Getting a let-down

How do I get the milk flowing?

A let-down moves milk from the milk sacs in the breast, where it is made, into the milk ducts and toward the nipple. It is important for effective breastfeeding and expressing. Many mothers have a let-down shortly after starting to express and have multiple let-downs during a session. Mothers who are not expressing effectively may need to increase and strengthen their let-downs. To do this, mothers need to make sure they are comfortable when expressing. They can stretch, relax, and block out noise. They may be able to stimulate a let-down by smelling the baby’s head, by looking at the baby, or having their partner stroke their back. They can try a warm compress on their breast or stimulate it with massage. They can adjust their techniques and use breast compressing or power expressing or consider switching from manual expression to pumping or vice versa.

A) Role of the let-down in expressing

To get milk out of the breast, mothers need the help of a let-down. It moves the milk from the milk sacs, where it is made, into the milk ducts and toward the nipple. Getting a let-down is critical for effective expressing.

The fingers and thumb then push the milk out of the ducts if mothers are using manual expression. If they are pumping, the pump creates a negative pressure (suction) outside the breast which pulls the areola forward and into the breast shield. The pressure from the increased contact with the shield and the vacuum causes the milk to flow into the pump.

Mothers can also use breast compression to push the milk out of the breast and stimulate further let-downs.

B) Effective let-downs

Mothers who express well will have a let-down shortly after starting to express and have multiple let-downs during each session. One study (Kent 2008) reported mothers have an average of five let-downs each pumping session, with the first being the largest.

If you are expressing well:

  1. The milk or colostrum flows fairly steadily with occasional faster and slower flows.
  2. You get the expected amounts of milk or colostrum.
  3. You can express within 20 minutes:
    1. On each side.
    2. In total, if you are double expressing.

If you are not meeting these goals, you may need to increase and strengthen your let-downs. There are several ways to do this. Every mother is unique, so it is not possible to predict which approach will be most effective. There many also be other barriers to getting milk from the breast.

C) Looking after yourself

Expressing can take a while. Make sure you are comfortable while expressing. Pain and stress can weaken or prevent let-down. Before expressing, consider the following options:

  • Take a bathroom break if you need one.
  • Find a comfortable, non-stressful place to express.
  • Have some drinking water available in your expressing area.
  • Reduce stress:
    • Treat your expressing time as a break from your busy life.
    • Relax (Mohd Shukri 2018).
    • Stretch tight areas of your body such as your shoulders and back.
    • Block out noise.
    • Ensure that you are not feeling hot or cold.
    • Make yourself smile even if you are not feeling happy (Neuhoff 2002).
    • Listen to music or relaxing audiobooks (Düzgün 2020).
  • Make sure your:
    • Hands are not cold if you are manually expressing.
    • Breast shields are not cold if you are pumping (Kent 2011).

D) Getting a let-down

You can stimulate the let-down in the following ways:

  1. Stimulate other parts of your body by:
    1. Having your partner lightly stroke or massage your back.
    2. Using a massage tool.
  2. Smell the baby’s head to activate areas of your brain (Lundström 2013).
  3. Look at your baby.
  4. If you are separated from the baby, you can smell an item of the baby’s clothing and look at a picture of your baby.
  5. Put a warm compress on your breast and nipple (Gardner 2019). If your breasts are larger, lean over and soak them in a bowl of warm water for a few minutes.
  6. Stimulate the breast for a few minutes using one or more of the following methods:
    1. Stroke the breast with an extremely light touch using your fingers or a slightly firmer item such as a comb or pencil.
    2. Lightly and repeatedly tap the breast with the finger tips.
    3. Gently massage the breasts starting at the ribs and moving gradually toward the nipple.
    4. Roll the part of the breast just behind the nipple (the nipple root) between your thumb and index fingers.
    5. If your breast are larger, bend forward and shake the breasts with your hands.

If your milk still does not flow well after trying some of the above, you can use breast compression or power expressing. You may also consider changing from manual expression to pumping or vice versa.

One study (Fewtrell 2006) on the use of oxytocin nasal spray to increase the amount of pumped milk showed no significant change in amounts. Another study (Ruis 1981) on it found an increase, but the study is older and looked at fewer mothers. We have not found oxytocin nasal spray useful.

References

Düzgün MV, Özer Z. The effects of music ıntervention on breast milk production in breastfeeding mothers: A systematic review and meta-analysis of randomized controlled trials. J Adv Nurs. 2020 Oct 10

Fewtrell MS, Loh KL, Blake A, et al. Randomised, double blind trial of oxytocin nasal spray in mothers expressing breast milk for preterm infants. Archives of Disease in Childhood Fetal and Neonatal Edition. 2006;91(3):F169-F174
 
Gardner H, Lai CT, Ward LC, et al. Thermal physiology of the lactating nipple influences the removal of human milk. Sci Rep. 2019 Aug 14;9(1):11854
 
Kent JC, Geddes DT, Hepworth AR, et al. Effect of warm breastshields on breast milk pumping. J Hum Lact. 2011 Nov;27(4):331-8
 
Kent JC, Mitoulas LR, Cregan MD, et al. Importance of vacuum for breastmilk expression. Breastfeed Med. 2008 Mar;3(1):11-9
 
Lundström JN, Mathe A, Schaal B, et al. Maternal status regulates cortical responses to the body odor of newborns. Front Psychol. 2013 Sep 5;4:597
 
Mohd Shukri NH, Wells JCK, Fewtrell M. The effectiveness of interventions using relaxation therapy to improve breastfeeding outcomes: A systematic review. Matern Child Nutr. 2018 Apr;14(2):e12563
 
Neuhoff CC, Schaefer C. Effects of laughing, smiling, and howling on mood. Psychol Rep. 2002 Dec;91(3 Pt 2):1079-80
 
Ruis H, Rolland R, Doesburg W, et al. Oxytocin enhances onset of lactation among mothers delivering prematurely. Br Med J (Clin Res Ed). 1981 Aug 1;283(6287):340-2