Catherine Watson Genna wrote:

< Tell me how you are taking milk out. . . .How many times a day are you managing to pump? 
How many times did you get to pump yesterday? (gets a better answer, and "managing" and 
"get to" are clues that we are talking reality, and reality is sometimes difficult). . . . Mom: but 
I pump for an hour each time.... Me: I can see how that would be very difficult. I wonder if we could 
help you with milk expression so it would be much shorter and then it 
would be easier to do it more often.  . . . .THEN we talk about where she 
keeps the pump, what the flange size is, does she use massage and compression. . . . .>


Her answers came the closest to some I have found helpful. As Cathy's example showed, 
too many mothers interpret "more pumping" as instruction to "keep on pumping as long 
as they are getting even a tiny bit out" as if likening it to keeping on tilting a bottle till 
it's completely emptied out, or continuing to keep on wringing out a dishcloth to get the 
most liquid out of it! 

In particular, 
she notes that explaining is only part of the equation. It is often crucial to 
interpret the mother's own interpretation of the words you used! Asking 
questions to figure out just how she is planning to put the words into 
action is often very revealing, because she may be having trouble 
dropping other self-defeating ways of looking at it. The questions about
where she keeps the pump etc. are very helpful if you explain to her to
simply use a zip lock bag to cover the flanges (in case of toddlers or pets).
If the room temperature is less tha n 75 degrees, there is no need to go to 
the bother of washing the flanges or refrigerating the milk until every 6+ 
hours or so (to be on the safe side.) Many moms feel relieved to find this
work-saving reassurance. 

The very first thing I always check on is whether she understands what 
the letdown reflex is (can she explain it back to me) and whether she 
understands she can trigger it herself by hand as often as every 5 to 7 minutes 
if she wants. She can easily do this by pressing for "the slow count of 50" on 
the nerves under the skin of the areola, either with finger tip expression or 
RPS. Some moms  find it empowering to know they don't have to depend 
on a piece of electrical equipment (or other "picture" or "baby aromas" to 
do that for them, if they don't want to!  It's a good idea to teach them to do 
alternate breast massage at the same time, (to move milk closer to the 
flange, because "vacuum doesn't pull-other forces push.)

Diane Wiessinger has a very helpful instruction sheet  called 
"How We Make Milk" in which she uses simple language to 
explain the concept of FREQUENCY OF REMOVAL being the key 
to increasing supply. (Pardon the capitals, they are the only
way I can ever think to add emphasis on LN;-) 


I have found it very helpful to explain it by blaming it on the milk itself! 

Actually using a "cartoonish" word picture to stand for feedback inhibitor of lactation (FIL) 
has seemed to help. I tell them that one of the neat special ingredients in her 
milk has two separate jobs: If it goes into the baby, it's good for the baby; if it stays in 
the breast for very long, it has another job it's supposed to do, which is to start to act 
like a policeman! (sometime I go so far as to name the cop "Phil"!) 
The longer he is "on duty" the more likely he is to start to hold up his hand, 
blow his whistle and begin to yell at the milk making cells:"Slow down . . . 
we don't need so much right now!!" So "giving the cop a break" by 
taking him off duty more often gives permission to the milk-making cells to speed up
production again for the next hour. 

The original Egnell graph enlightened me, so I just reduce it to "The breast makes
milk fastest the first hour after milk is removed, slower the second hour, slower yet
the third hour, and very slow the fourth hour." I encourage moms to trigger the MER
and spend only just 5-7 minutes pumping, pause,massage milk forward from the 
back of the breast, trigger the MER a second time, and pump for another 5-7 minutes.
Then, during their waking hours, for just a few days, I encourage them to jot down 
the time of each short milk removal, both by nursings and by these short periods of 
milk removal afterward, or at 1-2 hour short intervals between nursings. This may 
mean much less total time spent in actual pumpings but result in larger total number 
of milk removals.

Maybe a few of these ideas might add to the "tricks" others have developed.

K. Jean Cotterman RNC-E, IBCLC

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