“Breastfeeding” by Feeding Expressed Mother’s Milk

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Key points

  • About 85% of breastfeeding mothers have expressed milk.

  • Milk may be expressed by hand, hand-powered pumping, or electric pumping.

  • For working mothers, bilateral electric pumps are often more convenient than other methods, but individual mothers may prefer alternative methods.

  • For mothers of infants who cannot breastfeed directly, including preterm infants, bilateral electric breast pumps are important for developing and maintaining milk supply and may be used in conjunction with hand techniques.

Milk expression

Milk expression, defined as the removal of breast milk from a mother’s breast without an infant’s mouth at her nipple, is a normal component of breastfeeding for many mothers. Survey data indicate that 85% of breastfeeding mothers express milk at some point within 4 months of delivery.1 Mothers practice expression for a variety of reasons, including enabling another person to feed their infant, storing milk for unexpected maternal–infant separation, relieving engorgement and/or nipple pain,

Methods of milk expression

Mothers have several options for milk expression. Review of these options also requires some clarification of the terminology used for milk expression (Box 1). Hand expression may also be called manual expression and differs from hand-powered pumping, which may also be called hand pumping or manual pumping. The most commonly used form of milk expression in developed countries is electric-powered pumping. In addition, mothers may use “hands-on pumping,” which combines hand expression with

Anatomy of milk expression

The anatomy of breast pumping is different from the anatomy of hand expression. Hand expression uses positive pressure to release milk from the ducts, and with experience, may also generate let-down, which can assist in the removal of milk. A breast pump generates negative pressure, which works in 2 ways. First, the pump initiates let-down of milk an average of 4 times per pumping session. Second, the negative pressure generated in the phalange of the pump extracts milk from the ducts in a

Physiology of milk expression

During mature milk production, milk expression increases maternal levels of oxytocin and prolactin. Pumping has a much stronger effect on prolactin levels than does hand expression, and studies have shown that pumping increases prolactin levels even more than does direct breastfeeding.39, 45 However, higher levels of prolactin and oxytocin do not necessarily correlate with increased milk production; a study comparing 2 different pumps found that one yielded a higher milk volume and a higher

Mother’s experiences of milk expression

Women’s experiences of milk expression are diverse. Some mothers find expressing milk to be a pleasant, comfortable, or relaxing activity, whereas others find milk expression painful, stressful, or embarrassing. Providers must note that their own personal experience with milk expression may not be reflective of the experience of individual mothers in their practice. In a qualitative study of milk expression experiences, one mother reported, “I feel like a cow,” whereas another said, “I like to

Indications for milk expression

There are a variety of indications for milk expression, and the type and approach to milk expression may vary by indication. Return to work or school is the most common reason for regular breast pumping, and working mothers should note that the time of day affects the volume of milk extracted by pumping, with the highest volumes expressed from 6 am to noon and the lowest volumes expressed from 6 pm onward.42 Some mothers have no trouble expressing enough milk while working, but for those who

Early milk expression

Early milk expression, before the onset of lactogenesis II, differs from milk expression occurring after the onset of lactogenesis II in several important respects and is discussed separately in this section. In the United States, about half of breastfeeding mothers express milk during the first week after birth, and almost all who express milk in this early time do so using a mechanical pump.53 The first few days after birth are a period of dramatic maternal hormonal changes, with rapidly

Milk storage for healthy term newborn

Room temperature milk storage is safe for at least 3 to 4 hours and may be safe for up to 8 hours when it has been expressed in a clean manner and stored in cooler room temperatures. Milk may be stored for at least 72 hours refrigerated at 4°C or less, and may be stored for 6 to 12 months in a freezer at −17°C or less. New, warm milk should not be added to cooled, stored milk as this could increase bacterial contamination. Although several companies make cooler bags for the transport and

Expression of milk for preterm infants in the neonatal intensive care unit

Mothers whose infants are admitted to the neonatal intensive care unit (NICU) face more challenges than other mothers in initiating and sustaining breast milk feeding.75, 76 These mothers are more likely to have experienced complications in pregnancy and childbirth, such as cesarean section delivery, and may be receiving medications that may interfere with breastfeeding or milk expression.77, 78 In addition, the physical environment of the NICU may not be conducive for breastfeeding or pumping,

Maternal counseling for the preterm or critically ill newborn

Early counseling of mothers of preterm or critically ill newborns is a crucial component of ensuring sufficient breast milk for this population. Mothers who have given birth prematurely are more likely to have characteristics that make them less likely to breastfeed, including younger age; lower-income strata; having usage of tobacco, alcohol, and drugs; and having medical complications.80, 81, 82 Because mothers with these risk factors may not have thought about breastfeeding before delivery,

Creating an optimal environment for NICU patients

Adequate resources including equipment, environment, and staff training are necessary to support clinicians and parents in the effort to provide breast milk for premature and critically ill neonates. The success of a mother in initiating and sustaining breast milk expression until discharge requires a multidisciplinary approach.94 Education of staff on breast milk feeding should involve all health care professionals in the NICU, including nurses, nurse practitioners, therapists, neonatologists,

Timing of milk expression for the preterm infant

An early start to pumping greatly increases the likelihood of sufficient breast milk supply for the preterm infant. An earlier start to milk expression is more likely to lead to success in lactation and sustained expression. Mothers of newborns who are not breastfeeding should begin milk expression in the first 6 hours after birth, and there may be benefit to starting sooner, within 1 hour of delivery if no contraindications exist.97, 102

Earlier gestational age at birth is associated with

Approaches to NICU milk expression

Although the equipment and techniques of milk expression are the same for mothers of healthy newborns as for those of newborns in the NICU, the approach to milk expression needs to be more intense for mothers who are expressing for premature or critically ill infants. There have been several trials comparing the effectiveness of various pumping regimens and pump types, but the importance of any particular method is probably less important than having a concerted approach.4, 96

For premature

Storage and collection in the NICU

Each NICU should have its own guidelines about milk collection and storage. If a baby is not receiving milk immediately after pumping, the milk should be refrigerated. If the baby will not receive the milk within the next 48 hours, it should be frozen. General hygiene techniques including washing of hands with soap and water should be followed. Milk collected at each session of breast milk expression should be held in a different container and labeled. The Human Milk Banking Association of

Maintenance and monitoring of milk supply

Expression of breast milk for preterm infants is often required for several weeks to even months, and even mothers who were initially motivated require continued support to sustain adequate supply. For mothers of VLBW infants, the challenges of having to express breast milk in the absence of actual breastfeeding can ultimately lead to low rates of expression by the time of hospital discharge.75, 76, 81

The first 2 weeks are a critical period for initiation and maintenance of lactation in this

Special considerations for critically ill term infants

For term infants who are in the NICU, there may be several considerations for feeding. Some infants are admitted for critical illnesses, requiring a prolonged period without enteral feeding. Others are relatively well but require admission for monitoring, phototherapy, or intravenous antibiotics. These latter infants may be able to feed orally for some or all their feedings. In some situations, infants may start to feed orally but may not have the full strength and capacity to take enough

Summary

Breast milk expression, whether by hand, manual pump, or electric pump, is a useful tool for breastfeeding promotion and may be essential for the provision of milk to a baby who cannot breastfeed. The indications for breast milk expression are varied, ranging from maternal employment to extreme prematurity, and the approaches and techniques of milk expression should be tailored to the indication for expression. Milk expression is not necessarily an intuitive process for mothers, both in terms

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