• Reference Number: HEY-739/2016
• Departments: Maternity Services, Neonates
• Last Updated: 3 June 2019

Introduction

This leaflet has been produced to give you general information about expressing breast milk for your baby on the Neonatal Intensive Care Unit (NICU) or transitional care.  Most of your questions should be answered by this leaflet.  It is not intended to replace the discussion between you and your doctor or healthcare professionals but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team caring for you and your baby.

How do I make Breast Milk?

Milk is produced in milk making cells within the breast.

Adequate milk production relies on two hormones:

Prolactin tells the breast to make milk so that it will be ready and waiting for a feed. Prolactin is in your body from early in pregnancy but its effect is stopped by other hormones.  After delivery the hormones of pregnancy decline, allowing prolactin to take effect.  This means that, even if your baby is born prematurely, you can make breast milk.  A baby suckling at the breast, or when milk is expressed ensures prolactin continues to be produced.  Without removal of milk from the breast, the production of milk is reduced and eventually stops.

Oxytocin is released when a baby suckles (and when a breastfeeding woman sees or hears her baby).  Oxytocin causes muscular cells to squeeze the milk that is ready in the breast, down ducts (tubes) to the nipple. This is called the ‘let down reflex’.  To remove milk effectively from the breast, baby needs to be attached effectively (with a large amount of the breast tissue in baby’s mouth and the nipple drawn well toward the back of the mouth).  The effect of oxytocin means that milk will continue to be available as long as baby is taking a feed.

Why is Breast Milk best for baby?

Colostrum is the first milk you produce after your baby is born. It is thick, yellowish in colour and it is normal to produce only a few milliliters during the first few days. Colostrum delivers its nutrients in a very concentrated low-volume form but it contains sufficient nutrients for the first few days of life and is very good for your new born or premature baby.  It contains high levels of ‘immunoglobulins’ and white blood cells, helping to provide protection against infections.  Colostrum has a mild laxative effect, which helps to clear the baby’s gut of meconium (the first dark, sticky stool), this can help to prevent jaundice (yellowish staining of the skin).  High levels of Growth factors and some vitamins are found in colostrum, growth factors help a baby’s immature organs, especially the gut and vitamins, especially vitamin A helps reduce the severity of other infections the baby may have.

At around three days after having your baby your breast milk will be changing to a more mature milk, which is produced in larger volumes.  Babies fed with breast milk are better protected against diarrhoea and gastroenteritis, ear and chest problems, including asthma and are less prone to eczema.  They are also at less risk of diabetes, heart disease and obesity as they grow older.

When your baby is on the neonatal unit, it is even more important to make sure you provide them with breast milk.  These babies are very vulnerable and breast milk will work better than most medicines to protect them from illness and infections, as well as helping all their systems to mature, particularly the digestive system.  Breast milk is also important for the development of the brain.  Even if you did not plan to breastfeed your baby, it is really helpful to give them your expressed breast milk while they are in hospital, in order to give them the best opportunity to progress.

Expressing Breast Milk

There are a few important steps you need to take to make sure your milk supply is stimulated well.

• Ask a member of staff to show you how to hand express your breast milk as soon as possible after delivery.
• You can also watch a hand expressing video on line by visiting https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/breastfeeding-resources/hand-expression-video/
• You should start expressing within a few hours of delivery (within 6 hours is ideal). The amount of milk you get will be small at first, sometimes just a few drops glistening on the nipple but even at this stage, you will be doing a really important job to stimulate the hormones that make milk.
• Breast massage and nipple rolling prior to expressing will make expressing more effective and increase the amount of milk you get.
• Expressing next to your baby is the best way to increase the milk making hormone Oxytocin. If you choose not to express next to your baby then there are actions that can help, such as looking at a video or pictures of your baby, talking, touching or holding your baby skin to skin and smelling knitted bonding squares found in your expressing pack, that have been kept close to your baby may help to boost Oxytocin.
• Hand expressing works best to stimulate hormones; it is vital that you start with this and then move onto a pump when your supply increases over the next few days. This is when your milk ‘comes in’ and your breasts start to feel fuller.  Ask a member of staff, breast milk link nurses or neonatal feeding lead to show you how to use the breast pump when you are getting 3mls or more from each breast.
• There are hospital breast pumps on the neonatal unit and transitional care for you to use, these are very efficient for increasing and maintaining your milk supply. A hand breast pump will be given to you once you have been discharged from hospital to use when you are at home. Ask the nurse looking after your baby for more details.
• It is important to clean your hands effectively before hand expressing or using the breast pump. Effective hand washing will reduce the risk of infection to your baby.  See the handout within your baby’s admission pack on how to wash your hands effectively.
• A baby maybe ready to breastfeed within hours, days or weeks of their birth dependent on whether your baby is premature, small or unwell. Until your baby starts to breastfeed, you need to express at least 8 – 10 times within 24 hours and ensure there are no gaps longer than 5 hours between expressing.  This is really important to keep the hormone (Prolactin) levels up.  This is just within the first two weeks after birth and then you can often reduce the frequency of expressing to eight times within 24 hours.

• You should express from each breast until the milk flow slows or stops, and then express from the other breast. You should continue to alternate breasts until your breasts feel soft / emptier.
• The more premature your baby, the more your body has to do to produce milk as your breasts had less time to develop during your pregnancy. We know that if you can express nearer 10 times within 24 hours for the first 10 – 14 days you increase your milk supply to where you are expressing about 750ml of breast milk in 24 hours.  Producing this amount or more of breast milk promotes a healthy long term milk supply.
• You do not need to express at regimented times, for example every 3 hours. You can cluster express, which means express frequently over a short period of time, when it is convenient for you and have longer gaps (no longer than 5 hours) at other times.
• If you massage your breasts while using the pump, the milk you get may increase in volume and is richer in fat.
• Double pumping is expressing from both breasts at the same time, this method can increase the amount of milk you produce, and it takes less time. It also increases the amount of fat in the milk which helps baby gain weight.
• Ask the staff on the neonatal unit to let you know as soon as your baby is stable enough, and they can help you to have some skin to skin contact time. Spend as much time as you can with your baby skin to skin; it really boosts your milk supply.  It also helps you to get to know each other, reduces stress levels in both of you, helps baby keep warm and regulates baby’s breathing and heart rate.  Information on this can be found in the skin to skin with your premature baby leaflet, within your baby’s admission pack.
• Once your baby is breastfeeding effectively you can reduce the frequency and length of expressing. You will notice that you will express smaller volumes of breast milk as your baby starts to take more for themselves.  Discuss with the nurses, midwives, breast milk link nurse or neonatal feeding lead about the frequency and timing of feeds and expressing.
• Eventually, your baby will be able to breastfeed fully and you can express for times when it is convenient for you, for example when you want to go out or go back to work.

Cleaning your Breast Pump Kit

Your breast pump kit needs to be washed in hot soapy water, rinsed, dried with a clean paper towel and stored in an air tight container after every use. Before you express the breast pump kit needs to be decontaminated; the breast pump kit is compatible with all kinds of decontamination methods.  In hospital we use a microwave, please ask the nurse looking after your baby to demonstrate how to clean and decontaminate your breast pump kit effectively, when you are ready to use the breast pump.

Storing your Expressed Breast Milk

The hospital provides sterile disposable bottles and labels with baby’s name and unit number on for you to use. It is really important that you store your expressed breast milk correctly. On the neonatal unit breast milk is stored in dedicated fridges and freezers that only store infant milk.  The temperature of the fridges and freezers are checked twice a day to ensure they are kept within the correct limits.  In hospital, you will have your own fridge and freezer space in which to store your breast milk. Whether you store your breast milk at home or at hospital there are rules that should be followed:

• After expressing, each container must be labelled with your baby’s name, unit number and date and time of collection
• Breast milk should be placed in the refrigerator as soon as possible after expressing. Your breast milk should be placed towards the back of the refrigerator and not in the fridge door. This is because the temperature in the door compartment goes up and down when the fridge is opened and closed.  Your refrigerator temperature needs to be kept between 2 – 4^o
• Breast milk that has recently been expressed can be kept in the refrigerator for 48 hours.
• If your breast milk is not going to be used within 48 hours then it should be frozen. Frozen breast milk can be stored in a suitable freezer at -20^oC for up to three months.

Daily Record of Breast Milk Expression and your Baby’s Progress

• You can use this book to write any questions or thoughts you may have. The following pages are for you to record how many times you express your breast milk and the volume you obtain.
• The amounts will not be the same each time. When your baby begins to feed from the breast, they will take a different amount each time.  Your breasts know this and can change the amount it produces to suit your baby.
• The amount of milk you produce when expressing will change in volume just the same – it is important you just keep going and the amount you produce each day will increase. It is the total volume you produce over 24 hours that is important.

Research has shown that the more milk you are producing at two weeks, the better your long term supply will be. This is why we encourage you to express so frequently in the first two weeks.

Please read the information leaflet.  Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following delivery of your baby.

Day One

During pregnancy your body has supplied your growing baby with all the nutrients they have needed. Now your baby is born you can continue to help them grow and protect them. Colostrum comes in very small amounts and every drop is precious. That is why hand expressing is so important, so nothing is wasted!

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Containment Holding I have discussed containment holding with the nurse looking after my baby

Day Two

Holding your baby skin to skin can help to regulate breathing, heart rate and temperature. It is good for breastfeeding as it encourages pre-feeding behaviour, improves growth and helps you and your baby feel calm.

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I have discussed skin-to-skin with the nurse looking after my baby

Day Three

The nurses will give you information on skin to skin, expressing, storing and transporting your breast milk.

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby  for …………………hour(s)

Day Four

You may start to use a breast pump now; it is really important that you are shown how to use the pump properly.  When you get discharged from hospital; the nurse will give you a hand pump for you to use while you are at home.  Speak to the nurse looking after your baby to find out more

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Five

Everyone has good days and bad days. Some days will be better than others but be reassured that your baby is being cared for 24 hours a day. It is really important that you continue to express your milk 8-10 times a day, even on the not so good days, to ensure a better long term milk supply.

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Six

Express next to the incubator or cot. Being close to your baby will boost your milk supply.

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Seven

If you are away from your baby, smell your bonding squares, look at photographs and videos of your baby, this will help you to express your breast milk more easily

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Eight

Do not forget nipple rolling and breast massage before you express, and try double pumping to improve your supply.

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Nine

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Ten

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Eleven

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Twelve

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Thirteen

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Day Fourteen

By day fourteen you should be producing approximately 650mls or more of breast milk per day.  If you are worried about your supply ask to speak to the breast milk link nurses or Neonatal Feeding Lead

Today’s Date:
Number of expressions	Right Breast	Left Breast	Total mls produced
1
2
3
4
5
6
7
8
9
10
11
12
Total mls 24 hours
Skin-to-skin I had skin-to-skin with my baby for ………………… hour(s)

Be really proud of yourself. You are doing a wonderful job!

Should you require further advice on the information contained in this leaflet, please do not hesitate to contact the Neonatal Feeding Lead (Mobile) 0782 4320152