Thanks, Linda, for posting this link which I am including here for
convenience if you who are reading this missed Linda's post.
It is a short article by Jane Morton in which she suggests that
routine care "in the first several days for infants at risk for
suboptimal intake and/or mothers at risk for suboptimal milk
production should be to encourage hand expression and spoon feeding
after breastfeeding."

http://lactationmatters.org/2011/09/06/is-pumping-out-of-hand-why-hand-expression-in-the-first-3-postpartum-days-is-important/

She quotes a 2003 study which found that about half of mothers had
difficulty getting their babies well attached and feeding within the
first 24 hours, and she cited insufficient milk as the number one
reason women stop breastfeeding before they had intended. This was her
motivation for looking at factors in the first few days affecting milk
production later, because if supply can be ensured in the first few
days perhaps fewer women will stop breastfeeding prematurely.  So far
so good, right?

I don't dispute any of the components of her argument as she states
it, and the main reasons Norwegian mothers give for stopping BF before
they'd intended are 'the baby refused to feed' and 'I didn't have
enough milk'.  These reasons account for more than half of cases of
premature weaning, even in the second six months of the child's life.
It doesn't surprise me that 'baby refused to feed' persists through
the second six months because if you follow the standard advice on
introduction of solids here, your baby will not have any room for
breastmilk in its stomach.  But it surprises me that women who have
breastfed for seven or eight months suddenly find their supply to be
insufficient.   There is a fair bit of research linking perceived
insufficient milk production with low self-efficacy scores about
breastfeeding.  So, while many women report insufficient supply as a
reason for stopping, we don't really know how many of them in fact
don't have enough and how many of them are interpreting normal child
behavior as if it all consists of expression of satisfaction or
dissatisfaction with amount of food.  Where I live, if a baby cluster
feeds in the evenings, as babies do everywhere in the world, the
mother 'diagnoses' herself as having low supply because the definition
of 'enough' is that the baby will sleep for three hours between each
feed.  More often than not the diagnosis is confirmed by HCPs. A
common way to remedy this odd diurnal variation in milk sufficiency is
to pump in the mornings when these mothers are often overflowing with
milk, and then bottle feed the expressed milk to the baby in the
evening.  Before you know it they are pump-dependent in the mornings
but still don't produce larger amounts in the evenngs, and
breastfeeding seems not only mysterious and difficult tp do, it's a
lot of work besides.

Back to the first 24 hours: IF the baby is not attaching and suckling
in the first 24 hours, by all means show the mother how to offer her
colostrum to get the baby interested and to keep the nervous staff
calm while she waits for baby to start feeding normally.  The current
evidence supports hand expression rather than pumping for all the
reasons others have cited. But the current evidence also supports
keeping mothers and babies in close physical contact, encouraging
unlimited suckling by the baby whenever the baby shows signs of
wanting to do so, and ensuring that mothers know how to recognize good
attachment when the baby does it.  At least half of mothers don't need
to start expressing and measuring every drop they can put into the
baby.  It's the job of the staff to know which mothers need to do
something besides leave it to the baby to sort out. If staff are
encouraging all mothers to express 'just in case' it sounds like the
institution needs to take a long, hard and critical look at what kind
of intrapartum care mothers are getting there, and take steps to
improve it.

Rachel Myr
Kristiansand, Norway

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