Based on this more thorough assessment, the lactation consultant may be able to identify all of the factors contributing to this complex case. In some situations, her skilled interventions will suffice once the underlying problem is addressed. Occasionally, she will identify a factor that falls outside of her area of expertise; when this happens, she must make the appropriate referrals. For example, a referral to a physician for a frenotomy or suspected neurological or other medical problem is appropriate. It is clear that because Baby E's problems were not resolved after 6 weeks of concerned effort, something was missed. It would certainly be appropriate for the lactation consultant to refer the dyad to another lactation consultant who has more expertise in handling clinically challenging breastfeeding problems. If possible, the referring lactation consultant should accompany the dyad so that she can improve her clinical skills. Assuming Baby E does not have underlying medical problems, the most likely causes of Baby E's difficulties are anatomical variation and/or sucking dysfunction. Because the baby is so fussy, it also would be wise to consider the possibility of allergies or food tolerance. Our first rule is " Feed the baby." The second rule is " Correct or work on correcting the problem or problems." Our goal is to achieve exclusive breastfeeding or as close an approximation as possible. We almost never give up on this goal, but we do educate the mother and work professionally with her choices. Until the baby is breastfeeding well, the lactation consultant will probably need to instruct the mother to continue using a pump ( preferably a hospital-grade, electric, bilateral pump). The mother should use the pump physiologically, pumping as many times a day as the baby would breastfeed. As soon as the situation improves, the mother should be instructed to wean gradually from the pump and any other breastfeeding equipment she is using. The goal should always be to help the mother and baby acheive a breastfeeding relationship, preferably without the use of any devices. We usually suggest that the mother avoid all rubber nipples and pacifiers during this learning period. Babies have a strong need to suck. Correct sucking helps the baby organize and be soothed. Whenever possible, we prefer infants to use their mother's breasts for pacification, warmth, love, smell, and food rather than artificial nipples and devices. Mothers almost always want to know how much work and time is involved before committing to following suggested treatment plans. As a general rule, we have found that it will take approximately the same number of weeks as the baby's age to solve the problems completely. In this case, it will probably take about 6 weeks until mother and baby graduate from "breastfeeding school." The first 2 weeks would most likely be very intense for the whole family, with the mother getting very little sleep. VJ is likely to cry when talking to the lactation consultant during this period of intense change. It is helpful during these times to listen to the mother, reinforce that you know how hard she is working and that what she is feeling is normal. Giving the mother a hug and complimenting her mothering efforts go a long way toward encouraging her to continue. It is not a time to give up. The second 2 weeks typically are easier, as everybody is used to the workload and required skills. The focus becomes refining skills. The last 2 weeks is usually a time to reduce and then wean off the equipment and exercises. This timing is just a guideline and must always be individualized. Although it is a tremendous amount of work for the mother, baby, family, and lactation consultant to correct well-established but incorrect breastfeeding behaviors, we have never met a mother who was sorry that she chose to tackle the problem. Even if she tries and then gives up or achieves only a partial milk supply or partial breastfeeding relationship, she can take pleasure in knowing that she left no stone unturned. Unfortunately, mothers and babies with presentations similar to that of VJ and Baby E all too often fail to establish an exclusive breastfeeding relationship. Not only are patience, dedication, time, and skills needed, but there are often multiple underlying problems that need to be solved. With a thorough assessment and appropriate use of skills and equipment by the lactation consultant, success is much more likely. This particular dyad should be able to acheive an exclusive breastfeeding relationship.