"We know that there is a risk that when a mother gets used to supplementing
(with ABM, EBM or whatever) it can become a habit she gets into - every
time the baby squeaks, she thinks she can't have enough milk, and the baby
is given something extra. It does not promote confidence in the process, or
the relationship, of bf."

I hear what you're saying, Heather, about it not being necessary to
routinely express or pump the "extra" milk, but because I work with a fair
few low-weight-gain or failure-to-thrive babies, I have to respectfully
query that this can become a "habit".  Or that the mother can have her
confidence undermined if she needs to do this.

I do suggest pumping/expressing after breastfeeding when the baby is not
doing well, both to stimulate the breastmilk supply through good drainage,
and to provide supplements for the baby.  It really works!  But usually the
baby is being weighed by the paediatrician every week, or even more often,
and as the weight starts to creep on and then pile on, and as the baby
starts to *breastfeed* more effectively (as a consequence of improved
nutrition) then it seems to follow that the mom realizes by herself that she
can cut back and then discontinue expressing the extra milk.

The moms of these skinny little babies nearly always report a history of
unrelieved engorgement in the first few days after the milk first came in.
I'm convinced that the first week - 10 days after delivery are really
critical to establishing adequate lactation, and it's usually in this time
that the breasts have the potential to become overfull or engorged, with the
sequel of lactation failure if this is not addressed.

Consequently if I'm working with a new mom during this time I *always*
actively encourage the mom to pump or express to comfort, and not to throw
away the milk (because it's so precious!)  I suggest that this is an
"investment" in a future excellent milk supply, and well worth a few days'
hassle.  As the baby's appetite increases and as the initial over-supply
dwindles I find that, once again, regular weight checks will confirm that
her baby is thriving and give the mom the confidence to cut back and stop
taking off the extra milk.

In a way I kind of "trust" the mother on this - she is with her baby all the
time, and is usually most qualified to know if her baby is breastfeeding
well, or not.  I sometimes find that a mom of a newly discharged prem baby
will go on and on pumping and feeding EBM well past the time that *I* think
that the baby shouldn't need it any more.  But even in these cases,
eventually the mom will stop doing it once she sees that the baby is
continuing to gain.  I guess prevention is better than cure and my personal
wish is always that the moms of the "little-old-men" who find their way into
my office had thought of it too!

Pamela Morrison IBCLC, Zimbabwe
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