Jay, your report on your client who succeeded in pumping for a baby with
Pierre Robin for > l8 mo is another tribute to the gallantry of mothers who
will go to any lengths to give their babies the "best", and will succeed
too, with enough help from people like you!

But you go on, "what about this thought (or thoughts...)?  Maybe some women
can sustain full supplies while pumping and others simply can't...  So, if
it is possibly a "mind" thing rather than a pump vs baby thing, how do we
help the mother? ... I know that for me, I can not use an electric pump
effectively .. I got a whopping 1/2 oz after 20 min of pumping.  It was
pathetic...  But with this little hand pump I get SPRAYS ..."

I think your varied experience, your own and while working with other
mothers, serves to illustrate two fascinating facts about the MER:  1) how
effectively it can be inhibited by the mom's emotions, and 2) how it can be
conditioned to work well over time with repetition.

One of the most nail-biting things that I work with can be where there is a
baby in the Neonatal Unit (NICU), and the paediatrician is calling for
breastmilk for this little mite, and the mom finds to her dismay that she
can only "get" drops, or a teaspoonful, or whatever.  Furthermore, her
self-confidence can be totally shattered by the sight of all the other
mothers expressing lots of milk into their little cups for their babies.

I should mention that we don't have the luxury of these wonderful-sounding
hospital-grade double electric pumps, but we do have an array of hand pumps
and I know the one with the petal-flange which you mention,  which
personally I observe to have very gentle suction, so I am surprised when it
works!  So picture us working either with manual expression or a very basic
hand-pump with good suction, but if the mom is able to get even sustained
drops or slow dribbles of EBM with either of these methods, then we're in
business.  I simply show her how to express from one breast then the other
and back to the first until she has the 30 ml or whatever that the baby
needs for the next feed.  If she becomes very tired she can stop and stare
at the wall for half an hour, but she should resume expressing until she has
"enough".  As soon as the baby has received this milk, then she needs to
start again, ready for the following feed, which will usually be 3 hours
later.  And she just keeps going.

But this works!  At first it is painfully slow, but as the breasts drain the
milk comes a little less slowly, then a bit faster and so on.  Within 3 days
this mom has joined the others in only needing to express once every 3 hours
to supply all that her baby needs, and much more.  It's good drainage that
keeps the volume going.  It's repetition that conditions the let-down to
eventually become more efficient.  If the milk supply falters next week or
next month (usually because she is now only pumping 4 - 5 times/24 hours)
she knows to express more frequently until her supply again meets the baby's
need.

As to your second question, "why, if it is possibly a "mind" thing, do herbs
and meds (such as domperidone and reglen) work to increase the supply when
the moms supply drops (placebo effect??)?"   The drug we use here which
appears to show many similarities to reglan, from what all of you describe -
called sulpiride  - works by increasing prolactin levels.  If the mom drains
the breasts more frequently while she takes it she notices a jump in
breastmilk output within 3 - 4 days.  However if breast drainage is not
maximized (better or more frequent breastfeeding/pumping) she notices an
initial increase in supply, then a disappointing dwindling again.  I still
feel that there are pieces of this puzzle that are missing, but it's good to
throw these thoughts around.

Pamela Morrison IBCLC, Zimbabwe
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