Establishing milk supply with a pump

There are several reasons milk supply may have to be established by expressing and not by directly breastfeeding. Mother and baby may have to be separated after birth due to prematurity or illness, or maybe baby just cannot latch on for some reason. Maybe baby is tongue tied, has a cleft palate or is too sleepy to feed effectively.

So how do you establish your milk supply if you are not directly feeding your baby?

After birth you should be encouraged to hand express colostrum within an hour of birth if possible, or at least within the first 6 hours. Ask to be shown the technique by your midwife, or there are plenty of great video tutorials online. This one from Global Health Media is particularly good, click here. It is important to massage the whole breast and the nipple for a couple of minutes before starting. Hand expressing is recommended for the first two to three days until the milk begins to come in as colostrum is very thick and sticky and is in small quantities, so will get lost in a pump. However, if large quantities of colostrum are being expressed, you could move onto the pump earlier. Also there are settings on some hospital pumps designed for expressing colostrum and some mums respond better to this. The pump can also be used just for stimulation.

Babies only need a small quantity of colostrum, so every drop counts. These small drops can be sucked up with a syringe direct from the nipple or dripped into a small cup and then sucked into a syringe. This can then be given directly to the baby. You should be encouraged to hand express 8 to 10 times in 24 hours to mimic the baby’s feeding patterns. This will give enough colostrum to feed and to prime the lactation sites so that you will have the greatest chance to make a full supply or as near as possible. Some mums do struggle to express any colostrum in the first few days. It does not mean it’s not in the breast, we all start making colostrum in the second trimester of pregnancy, but it can be a bit challenging to get it out. If it is proving difficult then maybe ask about donor breast milk until your milk “comes in”. Most mums find they can express mature breast milk much more easily.

 

 

lilli put pumping

Moving on to the pump. Milk begins to “come in” around 3 to 5 days after birth, a process called “lactogenesis II”. It is triggered by the birth of the placenta and will happen whether a mum is breastfeeding, pumping or doing neither. Breast milk gradually changes from colostrum to mature milk over a number of days and volumes should begin to increase. Continuing to pump 8 to 10 times a day will help ensure you establish a full supply.

Top tips to establish a good supply!

Frequency – There really is no better way to get a full supply than to pump frequently; 8 to 10 times a day to begin with is essential. Some mums with large storage capacities may be able to drop a couple of sessions and continue to make enough milk, but for many frequency is the key. Expressing sessions do not need to be equally spaced. And if you miss one for some reason, try to shuffle up the others so you still get the same number over 24 hours.

Efficiency – Using a hospital grade pump is recommended. In hospital the staff should be able to provide one for you to use, normally in the pumping room, sometimes by baby’s cot or incubator. Once discharged, hospital grade pumps can be hired either direct from the manufacturer or from a local pump agent. If baby is in NICU there is often a discount code.

Breast shell size – It is really important to get the pump’s breast shell size correct. This will mean pumping should be comfortable and not cause any damage to the nipples, and it will also help maximise milk production. Just a note to say sometimes a pair of breasts need two different sized shells! And sometimes you need to change size as you go through your pumping journey as breast size changes. Nipple diameter is the key. Check your manufacturer’s information on this and experiment a bit.

Power pumping – This mimics a baby’s natural cluster feeding pattern and can help stimulate milk production. The pattern is as follows using a double pump: pump for 20 minutes, have a 10 minute rest, pump for 10 minutes, rest for 10 minutes and then pump for a further 10 minutes. This can be done once a day to help boost supply. If you are using a single pump then you can power pump by pumping 10 minutes on the left and then 10 minutes on the right, rest 5 minutes, pump 10 minutes on the left and 10 minutes on the right, rest for 5 minutes and then pump ten minutes on the left and 10 minutes on the right again.

 

power pumping

Hands on pumping technique – This is a technique which incorporates massage, hand expressing and pumping all at the same time. Many have found that this can greatly increase output. For a more detailed explanation watch this video

Hand expressing – after the flow has slowed you could try finishing off by doing some hand expressing. Often a little more can be squeezed out by hand

A hands free pumping bra – This can make the above massage much easier, as you use the bra to hold the pump onto the breasts and so hands are free. It also means you can pump and do other things at the same time. This can be essential, especially if you have older children. You can buy them or make your own by cutting vertical slots in an old bra or sports bra where your nipples are, and you can insert the cones through the slits.

Warmth – Applying a warm compress just before you express can help the let-down reflex.

Skin to skin with baby – Skin to skin, or kangaroo care as it is often referred to, helps boost oxytocin and encourages the milk to flow. Oxytocin is one of the key hormones involved in the production of breast milk and, amongst other things, stimulates the let-down reflex, meaning milk flows more easily when pumping.

Look at baby – Photos, videos, pictures, pumping next to the cot, listening to your baby. All these remind the breasts what they are supposed to be doing! They also stimulate oxytocin and help with supply.

Have something to remind you of the babies when you’re not there, photos, video, cloths that smell of them, some NNUs have fabric squares you can leave in the incubator with the babies and take home with you. Smell is a very evocative scent and this can help with bonding and milk supply!

Latch baby – If baby is beginning to latch on to the breast, pumping straight afterwards can make it much easier for the milk to flow as the baby will have stimulated the let-down reflex.

Distraction – “A watched pot never boils”. It’s the same with pumping. If you watch what you get, you will likely not get so much. Distracting with listening to music, relaxation recordings, mindfulness, watching comedy, chatting to other mums or friends and family all have been shown to increase milk production. Stress can inhibit the let down reflex so these techniques can help keep you relaxed.

Eat and drink – Good for health and energy of the mother, not necessarily for milk production.

Rest – It is really essential for mums to rest. Yes we also want them to wake once or twice a night to pump, but getting a good amount of sleep is so important to cope with the stresses and strains that you feel when a baby who is latching. Get help with all the usual household chores, looking after older children and cooking. Mother the mother so the mother is able to mother the baby.

Galactagogues – There are many foods or medications out there which either have some scientific evidence behind them or have anecdotal evidence that they can increases milk production. However, none of these work unless the milk is being removed frequently from the breast. They are not a magic wand. For more info on galactagogues have a look at this link
pump Sophie De Sousa expressed stash

It is important to look at 24 hour output, not necessarily what is expressed in each session. This is because there is often a wide variation in amounts from different times of day, and also each breast often gives a different amount. Over the first few weeks, we hope to see a gradual increase in volume in each 24 hour period.

Once babies are strong enough or well enough they should be able to move gradually on to breastfeeding directly. Make sure you seek some support from a trained breastfeeding specialist to help you achieve this.

Kathryn Stagg IBCLC 2018

 

Breastfeeding Triplets

Twins, I can understand twins, you have two babies, two arms and two breasts. The maths just works. But THREE babies! Where do you start with breastfeeding triplets? Joanne said: “My first thought when I found out I was expecting triplets was: “oh no I won’t be able to breastfeed them.” But after lots of research she found others have breastfed their triplets.

But why one earth would you even contemplate it? Well firstly there is obviously all the health benefits for mum and babies. And triplets are much more likely to be premature so these health benefits are even more important. But once breastfeeding is established, it is so easy. Don’t get me wrong, having triplets is hard, but it’s hard whatever way you feed them! Breastfeeding means feeds are always ready to go, no preparation, you won’t forget your boobs when you go somewhere, you don’t have to get out of bed to do the night feeds, and once they are older it is a really nice way to get some one on one time with crawling babies, and later there is no better way to subdue a tantrum! And it’s free! Although you may have an increased food bill due to how hungry it makes you! The reasons to breastfeed three babies are just the same as the reasons to breastfeed one or two.

I asked some of the triplet families on Facebook what would be their top tips.

Firstly, believe it is possible. Sue said “my body grew three babies, it can feed three babies”. And as with all breastfeeding, believing it is possible and trusting your body to produce what is needed is so important. As is having health care professionals who are on your side. Natasha said “I’d also recommend making connections with the hospital lactation consultant before your babies are due. Mine came and saw me 2 or 3 times a week when the boys were on SCBU and when we returned to our booking hospital 3wks after the boys were born she was there ready and waiting for me. We struck up a real friendship and she had my back the whole time. She was knowledgeable and empowered me to stand up to others who thought it wasn’t possible. She also helped educate me around bottles/dummies/kangaroo care etc which was great and helped me make informed decisions.”

The majority of triplets will be born early and end up in the Neonatal Unit. So mum should be prepared to start your breastfeeding journey with a breast pump, expressing every two to three hours round the clock to establish a copious milk supply. Once mum is discharged home she will need to hire a hospital grade double pump and continue this expressing pattern. We will shortly have a more in depth blog on pumping so watch this space! Once babies begin to feed at the breast, pumping can begin to reduce. Our other blog Transitioning a Premature Baby Onto The Breast is a good read of how to move from expressing for your babies to breastfeeding them when they’re discharged home.

Being educated in how breast milk production works is really important as mum will need to maximize her milk-making potential. For triplets the breasts receive three times the stimulation as from a single baby. This means the breasts are drained three times as often. This in turn promotes them to make three times as much milk. The more you feed the more you make. The hardest thing is finding the time to do this and some time to eat and sleep too! And you will be incredibly hungry. Breastfeeding one baby takes around 500 calories, so we can assume that three babies take 1500 extra calories! Having healthy snacks and lots of fluids will make you feel like you have enough energy to do this, although it probably won’t directly impact your milk supply.

Get support with positioning and attachment i.e. getting a good latch. For small babies it is so important to ensure they are latched on well so they can feed as efficiently as possible. They get tired very easily. Breast compressions can help get a bit of extra milk into them during feeding. Also vital for mum too as this will help prevent sore nipple and blocked ducts. When you are trying to feed three, you need to minimize the chance problems.

Some mums prefer to tandem feed two babies and then feed the third, rotating who gets the individual feed. Others prefer to tandem feed two and give a bottle of expressed to the third, rotating who gets the bottle each time. Or some prefer to breastfeed all three separately to get some individual time with each baby. Or maybe do more expressed feeds and less direct feeding. There is no right or wrong way to do this. It’s whatever suits you and your family best. And you can change what you do for different times of day or for different stages of breastfeeding. So keep an open mind and be flexible.

Many expectant triplet mums wonder how they will get the time to do everything. Will I ever sleep? The truth is you can’t do everything. So prioritize and delegate! If a mum is breastfeeding then she needs to prioritize that over everything else. Get help with all the things that anyone can do! Another pair of hands can be useful for general baby care; nappy changing, baths, feeding top ups, settling when they are cranky! Also help with the housework is a must in the early days. If family and friends can’t help out then it might be worth spending some of the money you are saving on formula on buying in some help. And the rule for visitors is that the must bring food and do one household chore before they are allowed a cuddle of the babies!

And of course if it all gets too much mix feeding is always an option. For example some triplet mums prefer to breastfeed two babies and formula feed the third, and then rotate. Or breastfeed one and formula feed two and rotate. Or use expressed breast milk and formula in bottles. Any amount of breast milk is incredibly valuable and should be celebrated.

To sum up Caroline commented: “All I would say is it takes patience and perseverance. You need a smile for those who say you can’t, and a finger for those who say you shouldn’t!” So if you have just found out you are expecting triplets, why not give it a go and see how you get on?

 

Kathryn Stagg, ABM BFC, 2017

Transitioning a premature baby onto the breast – a step by step guide for parents

When a baby or babies have arrived early, Mum often feel stressed and helpless and feel one of the few things they can do is to provide breast milk. Preterm breast milk is different to that of a mum who delivers at term. It has higher levels of energy, fats, protein, vitamins and minerals, and most importantly it has higher levels of immune factors. It is highly valued in the neonatal unit and mums are usually supported to hand express colostrum within the first 6 hours after birth, and then move onto the pump to provide breast milk for tube feeds. The hospital should be able to advise on renting a hospital grade double pump for when mum is discharged. It is important to pump frequently; we recommend 8-12 times in 24 hours making sure at least one is between 2-5am when hormone levels are at their highest. A more detailed blog on establishing milk supply is available here.

 But what next? How do we go about actually breastfeeding? Is it possible to move to exclusively breastfeeding when you have had such a traumatic entrance to the world? The answer is yes, but it will take time.

Once premature babies hit around 32-33 weeks gestation they often begin to start developing a suck, swallow, breathe pattern in short bursts and may start rooting for the breast. Hopefully you will have already been given the chance to have lots of kangaroo care with your baby before now, but at this point it can really help transition the baby from tube feeds onto breastfeeding.

Learning to breastfeed when you are a premature baby is a long, slow, tiring process and it requires everybody to have lots of patience. To start with babies can have skin to skin time, or kangaroo care, be encouraged to lick the nipple and if they are ready to possibly have a few sucks. A baby can begin with non-nutritive sucking at a recently pumped breast to provide a gentle experience without an overwhelming flow of milk. Then a fuller breast can be introduced. But at this early stage the majority of any feed will still be  expressed milk through the feeding tube. The staff will encourage you to try baby at the breast once or twice a day so as not to tire them out too much. Once they become stronger and start to suck and swallow more efficiently its time to move to more frequent feeds. It can be a good plan to try baby at the breast during their tube feed as they will begin to associate the act of breastfeeding with the feeling of having a nice full tummy. A nipple shield can help the smaller baby to latch onto the breast, especially if they have been given bottles. There is evidence that suggests shields can increase milk intake in preterm infants in the early days. Remember ask for lots of support from the hospital staff during this time. This is actually one of the benefits of having babies in special care.

When the babies appear to be feeding better and getting much more milk we can move on to the next stage. This can be at different ages for different babies. For some it can be around the 36-37 week gestation mark, others need to get to near full term. The hospital staff will help give confidence that it is time to move to the next stage. Whilst some babies will be able to move straight on to exclusive breastfeeding from tube feeding, this new enthusiasm for feeding can be a bit misleading as the suck can still be uncoordinated and inefficient and the babies can still tire easily. If we move on to exclusive breastfeeding too quickly, it can cause problems with babies not taking enough milk, becoming too tired and then starting to reduce their weight gain. So for many babies its advisable to continue to top up with expressed for a while. A lot of mums choose to top up by a different method than tube so the babies can get home. Hospital staff may use a tool like the Breastfeeding Assessment Score below to calculate how much top up to give baby. They will calculate to work out exactly how much milk  depending on baby’s weight, gestation, growth about how much a full feed is.

For twins and triplets it is important to remember that they are individuals. One baby may be much better at feeding than the other. It can be hard not to compare and be worried and frustrated  if one baby is not managing to feed as well. But, with time, it is very likely that they will catch up and both will feed well from the breast when ready. 

Generally hospitals prefer to use bottles to feed babies their top ups, or during the night when mum is not there. They are easier, there’s less waste and staff are pushed for time so go for the easier option. So to minimise the impact of using a bottle on breastfeeding, it is important to use a paced bottle feeding technique. Paced bottle feeding means letting the baby take control of the speed of the feed and when to take breaks and when to finish. Sit baby in an upright position and keep the bottle as horizontal as possible whilst still filling the teat with milk to avoid intake of air. Baby should be encouraged to latch on to the bottle like the breast, so touching the top lip to encourage baby to route and bring baby onto the bottle chin first, teat into the roof of the mouth. Stop frequently and make sure you do not force baby to have a certain amount. With this slower feeding technique, the baby will be able to tell it is full and finish the feed when satisfied. And baby will be more able to transfer  between bottle and the slower flow of the breast.

Mum and baby will hopefully be given the chance to ‘room in’ for a night or two before they are discharged. During this time they’re often encouraged to move on to more baby-led feeding as opposed to hospital routine based feeding. But babies can still be sleepy and not wake for feeds at this stage so its important to make sure that they feed at least every 3 hours as a minimum. 3 hours is measured from the start of each feed.

For a lot of preemie mums, their first experience of being at home with their early baby is to be in an intense breastfeed, top up, express routine, every 3 hours or more, day and night. This is utterly exhausting and overwhelming and mums can often not see past this stage. However with good feeding support from health visitors and breastfeeding specialists and the discharge team from NICU, mums can move on to exclusive breastfeeding.

Whilst the baby still needs top ups it is imperative that there should be somebody to look after mum. This routine is so full on that there is not much time for anything else, especially sleep! Somebody to do the top up whilst mum expresses can be a life saver as this can save time and could give mum half an hour extra break before she has to start the process again. Breastfeeding makes you hungry and for mum’s energy levels it is important that she eats properly, so having someone to feed her whilst she feeds the babies is a great idea. Every single breastfeed given and every single drop of expressed milk should be valued and encouraged. Emotional support reassuring her that she is doing a brilliant job and that soon it will become much easier can keep everyone going through this incredibly tough time.

Support can be invaluable at this time but a lot of mums feel unsure about taking their preterm baby out to groups due to risk of infections. This is where home visits from well informed health care professionals and good online support can step in. Online support especially can be great, as long as it is properly moderated, as mums can make contact with others who have been in the same position or are going through it at the same time. Peer to peer support is incredibly important. There is also often somebody around at 3am during the night feeds to sympathise!

So how do we know when a baby is feeding well enough to move on from this routine? Often around due date or just after, babies suddenly ‘get’ feeding. Their suck becomes more coordinated and they can remove more milk from the breast. You can watch for the full term feeding pattern of sucking fast for a minute to stimulate the let down, and then move on to deep slower jaw movements with pauses in between. You may be able to hear swallowing. Breast compressions can help to get a bit more milk into the baby if they are still seeming a little inefficent or sleepy at the breast. They often have a big feeding frenzy at around due date and sometimes want to cluster feed. This can be very unnerving for a preterm mum who is used to having a sleepy baby who needs to be woken for feeds. Cluster feeding should be encouraged and explaining to mum that it is completely normal behaviour and will help baby get lots of milk. However it does not necessarily translate in to weight gain immediately. It can be very discouraging when baby has been feeding all night and only put on a small amount the next day. However you often find a day or two later and it pays off.

For twins or triplets it may be a good plan to get some support with tandem feeding. Tandem feeding maximizes the time spent feeding as there’s less waiting time for babies and it is a more efficient use of time. It helps synchronize the babies’ feeding times and more importantly sleeping times! A strong feeder can help a weak feeder by stimulating the let down and getting the milk flowing. It also increases milk supply and the milk has a higher fat content.

Dropping or reducing the top ups gradually can make it a bit less stressful. For more detailed info in reducing top ups see our other blog here

But here’s an overview: Mums can reduce the volume of top ups and put babies back on to the breast if not settled. Mums often find that babies are more settled during certain times of day or night and these can be the first feeds to just breastfeed. Encourage mums to allow the baby to have a second or third go on the breast if they do not settle after the first feed. Offer the other breast so baby gets a nice fast flow of milk. For twins or triplets you can just put them back on the same one and mum will get another let down of milk.

Aiming for maybe 3 top ups of expressed a day and being baby led in between is a good starting point. Mum can keep an eye on nappy output during this time to give her peace of mind and she may prefer to weigh the baby before moving on from this stage to give her confidence that everything is going well. Sometimes when babies move on to more direct breastfeeding, their weight gain can flatten off a little bit. This can be really discouraging but it can take a bit more energy to fully breastfeed and they can tire themselves out and burn more calories. As long as they are still gaining this is usually ok and they will set off following their curve again given a bit of time. This may be a good time to get some reassurance from a breastfeeding specialist.

Once mum is feeling confident and babies are feeding well it is relatively easy to drop the last few top ups. Mum can either stop them all at once or drop one at a time. It is often a relief to have the relative simplicity of just breastfeeding without all the faff of expressing and washing bottles. Some prefer to still keep an expressed feed in their routine so that they can have a break.

 Breastfeeding is so important for babies, but even more so for premature babies. But establishing breastfeeding in the neonatal unit is like a marathon, not a sprint. It is a slow process taking every ounce of patience and determination. But it is worth every bit of stress.

Kathryn Stagg ABM BFC, Updated Nov 2019

References

Breastfeeding and Human Lactation, enhanced 5th edition, Wambach & Riordan, 2016

The Breastfeeding Atlas, 6th edition, Wilson-Clay and Hoover, 2017