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 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
Follow the steps below to assist the woman to learn the skill of expressing
her own milk if her baby is unable to breastfeed.
Start as soon as possible after delivery, (preferably within an hour or
two of delivery) or at least within 6 hours.
Ensure privacy as directed by the mother.
Wash hands (mother & staff) and provide a sterile container for collecting
Show the woman how to stimulate her breasts and assist the let down
gentle circular massage and tactile stroking
positive thoughts of her baby
sitting beside her baby if possible or looking at a photograph
Provide and discuss the pamphlet
Establishing and maintaining a milk supply.
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.
Follow the steps below as a general guide to expressing.
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.
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.
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.
Follow the steps below as a guide to maintaining lactation:
Once lactation is established increased flexibility with expressing can
occur (this can take 3-4 weeks).
Any change in expressing schedule
should be gradual as sudden changes increases risk of mastitis &/or sudden
drop in lactation.
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.
expressions can be gradually lengthened although most mothers with an
established milks supply find it difficult to go longer than 6 hours.
Dropping to less than 5 expressions per day can lead to dramatic decrease in
milk supply for some mothers and is not recommended.
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
Expressing and the Transition to Breastfeeding
Follow the steps below to assist in the transition from expressing to
As baby is learning to breastfeed, expressing should occur after
breastfeeds have been attempted.
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.
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.
When this happens expressing can be
gradually reduced. Slowly wean (reduce) expressing over 1- 3 weeks as
infant’s breastfeeding skills improve.
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 and breast massage
Expressing and maintaining a
Transport and storage of expressed breast
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.
Follow the steps below to assist women in hand expressing.
Wash hands and provide a sterile container for
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
thinking about baby
sitting beside her baby if possible or looking at a photograph
The mother should cup the breast using the C hold and position thumb and
finger behind the areola in opposition.
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.
Repeat expressing movement
rhythmically, moving around the breast and alternating breasts.
by sterile syringe initially to minimise wastage
using pink or
white topped sterile container when milk flows easily
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
Frequency and time as for RBP: Expressing – Basic Principles and
Breasts need to be handled very gently and expressing should never hurt or
Women may wish to hand express under a warm shower
to start milk flow or soften a firm breast however this milk can not be
Expressing – Basic Principles and Initiation
Expressing - By Hand
Breast Pumps Expressing – Manual or Electric
Disinfection of Feeding Equipment
Storage, Use and Transport of Breastmilk
Increasing Milk Supply
Administration of Human Milk
Medela Lactasets for use in NICU/home
Follow the steps below for the mothers responsibilities regarding the Medela
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’.
has been documented in infants care map.
The Lactaset can be used as
a hand pump or can be used on the Medela Lactina/Lactina Select electric
There are several Medela Electric Breast Pump on
mobile stands throughout the NICU. We encourage mothers to express at the
infants cot/incubator side.
Privacy can be given by screens at the
mother’s request or by simply turning her chair toward the wall/incubator.
It is the mother’s responsibility to clean and sterilise equipment between
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.
Any lost or broken pieces are the responsibility of the mother to replace at
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
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.
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.
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.
Instructions on using the electric breast pump will be given to the
Plug breast pump into power point and turn on at the
Follow instructions for each individual pump, ie Symphony
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
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
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
If a mother chooses to double pump it will be her responsibility to
purchase a second pump kit.
Newborn service will provide an extra
pump kit to allow mothers to double express for mothers of triplets.
Follow Newborn services RBP: Expressing – Using the Medela Lactina/Symphony
Expressing times can be reduced to 10 – 15 minutes however
frequency should be maintained at 8 – 12 times/24 hours along with night
The mother should stop once or twice during expressing
to massage her breasts prior to commencing double expressing again.
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.
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.
Assess for possible cause of delayed or decreasing milk supply.
Document any risk factors:
Absence of breast changes during pregnancy
Retained products of conception
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
Maternal medication use
Follow steps of Newborn Services RBP: Expressing.
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.
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. 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.
Do not share feeding equipment between infants or expressing equipment
between mothers .
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.
After use all equipment is to be washed in hot, soapy water and rinsed
well (use bottle brush for bottles).
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
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.
Do not rinse equipment prior to use by the infant or mother.
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.
Infant feeding bottles are to be replaced with new ones on a 24 hour
basis or sooner if soiled.
Containers for warming feeds will be labelled with infants ‘sticky
label’, dated and changed weekly. They are discarded at discharge.
Electric breast pumps should be wiped with mediwipes before and after
Daily cleaning of the breast pumps
and stands by hospital aides with a detergent and water solution (e.g.
Storage, Use and Transport of Breast milk
Follow the steps below to safely store, use and transport breast milk.
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
Use “Caution – Duplicate Name” sticker when
Note: Unlabelled milk is NOT to be used and must be discarded.
Fresh breast milk:
up to 4 hours at room temperature, but best stored in a cool
up to 48 hrs stored in a refrigerator.
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.
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.
24hours of thawing.
Warm breast milk once – do not reheat. Use immediately when warmed to
Stand container in hand-hot water. Do not use
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.
Follow the steps below to safely administer expressed breast milk to a baby.
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.
checking the EBM are to initial the baby’s feeding chart to document
that the breastmilk has been checked and is correct.
Check the date of collection.
Check the expiry date documented on
the container of breast milk.
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.
No milk is to be
given to the infant unless it is appropriately labelled and dated.
Check only one feed at a time.
Use the freshest milk first.
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.
Immediately notify senior nurse in charge of unit and other appropriate
When a nasogastric tube is in situ milk can be withdrawn if error
recognised within 30 mins of administration
Complete documentation of event on Datix - classify as below
Arrange for notification and counselling by senior medical/nursing staff
for parents of affected infant as soon as possible. The senior nurse /doctor
explains the event to the baby’s mother and to the mother whose milk was
inadvertently administered. Identity of donor mother must not be disclosed.
The senior nurse /doctor ensures that the parents of both babies are
counselled/informed about the risks and need for screening.
Donor mother: The senior nurse /doctor ensures donor mother’s consent is
obtained for giving blood samples for:
Hepatitis B and Hepatitis C antibody
CMV if recipient <32 weeks (at birth) or < 1500gm
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.
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