going to talk about Stacy, another mom who feels that she is not making enough milk for her baby. I am going to put on my LC ( lactation consultant) hat and walk you through her consult.

My goal is to give you an overview so you can begin to understand specific breastfeeding challenges and how we work with moms. Both are with moms who had low supply and yet their circumstances and outcomes were different. I have changed enough of the personal information, names and dates and ages and specific circumstances so that this will all be anonymous.

Just like the case history from last weeks show, Episode # 140, I am providing a shortened version of everything we did during the consult.

Second mom: Stacy is a 32 year old mom of 2 babies. First born 22 months ago and tried breastfeeding first 2 days, lost a lot of weight during her hospital stay, she got nervous and just switched to formula.

Stacy tells me that she has a lot of friends who are breastfeeding and decided she really want to have this experience with her baby. Stacy tells me that she exclusively breastfed her new baby, Alex and 8 lb 1 oz boy during her 2 days hospital stay. She was told the latch was good, although Stacy complained that it was pinching her a lot. Everyone agreed that baby seemed happy at breast and content after most feedings. A few hours before discharge, she was given news that upset her greatly. Her baby Luke had lost 10 oz and that was way too much weight loss. Stacy said that she felt like her world was crashing down around her as she had flashbacks to her first baby.

She came home with bottles of formula, with instructions to breastfeed first and then supplement with 1 oz of formula. She was devastated and worried that she was just going to repeat what happened with her first baby. And yet, she was determined to make this work. So, she continue to breastfeed Luke and her nipple pain increased and by the end of her first day home, Stacy was crying with every feeding and Luke was becoming more frantic at the breast. He would push away and arch his back and cry so loudly that Stacy had to keep stopping what she was doing to calm him down. When her neighbor who was a breastfeeding mom, came over to drop off a meal, she offered to help Stacy. She helped Stacy with latching her baby on. After spending about an hour with her and not really being able to make a difference with the pain with latch, her neighbor, who had been a client of mine, referred her to me.

I saw Stacy when her baby was 4 days old.

I ask questions regarding her health, babies feeding frequency, supplement volume, was she pumping, how much was she supplementing and other questions, as part of my normal intake.

Before weighing her baby and before observing latch, I could already see that her baby was not getting enough at breast as he was taking 1 1/2 oz each bottle feeding, after the breast. This was an above average intake for a 4 day old baby. Stacy described a behavior that I was quite familiar with. Alex would scream for a long time before finally latching on. He would finally settle down, begin to suck and then would easily fall asleep after a few minutes of sucking. He never seemed to have the interest of energy to feed for more than 5 minutes. Stacy was getting exhausted and frustrated and as she told me her story, she began crying. I am use to this. I cried a lot myself particularly with my first baby. I can handle crying. I just, of course, felt bad. Through her tears, she mentioned that her friend taught her how to use her pump, but she was frustrated with this too as several pumps in a row yielded only 5 – 10 ml between both sides after 30 minutes of pumping.

I take physical notes all of this information. Their are a few things I want to keep in mind as I work with Stacy:

1. The fact that her baby is taking a full feeding from a bottle does not automatically mean that Stacy does not have enough milk for her baby.

2. The fact that Stacy is only able to pump 5 – 10 mls. does not mean she is not making enough milk for her baby. This just means that this is all the pump can get
3. He keeps falling asleep very soon into the feeding.

There is a lot more information I need to gather. I continue to ask more questions as I carry on with the consult.

I now decide to weigh Alex and was pleased, and yet not surprised to see that his weight was actually quite good largely because of supplementation. Next I checked his oral cavity to rule out any oral issues and could not see any reason why he would have a problem breastfeeding. I checked Alex for any structural issues that might cause poor breastfeeding and there were none. Next, I watched Stacy get herself set up to breastfeed Alex. She first swaddled him, then pulled down her shirt and wrapped the pillow around her. She held baby in the cross cradle hold, and when he opened his mouth she brought him onto the breast. While the latch was fairly shallow and this presented a problem, I immediately noticed another problem. Her left breast, which she was supporting with her left hand, was not quite the shape I am use to seeing. I made a mental note of this.

The first thing I did was give Stacy a few ideas on what changes she could make to allow her baby to achieve a deeper latch. She tried a few of the adjustments until finding one that she felt most comfortable with. As I observe Alex breastfeeding, I could see that even with a deep latch, he had a hard time staying awake. After 15 minutes on her left breast, Alex showed 4 ml transferred. With my hands on Stacy’s breast as I showed her how to support and shape her breast, I made another mental note that her breast was soft and felt to me similar to a non-lactating breast.

Once she was ready to latch Luke onto the right breast, I requested that Stacy keep her left bra flap down so I could take a look at both breasts at the same time. Here is what I noticed:

She had several markers for insufficient glandular tissue and for Stacy I noticed that her breasts were

• widely spaced breasts (breasts are more than 1.5 inches apart)
• breast asymmetry (left breast was significantly smaller than her right breast

I asked her a few more questions about breast changes during pregnancy, did she need to purchase a new bra? Had she suspected as a young women that her breasts were different size? I reviewed her medical history as it pertains to lactation.

A few adjustments were made to latch on the right breast and Stacy was excellent in following direction and easily achieved a deeper latch and used the support of a pillow she was given to use. He drank 8 ml and was very hungry after spending about 25 minutes at breast.

Alex was clearly still hungry after spending about 45 minutes breastfeeding. I suggested that Stacy offer him milk in a bottle and once he settled into feeding, we were able to talk. I first explained to her upright and paced feeding to avoid Alex from drinking too much milk, too fast and overfeeding.

I then took time to explain to Stacy what IGT was and how this impacted her breastfeeding. I explained to her that this was only a few days into breastfeeding and while I could see this was going to be a challenge, that if she followed my suggested care plan, she will be a mom who is breastfeeding. I needed her to also understand that as a breastfeeding mom, who at least temporarily was not making enough milk for her baby, that because of this she will need to supplement her baby at every feeding. Her immediate goal is to keep her baby well fed, while working on building her supply. No,, I did not know the answer to her question of how much milk she would be able to make. The best I could do was have her understand that she will be breastfeeding and also will be supplementing and that she needed to give this a little time.

I reviewed options as far as pumping to increase her supply and which pumps I recommended she use. I encouraged her to use the best pump for the job, which was to rent a hospital grade pump.

Stacy asked about herbs and teas and foods and medications to help increase her supply.

From the responses she had given me during earlier questioning I had already determined that it would not be wise for her to take some of the more common herbs that helps to increase supply. She was also not a good candidate to take 1 of the prescription medication to help increase milk supply, however, she may have been a good candidate to take the other prescription medication.

If she was making just a bit less then what her baby needed and I felt that with a few changes she could increase her supply in a short period of time, I would not be discussing hospital grade pumps or galactagogues and certainly not medications to increase her supply.

I reviewed options for supplementing. These included bottlefeeding after each breastfeed or using a Supplementer Nursing System. If you have not heard about Supplementer Nursing System or SNS for short. I will leave a link in the show notes so you can see a picture of the SNS. The SNS is a plastic container that you fill with milk. It has tubes leading from the container that you tape to your breast that lead into the babies mouth. This way your baby can breastfeed, and get a full feeding, stimulate your breast tissue and avoid bottles. She said she was understanding the information and wanted to continue.

My years of experience working with woman during their pregnancy and being a doula at their birth and now as an IBCLC, has taught me that I should never assume that the mom is in an emotional place to hear what I have to say and that I have to keep checking in with her to see if it is okay to keep going.

I spent about 1 1/2 hours with her and still all tar and perhaps continue another time. Stacy responded in what I felt was appropriate and each step of thhis information is quite overwhelming. I understand that. It is something that I had to do though as I wanted her to leave my office with a plan on how she was going to be sure her baby had good feedings from this point on. We went over my suggested plan and Stacy was able to give me some feedback.

Stacy had a medical issue that prevented her from taking the liquid herbs. Once she saw the SNS, she quickly decided that was not something she wanted to use. With all that was discussed, here is the care plan that Stacy was comfortable with.

1. Work with this position and latch that I showed her as it was more comfortable and Alex seemed to be okay with this and not fuss as much at the breast. If he was too frantic to latch on, she could try feeding him about 1 oz first from a bottle to see if he calmed down enough to latch on.

2. Offer him milk in a bottle after each breastfeeding. Using upright and paced feeding that I demonstrated with her. We did discuss donor milk and I gave her references, however, her husband’s body language clearly told me he was not comfortable with this. Since there was so much info to process, I decided to let this idea sit for the time being. Stacy confirmed this with me a few days later.

3. Switch to a hospital grade p ump and pump every 3 hours, both sides, for 15-20 minutes each time.

4. Because she felt stressed before each feeding, anticipating Alex to be angry at breast or remembering the pain she had been feeling, I taught Stacy a few simple breathing exercises she could do before and while Alex was at breast. I also had Stacy think of a few positive affirmations that she could use over the next few days vs. negative self talk.

5. Touch base in 2-3 days with questions and feedback.

Stacy followed up with me in 4 days and said that her volume of milk was increasing, however, Alex was mostly sleeping at breast. She was now pumping about 20-30 mls between both sides. Care plan stayed the same.

Stacy emailed me 3 days later and said that Alex was refusing the breast altogether and she had come to accept this. She was happy that her supply seemed to be increasing to about 30-35 mls each pumping session. I offered her some tips on how to deal with this situation, however, she was pretty strong in her response. She basically said that she had come to accept this and that she was okay with him not nursing.

I kept in touch with Stacy for another week. She did not want to schedule a follow up appointment so I could re-evaluate latch and measure intake and discuss what she would be doing from this point on. She did say that her volume seemed to stay at a steady 35-40 mls for the last 5 days. At the moment, all she could tell me was that she was going to keep the pump for another full month to see if she could increase her supply. She was going to consider taking medication to help increase her supply and she was going to continue to try Luke at the breast from time to time.

Stacy sent me an email about 2 months later. She had recently weaned from pumping and was giving her baby formula for all feedings. She thanked me for all my help. She said that she spent some time researching IGT and does feel this is an issue for her with this baby and was likely with her first baby. While this makes her very said, she is happy to have some answers as to why she struggled so much. She did want to talk about why her HCP never said anything. The truth is, I don’t have an answer for her, however, I did suggest she learn all she could about this and when feeling confident about her knowledge base to bring this up with her physician.

What would I have wanted different for Stacy? Well, for starters, I wish that her HCP had the knoweldge that IGT is a marker for low supply. I feel that all providers who take care of moms during their pregnancy should have this information. They are doing breast exams at the beginning of pregnancy and at some point during the second trimester should open up the conversation about breastfeeding. Is it around this time that they should bring this breastfeeding and teach about IGT and explain to moms how this may impact breastfeeding.

This will also highlight the early days of breastfeeding in that mom can be prepared and this should motivate her to connect with an IBCLC before giving birth. While I was sorry that Stacy did not want to continue breastfeeding, I understand. While I was sorry that Stacy did not want to continue to breastfeed, I do feel that she is in a better place emotionally because she understands now why she had such problems with her first. Knowing the answer to WHY, was helpful and important to her Stacy told me

We have now come full circle with this discussion that we started in Episode # 138 when I posed the question:
Breastfeeding and Increasing your milk production… Do you really need to?

I really wanted to delve into this because I meet so many mothers who think one thing about their supply and then once we have a consult, they realize that they actually do have enough milk, or they realize why they should not push their bodies to make more then it already does as their supply is already enough for two babies and they only have one baby. Then there are moms who truly are not making enough milk for their babies. We then want to spend time figuring out why they are struggling to make enough milk and do what we can to make this better and to ensure they have a well fed baby.

I really enjoy sharing this information with you because it helps to empower you. I want you to know, as a new mother, that breastfeeding does not come easy for some, not all mothers make enough milk for their babies. I want you to know that you might actually be making enough for your baby and the only problem you have is poor positioning and latch, OR that you are doing other things such as scheduling babies, or timing your baby at the breast, or giving bottles and not pumping enough & all these things are causing you to have a low supply and yet you actually do have the ability to make plenty of milk for your babies. I also want moms to know that there are sometimes factors beyond your control that put you in the position of not being able to make enough milk for your baby.