General Information about expressing

Often it takes time and patience to learn how to express successfully, a skill that is both about the physical method of expressing and the mental or emotional aspect.

Do not be discouraged if you do not express much milk when you first try expressing – with practice it usually gets easier.

Some points to remember:

• The amount of milk you can expressdoes not indicate how much milk you are producing. Some women find expressing difficult to begin with, even if they have an abundant milk supply.
• The amount of milk you can expressdoes not indicate how much milk your baby is getting from the breast during breastfeeding. Well-latched babies are very efficient at removing breastmilk from the breast and often get 2 – 3 times more milk than a mother is able to express.
• It is advisable to only attempt expressing when one is unhurried and in a relaxed state of mind.
• Expressing should not be a painful procedure.
• Always wash your hands before expressing or handling containers or feeding equipment.
• You can express milk by hand, or by using a manual or electric breast pump.
• Breast pumps, containers and feeding equipment should all be sterilised.

Expressing Options

It is a matter of preference whether you express by hand, using a manual pump, or an electric pump.

Read more for information about which option might suit you best, including what is recommended for different stages, e.g. for the first few days after birth, or when you have a baby in hospital, or are going back to work.

Safety Considerations

Breast pumps are intended for only one user unless they are specifically manufactured in a way that makes them safe for multiple users each using their own, new attachments. There are health risks to your baby if you use a second hand breast pump.

It is important that you clean and sterilise your breast pump properly, according to the manufacturers instructions. Read more about the different sterilisation methods

Expressing By Hand

The first day: Should your baby be very sleepy, or too small or ill to breastfeed, it is recommended that you start expressing colostrum (the first milk) as soon as possible after your baby’s birth. Expressing by hand enables you to catch every drop of precious colostrum for your baby. A clean teaspoon or syringe is ideal for this purpose.

After the first day or two, when there is more milk you could express into clean, sterile containers with lids.  Wash and dry your hands well. It isn’t necessary to wash your breasts or nipples, a daily bath or shower is sufficient.  To build up and maintain a good milk supply it is essential to express 8-10 times a day.

Preparing to express: It can be helpful to sit in a comfortable chair to express, perhaps with a cup of tea to relax you, and to put a warm cloth over the breasts before expressing. The shower or bath may be a good place when attempting to express for the first time. Massage the breast towards the nipple with soapy hands. If you are not with your baby, perhaps at work, you could have a photo handy or think about your baby.

Method:

• Place your thumb and index finger behind the areola (brown area around the nipple), at the 6 and 12 o’ clock positions.
• Press slightly backwards then together and forwards as though massaging the palpable breast tissue behind the areola, release and repeat.
• Develop a rhythm.
• A wide mouthed sterile container is easiest to express into.
• It may take a minute or more before milk becomes visible.
• Once the flow slows down, move your fingertips to the 3 and 9 o’ clock positions and repeat.
• Change to the other breast when the flow slows or stops and repeat the whole process.

Do not expect an instant result, practise makes perfect.

Do keep in mind that babies are able to drink 2 to 3 times more than most moms can express.

Breast Pumps – Information & Safety:

Manual or Hand Breast Pumps

Hand/Manual Pumps are meant for individual use only.

Second hand, borrowed or hired pumps should never be used as there is a risk of passing on viruses not destroyed by sterilisation.

Various models of hand pumps are available from a number of manufacturers and individuals may have their preferences regarding which hand pump they like.

The bulb-and-funnel pumps are not recommended as they are difficult to clean and sterilise.

All pump parts must be sterilised according to the manufactures instructions. It is important that the pump isfully dis-assembled for washing and sterilising.

It may take some time and practice before you are able to express a significant amount.

Electric Breast Pumps

Most electric pumps function by suction and milk can enter the motor as these motors are not sealed, making them impossible to sterilize adequately.

Such pumps are strictly for individual use only and should not be shared, hired or bought second hand.

Only electric pumps that have a totally isolated motor, and no connection between any tubing and the motor, are suitable for multiple use (e.g. the Medela Lactina). These pumps are suitable for hire provided individual users buy their own kit (tubing, piston apparatus and bottles) to use with the pump. The kit can double up for use as a manual pump or be upgraded to an electric pump.

Single breastpumps (expressing from one breast at a time) or double breastpumps (expressing from both breasts at the same time) are available. Double pumping decreases the amount of time spent expressing and can increase the amount of milk expressed.

Which breast pump might I need and when?

For the first 12 to 24 hours it is preferable to hand express if expressing is necessary, even if you own a breast pump. This is because the first few precious drops or teaspoons-full of colostrum will be lost in your pump. Rather hand express and collect this colostrum in a sterile teaspoon or small syringe, ready to feed to you baby.

For short term expressing a hand pump may be all you need. It is however essential that you purchase your own new pump and not borrow or buy a second-hand one. There are health risks associated with using a second hand pump. While in hospital ask the staff about cleaning and sterilizing your pump and always follow the manufacturer’s guidelines.

If your baby is very small and you need to express for longer than a few weeks, you could consider a portable electric breast pump. Most electric pumps function by suction. As these motors are not sealed, it is possible for milk to enter the motor. These pumps are therefore strictly for individual use only and should not be shared, hired or bought second-hand.

Portable electric pumps are also a good option if you are returning to work and would like to continue breastfeeding.

Some hospitals will have a multi-user electric pump (Medela Lactina) available for you to use while you are in hospital and Medela Lactina multi-user pumps are also available to hire. This is the only multi-user electric pump available in SA. It is essential however that you purchase your own kit (Lactaset) to use with it. The Lactaset can also be used on its own as a hand pump. It is worth buying your own even if you are offered the option of a kit that has been autoclaved.

When considering how much you want to spend on a pump, keep in mind that most pumps cost no more than three or four week’s supply of formula.

Risks associated with second hand breast pumps

In South Africa, all the hand breast pumps and all the electric breast pumps available except one (the Medela Lactina) are for a single user only.

Breast pumps (other than the Medela Lactina) are strictly for individual use only and should not be shared, hired or bought second hand as there is a risk of passing on viruses not destroyed by sterilisation.

There is only one multi-user pump available in South Africa (the Medela Lactina) and it has a sealed motor, unlike most other electric pumps. Most electric pumps function by suction and milk can enter the motor as these motors are not sealed, thus creating the risk of transmission of infection.

A multi-user pump (the Medela Lactina) is available to hire (see useful contacts page) and for use at some hospitals. It is essential however that each |Medela Lactina user purchases her own kit (Lactaset – containing tubing, etc) to use with the multi-user pump. A new, unused kit is preferable to a second hand kit that has been autoclaved. The Lactaset can be used on its own as a hand pump too.

As stated in the ‘Breastmilk Protocol for Premature and Sick Babies in Hospitals and Clinics of April 2002′, Prof G. Kirsten Head of Neonatology, Neonatal Intensive Care Unit, Tygerberg Hospital and Prof M. Cotton, Paediatric Infection Specialist Tygerberg Hospital insist that individual user breast pumps or their attachments cannot be shared under any circumstances.

Cleaning and sterilising breast pumps.

Please note: Second-hand or hired breastpumps are not recommended, with the exception of the Medela Lactina multi-user pumps if each user has her own attachments unused by others.

• Fully disassemble pump – including any valves or washers.
• Valves and washers mustbe removed for washing and sterilising – see pump instructions.
• Wash all separate pump parts in hot soapy water.
• A syringe can be used to squirt water to rinse and soapy water to clean inside any tubing.
• Rinse and sterilise as stipulated by the pump manufacturer.
• Ensure tubing is filled with water for sterilisation by boiling or steaming, or with sterilising solution.
• Avoid sterilising solutions where possible. Boiling or steaming pump parts is preferable and more effective.

Sterilisation methods

Cold Sterilisation Method

Chemical sterilising solutions can be used according to manufacturers’ instructions. The sterilising solution container must be washed thoroughly every 24 hours and filled with fresh solution. All objects to be sterilised must be submerged and filled with the solution (e.g. fill tubing) for a minimum of 15 minutes.

After sterilising, all equipment and containers must be rinsed with boiled water.

Please note: For breastmilk donation, it is recommended that chemical sterilising solutions be avoided if at all possible.

Steam and Microwave Sterilisers

Can be used provided it is recommended by the bottle and pump parts manufacturers. Use strictly according to manufacturer’s instructions.

Boiling

Boiling the items for 10 minutes is the method of choice, provided it is recommended by the pump parts manufacturers.

Boiling is the cheapest and the most effective method of sterilising.

Ensure that all objects, including tubing, remain submerged and are filled with water while being sterilised. It is advisable to set a suitable saucepan and lid aside for this purpose. Always use a timer.

Expressing for Donation

If you are considering becoming a Milk Matters breastmilk donor, you probably have a few questions to ask about expressing your milk and the donation process.

Will I have enough milk to donate?

• By expressing extra milk for another baby, you will not deprive your baby in any way – in fact, expressing will increase your milk supply.
• Please do not put your own baby onto formula in order to donate milk – your baby comes first and needs your milk!

How do I become a donor?

• Contact us and we will ask you to fill in a Screening Form.
• An initial HIV and Hepatitis B blood test, done at no cost to the donor, is also required.
• Long-term donors will be requested to repeat the HIV test.

Will my donated milk be sold?

• A processing fee is charged to the hospital using the milk to partially cover the cost of collecting, screening, pasteurising and dispensing the donor milk. The milk itself is not sold.

How do I express milk?

• Always wash your hands well before expressing.
• Hand expressing is recommended.
• If using a pump, fully disassemble all the pump parts, wash and sterilise before each pumping session.
• Second-hand or hired breastpumps are not recommended with the exception of the Medela Lactina multi-user pumps if each user has her own attachments unused by others.

How do I clean and sterilise my pump?

• Fully disassemble pump – including any valves or washers.
• Wash all separate pump parts in hot soapy water.
• Rinse and sterilise as stipulated by the pump manufacturer.
• Avoid sterilising solutions where possible. Boiling or steaming pump parts is preferable and more effective.

What containers can I use?

• Sterile glass or hard plastic (BPA free) jars with screw top lids are ideal and available from Milk Matters.
• Please do not use ice cube trays or plastic bags (unless designed specifically for breastmilk storage).
• We are unable to guarantee that your containers will be returned.
• Containers need not be full but a new container must be used each time you express.
• Please leave plenty of head space in the container for expansion when milk freezes.

How do I sterilise the containers?

• Containers that you receive from our depots are sterile.
• Should you need to sterilise your own containers:
  • Wash the jars and lids in hot soapy water and rinse well.
  • Submerge in a pot of water and boil for 10 minutes.
  • Sterilising solutions are not recommended.
  • Do not touch the inside of the containers and lids.

How do I store breastmilk?

• Please label the jars with your name / donor number and the date. Masking tape is ideal for labelling. Please do not write on the container itself.
• Place jar of expressed milk back in the small paper bag it was supplied in.
• Freeze milk immediately, upright if possible. If necessary milk may be kept in the fridge but must be frozen within a maximum of 24 hours of expressing.
• Milk needs to be kept separate from other items in the freezer to prevent contamination.

How do I get my milk to the milk bank?

• Transport your donor milk to the nearest depot, in a coolbox with ice bricks. Milk must always remain frozen.
• Please contact Milk Matters for details of the depots in your area, or to discuss alternative arrangements.

Please note:

Milk cannot be allowed to defrost at all and must always be transported in a cooler box with ice blocks.

For further information about donating breastmilk please contact Milk Matters:

info@milkmatters.org  /  021 659 5599  /  082 895 8004

Expressing for your Healthy Baby

Expressed breast milk has antibacterial properties and may be stored at room temperature in a clean closed container for up to 6 to 8 hours if kept away from sun and heat.  After this time it must be refrigerated. Alternatively, expressed milk could be refrigerated for up to 48 hours before being used or frozen.

Please note: should you be expressing for your premature baby in hospital, your expressed milk must be refrigerated within 2 hours if not used immediately. It can be kept refrigerated for up to 24 hours and can then, if not used, be frozen.

Should one be expressing at work for use the next day, it could be kept in a fridge or small cooler bag with an icepack. For more information about breastfeeding options and the working mother, see The Working Mother.

Always cool milk in the fridge before freezing. Beforehand, measure what volume each container takes, for example the 100ml level, and fill depending on your baby’s needs. Rather freeze in smaller quantities, than defrost more than your baby requires and land up discarding milk.

Always allow room for the milk to expand once frozen.

Seal and label the container of milk with the date that the milk was expressed.

Always use the oldest milk first.

Breast milk can be kept for 3 months in a front opening freezer or 6 months in a chest freezer.

Defrosting and warming expressed breast milk

Frozen breast milk should be defrosted by leaving it in the fridge overnight, standing it in a jug of lukewarm water or running lukewarm water over it. Do not defrost or heat it in a microwave or in boiling water as macrophages and nutrients could be destroyed. Milk that has been frozen and thawed can be refrigerated for up to 24 hours but should not be refrozen.

Once defrosted it could be warmed in a jug of warm water.

Defrosted milk cannot be re-frozen or re-used if your baby does not take it all at one feed.

Do not mix breast milk and formula together to feed to your baby.  It is better to give your baby breastmilk first and then if your baby needs more milk and no breastmilk is available, use formula as a ‘top up’. The objective is that your baby gets the maximum amount of breastmilk and as little formula as possible.

Breast milk does tend to separate and look curdled when defrosted or left standing. Shake gently and it will be fine.

Add in about ‘sour’ milk – lipase?? Common question/problem.

Containers:

• Glass containers such as baby food jars are preferable, especially if the expressed milk is to be frozen.
• Hard plastic BPA free containers could also be used.
• Some companies produce special plastic bags specifically for storing breast milk. Ordinary plastic bags are not suitable for freezing breastmilk.
• Hard plastic ice cube trays with a lid or covered in cling wrap can be used for freezing smaller volumes. Once frozen the milk cubes can be kept in a sterile container.

NB: Containers and feeding equipment must be sterilised and securely sealed to prevent contamination.

Expressing for your premature or ill baby in hospital

YOUR BREASTMILK IS BEST FOR YOUR BABY – KEEP IT SAFE!

You are probably aware of many reasons why ‘breast is best’ for your baby. These multiple advantages include both short and long term benefits for mothers and their babies. Do ask the staff at your hospital for assistance and information about breastfeeding your new baby.

Your breastmilk has even greater value for your baby if he is unable to breastfeed after birth because he is too sick, premature or of low birth weight. The staff at your hospital will encourage, support and show you how best to express your breastmilk for your baby.

Most importantly, you need to start expressing as soon as possible and frequently – about 10 times in 24 hours. Don’t delay even if your baby is nil per mouth at the time.

It is vital that you begin stimulating milk production and increasing your milk supply so that you can meet your baby’s needs for milk later on.

Some guidelines:

• Expressing by hand:
  It is preferable to hand express for the first 12 to 24 hours even if you own a breast pump. This is because the first few precious drops or teaspoons-full of colostrum will be lost in your pump. Rather hand express and collect this colostrum in a sterile teaspoon or small syringe, ready to feed to you baby. (See Expressing by Hand)

• Expressing using a pump:
  Once your milk supply has increased, you could purchase a pump. The type of pump may depend on how long it will be before your baby is able to breastfeed.

• Containers that can be used for storing your breastmilk:
  Glass and hard plastic BPA-free containers with lids are best for expressing into and storing breastmilk.

Label your containers clearly with your name, the date and time of expression. Staff will check these details before giving your milk to your baby.  The same can be done if your baby is left with a caregiver or is in a crèche.

• Storing your expressed breastmilk:

In a Neonatal Intensive Care Unit, your expressed milk must be refrigerated within 2 hours if not used immediately. It can be kept refrigerated for up to 24 hour but must then be discarded if not used. Alternatively it can be frozen within 24 hours.

A healthy baby’s milk can remain out the fridge for up to 8 hours and be refrigerated for 48 hours before being used or frozen.

You can safely freeze breastmilk for 3 months in a fridge freezer or 6 months in a chest freezer.

• Is breastmilk still best after refrigerating or freezing?

Yes it is. Formula milk feeding is associated with a 6 to 10 times higher incidence of the potentially fatal condition necrotising enterocolitis (NEC) in very low birth weight (VLBW) infants compared to those receiving breastmilk. Frozen, donated, pasteurised breastmilk is undoubtedly superior to formula milk when a baby’s mother’s own milk is not available.

In 1998 Tygerberg Hospital introduced an aggressive breastfeeding programme that included skin-to-skin care for babies less than 1800g. Mortality was decreased by 9%, the average hospital stay decreased by an average of 5 days and the overall cost saving to the hospital was R1,000,000. As the programme became more entrenched these figures continued to improve.  Consequently, many hospitals in both the public and private sector have adopted similar programs. The use of donor breastmilk from a breastmilk bank contributes significantly to the positive health outcomes of the very low birth weight babies.