Pamela Morrison wrote about babies in Zimbabwe who "receive their
own mothers' manually expressed breastmilk, usually every two hours,
with *no* additions except perhaps Vit D.  The babies thrive!"

I wonder if the manual expression is what makes some of the
difference? Management of breastfeeding has become increasingly
commercialised and dependent on devices. Yet how often do we stop to
wonder about the impact that this departure from nature may be
having on the process nature evolved over centuries? Yes, we are
keeping babies alive today that mother nature did not plan for, but
I still trust that she has some answers.

Sandra Lang has published on the differences in milk composition
between manually expressed and pumped milk.  One difference was the
increased sodium in hand expressed breastmilk, the very ingredient
premature babies need. There were other differences. While hand
expressed milk is no doubt different again from breast-delivered
milk, I would expect it would be closer that milk removed by vacuum.

Studies have shown that when a baby is self-regulating feeds, the
baby is able to keep the amount of fat consumed per 24 hours
surprisingly constant, even though fat intake at different feeds may
vary greatly. What other nutrients do the breast and the baby jointly
regularly for intake? But when a mother is pumping milk for her
premature or sick baby, far in excess of what her baby needs, this
whole natural system is out of kilter. Are we unknowingly working
with the companies to create a need for human milk fortifier?

I recall Sandra Lang telling me over lunch one day that they had got
rid of the need for fortifiers for prem babies by changing the way
the mothers expressed their milk.

1.   They actively encouraged hand expression of at least some feeds,
even though this may result in lower overall production than if she
pumped all feeds. I think the message was not to sacrifice quality
for quantity.

2.    Where the mother was expressing/pumping  more than her baby
needed, they got her to keep a log for a couple of days of how much
she typically expressed at each session, noting the time of day.  If
her 24 hr production was, say one-third in excess of what her baby
needed, then at each session she put aside the first third of what
she expected to express/pump and then kept the next two-thirds to be
fed to her baby.  Obviously there would be some need for adjustment,
but you should get the idea.

Simply, this meant the baby was getting the second portion of the
milk. Probably more fats, but more of what other nutrients? She said
that the babies did particularly well on this regime and did not
need fortifiers.

I don't work in this area, so I am only reporting what I was told,
plus my thoughts.  Has anyone tried it?  Does anyone know of other
studies into the composition of milk obtained by different methods,
or related to the volume expressed/pumped? We need more
physiologists and biochemists to help up with our lactation
management regimes, but we also need to look to nature for the
answers.

Ros Escott BAppSc IBCLC
Tasmania, Australia