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From:
Chris Mulford RN IBCLC <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sun, 3 Jan 1999 23:04:38 EST
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I've been very interested in this thread.  My experience with actual moms and
babies is not all that extensive, so I'm very interested in reading the
comments of people who have worked with a lot of NICU moms.

However, the phrase from the original question was "NICU moms pumping 9-12 oz.
every 3 hours."  If indeed those moms ARE pumping every three hours, that's a
supply of 72-96 ounces per 24 hours, or enough for 3-4 average full-term
babies.  Surely those moms should be helped to drop their output back to the
32-40 ounce daily range!  That much milk will be ample for their baby's long-
term needs in the absence of some special circumstance like a cardiac defect.

Clearly we need to know more about the physiology and psychology of ...what to
call this?..."artificial milk production"?  The dairy industry has got it
figured out, so we should be able to do it for humans.  Cows lactate for
months on two expressions a day, and they'd probably be healthier and maybe
produce even more on three or four daily milkings instead of two, but that's
not economical in terms of labor costs.  My questin is: what is the process of
*establishing* milk production, and how does it differ from the process of
*maintaining* milk production?

I know I've posted before about a few long-term pumpers I rented breast pumps
to.  Two of them pumped 4x a day and maintained their supplies for a year.
One pumped 3x a day---if she pumped 4x she made more milk than her baby could
drink.  That baby's ceiling was about 19 ounces a day.  The baby was the
"built for speed" type---small, very healthy, very active.  I saw her the day
I picked up the pump.  She was about 1 year old, weighed about 16 pounds, and
was walking all around the living room terrorizing the family dog.

Another long-term pumping mom got all the milk her daughter needed by pumping
at 6 AM before she left for work, at 2 PM on her lunch break, at 6 PM when she
got home from work, and at 8 PM before she went to bed.  She didn't get much
at 8 PM, but she found that if she skipped that pumping session her overall
production would dip much lower.

These moms did not have to live through the stress of a NICU baby, but they
did have the stress of struggling to teach the baby to breastfeed, then making
the decision to stop trying and accept the need for long-term pumping and
bottle feeding.  They had all wanted very much to breastfeed, and the pump and
bottle option was not something they were happy about.  Nevertheless, they did
it very well.  These final pumping regimens of 3 or 4 times a day were what
they arrived at (despite my advice to pump more often!) AFTER their milk
supplies were established.  They all began with more frequent pumping.

I wish we knew more about the process Mike Woolridge refers to as
"calibration," that is, first weeks of lactation, the period during which "the
breasts are trying to find out how big the baby is."  One theory about what is
going on physically is that prolactin receptors are developing in the mammary
tissue.  Does that process happen in response to the pattern of time the baby
spends at the breast?  Do we have an idea of the mechanism, what it is that
makes the prolactin receptors develop?  Is it related to the serum prolactin
level?  Serum prolactin is bumped up with each nursing, and I believe that it
bumps up to a higher level when the feed lasts longer.  Thus the mom's
prolactin profile is a product of both frequency of feeds and duration of
feeds.  The length of interfeed intervals is important, too, because that's
the time when serum prolactin falls.  When you think how important
"breastfeeding intensity" will be later on as a reglator of the mother's
return to fecundability (ability to get pregnant), it's tempting to assume
that *intensity* is equally important at the beginning of lactation, playing a
role as the start-up regulator of the baby's long-term food source.

I suppose the other factor in the calibration process, in addition to bf
intensity, would be "degree of emptying" or autocrine control.  Thus the
pumping/expressing mom needs good technique (and good technology, if she's
using a pump) in order to remove milk effectively.  So we have two factors at
work to establish milk supply---prolactin (and/or some other hormone-s)
stimulation, and milk removal.  And we have Coach Smith's estimate of 140
minutes of suckling/expressing per 24 hours as the minimum time investment
required to establish lactation.  [She can explain her rationale for that
number.]

So what do you tell moms about a milk expression schedule?  Her 140 minutes a
day can be divided up into 10 14-minute sessions or 7 20-minute sessions.  But
to maintain high serum prolactins she probably wants to keep the average
inter-bout interval to three hours, and make the longest interval no more than
five hours.  I used to tell moms that the main problem with pumping is that
the pump doesn't cry.  She has to remind herself to express milk.

Do you find that the mothers with the big supplies are the ones who take the
expression task seriously?  Do you have moms who are expressing effectively
for 140 minutes a day and still don't get a good supply?

As far as the crowded freezers are concerned, wouldn't it be nice if milk
banks were like other banks, where you could make deposits and withdrawals.  A
mom who has a huge oversupply could donate some of her stash, with the
understanding that she would have access to donor milk if she ended up
drastically losing her supply at a later date.  I know this is an impractical
thought...  Maybe it's better for her to rent a freezer locker and store her
own milk for her own baby's long-term needs.

Bonnie also asked about the percentage of fat that a NICU baby gets if mom has
an oversupply.  I do know that more than one growing premie at my old
workplace had frequent watery stools and poor gain when their moms had gobs of
milk.  Suggesting that mom should set aside the first couple of ounces from
each breast in each pumping session (freezing it for later use) and bring in
the "hinder" milk helped those babies gain weight.

Chris in Swarthmore---16 degrees F (-9 C) yesterday; today a huge warm rain
that filled the creeks and flooded the streets.  If it had stayed cold I'd be
snowed in right now!

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