Breastfeeding… Do I need to express my milk?
Navigating motherhood for the first time is often overwhelming, especially when trying to get breastfeeding off to the best start for you and your baby.
“Do I need a breast pump?” or “How does breastfeeding even work?” are typical questions that I often receive as an in-home Lactation Consultant (IBCLC), so I wanted to break some of these down for you.
Do I need to buy a breast pump?
I am often consulted about what type of breast pump to buy as if all mums-to-be think that it is an essential item that must be on their shopping list. My answer is almost always “your baby will be your best breast pump”. This generally results in a very confused look from Mum until I explain to them the basic principles behind demand = supply. These principles should be the very foundation of ANY education regarding Breastfeeding. Sounds simple enough?
How does breastfeeding work?
The milk made in the first days is called Colostrum and on average if a baby has a really great breastfeed, they only require approximately 5 -7mls to fill their newborn tummies.
During the first few days after birth, your baby should demand the breast very frequently. This often leaves parents feeling concerned that baby is not getting enough milk however, this is the way nature works. The more your baby feeds, the more your body is able to establish its natural milk supply. If your baby is sleepy at this stage of life, you need to wake them and encourage feeding or hand express your milk (more on that later).
You want to make sure that your baby has access to the breast each time they show a feeding cue - turning their little head, open mouth, sucking etc. This will be frequent and this is exactly the way it should be. The more we offer the breast and the breasts are stimulated by feeding, the more milk Mum will make.
All of those frequent early feeds help to bring your milk in. A few days down the track, this can result in very full breasts making optimal attachment difficult. This frequent feeding, accompanied by a high amount of postnatal hormonal will result in a plentiful milk supply.
There can be instances where baby is happily lapping up all of this milk from a very full breast, but Mum is not quite so happy if baby is attached incorrectly causing nipple pain and damage. Suddenly all that was learnt during the 1st day or so after birth does not quite work at home with some now very full breasts! This is an all too common scenario and has poor mums reaching for nipple creams, shields, pumping milk and giving it by bottle or on their worst days , throwing in the towel.
There is a very simple solution to this problem. Your baby and your body have done amazing work establishing your supply. Now you are at the stage where regulation of supply needs to occur. This is where the art of hand expressing comes into play. Some of you may have mastered this in the Prenatal period and expressed drops of your colostrum. The only difference is now when you hand express, you will get squirts of milk rather than just drops…
Hand expressing your milk
Why might I need to hand express my milk?
It may be suggested by your Health Care Professional (HCP) to do some Pre/Antenatal expressing of your colostrum from around 36-37 weeks gestation. This can result in colostrum being stored away in case it is needed for baby after birth. This is often referred to as “harvesting your colostrum.” To learn more about Prenatal/Antenatal Expressing click here.
If your baby does not attach to the breast, is born premature, unwell, requires extra fluids or has a difficult birth he/she may take some time to start breastfeeding well. If your baby is still not breastfeeding after around 48 hours, this is when you might need to introduce a breast pump.
To give your breasts some extra stimulation after a breastfeed, helping your milk to come in. This will also provide extra colostrum for your baby which may be needed for numerous reasons.
To manage full breasts once your milk has come in. A few minutes to soften the full breast and the area around the nipple and areola will then make attachment much easier. This results in a more optimal, deep attachment and adequate draining of your full breast meaning less discomfort/damage to the nipples. Adequate drainage of the full breast prevents blockages that may go on to become mastitis. Click here to read more.
Hand expressing is preferable to using a pump to manage full breasts. Women who express large amounts of milk when they are very full do not understand that this then sends a signal to the body to continue making excess for baby’s needs.
When your breasts are full and baby feeds only on one side and has had enough. Hand expressing a small amount from the side baby did not feed on to aid your comfort levels. During babies’ next feed, make sure to go to the side you just hand expressed a little bit from to help regulate your milk supply.
When you might need a Breast pump..
If your baby is still not breastfeeding after 48 hours you should begin using a “hospital grade” pump at least three hourly. These pumps work like the baby would in establishing supply if you are using them in the correct manner. Hospital-grade pumps may be available for hire locally through your hospital, local ABA branch or pharmacy. An IBCLC can assist with the correct sizing of the equipment you require to express, often pumps are sold or hired as a “one size fits all”. Correct sizing is extremely important as too big or too small can result in problems such as mastitis and poor drainage of the breast, damaged nipples, and inadequate milk supply to name a few. You may like to print off my measuring tool and use this to determine your correct flange size
If your baby is born prematurely, he/she may take a while to get the hang of breastfeeding. If your goal is to breastfeed you will need to continue to pump to provide your milk for your baby and maintain your supply. Most hospitals that have a Neonatal Nursery will allow the use of their hospital grade pump. Ask to see the IBCLC on staff to assist with set up as they are usually available in public hospitals.
If you wish to increase your milk supply. In this case, you would be breastfeeding your baby, pumping for extra stimulation and providing your extra milk to your baby. This is usually short term and more economical to hire a hospital grade pump rather than purchase your own.
Breast pumps for sale in pharmacies and other stores are usually not hospital-grade and will not establish or “bring in” your milk supply like a hospital-grade pump will. Consult your IBCLC to ensure you are fitted for the correct size for you as this has an effect on how well the pump stimulates your breasts and the amount of milk obtained.
Want to know more?
It is important to note that the best removal of milk from the breast comes from your well-attached baby. After all, that’s the way nature designed things. So, expressing even with a hospital grade pump is not an indication of supply, your well-attached baby will always get more milk than what you would express.
I recommend learning the art of hand expressing and how your breasts work, well before your baby arrives, this can help to get things off to the best start possible. If you find that you do need to use a hospital-grade pump it is a good idea to make contact with an In-Home Lactation Consultant (IBCLC).
You will make lots of purchases preparing for the arrival of your baby. Instead of spending money on a breast pump, you may not ever need why not invest in an appointment with an In-Home Lactation Consultant? I encourage you to make a Prenatal appointment or look at the packages that might suit you by checking out my services page. Studies show * that being prepared can set you up for better feeding outcomes. I look forward to helping you feel as well prepared as possible before you welcome your little one.
*Blixt I, Johansson M, Hildingsson I, Papoutsi Z, Rubertsson C. Women's advice to healthcare professionals regarding breastfeeding: "offer sensitive individualized breastfeeding support"- an interview study.Int Breastfeed J. 2019;14:51. Published 2019 Dec 16. doi:10.1186/s13006-019-0247-
Cluster Feeding Vs Low Milk supply
Firstly, it helps to understand the basics of demand = supply. The more your baby breastfeeds or the more your breasts are emptied, the more milk is made. We know that a healthy term baby as a newborn will feed on demand very frequently until milk supply is established, this time can vary from a few days to a week. It is dependent on how often and how well the breast is emptied. Once that supply is established, for a short time, there can be too much milk. Then usually with easier access to more milk volume, and your baby’s tummy capacity becoming larger, the time between breastfeeds lengthens. If baby continues to breastfeed on demand, milk supply will regulate.
Cluster feeding is when a baby wants to breastfeed frequently. This can be over several hours. It often happens in the late afternoon or evening but can be any part of the day or night. It can seem like the breasts feel “empty” and your baby is feeding, not settling and then showing feeding cues again after a short time. This can feel exhausting. Rest assured that when breasts are emptier, production increases. The fat content of the milk is low when the breast is full and high when the breast is drained. The average 24-hour fat consumed by the infant is not related to the frequency or length of breastfeeds
Breastfeeding this way is a completely normal. Babies do this to naturally continue to drive milk supply to meet their growing needs.
Signs of cluster feeding:
Breastfeeding very frequently over a few hours somewhere in a 24-hr period
Can occur at certain predictable times of day
Mostly content & settled between feeds outside this time
Gaining weight and growing well
Adequate Output: > 5-6 heavy wet disposable nappies in 24hrs (after 5 days of age) Urine should be pale and odourless. In the 1st 6 weeks of life after milk transitions, bowel actions should be 2 or more soft loose mustard (sometimes green, brown, orange) *after 6 weeks bowel actions can be variable*
Can sometimes occur when: it is warm weather, if baby is unwell, or if there has been a recent healthy growth period (almost like they have put their order in for more milk please!)
What to do:
Feed on demand
Stay hydrated
Try to rest when you can
Remember this is how your baby naturally increases your milk supply
Topping up with large volumes regularly instead of allowing baby to cluster feed means less stimulation to the breast which can then decrease your milk supply
Low Milk Supply
What it is:
This is when your body isn't producing enough milk to meet your baby's needs consistently.
Why it happens:
It can be due to many reasons some of which include:
Not breastfeeding/emptying the breast frequently enough
Poor attachment/expressing with ill-fitting equipment
Topping up/supplementing early and often
Conditions for Mum which can include large post birth blood loss, hormonal imbalances, retained placenta, insufficient glandular tissue (IGT)
Conditions for Baby which can include jaundice, prematurity, infection, oral restrictions
Certain medications or birth control
Signs of low milk supply:
Baby isn’t gaining adequate weight
Baby seems persistently fussy or unsatisfied after feedings (not just at certain times).
Fewer than 5-6 heavy wet nappies per day after day 5
Short or very sleepy feeds that don’t seem effective (watch for signs of letdown, strong suck and swallowing sounds)
Little breast fullness or changes during feeding (breasts should feel softer post feeds)
What to do:
·See an IBCLC- this is a common issue that we provide support with
· Ensure proper latch so that there is adequate stimulation and emptying of the breast
· Breastfeed/express frequently- you may be advised to feed/express at least 3hrly if your baby is not demanding before this time
· Breastfeed/express at night when milk making hormones such as Prolactin are at their highest concentration
· As well as Breastfeeding, express after feeds for extra stimulation of the breast
· If you are expressing after feeds or exclusively expressing it is essential for you to have the correct size flange/flange insert as this will empty the breasts more effectively. Poorly fitting equipment can decrease milk supply and cause damage to your nipples
· Rule out any medical causes with your IBCLC
· Medication (Domperidone) may be option- discuss this with your IBCLC
· Eat a healthy well-balanced diet and drink to thirst. Whilst breastfeeding can increase your thirst, there is no evidence to suggest that increasing mum’s fluids will increase supply
· A breastfeeding plan such as “triple feeding” where there is a breastfeed, a top of breastmilk/formula and then expressing will require close monitoring including regular weigh ins for your baby on the same consistent set of scales for true accuracy
·Increasing the number of feeds and ensuring your baby attaches correctly and draining off the breast well are fundamental to increasing supply
References
Brodribb, W. (2012) Breastfeeding Management in Australia, Australian Breastfeeding Association.
Lauwers J & Swisher A (2021) Counseling the Nursing Mother- A Lactation Consultant’s Guide, Jones & Bartlett Learning.
Leanne O’Connor is a Registered Nurse/Midwife of 25 years and an IBCLC since 2018. Phone/virtual consults are also available. Leanne was inspired to become an IBCLC after experiencing feeding challenges with her own 3 children now aged 20, 17 & 14yrs.