Expressing breast milk for the baby – all the answers to your questions

Your goal

600-700 ml of breast milk on the 14th day after the birth of a baby
900-1000 ml of breast milk on the 14th day after the birth of twins

How and when do I start expressing breast milk for my baby?

Start expressing as soon as you can – best in the first few hours after delivery!

Your situation is very different from that in which a baby is born at term and healthy. The baby is not with you and you cannot rely on his/her sucking to trigger and maintain the production of breast milk.

For your body, however, things are no different. The baby was born, the placenta separated, the hormonal start of breastfeeding occurred. Your breasts expect to receive stimulation just as often as if your baby was born at term.

Breastfeeding depends entirely on you – you need to create a good organisation and technique of expression to allow milk to start on time and to achieve the required amount.

When start expressing?

Ideally, irrespective of when the baby was born, the stimulation of the breasts should begin during the first several hours after delivery.

With all the stress about the premature birth, you probably will not have a breast pump. Expressing milk by hand, however, is an affordable and easy way for stimulating the breasts during this time. Colostrum is thicker and in a small amount so it is often considerably easier to express it by hand than with a pump. You can ask the midwives to show you how to express milk by hand and begin to drain both breasts every 2-2.5 hours during the day and about 4 hours during the night.

The first day you will hardly be able to express breast milk more than 3-5 times. This is normal – but it is important for the breasts to receive a signal that the milk will be necessary! The next day you will feel much better physically, so then it is important to achieve at least eight expressions in 24 hours.

At first, the amounts of colostrum you express will be very small.

It is normal to obtain only drops of breast milk during the first expressions.

During the first 2-3 days, the amount increases to 2-5 ml (half a teaspoon to one teaspoon).

The amount of breast milk starts increasing significantly after 4-5days, depending on when you began to express frequently and regularly. The sooner you start after delivery, the faster the breast milk will increase!

The hospital will not probably have the proper conditions for storing colostrum. It is possible that your baby will not be able to receive anything through the mouth in the first 1-2 days. In our hospitals, there is still no practice of rubbing drops of colostrum on the lining of the baby's mouth as a hygienic measure and a first step towards parenteral nutrition. However, you can discuss this option with your baby's doctor.

The loss of colostrum probably makes you sad but think ahead. It is important that you, through frequent expressing, build a good milk supply for when your baby will be able to take it. Therefore, even if you cannot store colostrum and it does not reach your baby, it is still important to continue to express frequently and regularly, not less than 8 times in 24 hours.

How often should I express breast milk?

Why should I express frequently? In the beginning, your baby is very tiny and his/her needs are very small. Often premature babies begin with 1-2 ml per feeding. At first, you will be able to cover your baby’s needs with only one expression per day. If you express only 2-3 times a day, however, the amount of your breast milk will not increase but will soon start to decrease.

The first days after delivery are the “marketing phase” in breast milk production. Stimulation in these first days dictates how much breast milk you will be able to produce. The frequency of emptying the breasts determines whether you will build a large factory with a lot of milk or a limited dairy farm with small production.

The mammary gland contains multiple cells, whose function is to produce breast milk. In the first days after delivery, your body releases hormones that activate these cells. That is why after 3-4 days the amount of breast milk expressed starts increasing sharply. However, if the breasts are not stimulated constantly and frequently through complete emptying, most of these cells go into “sleep mode” and stop producing. The few remaining cells will produce as much as is set by the frequency of expressing. If for several weeks you set approximately 100-200 ml per day, because that is how much the baby needs, your breasts will gradually adapt to produce such an amount.

However, a premature baby needs 700-800 ml of breast milk per day the end of the first month. When you need more breast milk, it will be very difficult to awake the “sleeping” cells. Increasing breast milk supply in such a situation requires a lot of work and effort and is associated with many concerns and fight. Therefore, in situations like yours – when a long period of separation from the baby can be expected, in the first weeks it is extremely important to maintain a frequency of expressing corresponding to the frequency of feeding a term baby – at least 8 times in 24 hours. The aim is to strive to achieve and maintain that amount until your baby becomes stronger.

Expressing and maintaining plenty of breast milk is important for several reasons:

Even the best breast pump available on the market does not have the same effect on your body as your baby. The cold plastic is quite different from the feeling of a warm hungry baby in your arms. That is why the body does not secrete hormones in exactly the same way. However, it is important to know that breast milk can be maintained only through pump expressions in the course of many months.

This, however, requires more effort and more attention on your part. When maintaining breast milk only through expressing it, the amount of milk usually decreases slightly after the first 3-4 weeks. Therefore, the initial quantities of breast milk should exceed the needs of a term baby. Thus, the expected reduction will not be of particular importance and will still cover the needs of your baby, even when he/she is big enough and close to the term.

The abundancy of breast milk has another very important aspect – when there is a lot of milk and it flows easily, it is significantly easier for the baby to feed at the breast and he/she learns to suck much more quickly.

How should I organise the expressing of breast milk? I should still be able to rest and visit my baby at the hospital...

Clearly, it is almost impossible to express breast milk every three hours around the clock – it is impossible to do it for weeks or months. It is therefore necessary to find a way to combine the eight expressions with at least one longer break for sleep.

The longest possible period in a day without expressing breast milk is 5-6 hours. It is a good idea to use it for a night's sleep, which will allow you to relax and be in a good shape. I.e. assuming the last expression for the day occurs around midnight, you need to wake up around 5-5.30 am for the first expression of the new day (your breasts will probably signal you before the alarm because they will begin to overfill).

Since you did not express breast milk in those 5-6 hours, you have 18-19 hours remaining to do the eight expressions. Apparently, there is no way to do the eight expressions at 3-hour intervals, so it is wise to try expressing every 2 hours. And because at some point you will surely need to go to the hospital to see your baby, where you will probably spend some time, the pace will be broken.

It is almost impossible to achieve equal intervals between the expressions of breast milk – fortunately, this is not necessary. Contrary to what you hear and what you see as a pattern of feeding at the hospital, babies do not feed at regular intervals either. At times they feed more frequently and at other times they take longer breaks. Therefore, you should seek to express breast milk every 2 hours during the day when you are at home. If you need a longer break, you can express several times at shorter intervals – every hour or so. It is very typical of babies to suck every half an hour or every hour for a few hours in the evening, so it is not a strange rhythm to your body.

If at the beginning you express breast milk at larger intervals and then start to express more frequently, it may seem that you express much less. The feeling of filling the breasts will also confuse you. It is important to watch the amount expressed for a total of 24 hours and not per session. In fact, eight expressions of 30 ml is the same amount as six expressions of 40 ml or four expressions of 60 ml. The difference is in the frequency of breastfeeding – and hence in its effect on the amount you produce. Expressing 30 ml 8 times will result in an increased amount of breast milk after a few days because the breasts are stimulated frequently, whereas expressing 60 ml 4 times can lead to a gradual reduction after a week or two (or even faster).

How should I express breast milk?

It is important to choose the way that is most convenient for you and gives the best result. You can either use a breast pump or express by hand. You need to try to see what will be most appropriate for you.

How long and how much should I express?

With a little practice, you will quickly learn to understand when your breasts are fully emptied. At first, while still building a routine, you can follow these steps:

• Wash your hands thoroughly with soap and water
• Wash your breasts according to the instructions given to you at the hospital.
• If you want, you can apply a warm moist compress for several minutes
• Massage, caress and stimulate the breast for a few minutes
• Start draining the first breast
• When the milk flow decreases to drop, start draining the second breast
• Once again, massage, caress and stimulate the nipples
• Go back to the first breast – milk should flow again, though less and for a short time
• Drain the second breast in the same way
• If necessary, repeat the whole procedure
• If you need to increase the amount of milk, continue to drain each breast for another 2-3 minutes although you get only drops.

After a good expression, the breasts feel relieved and softened. There are no painful lumps or hard areas sensitive to pressure (on the side of the breast the mammary gland expands most rapidly so there are always tough and hard patches which, however, are not painful when the breast is emptied).

In the beginning, while your breasts are not yet used to responding to the pump and while you are looking for the best technique, expressing will probably take a long time – about 45-60 minutes. After building a routine, for most women the whole procedure of draining both breasts by hand or by a single pump takes about 30 minutes. An electric pump, which allows you to drain both breasts at the same time, can reduce the time needed to about 15-20 minutes per session and generally stimulates breast milk production to a greater extent due to the simultaneous stimulations of the breasts.

The important thing in the first month is to express breast milk at least 8 times per day, always until both breasts are fully emptied. Ideally, your goal 10-14 days after delivery is to produce 600-700 ml of breast milk (900-1000 ml if you have twins) per 24 h.

When you reach this amount and keep it steady for about a week, you can try to see if you can maintain it with 6-7 expressions a day – it is usually possible for most mothers. Depending on how early the baby was born and what his/her condition is, the baby may be home by this time and help you maintain your breast milk supply through sucking.

Expressing breast milk is difficult and takes an awful lot of time – how to do it easily and efficiently?

Expressing breast milk is not an easy job and despite your strong motivation and desire, it quickly becomes tedious and difficult. Therefore, it is important to find a way to do it in the most efficient way. This will help shorten the duration of the sessions.

Your breasts are programmed to release milk in response to the various sensations caused by the baby’s touch, wet mouth and sucking movements, as well as the rush of hormones, which occurs in your body when you simply take your baby in your hands. All this is infinitely different from the cold plastic of the pump, the stress connected with the need to express and the concerns how much you will be able to express. Therefore, it is quite normal that your body may not respond to the pump very enthusiastically at first.

Expressing breast milk is not in your nature – it is a skill, which along with a purely physical dexterity and understanding of the operation of the pump, requires the creation of a certain emotional attitude and habits concerning the facilitation of the release of breast milk in order to make the pumping successful.

The following can facilitate the expression of breast milk:

Physically:

• A warm moist compress on the breasts 10-15 minutes before expressing
• Breast massage
• Nipple stimulation
• A glass of fluid (especially a warm soothing tea, e.g. linden or chamomile)

Mentally:

• Meditation
• Relaxation techniques
• Breathing techniques (yes, the same you learned when preparing for delivery)
• Visualisation (imagine certain things, especially running water, a river, a waterfall)
• A photo of your baby
• Baby’s clothes that smell of him/her
• A record of your baby’s cooing and crying (on your phone)

The creation of a routine in the preparation for expressing breast milk will help you immensely. The hormone oxytocin, which is needed to trigger the milk flow and to empty the breasts properly, can be stimulated successfully with physical as well as with mental and emotional stimuli.

If you regularly do the things that are most successful specifically for you, especially when done in the same sequence, this will create not only a physical, but also a mental attitude. It will allow you to trigger the oxytocin easily and release the breast milk. This requires time and patience – but usually in about a week your body will begin to respond automatically to these stimuli.

Do not be discouraged if at first you only express 10-15 ml and it seems like that is all. The vacuum of the pump sucks only the milk that is located directly behind the areola. For the full draining of the breast, it is necessary to excite the reflex ejecting the milk located in the upper parts of the breast.

Stimulating the let-down reflex

It is no coincident that oxytocin is called the love hormone – it is stimulated by a variety of physical interactions (e.g. a hug, a touch), as well as by stimulating the nipples.

Breast massage and the gentle teasing of the nipples will cause oxytocin release and will facilitate pumping.

Breast massage

• Place your fingers on the upper part of the breast.
• Press toward the chest so that you can feel the pressure – but not pain!
• Massage gently in a circular motion round the breast

Caressing

Try the different options to decide which of them feels best for you

• Using your fingers caress your breast from the top toward the nipple
• Gently move your fingertips from the top of the breast to the nipple
• Bend your hand into a fist and using you knuckles caress toward the nipple

Nipple stimulation

• Hold the nipple at its base with the thumb and forefinger
• Rhythmically squeeze between the fingers several times, making sure to do it gently and tenderly
• Tease the nipple by gently pulling it forward (particularly useful with poorly shaped nipples)

Remember – your goal is to encourage your breasts to release the milk and not to mistreat them! After the massage, the skin of the breast should have a normal colour and not be irritated or chafed.

The duration of the massage, caressing and nipple stimulation usually takes 2-3 minutes for both breasts.