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Breastfeeding - expressing

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Introduction

All mothers of unwell, preterm and full term babies in a neonatal intensive care environment should be supported to provide breastmilk for their babies. It is vital that an adequate supply be established early. The aim of expressing is for the mother to establish a good milk supply in the beginning for the long-term needs of her infant. This will mean that some mothers will be expressing volumes of milk that far exceeds the infant's current needs. Having an abundant milk supply allows for this to occur, is an 'insurance policy' against a dwindling supply (that can occur with prolonged expressing) and allows milk to flow freely when the infant begins suckling. The longer it takes for a mother to establish a milk supply, the less likely she is to be successful.

If the woman is an inpatient of ADHB Womens Health the responsibility for teaching expressing is that of the midwife on the ward or her LMC. It is expected however, that all newborn service staff will be able to give instructions and advice on all methods of expressing.

The respect of, and sensitivity to each woman's personal and psychosexual dignity is to be upheld when assisting her to breastfeed or express. This includes seeking each woman's permission before touching her breasts and gentle handling of her breasts. It is expected that there will be minimal handling of the mother's breasts by the health professional. A mother can be shown by placing the health professionals hands on top of the mothers hands and or by using a breast model. This can easily fashioned by using a balloon or inflated rubber glove.

Initiating lactation

Follow the steps below to assist the woman to learn the skill of expressing her own milk if her baby is unable to breastfeed.

  1. Start as soon as possible after delivery, (preferably within an hour or two of delivery) or at least within 6 hours.
  2. Ensure privacy as directed by the mother.
  3. Wash hands (mother and staff) and provide a sterile container for collecting milk
  4. Show the woman how to stimulate her breasts and assist the let down reflex by:
    - gentle circular massage and tactile stroking
    - applying warmth
    - positive thoughts of her baby
    - sitting beside her baby if possible or looking at a photograph
  5. Provide and discuss the guidelines in the Expressing and Breastfeeding booklet.

It is generally recommended that the mother hand express until her milk 'comes in', then manual or electric pump may be used. Some women prefer to use an electric pump before her milk comes in, discuss options and recommendations based on the individual indications and expected outcome.

Some women may prefer to hand express all the time. This is acceptable if the mother is proficient at hand expressing.

General guidelines

Follow the steps below as a general guide to expressing.

  1. Frequency of expressing - aim for 8 - 12 times in 24 hours during the initiation of milk supply. One or two night-time expressions, especially in first 2 weeks, is strongly recommended. Intervals don't have to be regular; flexibility makes it easier. Frequency may depend on parity, multiple births, caesarean section and previous lactation history therefore individual advice is advisable. Individualised, up to date research information should be given.
  2. Length of expressing episodes - aim for a minimum of 20 to 30 minutes, or until the milk flow stops or slows down. Swap breasts frequently, approx. 2-3 times each expressing episode is recommended.
  3. Volume - initially a small amount, increasing dramatically within 72 hours post delivery with regular expressing. An estimated guide of volume for one infant is:
    300mls/24 hours by day 5
    500mls/24 hours from 7 - 14 days
    >800mls/24 hours from week 3-4

The total volume obtained in 24 hours is important, not volume obtained at each session. It is more efficacious to express 8 times in 24 hours for 20 minutes than to express 5 times per day for 45 minutes.

Maintaining lactation

Follow the steps below as a guide to maintaining lactation:

  1. Once lactation is established increased flexibility with expressing can occur (this can take 3-4 weeks).
  2. Any change in expressing schedule should be gradual as sudden changes increases risk of mastitis &/or sudden drop in lactation.
  3. Once a milk supply is established it is easier to manipulate supply up or down depending on the infants needs. It may be difficult to establish lactation if it does not occur early.
  4. Night expressions can be gradually lengthened although most mothers with an established milk supply find it difficult to go longer than 6 hours.
  5. Dropping to less than 5 expressions per day can lead to dramatic decrease in milk supply for some mothers and is not recommended.
  6. Consider increasing expressing to 12 times per 24-48 hours every 10-14 days to boost milk production. This is commonly referred to as a "marathon expressing day".

Expressing and the transition to breastfeeding

Follow the steps below to assist in the transition from expressing to breastfeeding.

  1. As baby is learning to breastfeed, expressing should occur after breastfeeds have been attempted.
  2. If milk is flowing too fast for the infant to cope with, consider expressing 20 - 40ml pre feed. Then express after the infant has breastfed if necessary.
  3. Most mothers will need to continue to express after discharge. Avoid any sudden decrease in frequency of expressing. It will take most infants several weeks at home to develop mature suckling skills.
  4. When this happens expressing can be gradually reduced. Slowly wean (reduce) expressing over 1- 3 weeks as infant's breastfeeding skills improve.
  5. The mother may need to continue with some expressing longer if the infant is sleepy or is a slow feeder. This will assist in the maintenance of milk supply. This may also apply for infants with special needs e.g. CHD, Down's syndrome, cleft lip or palate etc.

Hand expressing

Follow the steps below to assist women in hand expressing.

  1. Ensure privacy.
  2. Wash hands and provide a sterile container for collecting milk.
  3. Show the woman how to stimulate her breasts and assist the let down reflex by doing the following for 1-3 minutes immediately prior to expressing as with initiating lactation above
  4. The mother should cup the breast using the C hold and position thumb and finger behind the areola in opposition.
  5. Press in towards the rib cage then compress thumb and finger toward each other, gently massaging the underlying lactiferous sinuses. There should be no pain or discomfort. Do not slide the fingers over the skin.
  6. Repeat expressing movement rhythmically, moving around the breast and alternating breasts.
  7. Collect colostrum/breastmilk:
    • by sterile syringe initially to minimise wastage.
    • using pink or white topped sterile container when milk flows easily.
    • Label container with name and hospital number (of infant), date & time of expression.
    • Store container in refrigerator or freezer. See Storage, use and transport of EBM
  8. Frequency and time as for General Guidelines above.

Note: Breasts need to be handled very gently and expressing should never hurt or cause bruising.
Women may wish to hand express under a warm shower to start milk flow or to soften a firm breast however this milk can not be collected.

Medela Lactina for use in NICU/home

Follow the steps below for the mother's responsibilities regarding the Medela lactaset.

  1. Newborn Services provides each mother with a breastpump set for her personal use with the symphony breast pump. 
  2. Ensure this has been documented in infants care map.
  3. There is an attachment so the breast pump set can be used as a hand pump or can be used on the Medela Lactina/Lactina Select electric breastpumps. This can be given to mothers on request.
  4. There are several Medela Electric Breast Pump on mobile stands throughout the NICU. We encourage mothers to express at the infants cot/incubator side.
  5. Privacy can be given by screens at the mother's request or by simply turning her chair toward the wall/incubator.
  6. It is the mother's responsibility to clean and sterilise equipment between use.
  7. It will be the mother's responsibility to bring the breastpump set to and from the hospital so that she can express both at home and in hospital.
  8. Any lost or broken pieces are the responsibility of the mother to replace at her cost.
  9. The breastpump set does not need to be returned once the mother has finished expressing.

Using the Symphony Medela Select

Follow the steps below to show a mother how to use a manual or electric breast pump. Show the woman how to stimulate a let down reflex by following the steps in the initiating lactation section above

Manual Pump (Medela)

  • Explain how to place pump centrally over the nipple and press gently against the breast.
  • Outer piston of the pump is to be pulled rhythmically. The pull should be strong enough to obtain milk but not excessive, it should not cause pain or damage.
  • Commence expressing on minimum setting. As milk begins to flow suction pressure can be increased to a comfortable level. As the milk flow slows down, increase frequency of pull on piston. Note: Suction pressure does not need to be on high to be effective.
  • Swap breasts frequently as milk flow slows down or stops.

Electric Pump

  • Instructions on using the electric breast pump will be given to the mother.
  • Plug breast pump into power point and turn on at the wall.
  • Place cup centrally over nipple and turn breast pump switch on.
  • Once let-down occurs, or after 2 minutes, increase suction pressure gradually and turn rate setting to 4. Note: Suction pressure does not need to be on high to be effective.
  • Expressing should not hurt. If suction pressure is too high this can cause nipple and duct damage and bleeding.
  • The mother should not press too hard against the breast with the breast shield. A small puff of air should be observed around the cup of the breast shield as the breast pump releases suction pressure.
  • Initially mothers can alternate breasts 2- 4 times during session, as milk flow slows or stops. Alternatively express until 2 minutes after milk flow stops.
  • Expressing times can be reduced to 10-15 minutes however frequency should be maintained at 8 - 12 times/24 hours including night expressing.
  • Double pumping allows simultaneous breast expression. It saves time, may raise prolactin levels and may increase milk supply for some mothers.
  • Turn machine off before removing from the breast.
  • Show mothers the link to the YouTube clip "Hands on Pumping" by Stanford University.
  • If mothers are experiencing pain or discomfort with expressing they may benefit from trying a larger size breast shield. There are size 27 and 30 available if needed.

Increasing lactation / milk supply

The breasts provide glandular tissue for milk production. The brain releases hormones to stimulate milk release. The baby or breast pump provides stimulation to trigger and maintain milk production. All three are necessary to establish lactation, and milk may appear on day one or take several days and will take weeks to become fully established.

Follow the steps below to increase milk supply.

  1. Assess for possible cause of delayed or decreasing milk supply.
  2. Document any risk factors:
    • Absence of breast changes during pregnancy
    • Smoking
    • Retained products of conception
    • Caesarean Section
    • Primipara - delay in lactation establishing
    • Previous breast surgery - reduction / augmentation
    • Delay in breastfeeding initiation / expressing
    • Not expressing or feeding frequently enough
    • Previous history of delayed lactation
    • Delivery complications
    • Obesity
    • Maternal medication use
    • Maternal diabetes
    • PCOS
  3. Follow steps of General Guidelines above.
  4. Increase milk production
    • Increase frequency and duration of expressing
    • Ensure one or two night expressions
    • Provide Kangaroo care of the infant
    • Increase maternal rest / reduce stress
    • Maintain adequate maternal nutrition and fluids
    • Consider double expressing
    • Ask mother to keep a diary of expressing record
    • Consult with Lactation Consultant if unresolved
    • May consider pharmacological treatment with domperidone
  5. Increase milk release
    • Visual imagery / relaxation.
    • Warm compresses to the breasts / nipple stimulation
    • Massage of the breast prior to and during expressing.
    • Consider use of different breast pump e.g. Avent Isis or hand pump.
    • Reduce stress / increase rest.
  6. Review and document management plan, and follow-up.

Disinfection/sterilising of feeding equipment

Follow the steps below for safe use of disinfection/sterilising feeding equipment and expressing equipment in NICU.

  1. Do not share feeding equipment between infants or expressing equipment between mothers.
  2. Each infant will have his/her own sterilising container at the bedside.
    The container must be washed daily in hot water and detergent, rinsing thoroughly, prior to making up new solution and following discharge of infant.
    This is traditionally done by the night staff.
  3. After use all equipment is to be washed in hot, soapy water and rinsed well (use bottle brush for bottles).
  4. Soak in sterilizing solution as per manufacturers instructions, completely immersing equipment, with no air bubbles visible.
    Milton a minimum of 1 hour
    Sterinova a minimum of 40 minutes
    The items soaking for the desired time will be ready to use even if another item is added to the container, handling or adding utensils will not contaminate remaining articles.
  5. All teats, standard teats, Haberman teats and cross cut teats will be washed (as above) and can be soaked in sterilising solution as per manufacturers instructions. They are then stored dry, between feeds, in a sterile container in the fridge (ensure infants sticky label on container). The life of these will be prolonged by not soaking continuously.
  6. Nipple shields are to be washed in warm soapy water, rinsed and air dried then placed in a container with a lid. They do not need to be placed in the sterilising solution.
  7. Do not rinse equipment prior to use by the infant or mother.
  8. Bottle brushes should be rinsed under water after use and stored dry. The bottle brush and its container will be replaced weekly by the Newborn Services Hospital Aide.
  9. Infant feeding bottles are to be replaced with new ones on a 24 hour basis or sooner if soiled.
  10. Containers for warming feeds will be labelled with infants 'sticky label', dated and changed weekly. They are discarded at discharge.
  11. Electric breast pumps should be wiped with mediwipes before and after each use.
  12. Daily cleaning of the breast pumps and stands by hospital aides with a detergent and water solution (e.g. Taski).

Storage, use and transport of breast milk

Follow the steps below to safely store, use and transport breast milk.

Containers

  • Expressed breast milk is to be stored in a sterile container with lid.
  • Each time breast milk is expressed - store in a different container. Cold milk can be added to cold milk however date and time should be that of the first expression.
  • Label the container with:
    Baby's Surname and Hospital Number
    Date/Time milk was expressed.
    Use "Caution - Duplicate Name" sticker when appropriate.
  • Note: Unlabelled milk is NOT to be used and must be discarded.

Storage

  • Fresh breast milk:
    up to 4 hours at room temperature, but best stored in a cool place.
    up to 48 hrs stored in a refrigerator.
    If EBM is to be frozen it should be done so within 48 hours.
  • Expressed breast milk will not be stored with any other food products Store breast milk towards the back of fridge or freezer, not in the door. It can be stored in the same refrigerator as infant formula but on a shelf lower in case of spillage/leakage.
  • Milk stored in Newborn Service freezers should be used within 3 - 6 months.

Safe use of stored breast milk

  • Thaw frozen breast milk in the refrigerator for several hours or stand sealed container under running cold water or stand in warm water changing the water several times until thawed (this milk must be used immediately then discarded).
    Document on label date/time frozen breast milk is removed from freezer.
    Use within 24hours of thawing.
  • Warm breast milk once - do not reheat. Use immediately when warmed to body temperature.
  • Stand container in hand-hot water. Do not use boiling water.
  • Swirl gently to mix. Breastmilk is not homogenised, fat will separate
  • Discard any unused milk that has been warmed, or thawed over 24 hours.
  • Note: Microwaves will not be used as they destroy immunological properties and causes localised "hot spot" in milk.

Safe Transportation of breast milk

  • Transport fresh or frozen milk in a chilled container surrounded by ice or ice packs to maintain the chilled or frozen state of the milk if travelling long distances.
  • For short distances EBM may be wrapped in several layers of newspaper
  • Transfer to fridge or freezer as soon as possible.

Administration of Expressed Breast Milk (EBM)

Follow the steps below to safely administer expressed breast milk to a baby.

  1. Prior to administrating stored breast milk (via bottle or naso-gastric tube) it must be checked by two people.
    One person is to be a member of the clinical staff, the second person may be another staff member or the infant's parent.
    Both people checking the EBM are to initial the baby's feeding chart to document that the breastmilk has been checked and is correct.
  2. Check the date of collection.
  3. Check the expiry date documented on the container of breast milk.
  4. Check that the ID number and name documented on the container of breast milk matches the details on the ID bracelet of the baby who is to receive the milk.
  5. No milk is to be given to the infant unless it is appropriately labelled and dated.
  6. Check only one feed at a time.
  7. Use the freshest milk first.
  8. If there is colostrum in the freezer, this can be defrosted and given half in half with the fresh milk.

Administration of incorrect breast milk

If a baby inadvertently receives breast milk other than his/her own mother's follow the steps below.

  1. Immediately notify senior nurse in charge of unit and other appropriate personnel.
  2. When a nasogastric tube is in situ milk can be withdrawn if error recognised within 30 mins of administration
  3. Complete documentation of event on Datix - classify as below
    Datix Classification
  4. Arrange for notification and counselling by senior medical/nursing staff for parents of affected infant as soon as possible. The senior nurse /doctor should explain the event to the baby's mother and to the mother whose milk was inadvertently administered. Identity of donor mother must not be disclosed.
  5. The senior nurse /doctor ensures that the parents of both babies are counselled/informed about the risks and need for screening.
  6. Donor mother: The senior nurse /doctor ensures donor mother's consent is obtained for giving blood samples for:
    HIV antibody
    Hepatitis B and Hepatitis C antibody
    CMV if recipient <32 weeks (at birth) or < 1500gm
  7. Recipient mother: The senior nurse/doctor ensures consent is obtained to review antenatal blood test results and repeat if risk factors suggest any change in status as well as test for CMV antibody if infant < 32 weeks at birth or < 1500gm.
  8. If donor mother should refuse consent for blood test, then risk assessment should take place and baby screened and/or treated appropriate to the level of risk.

Consideration of risk should be discussed in terms of:

  • Exposure is all most always via a naso-gastric tube or teat rather than the breast.
  • The duration of exposure is limited to one, in contrast to the hundreds of feeds that occur over the first months of life on which most risk is documented
  • The dose (volume) of exposure is usually small
  • There have been no reports of HIV, HTLV 1&11, HBV, HBC transmission with this level of exposure in the literature
  • Breast milk stored in the neonatal intensive care situation has most likely been frozen
  • Women are screened in early pregnancy for HIV, hepatitis B, and syphilis.

Associated documents

  • All mothers are to be given Starship Children's Health Expressing and Breastfeeding Booklet on arrival in NICU.

References

  • Hill, P., Aldag, J., Chatterton, R. (2001). Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants. Journal of Human Lactation, 17(1), 9-13.
  • Kent, J.C., Mitoulas, L.R., Cregan, M.D., Geddes, D.T., Larsson, M., Doherty, D.A., Hartmann, P.E., (2008) Importance of vacuum for breastmilk expression. Breastfeeding Medicine, 3(1), 11-19.
  • Meier, P. (2001). Breastfeeding in the special care nursery. Premature and infants with medical problems. Pediatric Clinics of North America, 48(2), 425-442.
  • Mitoulas, L., Lai, C., Gurrin, L., Larsson, M., Hartmann, P. (2002). Efficacy of breast milk expression using an electric pump. Journal of Human Lactation, 18(4), 344-351.
  • Spicer, K. (2001). What every nurse needs to know about breast pumping: Instructing and supporting mothers of premature infants in the NICU. Neonatal Network, 20(4), 35-41.
  • Jones, E., Dimmock, P., & Spencer, S. (2001). A randomised controlled trial to compare methods of milk expression after preterm delivery. Archives of Disease in Childhood, Fetal & Neonatal Edition, 85, F91 - F95.

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Document Control

  • Date last published: 01 November 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years