Heather,
You wrote, "I also know that many women would feel strange squeezing and
manipulating their breasts..."

I think this "knowledge" you have is an assumption.  If you have offered and
been turned down repeatedly, then you certainly have proof  that many women
would rather  not use their hands to express milk.  Most mothers I have
worked with are very interested in learning to hand express.  And no I don't
live in Amish country...I drive to work, too.

You also wrote,
"Word processing, the internet, the ability to retrieve information without
going to the library, or asking the village Wise Man--these are realities,
and most women (including me) have acclimated to this world as the norm.
Touch is wonderful and I'm sure that many let-downs have been facilitated by
the human hand, but I can guarantee that since pumps have become commonplace,
many more have been elicited by them.  The dairy industry would founder if it
relied exclusively on
hand-milking, no doubt, and so would my lactation success cases."

I think women in the olden days went to the village Wise Woman in regard to
breastfeeding because the village Wise Man wouldn't have the answers :)  Just
a little humor...

I think you are mistaken in believing that pumps elicit let-down.  If you
want to read a little about the dairy industry and the studies they have done
in regard to the use of milking by hand prior to use of their pumps see
http://www.wisc.edu.dysci/uwex/milk/pubs/habits.pdf

Certainly, the dairy industry would founder, if it exclusively used
hand-milking.   Are nursing mothers an industry?  Are mothers needing to
produce milk for the general population?  No they are producing milk for
their baby or babies, not for 100 local citizens. Of course, with the advent
of Prolacta Bioscience, maybe I should amend that statement, since that will
be our first "for profit" milk bank.

Let me explain my comment about being more in touch with reality through hand
expression.  I worked with a mom who had a c-section and a 10 pound baby.
She was two days postpartum and in the hospital.  She called me to come visit
her  because there are no LC's during the weekend at this particular
hospital.  She had a beautiful breast pump in the corner of her room and she
had used it the day before because they could not get the baby to latch on
and nurse.  Since she had a c-section and had great difficulty moving around
and no family help (and all the nurses seemed to have disappeared), I
suggested that we use hand expression to get a little milk to entice this
beautiful baby to breastfeed.  This to me was a simple  and workable solution
to leave with this woman because she had no help and obviously they were
short staffed.  I showed her how to hand express and she was surprised and
amazed that she had milk!!  I was surprised that she was surprised. This is
someone who had used a premium hospital grade pump the day before.  The
hospital pump had in no way reassured her that she had milk yet hand
expression gave her that reassurance.  Why?  I suspect that for this woman
the pump placed a barrier to self-knowledge.  With touch, her brain truly
assimilated the fact that she had milk.  Many of us need touch to recognize
reality.  Montague in his book writes about Helen Keller, who was blind and
deaf, and how the only way to reach her was through touch.  As Montague
suggests, our skin is more than a bag that keeps our skeleton and organs
together.

There are enormous questions in my mind in regard to hiv passing into
breastmilk, particularly when there are over 100 human milk patents on using
human milk components (recombinants--a few that aren't recombinants) to
inactivate, prevent and treat hiv/aids.  Because of the fear of hiv/aids,
many milk banks have closed (yet no blood banks have closed and blood is much
more a threat to infection than human milk ever can be).  I think wet nursing
like milk banking can be relatively safe. If we can test the milk, we can
certainly make sure a mother who intends to wet nurse is healthy.  But, if we
pretend that wet-nursing doesn't exist or shouldn't exist, then we cannot
help moms determine the risks of this option.

When breastfeeding doesn't happen and the mother doesn't have enough milk,
what can we offer?  Infant formula is just about the only option, when we
have limited access to milk banks.  Interestingly,  Nestle of Japan holds
patents on human lactoferrin to inactivate hiv (one patent is on recombinant
human lactoferrin and one patent is the real thing). I believe that hiv/aids
has been the greatest gift given to the infant formula industry since the
surplus of whey.  Why would a formula company have these patents?  It takes
money to maintain patents.  Why does John Hopkins have a patent on HMFG
(Human Milk Fat Globule) to prevent and treat hiv/aids?  Sure looks to me
like we are being told one thing while quietly some industries and
institutions are investing in solutions that contradict what we are being
told publicly.

I am not sure if any of us truly know what our "scope" of practice is and I
say this philosophically.  When you say it is not our job to convince a
mother not to feel that hand expression is "icky," I am surprised.  Yet, in
the medical field, if a woman told her health care professional that she
thought sex was icky, wouldn't we want to recommend that she get help and
make a referral?  Of course, the problem in regard to breastfeeding and
handling our breasts is that most of society has a problem with it, too.   So
who could we recommend to help this mom?

Breastfeeding equipment is nice to have in a modern wealthy nation with
"unlimited resources."  We can easily follow-up and track its use to make
sure it resolves the problem.  And we have the ability to sustain an
investment in plastic and its disposal.
Although one might question the environmental soundness of one-time-use
plastic equipment.

I  worked a number of years in the WIC Program and was grateful that
administrators made sure we had electric pumps for our premie babies.
Believe it or not I worked hard to have more of these pumps available to our
moms.  Yet, when I worked with low income populations, I began to recognize
the hazards of giving out breastfeeding equipment.  The follow-up can become
treacherous because you may have a mom who because of her poverty does not
have a phone (or sometimes its working and sometimes its off because of
non-payment).  She may have no transportation and she may move so often that
you cannot find her.  You give her a pump or an SNS and you may never see her
and her baby again.  Should you give out equipment when the possibility
exists that you will never see them again?  What can you do for this mom?
Hand expression is one very simple solution to pumping when dealing with low
income populations.  It's not thee solution...a solution among many.

Many programs invest heavily in breastfeeding equipment and that sure looks
good on paper.  Administrators can say, "Look what we are doing for
breastfeeding!" But, they refuse to invest in lactation consultants--hiring
too few, giving them part-time work with no benefits, or not even having a
job description called lactation consultant.

There is more to the equipment issue than just whether one is pro-technology
or against technology.  I see equipment as a symbol.  Lots of equipment sure
makes it look like we are making breastfeeding happening and it sure makes
programs look good. The reality is that we have a great inventory.   But
often our investment in people whether it is the mother and baby or the LC is
short-changed.
Valerie W. McClain, IBCLC





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