My surprised introduction to expressing started 12 hours after my daughter Sophie was born by emergency C-section at 24 weeks. Initially I was stunned when the nurse asked me had I considered if I wanted to breastfeed her. My initial thoughts were consumed on ‘was Sophie going to survive or not?’ Little did I know that from that point forward I would become hitched to an electrical pump and continue the pump and bottle feed boogie for the next 12 months.

Despite trying everything to assist Sophie to attach (nipple shields, different positions, different times of day etc,) she never got the hang of sucking at the breast. Was it too many bottle feeds prior to discharge, was it my impatience to get her home, or was it just her? who will ever know! Over time I was able to let go of my feeling of failure of not being able to traditionally ‘breastfeed’ although it often hurt when family and friends would make comments such as ‘why are you still expressing for & haven’t you done that for long enough?

The emotional fatigue, anxiety, stress and physical exhaustion of caring for a premature baby can make it extremely difficult to express short or long term.

I hope this article is not seen to dishearten those mother’s who make the heart breaking decision to bottle feed but rather to offer those that are able to express some informed information and encouragement.

Pre-term infants and expressed breastmilk

Excerpts taken from:

• Breastfeeding: Best Practice Guidelines (2004), Chapters 4 & 5, The Royal Women’s Hospital. pp 53-54, 58-65.
• Breastfeeding Guidelines (pdf)

A mother’s freshly expressed breastmilk is the most suitable feed for premature babies. The breastmilk of the pre-term mother differs from that of mothers with full-term babies.

Pre-term breastmilk contains significantly more nitrogen, sodium and chloride magnesium and iron during the early weeks postpartum. Pre-term and term breastmilk are similar in calories, fat, fatty acids, potassium, calcium and phosphorus. Levels of digestible nitrogen are usually higher in mature pre-term milk.

There is continuing research into various aspects of pre-term breastmilk and its components in relation to the growth and health of premature infants. Several studies have shown that Pre-term infants fed breastmilk rather than formula have increased protection against the development of necrotising enterocolitis and a higher intelligence quotient at follow-up (Lucas, Morley et al. 1992).

Kangaroo care

Parents with infants whose condition is stable are encouraged to use ‘kangaroo mother care’.

The advantages of kangaroo care include:

• Maintenance of infant body temperature
• Reduced episodes of apnoea and bradycardia
• Increased regular sleep
• Reduced crying during kangaroo care
• An increase in alert activity.

Other studies show that breastfeeding outcomes are improved:

• Mothers produced more milk
• Were more inclined to breastfeed & breastfed longer
• Enhances bonding
• Fosters confidence in caring for their baby

Breastmilk expression – frequency & volume
There have been few studies of expressed milk volumes, but a number report on the daily volume of milk produced by breastfeeding mothers (Saint, Smith et al.1984; Arthur, Smith et al. 1989; Lucas, Morley et al. 1992). Overall they show that the greater the frequency of expression or suckling, the more breastmilk is produced.

Allowing for individual variation, a rough guide to milk production volumes for a mother of a single baby can therefore be 600mls/day or more by 2 weeks postpartum (Houston 1983).

Over time, some mothers find that their milk supply drops because they have problems which prevent them from expressing often enough. When the baby is able to start breastfeeding, the mother often notices a rapid increase in her supply. Even if the milk supply is severely depleted, the suckling by her baby stimulates supply.

When to commence expressing
Expressing should also start as soon as possible after birth, preferably within the first four to six hours to facilitate early and adequate milk production. Initially the amount of colostrum produced is small so the time spent expressing will also be short. If the mother is ill and/or has had a caesarean section she will need assistance to hand express from the staff caring for her.

Frequency of expression
Babies demand feed on average 2-3 hourly i.e. 8-12 times per 24 hours, especially in the first few weeks. This is an initial guide to the frequency of expression. The time between expressions can vary giving the mother flexibility to schedule expressing around her other activities.

Night time
Before her milk ‘comes in’, a mother can plan an unbroken sleep of about 6 or 7 hours if she wishes and is able to. Once milk production has increased, it is unwise to wait longer than 4 or 5 hours without expressing, as the breasts can become engorged.

When the milk supply is well established and the initial swelling of the breasts has settled down, the mother can experiment with the frequency of night expressions.

Some mothers may find that their overall production starts dropping if they do not express overnight. This may be connected with prolactin production, which peaks during the early morning hours, or it may be an effect of individual breast storage capacity.

When the initial milk supply is abundant and exceeds the baby’s requirements, some mothers are advised to express less frequently. This is not a good recommendation as invariably the milk production drops and the mother then must initiate strategies to increase her supply. Instead she should aim to reach a level of production and then maintain that level.

The breastmilk not immediately used can be frozen and kept in reserve.

Colostrum

Expressed colostrum, no matter how small, is uniquely valuable and should always be saved and sent to the NICU or Special Care Nursery.

The let-down reflex
Oxytocin is released in a pulsatile manner during breastfeeding and similarly when expressing.

Signs of let-down:

• An increase in milk flow
• Cramping uterine pains
• Increased lochial flow
• Tingling feeling in breasts
• Thirst

Many mothers find they will get a better let-down by visiting their baby if they are separated. Much has been written about the potential for the let-down to be inhibited if the mother is mildly or chronically distressed. However this has been shown to slightly delay let-down, not prevent it (Lawrence and Lawrence 1999).

How long to express
Frequent short expression is effective – at first only a few minutes is necessary, and this can be increased until there is a total expression time of 30 minutes (15 minutes each breast in blocks of 5 minutes before switching to other breast).

This information is important for the mother to know when attempting to increase her supply.

It is important for the mother to learn how to assess when her breasts are thoroughly drained, as this is one of the main stimuli to adequate milk production. As the breasts drain the fat content increases thus providing a considerable proportion of her milk’s caloric value (Woolridge, Baum et al. 1982).

Hand or pump expression?
Hand expression is a useful skill to have, as it is economical and there may be a time when access to a pump is not possible. Some mothers find it difficult to express by hand while others feel it is more natural and less trouble. It is an individual choice based upon individual circumstances.

Breast pumps
Pumps are not suitable until the milk comes in and there is a reasonable flow. Pumps should not be used if the nipples are painful or damaged.

Manual pumps
A wide variety of hand pumps are available. Some are more effective and ‘user-friendly’ than others. All pumps should be easy to use and clean. When using any pump, the flange must be placed centrally over the nipple so there is no damage done to surrounding tissue and to ensure maximum milk removal.

Electric pumps
Some mothers find electric breast pumps easier and more efficient to use. Electric pumps can be quite expensive to buy, and many mothers hire them. Efficient portable pumps are now readily available. Recommending a specific pump is difficult, as each tends to have its own advantages and disadvantages.

An important feature of a well-designed electric pump is adjustable suction pressure. Suction should be cyclical and not constant.

Pumps with dual cups to express both breasts concurrently save the mother considerable time and take advantage of the bilateral effect of the let-down reflex. Dual pumping can reduce the mother’s total expressing time.

Storage and transport of expressed breastmilk
Breastmilk is best used when fresh. However if this is not possible, then refrigeration or freezing is necessary.

Guidelines for collecting and storing breastmilk are more stringent for sick and preterm babies than for healthy babies at home. Sterilised containers are recommended.

Frozen breastmilk can be stored for varying amounts of time, depending on the freezer temperature and stability. It can be stored at -20°C for 3-4 months and up to 6 months if stored at – 60°C. If stored in a refrigerator-freezer unit with less stability of temperature, the storage time should be not more than two weeks, never refreeze or re-warm breastmilk.

During transportation of breastmilk the chilled or frozen state of the milk can be maintained by using insulated containers with refreezable ice packs. Cleanliness is essential although disinfecting (sterilising) is not necessary when unprocessed breastmilk is used, providing there is no sharing of equipment. Any utensils should be cleaned well in hot soapy water and rinsed thoroughly and stored in a clean dry covered container.

Freshly expressed milk should be chilled in refrigerator before adding to frozen milk.

Thaw breastmilk by placing in cool or warm water, thawed milk should be used within 24 hours

For more information:

Your local Maternal & Child Health Nurse
Breastfeeding Education and Support Services (BESS)

Royal Women’s Hospital
Tel: (03) 9344 3651

Maternal and Child Health Line
Tel: 13 22 29 (24 hours)

Australian Breastfeeding Association
Tel: 03 9885 0653 (Helpline)
Web: www.breastfeeding.asn.au

Expressing tips from other mothers

• Eating well and keeping fluid intake up – have a bottle of water at hand
• Enough rest
• Trying to relax (stress reduces milk supply) – listening to music, reading a good book, watching television, anything that can help you switch off.
• Having a special place to relax while expressing and all the things you need at hand
• Warmth – having a hot drink, warm bath, hot shower, warm compress on breast
• Increase frequency of pumping
• Ask your partner for a massage
• Breast massage prior to pumping
• Double pumping.
• Emptying the breasts completely.
• Frequently alternating breasts during pumping.
• Have your breast pump checked
• Kangaroo cuddles
• Expressing with your baby near- next to the isolette, in same room at home
• Having a picture of your baby to look at when you are away from your baby
• Herbal and medicinal preparations – discuss with your doctor first

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