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Breastfeeding, expressing, and taking your preterm baby home

Information for parents

Breast milk is a nutritionally ideal food for fullterm, pre term and sick babies. Mothers who give birth to premature babies produce breast milk that differs from full-term milk in the amounts of some nutrients, making it especially important for the premature baby.

Breast milk is more easily digested and provides babies with essential vitamins, minerals, fats, carbohydrates and proteins, hormones, growth factors and many enzymes. It also contains antibodies and other living cells that work to protect your baby from disease. Each component works together to make breast milk superior to infant formula and ideally suited to each baby.

The principle behind expressing breast milk is to copy as closely as possible what occurs with normal breast feeding. 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.

Breast pumps

While you are an inpatient you will be able to use the hospital’s breast pumps on the wards and in the nursery. These pumps have been designed for times when mother and baby have been separated due to prematurity or illness of either mother or baby. The expressing kits required when using these pumps are available for purchase at the nursery reception. These kits also include some breast milk bags that attach directly to the pump kits.

When you are discharged from the hospital and your baby remains in the nursery you can continue to use the nursery breast pumps, but will need to consider hiring or purchasing a breast pump for use at home. You can either express by hand, and/or use a hand operated, battery operated or electric pump. However, if you need to express milk for a week or more it is recommended that you hire an electric breast pump the same, or similar, to those used in hospital. Electric breast pumps are available for hire through your local Australian Breastfeeding Association group, some pharmacies or baby equipment hire companies. Your baby’s nurse can provide you with a current list of hiring outlets.

Expressing breast milk for your baby

Breast massage

Breast massage, and the use of warm compresses before expressing, assists your breasts to release milk for your baby. Gently massage the breast toward the nipple. At the same time assess each breast for lumpy areas within the breast tissue, and massage these.

Any lump within the breast that does not resolve with breast massage and regular expressing needs to be reviewed by your doctor or lactation consultant.

Hand Expressing

Always wash your hands well before handling your breasts. The amount of colostrum initially, may only be a few drops or several millilitres. In the first few days colostrum may be hand expressed, and collected with a syringe which may require some assistance, or you could use a small clean container. Please see pictures included, on page 4.

The midwife caring for you will assist and teach you how to hand express. Hand expressing should take 20 minutes, alternating between each breast, every five minutes as this usually results in more let-downs and more colostrum being collected.

How do I hand express?

  • Position your thumb and first two fingers about 2.5–4 cm behind the nipple. Place your thumb pad above the nipple and the finger pads below the nipple forming the letter ‘C’ with the hand as shown on page 4.
  • Push straight into the chest wall.
  • Roll thumb and fingers forward as if making thumb and fingerprints at the same time.
  • Repeat rhythmically to drain the breast. Position, push, roll, position, push, roll…
  • Rotate your thumb and finger position to milk the other ducts.
  • When hand expressing, try not to squeeze or handle your breast roughly.
  • Hand expressing and using the electric breast pumps should not hurt.

How often should I express?

We recommend that you commence expressing within the first six hours after your baby is born. You should express at least 8 to 10 times per day or more, with a maximum break of five hours (usually at night); especially in the first two weeks. You do not need to express at set intervals and you may express after one, two or three hours, as long as you can do this eight times per day. The nursery staff can provide you with Mater Mothers’ Hospitals Expressing log book to record your progress. This book is included in your information pack. This is the most crucial time for establishing a good milk supply. Expressing frequently during this time, will assist you to build and maintain a good supply.

Many mothers need to continue to express eight times each day, with one or more sessions during the night time in order to maintain their milk volume although some mothers may be able to reduce the number of expressions to six times per day when their milk volume reaches greater than 750 ml per day.

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.

  • 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. This is ideal for stimulating 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 5 ml 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 the highest level that you are comfortable with.

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 to 30 minutes, or ‘double pump’ using two kits to express both breasts at the same time for 10 to 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.

Remember

  • While your baby is in the Neonatal Critical Care Unit, try to express beside your baby. Looking at your baby will assist your milk to let-down.
  • If you are having any problems hand expressing your breast milk, or using the electric breast pump, please talk to the midwife or nurse caring for you or your baby, or the lactation consultant.
  • Milk needs to be used within 72 hours of expressing while your baby is in hospital, or frozen within 24 hours for future use. Fresh milk should be transported to the nursery in a cold esky. You may need to freeze some of your milk at home.
  • The aim of expressing is to build up a daily volume of approximately 750 to 1000 ml over the two to three weeks following your baby’s birth.
  • Prior to discharge from hospital think about how you will maintain your milk supply at home.

Milk volume

Milk volume will vary from mother to mother, and vary over the day. All mothers’ breasts have a different capacity to hold milk and this is not determined by breast size but by the amount of glandular and ductal tissue in your breasts.

Some things that may affect or enhance your supply include the following:

  • Stress, pain, anxiety and illness may decrease your milk supply.
  • Having a photo of your baby with you can assist your milk let-down.
  • Warm compresses and massage of your breasts prior to expressing will help you express.
  • Relaxation exercises, aromatherapy and gentle music at home may help decrease anxiety levels.

If you feel there are ongoing concerns with expressing your breast milk, please talk to the nurse or midwife caring for your baby, or the lactation consultants.

Over time some mothers may find their milk volume has dropped. Often supply can be improved by planning an intensive expressing campaign at home for a few days. You may need assistance at home so that you can rest and concentrate on expressing. You will get a smaller volume each time you express for the first 48 hours but the extra stimulation will increase the overall production noticeably within two to three days. You can use your ‘log book’ to track these changes.

If there are ongoing concerns regarding milk volumes, despite frequent expressing, some medications have been proven to be effective in supporting supply. Speak to the lactation consultant about these medications. Prescription medications will need to be prescribed by your obstetrician or your G.P.

All milk given to your baby is valuable and all your efforts appreciated, so remember that every drop counts. No matter how small each expression is, ALWAYS save the milk for your baby.

As a general guide optimal amounts to express would be:

  • By day 5: 200 to 300 ml per 24 hours
  • By day 8: 400 to 500 ml per 24 hours
  • By day 14: 750 ml per 24 hours
  • Thereafter: 750 to 1000 ml per 24 hours.

Transporting your breast milk to hospital

Breast milk expressing bags are available in the Neonatal Critical Care Unit for expressing, storing and transporting your breast milk. Each bag of expressed breast milk (EBM) should be clearly labelled with yoru baby’s identification label. Please write the following information on the label:

  • EBM
  • date
  • time (am or pm).

Up to three consecutive expressions can be added to each bag as long as it is labelled with the time of the first expression. All milk needs to be at the same temperature prior to adding together. i.e. after you have used the expressing bag the first time, you would need to express using a clean bottle, cool the milk in the refrigerator and then add the milk to the bag.

We will store approximately 400 to 600 ml for each baby in the freezer at the hospital for use when there is no fresh breast milk available for your baby. Unfortunately, we are unable to store large volumes. If you live in Brisbane we would like you to bring in enough milk each day for your baby’s needs, plus a little extra to allow for changes to feed volumes—ask the midwife or nurse caring for your baby to calculate the required volumes.

Expressed breast milk should be transported to the hospital in an insulated container containing reusable ice bricks to keep it cool.

Storage of breast milk

Breastfeeding

Positions for feeding

Before you start breastfeeding make yourself comfortable. Have a bottle of water close by as many mothers find they become thirsty during a feed. If possible, sit upright in a chair to feed your baby. Use a footstool for comfort if needed.

You may choose to hold your baby in one of the following ways while breastfeeding:

Support your baby with your opposite arm to the breast you are feeding from. Use your forearm to hold your baby close to you. Position the heel of the palm of your hand in between your baby’s shoulder blades and your outstretched hand behind your baby’s shoulders, no higher than the base of your baby’s skull. This allows your baby’s head to tilt back slightly. Remember to support your baby’s bottom so your baby does not drag on your breast. In the early days of breastfeeding many mothers prefer this hold as they can guide their baby towards the breast more easily.

or

Cradle your baby inside your arm on the same side you are feeding from. This hold works better for older babies

or

Hold your baby under your arm in a ‘football’ or ‘rugby’ hold. This hold may be suitable after a caesarean birth. ‘Twin feeding’ pillows are available for use in the nursery. These pillows may make it easier for you to hold your baby in the ‘football’ hold.

Useful tips for attachment and positioning at the breast

  • Take your time. Rushing may cause stress for you and your baby.
  • Ensure your breast is free of clothing, your baby is unwrapped and is preferably in skin to skin contact with you.
  • Hold your baby close to you with their chest facing yours and their lower arm wrapped around your body.
  • If necessary, you can support and shape the breast in a “U” hold, with your thumb opposite your baby’s top lip, with most of your hand underneath the breast, your fingers well back from the areola (the darkened area around the nipple), and in line with your baby’s chin.
  • Your baby’s nose should be level with your nipple.
  • Bring your baby to your breast when their mouth gapes wide and not your breast to the baby. Your baby needs to take a larger amount of the areola into the mouth on the side nearest the baby’s chin and lower jaw.
  • Direct your nipple to your baby’s nose when latching and then “plant” the lower rim of the baby’s mouth well below the nipple and fold the breast into the baby’s mouth.
  • If your baby is latched on the breast properly you should not feel any pain. There should be no stinging, burning, or pinching of the nipple during the feed. At the start you may feel uncomfortable for 10 to 15 seconds. If pain persists, take your baby off the breast by gently inserting your little finger in between your baby’s gums to break the seal.
  • Your baby’s chin and cheek should be against the breast with the nose free.
  • It should not be necessary to hold the breast away from your baby’s nose.
  • Some signs of a correct latch are that your baby has a wide open mouth like a yawn when latching and once latched your baby’s chin is very close into the breast tissue. As your baby is sucking you may experience a painless drawing sensation and you will see full movement of your baby’s lower jaw. After the feed your nipple should appear as it did before your baby latched, just softer around the areola. Your nipple should not be white, squashed, ridged or damaged when it comes out of your baby’s mouth.
  • Please ask for help if you have any problems.

Preparation for going home

  • Regularly provide all care for your baby ie feeding, bathing, nappy changing and giving medication (if required).
  • Break the habit of always watching monitors and look at your baby to check that all is well.
  • Learn infant CPR.
  • Contact child health for an appointment before you go home, and book an appointment with your GP, for a check-up, in the first week post discharge.
  • Have your baby’s car restraint installed a couple of weeks before you are due to go home, and become familiar with how to use it.
  • Continue expressing milk while your baby is learning to feed in the hospital, and initially at home, until your baby is regularly waking for feeds and putting on weight.

Rooming-in

We understand that it can be daunting to go home with a new baby, or babies. Mothers with babies who have spent a period of time in the Neonatal Unit may room-in for one night, if necessary. A room on the postnatal ward may be offered to you to room-in with your baby, and your partner. You will also be given the Mater Mothers’ Hospitals’ brochure: ‘Rooming-in; before taking your preterm baby home’ which provides you with practical information on rooming-in with your baby.

Useful tips on rooming-in

  • Do not hesitate to be active in making decisions for your baby while you are rooming-in.
  • If you are expressing breast milk it can stay in your room with you, ready for you to use at any time. There are small refrigerators in each room.
  • Electric breast pumps are available for your use.
  • You will need to supply your own baby clothes—the rooms can be quite cool so have some warm clothing available for your baby.
  • You can check your baby’s temperature just before feeds. Tell the nurses you have done this.

Taking your preterm baby home

Being as relaxed as possible when you go home with your baby can help make the first month at home enjoyable for you and your family. It may also be helpful to have your partner at home with you if possible, or a family member or friend to help with the daily activities around the house. Discourage visitors who are ill from visiting until they are recovered.

In hospital there is a focus on feeding preterm babies, and on growth. At home your baby’s milk intake is still important for growth and development. Community support services do realise that you and your baby are continuing to learn to feed well, and will support you in these early days,

Feeding your baby once you are home

Breast milk is the main food your baby will need in the first 12 months of life (corrected age).

Your baby may feed more actively at some times of the day than at other times, and may ‘cluster feed’ (several feeds close together). If your baby is sleepy at the breast, particularly towards the end of a feed, use breast compression to push more milk into your baby’s mouth as they suck. This helps them to obtain more fatty ‘hind milk’. When your baby becomes more mature, often around term or two weeks post term, they develop their own feeding pattern.

  • Write down your baby’s daily activities such as breastfeeds, urine output and bowel motions. This can help you keep up with what is happening during this time and this record may also assist the child health nurses and your family doctor, when they review your baby.
  • After 42 weeks corrected age, self-regulatory feeds should be starting to emerge. Your baby will generally wake for feeds and feed more consistently. Your confidence, that your baby is getting enough milk when breastfeeding will increase. It is normal for babies to feed frequently i.e. from 8 to 12 times each day.
  • Begin to teach your baby the difference between night and day. Your baby will need to feed at night, but keep night-time feeds calm and quiet, not spending too much time interacting with your baby. Speak quietly at night and try to settle your baby quickly after the feed. Do not turn on many lights when you are feeding at night. Gradually your baby will begin to know there is a difference between night and day. During the day you can be more animated and talk, read and sing to your baby.

Your baby will indicate they are hungry by:

  • making sucking movements with their mouth
  • turning their head to one side or the other
  • opening their mouth (rooting)
  • looking for something to suck on.

Crying is a late feeding cue.

How do I know that my baby is getting enough breast milk?

It is good to offer feeds when your baby appears hungry, especially when you first go home and while you and your baby are getting to know each other. Generally signs of good milk intake include:

  • 8 to 12 feeds per 24 hours; generally a minimum of six
  • six to eight wet heavy nappies with pale urine
  • soft bowel motions. These are loose but not watery and may vary, but are usually mustard yellow in colour and contain soft curds. Four or more per day, in the first month of going home, is usual, but some breastfed babies may go several days without a bowel motion
  • gaining weight
  • bright and alert when awake
  • settling after most feeds.

Most preterm babies require more kilojoules for adequate growth in their first and second years. When you first go home your child health nurse will monitor your baby’s weight for you. Your baby will be gaining an average of 100 to 250 g per week.

As babies get older this growth pattern does slow down. By about four months corrected age the average weight gain is around 100 g per week. Your baby’s length will also be measured during this time.

If there is any change in your baby’s behaviour, urine output or bowel motions, it is a good idea to contact your doctor, child health nurse or lactation consultant and check things out.

When you go home you will probably still be expressing after some feeds. As your baby reaches term, becomes better at feeding and is gaining weight you will be able to wean off expressing—usually around term. Your milk supply will then be regulated by supply and demand. As your baby has growth spurts they will demand more feeds for a few days to stimulate your breasts to supply more milk.

Supplements

Some small babies may require ongoing supplements to assist them in growing well. This is a time to work closely with your doctor, child health nurse and lactation consultant. There are many ways supplements can be given, while still protecting your breastfeeding.

Vitamins and Iron supplements

Multivitamins and iron supplements are often given to small babies in their first year of life. It is important to keep providing these for your baby, and your doctor will be able to assist you with any concerns you may have regarding these.

Extra water

Extra water is not required for your breastfed baby in the first six months of life. In hot weather, breastfeeding your baby more frequently provides your baby with extra fluid.

Small amounts of water can be added after six months corrected age, when your baby is starting solids. Please talk about this with your child health nurse.

If your baby is constipated, unwell or has a fever i.e. greater than 37.5 degrees Celsius please seek medical help.

Further information can be found at:

www.breastfeeding.asn.au
www.breastfeedingmadesimple.com
www.kellymom.com
www.lowmilksupply.org

www.breastfeedinginc.ca

© 2011 Mater Misericordiae Ltd. ACN 096 708 922

Mater acknowledges consumer consultation in the development of this patient information.
Mater Doc Num: HOSP-011-03153
Last modified 16/11/2015.
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