The World Health Organization (WHO) recommend that infants be exclusively breastfed until the age of 6 months . The general public assumption about the term ‘breastfeeding’ is the provision of human breastmilk to the infant by direct feeding at the breast. This does not consider situations where mothers use breastmilk expression. Indeed, the WHO definition of ‘exclusive breastfeeding’ specifically states that this feeding practice requires that the infant receive ‘breast milk (including milk expressed or from a wet nurse)’ . In reality, mothers who exclusively feed their infants breastmilk fall into three main categories: direct feeding only, a combination of direct feeding and expressing, and exclusively expressing only. The fact that the existence of these categories is not widely understood or precisely quantified is evident in the questions and manner in which results are published in infant feeding surveys, such as in the United States of America , United Kingdom , and Australia . Furthermore, the Australian Medical Association discusses only breastfeeding and formula feeding in its position statement on infant health , with no reference to expressing generally. These examples demonstrate ways in which both expressing and exclusive expressing is subsumed under the umbrella term of ‘breastfeeding’, even though the actual experience of expressing and feeding expressed milk is vastly different from at-breast feeding for both mother and baby.
We hypothesise that the language used in this domain has emerged because of the infant-focused nature of most work – ‘breastfeeding’ as a proxy for ‘breastmilk-fed’ – when the outcome of interest is what the infant is consuming rather than how the substance has been produced or what the mother’s actions have been. Whilst we might prefer to use ‘breastfeeding’ solely in terms of the lay understanding, we must respect the context in which we work and the historical definitions in the infant feeding space. Therefore, in order to clearly identify and distinguish our population of interest, we will be using the terms ‘direct feeding’ to represent the provision of breastmilk directly from the breast into the infant’s mouth, and ‘breastmilk expression’ to represent the provision of breastmilk indirectly to an infant through the expression of breastmilk using an intermediary measure, such as mechanical pumping or manual extraction, and delivery to the infant via an infant feeding device such as bottle and teat.
As mentioned previously, there is a subset of mothers who exclusively feed their children expressed breastmilk, and never direct feed at the breast. The reasons for this can involve child or maternal physical health (for example an infant with a cleft palate, or maternal nipple trauma), maternal mental health (past trauma, anxiety/shame over breastfeeding), breast refusal, or environmental factors such as the requirements of other children or employment. These women are our population of interest and are our ‘exclusively expressing mothers’. The limited data available suggests that this group may include a substantial portion of parents, with studies indicating exclusive expressers to be between 5 and 22% of the total breastmilk-fed cohort [7,8,9,10].
It is common for the unique experience of exclusively expressing mothers to not be mentioned or considered in studies investigating the topic of infant feeding, particularly when there may be more striking comparisons to be made between the provision of breastmilk and of breastmilk substitutes such as artificial formula. Exclusive expressers are therefore somewhat hidden, both in the literature and in reality, as they deal with pumping around the clock in order to maintain supply, on top of all of the other responsibilities that come with having a new baby.
There are mixed results when considering the impact of expressing breastmilk on the duration of any (not exclusive) breastmilk feeding amongst all infants. Some studies identify that the introduction of expressed breastmilk into the infant’s feeding experience (either expressed only or a mix of expressed and direct) is a risk factor for earlier cessation of breastmilk feeding when compared with infants who receive breastmilk only directly at the breast [8, 11, 12]. Another study suggested the opposite – that introduction of expressed breastmilk meant a mother was less likely to discontinue breastmilk feeding before 6 months than a mother who only ever provided breastmilk directly – but did not compare the category of women who only ever expressed breastmilk- . The outcomes of these studies did not stratify their participants into those who exclusively breastmilk-fed their infants, and therefore included formula supplementation. A single study which specifically considered exclusive expressing for the exclusively breastmilk-fed child identified that if a mother made it to 3 months post-partum exclusively expressing, she was at no higher risk of ceasing exclusive breastmilk feeding than her direct feeding counterparts, although she was more likely to cease breastmilk feeding in general. This study unfortunately was unable to include infants who were weaned prior to 3 months of age, and therefore could not comment on the risk of early cessation in the first months of an infant’s life [7, 8].
In our initial perusal of the breastfeeding literature, we found that when expression was the primary focus of the paper, it generally dealt with the initiation of expression or was focused on Neonatal Intensive Care Unit (NICU) experience. Studies and investigations such as these have mostly focused on education around breastmilk expression and the prevalence of lactation initiation. This is understandable, because the majority of women who need to express for a premature infant often have an ultimate goal to direct feed once their infant is able . However, we did not find any literature on how to maintain full-time exclusive expression in situations where this will be the ongoing primary method of feeding. As noted above, there is a common thread that: a) any use of expressed breastmilk instead of direct feeding is suggested to be a risk factor to early cessation of exclusive breastfeeding (early being considered < 6 months duration); and b) that exclusive expression specifically is a risk factor to early cessation. A 2016 study  that included women who either aimed to express, or currently did express, in any way (casually through to exclusively) identified that women who express can be emotionally burdened, and this is accompanied by the physical and mental fatigue from the extra tasks of expressing and its associated management. Corroborating this is other qualitative work that suggests the time required for implementation of exclusive expressing is incompatible with full-time employment .
This limited literature is evidence of the paucity of research that examines how women can be supported to maintain exclusive breastmilk provision. If the WHO target of 6 months is to be met, this group of women need to be identified within the community and appropriate, tailored support provided. The needs of an exclusively expressing mother will be different to those of a direct feeding mother, and existing mechanisms of support may not translate across the two groups. We were interested in understanding what, if any, support programs, networks, education, or promotion, whether formal or informal, might be actively targeting exclusive expressers. Support could be practical or emotional, regarding the management of pumping equipment, the shared experience of expressing, schedules for pumping and volumes for feeding – anything that prioritises the exclusively expressing mother and specifically seeks to assist her.
A preliminary search for previous reviews on topics aligned to exclusive expressing was conducted in the Johanna Briggs Institute database and the Cochrane Library. Systematic reviews were found on the following complementary topics:
Prevalence and outcomes of breast milk expressing in women with healthy term infants 
Methods of milk expression for lactating women 
Structured versus non-structured breastfeeding programmes to support the initiation and duration of exclusive breastfeeding in acute and primary healthcare settings 
Each of these reviews captured an element of the topic of interest but did not answer the question of whether support networks and programs exist for mothers who exclusively express. This scoping review therefore aimed to collate any available literature regarding exclusive expressing and forms of formal and informal support for the exclusive expressing population. The review question was “For mothers who exclusively express their breastmilk, what, if any, formal or informal supports are available in the community?” We focused on supports in the community setting, rather than hospitals and NICUs where expression is a short-term solution and direct feeding is usually the final goal.