Meggie Ross asks for input about how to accommodate mothers who need to get
milk production started without a fully breastfeeding baby in the first
three days.
First, thanks, Meggie, for a concise overview of best practice - I plan to
copy it as we are reviewing our procedures where I work. The mothers in
your area are lucky to have you there :-)

The one study that people here in Norway are aware of, thanks to the
tireless efforts of the Medela sales rep, on pumping from day one for
premature babies, is the Medela-funded one which compared the Symphony pump
with standard suction pattern and the Symphony pump with the preemie
suction pattern. They found that for mothers of babies born before 34
completed weeks of gestation, the preemie suction pattern was preferable to
the standard pattern. They did not compare pumping with any other pump and
they most certainly did not compare pumping with hand expression. Hands
don't touch breasts in the world according to Medela - even babies are
never seen touching breasts in their world. Go figure.

There is good evidence to support starting to stimulate milk production as
soon as possible after birth. If the baby is unable to do so, it is good
practice to show mothers how they can do what baby would otherwise be doing
and encourage them to stimulate supply until the baby can take over.
If the goal of expression is to have colostrum or milk to give the baby, or
to help mother establish a sustainable breastfeeding relationship, then
hand expression is preferable.  Most women in my experience have more
discomfort from pumping than from correctly performed hand expression in
the first days after birth, before there is much water in their milk.
Pumping from day one is more costly, requires staff time and
equipment, must generally be done with mother sitting upright and leaning
forward, prevents baby from getting much colostrum as it all ends up as a
thin film in the pump, and worst of all, is associated with a markedly
lower likelihood that she will be breastfeeding three months later,
compared to women who established milk supply by hand expression in the
first days.

Our procedures call for hand expression until milk is flowing freely. Staff
do have trouble understanding that, and I hear constantly of women being
advised to switch to pumping on day two or three 'to get more stimulation'
even though they are harvesting normal amounts of colostrum by hand
expression.

Once there is copious milk flowing, some women will prefer using a pump,
and some of them prefer double pumping. The hands-on pumping technique
appeals to me because it makes it so clear that the pump is an aid, while
it is the mother's efforts that are being aided. Pumping large volumes can
seem like the goal sometimes, rather than the means to get to the goal of
breastfeeding.

I did find the Cochrane review from 2011 helpful, because it shows that
there is no unequivocal answer, and it did find that there is no clear
advantage of pumping over hand expression. When trying to stem the tide of
marketing influence, negative findings from an independent source are the
best thing we have. I'm still waiting for the evidence that providing women
with a machine that only exerts suction on their breasts has any role at
all before lactogenesis II is harmless, let alone effective!

Rachel Myr
Kristiansand, Norway

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