Nan writes:

<. . . . . . that expressing from one breast while nursing at the other is a
practical way to do this.  I found that when I was in this position, I had
difficulty expressing because I was too tense to get a let down when I tried
to between feeds.  It worked well to express while I gave the early morning
feed.>


A valuable suggestion to remember is that reverse pressure softening (RPS)
applied for a minute or so seems to elicit a milk ejection reflex very
promptly,
at any stage of lactation, even apparently in spite of stressful conditions.
This
is what I have observed and what has been reported to me many times since
RPS was developed. (I would be most happy to receive feedback to the
contrary if anyone finds it is not always so for them, so I can "temper"
the
absoluteness of that statement if need be.) This is called the "tap" reflex
in
agriculture, the theory being that myoepithelial cells are able to respond
reflexively, possibly without the oxytocin stimulation, to cause MER. The
calf or kid butting the mother's udder is the example we all may have seen.



That idea may enter into the fact that breast compression, made well-known
by Dr. Newman, "simulates" and often "stimulates" an MER. I have had
feedback about RPS that when a mom in NICU starts her pumping session
with RPS, pumps for a short time (5-7 minutes), uses compression and/or
massage, then repeats all 3 parts of that same sequence again several
times, "She get tons more milk".



We have many WIC moms who work and need to pump. We try to keep
emphasizing to them that the milk ejection reflex is THE most powerful
force in milk transfer, and we explain that RPS and intervals of massage
to help milk transfer yield much more than vacuum alone, along with the
fact that "suction doesn't 'pull' directly on milk-it 'pulls' on flesh, so
be very
careful of the vacuum strength and the length of the pumping session, at
least at first."



After our WIC office issues or loans their double pump, they of course
need to get a "stash" saved, as well as making adjustments for those
days/jobs where they cannot pump 3 times in an 8 hour shift. Some
mothers (with a larger storage capacity) seem to be able to get away
with this, at least for a time. They seem surprised to hear that it's
possible to "make up" by pumping at home on one side while feeding
the baby on the other, especially on their days off.



They are happily surprised with the news that milk is made more rapidly
the hour after feeding or pumping, and that neither the pump nor the baby
removes more than 75-80% of the milk. Therefore if they pump between
feedings, or when they feel fullest, in order to get the most, even if the
baby
wakes up soon after, the baby will probably get higher calorie hind milk
and just nurse a little oftener for a while to get what he needs.



I remember an illustration of the "Swedish milk curve", perhaps in old
Egnell literature written back in the 1950's, long before the theory of FIL
was advanced. The graph indicated that 50% of the milk for the next
feeding was made in the first hour, 35% more in the second hour, only
10% in the third hour, and if the mother went a fourth hour, only another
5% could be made (underscoring the fact that feedings/pumpings would
yield more in 24 hours if feedings were not spaced at the then common
4 hour intervals).



I believe in those days, this empirical-sounding observation was based
on the idea of pressure inside the mammary gland as being one of the
factors responsible. I also remember hearing on an agricultural station
in the '50's, that in dairy animals, that when the "inside" pressure against
the walls of the milk making cells became too high, it slowed production.
I have since heard a lecture on lactation physiology by an agricultural
scientist from Ohio State University that indicated that this is still
considered one of the factors in the control of the rate of synthesis and
secretion.



The dairy industry, of course, was way ahead on this track because
"milk means money" to them. Much of what was learned in basic
dairy management laid the foundation for scientific study of human
lactation. Whatever the mechanism(s) may be, it seems comforting
to mothers to hear that milk is made faster for a while after each time
milk is removed.



One thing we often find is that it's difficult to get moms to "hear" that
they
should not necessarily expect to get quantities of even 1, let alone 2,3,4
ounces or more at one (or every) pumping, as if turning on a faucet. Our
explanation sometimes goes "unheard" because of their cultural
expectations. Even if they hear, many of them get very, very discouraged
when their efforts to pump yield less than an ounce after "a whole hour of
pumping!" So (in addition to double-checking the size of the flange in
relation to where fingertip expression elicits the best flow) we once again
1) explain the MER and its importance to milk transfer 2) review RPS, and
3) encourage breaks after short periods of pumping for compression/massage.



Being over 3 decades beyond my "bicycle horn" personal experience, I can
only report directly on what I see and hear in helping WIC moms.


Jean
**********
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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