Nice to get some more support from Dr Jack on the benefits of exclusive
breastmilk-feeding for pre-term babies!  And thank you Ros for your very
interesting reply raising the possible differences between manually
expressed and pumped breastmilk.  Definitely food for thought! Is it
possible that the *frequency* of breast drainage plays a part in the
composition of the milk too? I am not aware of any studies done here on the
composition of the mothers' milk, and the mothers are certainly given no
information on feeding less foremilk and more hindmilk. I have worked with
one pre-term baby who gained over 60g/day on his mother's milk alone.  In
theory the shorter the intervals between expressings, the higher the fat
content would be.

However, on the possible benefits of making sure that the baby obtained
*all* the mother's milk (i e she was not discarding any), and I confess I
have wondered about this, whether some of the immunological properties are
"watered down" (??) in practice I would be a little wary of suggesting that
a mother express only what her baby required (some of the tinies are
receiving only 2 - 3 ml every 2 hours!) because engorgement wreaks such
havoc on later breastmilk production.  When the mother is going to have to
express for many weeks we know it is going to be potentially difficult to
maintain production anyway, let alone increase it.  I also find that when
these little ones are learning to actually breastfeed it is very helpful if
the mother has a very abundant breastmilk supply so that the baby receives
an adequate intake with minimal effort.  The premie babies I have worked
with seem to gain well even though the mother is discarding large quantities
of breastmilk at the beginning.  I once worked with a mother of a 29 week
gestation baby who had 20 litres of frozen breastmilk stored by the time the
baby was discharged home (usually 1800 - 1900g here). It seems to be easier
to generate a very good milk supply by draining very well in the beginning
and then simply waiting for the baby's requirements to catch up than to
start off expressing/pumping only a little more than the baby needs and
having to build it up later.  In the private hospitals where I visit a lot
of the moms prefer to use a pump, and I don't think it seems to make a
difference to the babies' rate of gain.  I definitely agree that we need a
lot more research into this intriguing area!

Pamela, Zimbabwe