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Expressing breast milk

There may be times when you need to express breast milk for your baby, e.g. if you are going out or returning to work; or if your baby is preterm or unwell and unable to breastfeed. The principle behind expressing breast milk is to copy as closely as possible what occurs with normal breastfeeding. Frequent and thorough removal of milk from the breasts is very important for milk production. Expressing by hand or using an electric pump needs to commence as soon as possible after the birth of your baby.

Mothers who give birth to preterm babies produce breast milk that differs from full-term milk in the amounts of some nutrients, making it especially important for the preterm baby.

Getting started

If you are unable to breastfeed your baby, then expressing breast milk is the next best option. Donor breast milk may be offered to some preterm babies until mothers own milk is available.

  • Start expressing as soon after delivery as possible (ideally within 6 hours). The earlier you start, the easier it will be to sustain your milk supply long term.
  • Learn how to express. Ask your midwife to teach you how to express. Breast pumps are also available on the ward and in the Neonatal Critical Care Unit (NCCU). Recommendations include ‘double pumping’ (pump both breasts at the same time) and also hand expressing to collect the small amounts of colostrum.
  • Have skin to skin cuddles with your baby as soon as baby is able.
  • Express at least 8 times each day. Intervals between expressing can be 30 minutes to 3 hours. If you express enough during the day you can have up to 5 hours rest at night. Frequent expressing is the key to establishing a good milk supply.
  • Label all expressed milk. Printed label stickers are available from the nurseries. Labels need to include the following information
    • Mothers and baby’s identification labels
    • Date and time (am/pm)
    • EBM
    • Mother’s initials
  • Arrange to have a pump at home if you will continue 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 each day. It can take 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.
  • 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 your baby is stable enough have skin-to-skin cuddles and/or nuzzle feeds.
  • Continue to express while your baby is learning to breastfeed. Once your baby is having consistent full breastfeeds then you can start weaning off expressing.

Expressing

  • Wash your hands. It is important to minimise the introduction of bacteria.
  • Develop an expressing routine. A routine will help develop cues for your body to letdown when it is time to express. Make yourself comfortable; try to relax and look at your baby (or babies). If you are not with your baby, have a photo/video of your baby, or your baby's clothing or blanket with you.
  • Manage stress. While having a baby admitted to NCCU 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 of this stress.
  • Manage pain. Pain will inhibit your letdown reflex which will affect your milk supply so aim to keep any pain under control. Pain medication is safe to take while you are 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. Tips to assist with letdown can include:
    • massaging and stimulating your breasts before expressing
    • spending time with your baby or looking at photos/videos of your baby.
    • applying warmth to your breast; warm showers may help.
  • Maximise milk removal. Double pump i.e. express both breasts at the same time). Combine hand expressing/massaging with using breast pump.

How does expressing work?

It is important that expressing does not cause pain or bruising and that the pressure is individually right for you. The aim is to create hormone stimulation and not extraction of milk. A gentle, rhythmic technique stimulates your pituitary gland to release the hormones (prolactin and oxytocin) into your blood stream.

This gentle rhythm is similar to the baby’s draw-swallow when breastfeeding. The baby first stimulates production of hormones and when the levels are high enough in your blood stream, droplets of milk will 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 their throat. At the point the milk flows, the baby changes to a longer, deeper draw-swallow rhythm.

Expressing the breasts using 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 hormone levels have increased, droplets of milk will appear at the nipple ducts.
  • Continue with this gentle rhythm until the milk flows.
  • Express until the milk flow slows, rest for a minute or 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 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 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 midwife or nurse to show you how to use the pump (instructions for use are also attached to the pump) and to recommend the correctly-sized kit for you. Sizing may change as your breasts change

  • ‘Initiate Program’ – this program is designed to be used in the first few days before your milk comes in. If your pump has this new program, press the start button on the left, then the flow button on the right. This will commence the initiate program. This program will automatically complete in 15 minutes. Hand expressing on completion will help to collect more colostrum. After the first couple of days or before, if you are obtaining up to 20ml at an expressing, you may commence using the Maintain program.
  • ‘Maintain Program’:
    • Stimulation phase – the ‘stimulation phase’ 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, the pump will automatically change to the pumping phase.
    • Pumping phase – Allow pumping phase to continue for up to 15 minutes for each breast at your comfort level.
  • Note:  the suction should be set at a comfortable level to avoid any damage. Every mother is different and your plan should be re-evaluated daily if required. Speak to your midwife if you have any concerns.

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 or more times in each 24 hour period 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

200–300 mL per 24 hours

By day 8

400–500 mL per 24 hours

By day 14

750 mL per 24 hours

Thereafter

750–1000 mL 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 breast milk 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. You may not collect any breast milk initially; continue with your expressing plan as this can be normal.
  • If you are unable to express the desired volumes, ask to see a Lactation Consultant.

Storage and transporting expressed breast milk

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.

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*Do not store milk in the door compartments of the refrigerator or freezer

**Discard as clinical waste ONLY in hospital

Transporting milk

If your baby is not going to consume EBM within 6 hours of expressing (4 hours for babies in NCC) 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 NCCU has limited space to store frozen EBM. Communicate with the staff caring for your baby 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

  • Enhances milk production by increasing milk making hormones and let down
  • Facilitates bonding
  • Stabilises baby’s heart and 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. 
  • If your flow is too slow for baby, express to start a letdown prior to breastfeeding and use breast compression during the feed.
  • If your flow is too fast for baby, express to the first let-down then breastfeed and be prepared to interrupt the feed with short rest breaks.
  • Sucking, swallowing and breathing require coordination and rest breaks.
  • Babies who are preterm 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 successfully your baby fed.

Frequently asked questions

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

  • Breast drainage i.e. softening of breast after feed
  • Swallowing at the feed means milk transfer
  • Output – at least 5–6 heavy wet nappies and 2–3 yellow loose stools in 24 hours
  • Weight – gain 10–25 g a day, and/or  100–250 g 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 mothers and their babies 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 – locate online
  • 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

 

Mater acknowledges consumer consultation in the development of this patient information.
Mater Doc Num: PI-CLN-430041
Last modified 09/1/2018.
Consumers were consulted in the development of this patient information.
Last consumer engagement date: 10/11/2017
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