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5.1 Expressing breast milk

Almost all breastfeeding mothers in Australia express breast milk at some time before their infant is 6 months old. An online survey of Australian mothers who were members of the ABA found that 98% of respondents (n=903) had expressed breast milk.368 _{In the Us, the national Infant Feeding Practices study found that 92% of}

breastfeeding women had expressed breast milk at some time.369 _{In the Perth Infant Feeding study, at 1 month}

76% of mothers had expressed breast milk, increasing to 84% at 5 months.370 _{mothers who expressed breast milk}

were more likely to breastfeed to 6 months (any breastfeeding), but expressing breast milk is not an essential component of successful breastfeeding.

teaching mothers how to express and the appropriate use of expressed breast milk may be a means of helping mothers achieve 6 months of predominant breastfeeding while giving more lifestyle options.

measurement of breast milk quantity obtained by expression is not an appropriate way of measuring the adequacy of breastfeeding because of the variation in individual feeds. no published studies in english have evaluated assessment of breastfeeding in this way, but there are a number of theoretical difficulties associated with this procedure:

• mothers not familiar with expression may have difficulty with the procedure

• there is no evidence that measuring one or two breast milk expressions is useful in assessing breast milk adequacy • it is beneficial to the infant for breastfeeding to continue.

Assessment of overall infant growth is the most appropriate way to assess breastfeeding adequacy.

5.1.1 Indications for mothers to express breast milk

In the Perth Infant Feeding study, the most common reason for expressing breast milk was to manage difficulties in breastfeeding, usually due to distended breasts or mastitis.370,371

other reasons given by mothers include: • the infant is sick or preterm

• mother and infant are or will be temporarily separated • the mother is returning to paid work

• the milk supply needs to be increased • the mother’s breasts are uncomfortably full.

In the Us, most descriptive papers report mothers expressing breast milk when returning to paid work. the requirements for collecting breast milk for sick or preterm infants in hospital are more stringent than

those applying to collecting milk for healthy infants at home. midwives, lactation consultants, early childhood nurses and ABA counsellors are available to provide advice about expressing.

there are three methods of expressing – hand expressing, hand pump or electric pump. the mother’s choice will depend on her reason for expressing, cost, duration of expression and her personal preference. A cochrane review demonstrated that, overall, electric or foot operated pumps are more efficient than hand expression.372

the ABm protocol for expression and storage of breast milk states:373

women should wash their hands with soap and water, or a waterless hand cleanser if their hands don’t appear dirty, before milk expression. Unclean hands may transmit viruses and bacteria, some of which can cause illness. studies show that human milk containing fewer bacteria at the time of expression develops less bacterial growth during storage and has higher protein levels compared to milk that has an abundance of bacteria. As long as the appropriate steps are taken for hand cleansing and cleaning of pump parts as per the pump manufacturer, there does not seem to be a difference in milk contamination with pumping versus manual expression.

Table 5.1: General principles for expressing breast milk by any method • Express in a comfortable, private place

• Disable the telephone • Have a glass of water nearby • Have all expressing equipment ready • Relax! Music may help

5.1.2 Hand expression

every mother should be shown how to hand express her milk, regardless of whether she chooses other methods to use in the longer term.217 _{this method has many advantages – it is convenient and the skin-to-skin contact}

stimulates milk production. many women find that hand expressing becomes easier with practice. Table 5.2: Steps for expressing breast milk by hand

• Wash hands with soap and warm water (cold hands can cause the process to take longer than warm hands) • Hands must be thoroughly dried with a clean towel, single-use towel or hand dryer374

• Gently massage the breast – start from the top of the breast and stroke towards the nipple, massage the underside too and repeat several times to ensure that the whole breast is massaged

• Hold a clean plastic dish under the breast to collect the milk – this may be difficult for some mothers to manage when they are learning and, instead, a wide bowl can be held between the legs or placed on a low table, leaving both hands free, a towel may be needed to catch any spills

• Place thumb and finger diagonally opposite each other on the edge of the areola

• Gently press inward towards the centre of the breast, squeezing the finger and thumb together

• Repeat with a rhythmic rolling movement, feeling for the milk sinuses – the fingers should not slide over or pinch the skin • Once the milk flow has stopped, move the fingers around the nipple and press again – this helps express more milk and empty all

sectors of the breast

• Repeat the process on the other breast

• If more milk is required, the mother can change from breast to breast until she has the amount of milk needed or she can wait and try again later

5.1.3 Hand pumps

Hand pumps are portable and relatively inexpensive. many types are available and should be used according to the manufacturers’ instructions.

Table 5.3: Steps for expressing breast milk using a hand pump • Wash hands with soap and warm water

• Have a clean, sterilised pump ready

• Gently massage the breast – start from the top of the breast and stroke towards the nipple, massage the underside too and repeat several times to ensure that the whole breast is massaged

• Place the flat rim of the breast cup on the breast, centring the nipple

• Gently work the pump with a smooth action, pulling the piston and releasing the suction rhythmically –  by releasing the suction, the blood circulation to the areola and the nipple will be maintained

• Continue working the pump until the breast is soft and about half the required amount of milk has been expressed • Change to the other breast and repeat the process, starting with the gentle massage

• If more milk is required the mother can change from breast to breast until she has the amount needed or she can wait and try again later

• Pour the collected milk into a storage container and put it in the refrigerator (see Section 5.3)

5.1.4 Electric pumps

electric breast pumps may be preferable for longer-term use. electric breast pumps can be purchased or hired from many pharmacies or from the ABA.

Table 5.4: Steps for expressing breast milk using an electric pump • Wash hands with soap and warm water

• Have the sterilised pump equipment ready

• Gently massage the breast – start from the top of the breast and stroke towards the nipple, massage the underside too and repeat several times to ensure that the whole breast is massaged

• Hand expressing for a few minutes before and after pumping can optimise milk output • Place the breast cup on the areola, centring on the nipple

• Ensure that the flange is the correct size – women with larger nipples may need a larger flange • Turn the suction strength to low, start the pump, and relax

• Gradually increase the suction strength – as long as there is no discomfort. The strength should not be increased above the recommended level for the type of pump being used. High levels of suction do not increase milk production

• Continue until the breast is soft and about half the required amount of milk is collected

• Change the cup to the other breast, turning the suction to low, and repeat the process, beginning with the gentle breast massage • If more milk is required, the mother can change from breast to breast until she has the required amount or she can wait and try

again later

• Pumping both breasts at the same time (double pumping) may increase milk yield and saves time • Pour the collected milk into a storage container and put it in the refrigerator (see Section 5.3)

5.2 Feeding with expressed breast milk

expressed breast milk can be fed to an infant by bottle, cup or spoon. whether a bottle, a cup or a spoon is used, the same procedures for sterilisation and storage apply (see section 8.3.3).

Health workers should advise against top-up feeding (i.e. adding infant formula to expressed breast milk) when mothers perceive that their infant is not getting enough breast milk.

5.3 Storage of expressed breast milk

As for collection, the requirements for storing breast milk are more stringent for sick or pre-term infants in hospital than for healthy infants at home. the literature review identified evidence suggesting that the maximum storage time of breast milk under clean conditions in a refrigerator at 0–4°c is 96 hours (evidence grade c).375 _{note that}

breast milk storage guidelines vary.

5.3.1 Storing breast milk in hospital

storage of breast milk in hospital is out of scope for these guidelines – reference should be made to specific guidelines available for hospital milk banks.

5.3.2 Storing breast milk at home

the ABm has recently updated its protocol for storing breast milk for home use.373 _{the safety measures for storing}

breast milk outlined in these guidelines are consistent with the recent ABm protocol. Breast milk can be stored in glass or plastic containers, including sealable plastic bags. Freshly expressed milk that is being refrigerated or frozen should be stored in a new container rather than added to previously refrigerated or frozen milk.376

Table 5.5: Guide to storing expressed breast milk at home

• Wash hands thoroughly with soap and water – hands must be thoroughly dried with a clean towel, single use towel or hand dryer • Refrigerate or freeze milk after expressing

• Use fresh milk whenever possible

• Freeze milk that will not be used within 2 days

• Date the container at the time of collection and use the oldest milk first Sources: WHO374 _{and Barger 1987.}377

Table 5.6: Length of time breast milk can be stored