Dear wise ones, 
This debate has come up once again and there is some urgency to determine what is considered current best practice. In Canada, Health Canada has issued a notice that we can no longer reprocess breast pump kits (long story to explain why, but it is to do with the manufacturers not having the evidence that the product is safe after reprocessing - or something to that effect). This takes effect May 1st and has us all scrambling to develop alternative procedures. No matter what is decided upon (there are various options including disposable and short term/single person sets) there will be a significant budget impact. This has prompted us to reexamine our current practices to determine what really is best practice for hand expression/pumping in the first 0-72 hours. I have done a quick lit search and have found (I think) the recent key studies and conclude that our recommendations should include the following: if baby isn't latching effectively, or is separated from mom then:
- when able, maintain skin to skin as much as possible 
-if baby is making latching attempts, encourage these (start with laid back, baby led approaches)
-if not latching effectively, start hand expression by 6 hrs
-if baby is separated from mom, start hand expression as soon as possible (even within the first hour if mom able - depending on her circumstance, but no later than 6 hours). 
-continue with hand expression if suitable volumes obtained (2-10 mls). Feed ebm via spoon or syringe. 
-after 24 hours, if still not latching well, continue hand expression but start hands-on pumping (a la Jane Morton). 
The literature does seem to be all over the place as none of the studies have large numbers, use the same techniques, some are on healthy newborns with moms who have an established milk supply, others on pre terms, some that demonstrate hand expression has advantages over pumping in the first 12-36 hours didn't use 'hands-on' pumping etc. The Cochrane 2011 review isn't really helpful. I realize we don't have all the answers and need to proceed with the best evidence we have. So my questions are: 
-If a baby is separated from mother, do you begin pumping immediately (hands-on pumping) or do you use hand expression alone for the first 24? 48? 72? hours, then add hands-on pumping?
-If we needed to conserve sets (and $), do you think teaching mothers the hands-on pumping technique - but using single pumping instead of double pumping would be just as effective? 
-or do you think there is enough evidence to  advise hands-on double pumping at least for any babies in NICU?
Of course, this is assuming mothers preferences are also taken into consideration. 
I await your thoughts, 
Gratefully, Meggie
PHN, IBCLC
BC Canada

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