Establishing a milk supply

How do I establish my milk supply?

To establish a milk supply and ensure there will be enough milk for the baby, it is important to stimulate the breasts by removing colostrum as soon as possible after delivery, ideally within one hour and no later than six hours after delivery. Colostrum or milk should be removed at least seven times each day afterwards. The best way is to breastfeed but sometimes that is not an option. Mothers then need to replace breastfeeding with expression. Expression using the hands (manual expression) for ten minutes followed by pumping with a double electric pump for ten minutes should be used until the milk has come in, usually on Day 3 or 4. Manual expression alone may be effective, but combining the methods seems to result in more milk and milk with more fat. Once the milk is in, most mothers stop manual expression and just continue to double pump. However, if manual expression gets more milk, they can use this without pumping.

A) Describing establishing the milk supply

The long-term milk supply depends on effective removal of milk from the breast in the hours and days after birth. During this time, the breast is programmed to produce milk.

The best way to establish a milk supply is to

If breastfeeding is not an option, mothers then need to replace breastfeeding with effective expression to establish and support the milk supply.

Expression should be done within six hours of delivery and ideally within one hour (Crowe 2020; Fok 2018; Parker 2015). Delaying the first expressing may reduce the eventual amount of milk that a mother will produce (Maastrup 2014; Parker 2019). Regular expression at least 7 times each day is similarly important (Parker 2020).

B) How to establish a milk supply using expression before the milk has come in

If your newborn baby is hungry after breastfeeding, cannot breastfeed or breastfeed effectively, or if you are using a nipple shield to breastfeed, consider starting to express as soon as it is clear there is a breastfeeding challenge, and ideally within one hour of birth:

  1. Feed the baby:
    1. Offer the breast alone or with a nipple shield. 
    2. Supplement the baby with milk following the baby’s hunger signs if:
      1. The baby is hungry after breastfeeding.
      2. The baby is hungry after breastfeeding with a nipple shield.
      3. If the baby cannot breastfeed effectively or often enough or breastfeeding is not an option.
      4. The baby shows other signs of not taking in enough milk.
    3. Use expressed colostrum or breast milk for the baby’s supplement, or if neither is available, another appropriate milk.
  2. Manually express each breast for 10 minutes.
  3. Pump both breasts for 10 minutes with a double electric pump
  4. Store expressed colostrum or breast milk in a refrigerator for the next feed. Unused colostrum or milk can be frozen.
  5. Repeat each step every time the baby feeds, so that the baby is fed and the breast is stimulated at least 7 times in 24 hours.

This whole process of breastfeeding, supplementing, and breast expressing should not take more than one hour. Make sure that your process is effective. For example, other caregivers can supplement the baby while the you express.

Unless the baby is breastfeeding effectively, supplementing the baby and manual expression followed by pumping should continue for the first two to four days after delivery until the milk comes in. The baby’s growth should be monitored to ensure the baby has not lost too much weight.

Mothers who find that pumping is much more effective than manual expression in obtaining colostrum, can stop manual expression and just pump.

Some babies have a longer sleep at night, but it should not be more than five hours.

Breast compression while pumping can help in obtaining more colostrum.

C) Reasons for using both manual expression and double electric pumping

We recommend regular expression using both manual expression and pumping with a double electric breast pump until the milk has come in.

There is some evidence that manual expression alone is effective at establishing a milk supply (Becker 2016), but combining manual expression and pumping seems to result in more milk production (Alekseev 1998; Morton 2009). There is also evidence that combining the methods produces milk that is higher in fat (Mangel 2015; Morton 2012).

Manual expression may be more effective at getting the small amounts of colostrum (Ohyama 2010). Pumping for short periods can compensate for poor manual expression technique and get the nipple used to being manipulated.

D) How to maintain the milk supply using expression once the milk has come in

As the milk comes in on Day 2 to 4 after delivery, the colostrum changes to milk and the amount of expressed milk increases dramatically. 

At this time, if the baby is not breastfeeding effectively or using a nipple shield effectively, most mothers stop manual expression and just continue to double pump after each of the baby’s feeds. However, if manual expression gets more milk, they can use this without pumping or they can use a combination of both. Using a single pump is much more time consuming. 

The breasts should feel soft and emptied after expressing. Engorgement is a sign of ineffective milk removal and must be treated. There are a number of approaches to increase the effectiveness of expression.

By 14 days after birth, expressed milk amounts are ideally more than 500 millilitres (17 U.S. fluid ounces) a day.

References

Alekseev NP, Ilyin VI, Yaroslavski VK, et al. Compression stimuli increase the efficacy of breast pump function. Eur J Obstet Gynecol Reprod Biol. 1998 Apr;77(2):131-9

Becker GE, Smith HA, Cooney F. Methods of milk expression for lactating women. Cochrane Database Syst Rev. 2016 Sep 29;9(9):CD006170

Crowe SD., Miller H, Faulkner B.  Use of Hand Expression of Breastmilk Within First Hour of Delivery to Increase Exclusive Hospital Breastfeeding Rate. Obs Gyn 2020;135(5):167S 

Fok D, Aris IM, Ho J, et al. Early initiation and regular breast milk expression reduces risk of lactogenesis II delay in at-risk Singaporean mothers in a randomised trial. Singapore Med J. 2018 Jun 7
 
Mangel L, Ovental A, Batscha N, et al. Higher Fat Content in Breastmilk Expressed Manually: A Randomized Trial. Breastfeed Med. 2015 Sep;10(7):352-4
 
Maastrup R, Hansen BM, Kronborg H, et al. Factors associated with exclusive breastfeeding of preterm infants. Results from a prospective national cohort study. PLoS One. 2014 Feb 19;9(2):e89077
 
Morton J, Hall JY, Wong RJ, et al. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol. 2009 Nov;29(11):757-64
 
Morton J, Wong RJ, Hall JY, et al. Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. J Perinatol. 2012 Oct;32(10):791-6
 
Ohyama M, Watabe H, Hayasaka Y. Manual expression and electric breast pumping in the first 48 h after delivery. Pediatr Int. 2010 Feb;52(1):39-43
 
Parker MG, Melvin P, Graham DA, et al. Timing of First Milk Expression to Maximize Breastfeeding Continuation Among Mothers of Very Low-Birth-Weight Infants. Obstet Gynecol. 2019 Jun;133(6):1208-1215

Parker LA, Sullivan S, Krueger C, et al. Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med. 2015 Mar;10(2):84-91

Parker LA, Sullivan S, Kruger C, et al. Timing of milk expression following delivery in mothers delivering preterm very low birth weight infants: a randomized trial. J Perinatol. 2020 Aug;40(8):1236-1245