Another thing to think about in terms of lactation management for these women 
is--at some point--to cut your losses and encourage exclusive pumping and 
bottle-feeding, especially if the whole experience is miserable for the woman and 
you sense she is going to quit completely.  I have had two women with 
hypoplasia get to nearly full supply (one was put on Metformin and Dom Peridone), but 
only with pumping (maybe produced 25-30 oz a day and the baby needed about 35 
oz).   As Lisa pointed out, a flow-dependent baby is going to (most likely) 
stop driving the supply when the initial let-downs pass.   It is incredibly and 
erosively demoralising for a mother to breastfeed and then watch her baby 
down four ounces of formula.   And then get on a pump and yield a trickle.   It 
feels much better for these women, sometimes, to pump every three to four hours 
and yield a "high" two ounces (or even one and a half, or even three).   I 
find that the same phenomenon can happen wtih the SNS; it is psychologically 
tough for a woman to tape a tube to her breast, because it sometimes serves as a 
visual reminder that the breast is not (yet?) working as it should.    

I know we all value the bonding associated with nursing, but of course if a 
mom is going to quit entirely because she is in an untenable position, it is 
imperative that we switch to prioritizing the baby's health.   

Which brings me to another point:   It's high time someone addressed the 
issue of exclusively pumping and bottle-feeding (perhaps at a "Controversies in 
Lactation" conference?).   We cannot ignore that this is a viable alternative to 
breastfeeding, an alternative that should, in my opinion, sometimes be 
encouraged versus waiting for the mom to "discover" how great breastfeeding can be.  
 With the polarization of breastfeeding in this culture ("If I can't get to 
full supply, I'm just going to formula feed"), there are about three instances 
in my career where I have instructed mothers to exclusively pump and 
bottle-feed, and not put the baby to the breast at all.   All three of these moms have 
called me or come to my support group and emphatically told me that they would 
be formula-feeders if I hadn't told them to do that.   One mom even went on 
to breastfeed after the dust settled and she realized that she took "step 1" 
with no problems and with great success.

There is a momentum to breastfeeding that has developed over the past 10-12 
years that has much to do with the evolution and commercial availability of the 
electric breastpump.   Yahoo and other websites boast "exclusively pumping" 
boards; these are full of women who formerly would have been formula-feeders, 
but because of the great pumps available, they are now breastmilk-feeders.   
Someone should speak on this at an ILCA conference, as exclusive pumping, its 
establishment, the profile of women that benefit from it, etc., are 
conspicuously absent amidst all the breastfeeding talks.   Something to think about...

Heather Kelly, MA, IBCLC
Manhattan Lactation Group, NYC, NY       

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