Dear All:

The one thing that I have not noticed (and someone may have posted this before) in the posts 
about Hurricane Katerina is the importance of cup feeding, rather than bottle feeding, when water 
and sanitation are poor whether it is human donor milk or formula to complement the relactation.  
From my international perspective - the reason why I think cup feeding became so popular as an 
alternative feeding device is that you can easily clean a cup and they are readily available.  As a 
long term feeding device, I have seen that the cup can have just as many problems as any other 
device and sometimes even more because some cup fed babies lap, lick or sip at the breast futilely 
without creating the negative pressure needed to create a seal.  I actually find that it is easier for 
me to teach the babies I see (for all of you who work in the hospital - I have a different audience - 
not the 1,2, 3 or 4 day olds who probably can tip the balance with judicious cup feeding - but 
babies that are 4 days to 2 years old and are taking greater volumes of milk and if they aren't 
latching it is usually from a more significant problem).   In the case of a disaster like Katerina - I 
would be tossing all the bottles and handing out cups to every mother who isn't exclusively 
breastfeeding with a large-group demonstration.  DItto for a demonstration on hand expression.

Karleen had mentioned that some lactation consultants may not be as familiar with relactation, but 
I have to say that if I really think about it with my clientele of which only about 10% exclusively 
breastfeed (and I'm not even sure about that 10%) is that most of my job is relactation - that is 
increasing the milk supply typically from iatrogencically or culturally induced impediments to the 
natural course of establishing lactation.  Yes, one might quibble that it is different when you start 
off with a supply that is at zero - but really I see this as only a matter of degree.

Yes, I totally agree that pumping has its problems in unsanitary conditions, but I can see how it 
could be helpful once these women are in a stabilized center IN ADDITION to putting the baby to 
the breast.  I always find it is faster to relactate a mother using both at once.  

Finally, now I'm bracing for the flames with my asbestos suit for this one, I have concluded that it 
is simply not true to state that a baby is alway more efficient than the pump.  Babies who are 
sucking well are MORE PHYSIOLOGIC at stimulating an appropriate milk supply for their needs.  
But I still remember Peter Hartmann's talk from the prevous year's talk at ILCA about how babies 
drained the breast to about 50% capacity and the pump drained it to about 80% capacity.  What 
that told me was that a half drained breast is physiologically appropriate when all is going well, 
but when a mother does respond to the pump and has a low supply, the pump IS an efficient tool 
and for many women may very well be more efficient than the baby in bringing the supply up.  
This is particularly true for newborns who may normally take 50 min or more to finish a feeding.  
When mom has an iatrogenically induced low supply, the pump can drain the breast in 10-15 min.    
In these instances, the pump is more efficient than the baby - but is no substitute for the skin-to-
skin contact and the breastfeeding practice that will eventually make feedng at the breast 
possible.

So, what this means to me is not that I'm going to be running around telling every mother who has 
a normal breastfeeding situation to use the pump instead because its faster.  Not at all because in 
those circumstances pumping may delay mother and baby getting in sync with other. On the other 
hand, when a mother is building up a supply, breast practice time, skin to skin contact and a 
judiciously planned schedule that INCLUDES frequent brief pumping with an appropriately fitted 
breast shield, a hand made hands-free bra (Target sells cheap sports bras that are great for 
cutting up for this purpose) and a little olive oil really helps.  When sanitation is not good - or 
moms are comfortable and efficient - hand expression is a good option.  My best example of hand 
expression was a mother whose baby did not latch onto the breast for two weeks.  She and her 
baby nurse couldn't figure out how to put together the pump (they had left out the white suction 
flaps) so her marvelous baby nurse sat with her every three hours and had her hand expressing 5 
ounces each time.  The day after I saw her and helped her get her 2 week old onto the breast for 
the first time (and the baby completed the feeding too) we had the black out here in Manhattan.  I 
knew she would have no trouble at all coping with the situation.

I also have worked with an important minority of women, who simply just do not release to the 
pump whlie they have no problem releasing for the baby.  When they have babies that do not suck 
well, hand expression is an important tool.

So, for all of you who are working towards getting attention for breastfeeding in emergency 
conditions, do NOT forget cup feeding and reconsider judicious use of breast pumps once things 
stabilize and sanitary conditions can be established.  While it may not always be our ideal vision of 
how relactation should occur, it may be a useful tool that we shouldn't deny to some of those 
women who might take us up on the prospect of relactating but be less comfortable with hand 
expression.

Susan E. Burger, MHS, PhD, IBCLC.

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