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Breastfeeding, expressing and taking your preterm baby home from Neonatal Critical Care Unit

• Have Skin to skin cuddles with your baby as soon as baby is able.

• Arrange to have a pump at home if you will be expressing after discharge. If you will be expressing long term, you should consider hiring or purchasing a good quality electric pump.

After your milk comes in

• Continue expressing 8 or more times a day. It takes up to 3 weeks to establish a good milk supply.
• Keep a record of the time and amount you express each day. You may use the hospital record sheets, a diary, or there are apps available for this purpose (see page 10 for desired daily volumes).
• Never allow your breasts to feel full. This is a signal to your body to slow down milk production.
• Spend as much time with your baby as possible. When baby is stable enough have skin-to-skin cuddles and/or nuzzle feeds. See page 14.
• Continue to express while your baby is learning to breastfeed. Once your baby is having consistent full breastfeeds then you may start weaning off expressing.

How to express

• Wash your hands – It’s important to minimise the introduction of bacteria.
•  Develop an expressing routine. A routine will help develop cues for your body to letdown when it's time to express. Make yourself comfortable. Try to relax and look at your baby/s. If you are not with your baby have a photo/video of your baby/s, or your baby's clothing or blanket.
• Manage Stress. While having a baby admitted in the nursery is very stressful for many parents, keeping informed about your baby's condition, and being involved as much as possible with your the care of your baby will help manage some stress.
• Manage Pain. Pain will inhibit your letdown reflex which will affect your milk supply. Try to keep pain under control. Pain medication is safe while breastfeeding or expressing.
• Promote Let down. The letdown reflex allows the milk in your breast to be expressed and is signified by an increased flow of milk. You may or may not feel the letdown. Massage and stimulate your breasts before expressing. Try to spend time with your baby or look at photos/videos of your baby. Apply warmth to your breast. Warm showers may help.
• Maximise milk removal. Double pump (express both breasts at the same time). Combine hand expressing/massaging with using breast pump.

Expressing

It is important that expressing does not cause pain or bruising and the pressure is individually right for you. The aim is to create hormone stimulation not extraction of milk. A gentle, rhythmical technique stimulates your pituitary gland to release the hormones (prolactin and oxytocin) into your blood stream. The gentle rhythm is similar to the baby’s draw-swallow when breastfeeding. The baby first stimulates the hormone levels and when they are high enough in your blood stream droplets of milk appear through your nipple ducts. The baby continues intermittent stimulating episodes until your hormone levels are high enough for the milk to flow through the nipple ducts and over the throat. At the point the milk flows the baby changes to a longer, deeper draw-swallow rhythm. Expressing the breasts with the Thompson Method is based on simulating the draw-swallow rhythm to stimulate hormone production and milk flow, not milk extraction. The flow of milk stimulates the swallow reflex. Hence, maintaining the gentle (not painful) rhythm is the key to creating milk flow.

Hand expressing

• Wash your hands
• Position the pad of your thumb and the pad of your first finger on the edge of your areola.
• Your thumb and index finger are bent so both pads aim to make direct contact.
• It is important that the thumb and forefinger are not straight.
• The pressure applied should not cause pain and/or bruising.
•  Place your thumb pad above the nipple and the finger pad below the nipple.
• The thumb and forefinger pads move together to create a gentle, rhythmical movement.
• The pressure between the thumb and forefinger pads is comfortable for you.
• Continue this gentle rhythm to stimulate hormone release into your blood stream
• Once the hormones have droplets of milk will appear at the nipple ducts
• Continue the gentle rhythm until the milk flows
• Express until the milk flow slows, rest for a minute of so then repeat these intermittent episodes until the volume you require is achieved..

• When hand expressing, try not to squeeze the breast or handle the breast roughly.
• Hand expressing and using the electric breast pumps should not hurt,  the pressure used is individual. When using the electric pump, slow the motor until the you hear the rhythmical draw-swallow sound again to simulate the baby at the breast.

Expressing using a pump

Using a breast pump in the first few days

The yellow hospital grade pump, which is available for use on the wards and in the nursery, can be used from day one to aid with the stimulation of your milk production. Ask your nurse or midwife to show you how to use the pump and to recommend the correctly sized kit for you. Sizing may change as your breasts change.

• Stimulation phase: In the first few days before your milk has come in, only use the ‘stimulation phase’ which has low suction combined with a rapid pumping speed which is ideal to stimulate milk flow. After using the pump on the stimulation phase for two minutes on the first breast, turn the pump off then hand express for up to five minutes. Repeat this stimulation phase on the other breast for two minutes, and then hand express for up to five minutes. Repeat this process again.
• Pumping phase: Once you are able to express approximately 5ml of breast milk by hand you can allow the pump to proceed to the next phase of expressing---the ‘pumping phase’. Signs of increasing milk production include warming, tingling and firming of the breast tissue.

Note:  the suction should be set at a comfortable level to avoid any damage.

When you are expressing with an electric pump you may use a single kit and alternate between each breast every 5 minutes for a total of 20-30 minutes, or ‘double pump’ using two kits to express both breasts at the same time for 10-15 minutes. If you are expressing for twins, or will need to express for a number of weeks, double pumping may be the preferred option.

How much is enough?

It is normal to get varying amounts of milk each time you express.  Factors influencing how much you get include:

• Time of day. Most mothers may express more in the mornings than evenings.
• Whether you are with your baby. You may notice you express more when you are with your baby. Try to express after a cuddle to take advantage of enhanced letdown.
•  Intervals between expressing.  You will generally express more if you have a longer interval between expressing. Caution: Regular long intervals will result in overall reduced supply. Expressing ≥8 times a day is recommended to maintain a good supply.

Your daily total is a better indicator of how good your supply is rather than individual expressions. It is recommended that you keep a record of the daily amounts that you express.

This is a guide as to how much you should be expressing each day:

By day 5	200-300mls per 24 hours
By day 8	400-500mls per 24 hours
By day 14	750mls per 24 hours
Thereafter	750-1000 per 24 hours

 

Try to maintain this volume even if your baby's milk intake is much less, because it is more difficult to increase milk production later.

Tips on increasing supply

• Increasing the number of times you express in a 24 hour period is the MOST effective strategy to increase supply.
• Try to spend as much time as possible with your baby. Have as much skin-to-skin cuddles as you can.
• If you are not with your baby, look at a photo or video of your baby while expressing. Try to visualise holding your baby.
• Promote let-down by massaging breast before and during expressing.
• Apply warmth before and during expressing. Warm showers often help.
• Use both pump and hand expressing to facilitate breast emptying.
• Try to relax. Try to manage your stress levels.
• Maintain an adequate well balanced diet.
• If you are prescribed medication to assist with your milk production, you still need to express at least 8 times a day to take advantage of its effects.
• Remember your baby will benefit from any amount of breast milk you express.

 If you are unable to express the desired volumes, ask to see a Lactation Consultant.

Storage and transporting Expressed Breast Milk (EBM)

Storage of breast milk

Ensure all expressed milk is labelled correctly before storing or given to baby.

Any milk that is defrosted must also be labelled with time and date it was fully defrosted.

Milk bags for storage are available from the nurseries.

Breast milk	Room temperature	Refrigerator	Freezer
Freshly expressed into closed container	4 hours at less than 26oC       If milk is not going to be used within 4 hours then refrigerate.	3 - 5 days at 4oC Store in back of refrigerator where it is coldest   For the hospitalised baby - 72 hours	2 weeks in freezer compartment inside a refrigerator   3 months in freezer section of refrigerator with separate door 6 - 12 months in deep freeze at -200C
Previously frozen and thawed in refrigerator - but not warmed	4 hours or less i.e. next feeding	Store in refrigerator 24 hours – if milk has not been warmed	Do not refreeze
Thawed outside refrigerator in warm water	For completion of feeding	Hold for 4 hours or until next feeding	Do not refreeze

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transporting Milk

If your baby is not going to consume EBM within 4 hours of expressing, it will need to be placed in an appropriate fridge to be cooled.

Transport all EBM in a closed, insulated container with ice bricks to keep it cool. Avoid transporting frozen milk. If frozen EBM partially defrosts, it cannot be refrozen.

The nurseries have limited space to store frozen EBM. Keep an open communication with the nurseries about how much EBM your baby is expected to require each day.

We encourage mothers to express while visiting their babies so we can give babies fresh, unrefrigerated milk whenever possible.

Transitioning to breastfeeding

The benefits of skin-to-skin are

• Enhances milk production by increasing milk making hormones and let down
• Facilitates bonding
• Stabilises baby’s heart & breathing rate
• Calming for both mother and baby
• Stabilises baby’s oxygen saturations and blood sugar levels
• Maintaining baby’s body temperature
• Positively affects growth and development
• Leads to earlier breastfeeding and discharge home

• Transitioning to breastfeeding – early, frequent, long periods of skin to skin leads to earlier more effective breastfeeding.
• Feeding behaviours – Observe for feeding cues. These may be subtle or reduced if baby is premature or unwell.
• Breastfeeding positions - Your baby may need extra support. Staff will assist you.
• Babies like an easy even flow – not too fast, not too slow.  Therefore,

• If your flow is too slow for baby – express to start a letdown, prior to breastfeeding & use breast compression during the feed
• If your flow is too  fast for baby– express to the first let-down then breastfeed & be prepared to interrupt the feed with short rest breaks

• Sucking, swallowing and breathing requires co-ordination and rest breaks.
• Babies who are premature or have been unwell will require time to transition to full breastfeeds.  Initially, start with one breastfeed a day and increase according to your baby’s energy level.  Alternating breastfeeds with naso-gastric tube feeds allows rest periods between breastfeeds.
• Breast compression may be necessary to deliver a steady easy flow
• Observe swallowing
• Assessing breast emptying – feel the weight or softness of the breast before and after the breastfeed.  Think about how much milk you would expect to express from the breast at that time of day and estimate the volume taken by your baby according to breast weight.
• Top up baby according to how well the feed went.
• Baby led breastfeeding – while having skin to skin with your baby observe feeding behaviours – follow your baby’s lead sliding them down your chest so they remain skin to skin until the nipple is positioned at their top lip where they will be able to gape and take the nipple/ areola into their mouth. Keep your baby close.
• Breast shaping is used only if necessary e.g. Low energy &/or premature babies
• Effective attachment to the  breast

FAQs

How do i know if my baby has had enough breastmilk?

• Breast drainage (softening of breast after feed)
• Swallowing at the feed – milk transfer
• Output – 5-6 heavy wet nappies & 2-3 yellow loose stools in 24hrs
• Weight – 10-25gms a day, &/or  100 – 250gms a week
• Percentile curve in your baby’s Queensland Health red book

When is my baby ready to room in?

• When your baby is able to breastfeed effectively 3-4 consecutive

   feeds in a day

• Babies do not need to have bottles overnight, or be able to have

all suck feeds to progress to room-in or go home.

Do I need to continue expressing once I am rooming in with my baby?

• It is important to continue expressing.  This will maintain an abundant supply for your baby.  As your baby increases in effectiveness your need to express will diminish - usually when your baby reaches term.
• How much you will need to express will be determined by your supply.

• A lactation consultant will aim to review all mother/baby dyads who are rooming in.  A feeding plan can be discussed.
• Express after breastfeeds

Community Support

Community and breastfeeding support

• Mater Mothers’ Parenting Support Centre  - 07 3163 2229
• Private lactation consultants found on line
• Australian breastfeeding association – 1800 686 268
• Your GP
• Child health clinics
• 13 HEALTH – ask for the Child Health Nurse for breastfeeding questions

Further information

Breastfeeding websites:

www.breastfeeding.asn.au

www.breastfeedinginc.ca

www.amba.org.au (multiple birth assoc)

http://raisingchildren.net.au/

www.newborns.stanford.edu/breastfeeding/maxproduction