Introduction

If a woman chooses to express milk for her infant it is vital that an adequate milk supply be established early. This will mean that some mothers will be expressing volumes of milk that far exceeds the infant’s current needs. 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. 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 NWH 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 & 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 pamphlet 
   • Breast Massage and Hand Expressing breast milk.
6. 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.
7. 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.
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

Note: The total volume obtained in 24hours 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 milks 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.

Associated Pamphlets

• Hand expressing and breast massage
• Expressing and maintaining a milk supply
• Transport and storage of expressed breast milk

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:
   • gentle circular massage and tactile stroking 
   • applying warmth
   • thinking about baby 
   • sitting beside her baby if possible or looking at a photograph
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 RBP: Storage use transport of EBM 
8. Frequency and time as for RBP: Expressing – Basic Principles and Initiation. 

Medela Lactasets for use in NICU/home

Follow the steps below for the mothers responsibilities regarding the Medela lactaset.

1. Newborn Services provides each mother with a Lactaset for her personal use on admission for infants born at less than 35/40. Including the information sheet titled ‘Mother’s responsibilities for Lactaset’. 
2. Ensure this has been documented in infants care map.
3. The Lactaset can be used as a hand pump or can be used on the Medela Lactina/Lactina Select electric breastpumps. 
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 Lactoset 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 Lactaset does not need to be returned once the mother has finished expressing.

Using the Medela Lactina/Lactina Select

Follow the steps below to show a mother how to use a manual or electric breast pump.

1. Show the woman how to stimulate a let down reflex by gentle breast massage and stroking, applying warmth, thinking about her baby, sitting beside baby or looking at a photo of her baby.
2. 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.
3. 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.
   • Ensure pump is set at minimum setting for lowest suction pressure and rate setting of 7.
     Note: The suction pressure settings are Min. Med. & Max. located on the lactaset piston arm. The rate settings can be found on the Lactina select model only and has settings from 1 to 7 setting (7 being fast and 1 being slow). Setting 4 is standard at 1 suction per second.
   • 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 lactaset. A small puff of air should be observed around the cup of the lactaset as the breast pump releases suction pressure.
   • Alternate breasts 2- 4 times during session, as milk flow slows or stops.
   • Turn machine off before removing from the breast.

Simultaneous (Double) Expressing

Double pumping allows simultaneous breast expression. It saves time, may raise prolactin levels and may increase milk supply for some mothers.

Follow the steps below to assist the woman to use a double breast pump effectively.

1. If a mother chooses to double pump it will be her responsibility to purchase a second pump kit.
2. Newborn service will provide an extra pump kit to allow mothers to double express for mothers of triplets.
3. Follow Newborn services RBP: Expressing – Using the Medela Lactina/Lactina Select
4. Expressing times can be reduced to 10 – 15 minutes however frequency should be maintained at 8 – 12 times/24 hours along with night expressing.
5. The mother should stop once or twice during expressing to massage her breasts prior to commencing double expressing again.

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
3. Follow steps of Newborn Services RBP: Expressing.
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.
   • Reduce stress / increase rest.
6. 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 30 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, cross cut teats and nipple shields 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. Do not rinse equipment prior to use by the infant or mother.
7. 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.
8. Infant feeding bottles are to be replaced with new ones on a weekly basis or sooner if soiled (night staff Monday pm).
9. Containers for warming feeds will be labelled with infants ‘sticky label’, dated and changed weekly. They are discarded at discharge.
10. Electric breast pumps should have any spilt milk wiped clean with hypochlorite solution after use.
11. 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.

1. 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.
2. Storage:
   • Fresh breast milk:
     • up to 4 hours at room temperature, but best stored in a cool place.
     • up to 4 days 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 months. 
3. 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.
4. 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

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.

Wrong Breast Milk Inadvertently Given to Infant

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

1. Complete documentation of event on Significant Events Form CC379. Notify senior nurse in charge of unit. Ensure that the form is forwarded to the RC Manager as per company policy.
2. The senior nurse /doctor explains the event to the baby’s mother and to the mother whose milk was inadvertently administered. 
3. The senior nurse /doctor ensures that the parents of both babies are counselled/informed about the risks and need for screening.
4. The senior nurse /doctor ensures mother’s consent is obtained for giving blood samples for:
   • HIV
   • Hepatitis B and Hepatitis C
   • CMV
   • Note: The HIV antibody test should never be ordered as part of a batch of tests, but always separately with the person’s name not to be used on the form. 
     Recommended code for use is first two letters of the person’s surname (excluding “Mac” or “O”) then by the first initial, then an F to denote female sex and finally the six digit date of birth. This system enables test duplications to be checked. 
5. When all test results are obtained, the senior nurse /doctor notifies the parents if test results are negative, however a senior paediatrician is to explain the outcomes of positive test results. Results must be conveyed to parents in a personal consultation and must not be given by phone or by mail.
6. All three blood tests need to be repeated three months later. The option is to be given that either a mobile laboratory technician can call at their home, or a Laboratory Request Form can be provided for them to have the tests done at a laboratory, at this time.
7. When all test results have been repeated, a homecare nurse is to notify the parents if the results are negative (see point 5), however should the results be positive, the senior paediatrician will explain the outcome of the tests to the parents.

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