Sorry I'm late chiming in. I thought that was an excellent point that the increased volume seen after delivery may be due to milk stored up during pregnancy. I hadn't thought of that before. I always thought it was maybe due to the fact that the only time both estrogen and oxytocin are both high is right after delivery. That's just complete speculation on my part though. 

Regarding when to start milk expression and expression being difficult in the hospital within the first hour, yes I agree that we are seeing the same thing in the hospital where I work. The L&D staff do not want to set up a breast pump right after delivery, they are extremely busy. We want to implement the protocols that Jane Morton has listed on her website at Stanford University hospital. She has some wonderful protocols for term and preterm babies. One minor change we want to make is to change the timing of first milk expression from 6 hours to within 1 hour, but have the L&D nurse teach hand expression in the first hour. Then later in mother/baby she can be set up with a breast pump within 6 hours. I think this is more doable for the L&D nurses. Within 5 minutes they should be able to teach hand the mother a container and show her basic milk expression and then let her complete it herself. We are making different protocols for NICU/SCN babies who are not with their moms in their room (start milk expression in 1 hour) at-risk babies such as those on hypoglycemia protocol like SGA and late-preterm babies (also hand expression in the first hour), and then for babies who do not latch but are healthy and in the moms room we start hand expression by 12 hours and then hand expression and pumping at 24 hours.

We also have been doing 15 minutes of pumping followed by 10 minutes of hand expression because even with the new symphony Initiate program, we don't get any collectible colostrum with 90% of the new mothers with the pump. The majority of milk collected is with HE. I'm beginning to even question the necessity of the pumping in the first 24 to 48 hours and wondering if just HE would be better. But I know there was apparently one study that said that suction could be important to the release of oxytocin. I personally haven't seen much difference with the new Symphony Initiate program over the old maintenance program in the volume of milk collected. Has anyone else seen better results?

My original question had to do with recommended volumes of supplemental colostrum if the baby didn't latch. Because another thing we would consider revising from Jane Morton's recommendations would be the volume of colostrum she recommends. At least 5 ml on day 1, 10 ml on day 2, 15 ml on day 3. I rarely see a mother that can produce that volume. That doesn't seem to me to be a normal volume of milk. There was a very good study by Santoro in the Journal of Pediatrics in 2010 that found an average feeding in the first 24 hours was 1.5 ml, plus or minus 1.1 ml. In my experience in the hospital, that is exactly the volume I'm seeing on day one and two. And this volume was for babies that were latching right away, moms not supplementing or using a pacifier, and are feeding on demand frequently and not watching a clock. Really an ideal situation that most babies don't get. https://www.ncbi.nlm.nih.gov/pubmed/19783000

Here's another study in which they found that supplementing with formula affected the volume of colostrum produced. However, the mothers who were exclusively breastfeeding were producing 5 ml colostrum at 48 hours, and those that were supplementing were making 2 ml.  https://www.ncbi.nlm.nih.gov/pubmed/18041411

Which brings me to the question that I have been pondering lately and wondering what everyone else thinks - Is colostrum actually food or is it something else? Do babies need "food" during the first 48 hours? If the volume described by Santoro is correct that means the average baby breastfeeding exceptionally well on the first day consumes a total of about 8 calories in the entire first 24 hours of life!

If we need caloric intake for our health, I think we would be in big trouble as newborns with 8 calories per day. The sources I'm finding say 55 calories per 100 ml for colostrum. Not a lot. Could it be that this is why humans have more fat stores (healthy, term babies anyway) than any other mammal in the entire world except for harbor seals? Maybe babies "need" immune protection and priming of their intestines on the first day more than actual food? Could it be that evolution has designed a system in which spends the first couple days resting, recovering, getting small drops of colostrum to colonize their intestines, getting great immune protection, learning to latch to the breast while it is soft, learning to suck/swallow and breathe without choking, and digesting the amniotic fluid that's already in their stomach? I hear people say sometimes that colostrum is high in protein, but I don't really think it is exactly. It's still only about 2.2% protein. And the reason it's a little higher is primarily because most of the things like cytokines, immunoglobulins that are in the colostrum are composed of proteins. It's not like it's tons of protein for nutritional reasons. I work with many well-meaning RN's who freak out if the volume of colostrum dips down on the second day and are worried that the baby is going to starve. I understand their concern, but I just feel that if this is what nature has given us, it has to be normal and beneficial for the human body.

 I realize this may not apply to preterm, SGA and IUGR babies that do not have as many fat stores. But I'm beginning to question lately whether or not colostrum is technically even "food" at all. I was reading the most recent paper from the Pediatric Endocrine Society on normal transitional hypoglycemia and they said that in the 1960's it was common practice to keep all of the babies NPO for 24 hours, and that the average blood sugar reading then about 57, is the same average blood sugar reading that they are seeing now when babies are eating immediately. Anyway, just some food for thought. Pun intended. I would love to hear other peoples opinions. Maybe it's time we reexamine the entire purpose of colostrum?
Tricia Shamblin, RN, IBCLC






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