I think it must be really difficult to measure just how empty the breast is
without the sort of resources they use at UWA. Next time I see Peter
Hartmann I'll ask him to consider looking at breast emptying in cases of low
milk supply where it may be that the baby is removing all the milk available
to them! I would also love to have them look at prolactin levels in women
relactating with a pump, different pumps, different pumping regimes and
methods.....might be waiting a while for that though!

It's shame that women might prefer to pump if their baby is willing to
suckle frequently. You might be interested in the following excerpt of an
article originally published in BFHI News. While the population is clearly
very very different from what you see the problem of very low milk supply is
not.

Karleen Gribble
Australia

Supplemented Suckling method gets malnourished infants back to the breast
Severely malnourished infants in Liberia were able to regain the strength to
breastfeed exclusively after  intervention that combined therapeutic feeding
with a programme to increase breastmilk production, according to a study
conducted by Mary Corbett, a graduate student from the University of
Aberdeen (Scotland). The results "exceeded expectations," said Dr. Michael
Golden of the Department of Medicine and Therapeutics at the University of
Aberdeen, who supervised the programme. The programme has since been
repeated with similar success in Burundi and Chad. According to Dr. Golden,
a number of partially breastfed infants under six months of age who were
admitted to a therapeutic feeding centre operated by Action contre la faim
(Action against  hunger) in 1998 in Monrovia were in dire need of corrective
nutrition. The initial stages of malnutrition are often due to infants
receiving foods other than breastmilk, so that adequate production of
breastmilk is not stimulated, said Dr. Golden. "Once the infant becomes
malnourished, even switching back to exclusive breastfeeding may not work
because by that time the baby may be too weak to suckle effectively."
Therefore, attempts to reinstate exclusive breastfeeding often fail and
relief workers turn to feeding alternatives.However, Dr. Golden said, "If
these infants are discharged without the protection of breastmilk, it will
be a  disaster." But simply giving a therapeutic milk diet by cup or tube,
even with the mother's expressed breastmilk added, does not ensure continued
breastfeeding, and thereby increases risks to the child's subsequent health.

Twenty-one infants were selected to partake in the study. Initially, they
all had a trial of exclusive breastfeeding to see if they could gain weight
on breastmilk alone. For those who did not, Dr. Golden and his colleagues
then turned to a technique that he calls 'supplemented suckling', which
allowed infants to benefit from a nutritional supplement while at the same
time partaking of their mothers' milk at the breast, until full
breastfeeding could be re-established. The infants were fed F100, a
therapeutic milk product used for nutrition rehabilitation, diluted to 70
kcal/100 ml. The feeding method, which is outlined below, helped infants
become reoriented to suckling at the breast, allowed them to regain their
strength to do so, and eventually re-established the mothers' milk
production.

. The mother put the baby to her breast every three hours, around the
clock. . One hour after the breast-only feed, the infant was put back on the
breast, but this time with a fine tube put into the infant's mouth along the
nipple. (This made a total of 16 breastfeeds in each 24-hour period, half
with the supplementer.)

. The infant was fed diluted F100 through the tube from a cup held by the
mother.

. The energy required for suckling depended on the height at which the cup
was held, so the mother could adjust the height of the cup as the infant's
strength increased.

. As it suckled on the tube and breast together, the infant was stimulating
the breast, so increasing amounts of maternal milk were produced and mixed
with the supplement at these eight feedings.

. The infant's weight gain was monitored daily.

. The amount of diluted F100 was reduced as the mother's own milk began to
flow more amply.

According to Dr. Golden, the infants in the study gained weight at a
"phenomenal rate," averaging about 14.7 grams per day per kilo - 44 grams
per day for a 3 kilo infant. The supplemented suckling routine was followed
on average for 13 days per infant, and in that time a 3 kilo infant would
put on another half kilo of weight. "By this time, the infants had regained
weight to 85 per cent of the expected weight for their length, and the
supplemented suckling was stopped," said Dr. Golden. "The babies were
vigorous and were suckling effectively." Another week of observing the
infants breastfeeding exclusively showed that the babies continued to gain
weight well; for the 3.5 kg infant, this was about 35 grams a day, or a
quarter of a kilo per week. At this point, babies and mothers were
discharged. Although some issues need to be resolved, including proper
hygienic care of the fine tube during emergency conditions, the method has
since been introduced in all the Action contre la faim therapeutic feeding
centres around the world. According to Dr. Golden, "Supplemented suckling
has been found to be a simple and effective technique."

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