1. IF THE BABY
CANNOT
FEED AT THE
BREASTSession 11

2. SESSION OBJECTIVES
 1. Describe why hand expression is useful and how to hand
express.
 2. Practice assisting to learn how to hand express.
 3. Outline the safe use of milk from another mother.
 4. Explain how to cup feed an infant

3. INFANT FEEDING HIERARCHY
1. Optimal Choice: Human milk from the breast.
… Breastfed infants should not receive formula unless
medically indicated.
2. In the absence of feeding at the breast, expression
and feeding of mother’s own milk is best choice
for her infant.

4. INFANT FEEDING
HIERARCHY II
3. When expressed human milk is unavailable and
breastfeeding is impossible, banked donor milk
from a qualified milk bank is preferable to
formula.
4. Infant formula is the least optimal choice.

5. REASONS TO EXPRESS MILK
 To establish and maintain an adequate
supply when mother and baby are
separated due to hospitalization/serious
illness of mother or infant
 To maintain milk supply of working
mothers and provide mother’s milk for the
infant in day care
 To provide milk for an occasional relief
feeding by someone other than mother

6. METHODS OF MILK
EXPRESSION
 Relaxation and massage
… Mothers should be instructed to use all sensory
means to foster relaxation and effective let-down.
… Gentle breast massage should be taught to
facilitate milk flow.

7. MANUAL EXPRESSION
 All mothers should know how to express
milk by hand. For many, it is faster, easier
and more cost-effective than pumping.
 Steps to manual expression:
… wash hands and massage breasts
… place thumb and forefinger on areola
… push back toward chest wall
… while pushing back, press thumb and forefinger gently
together

8. MANUAL EXPRESSION II
… repeat gentle compression of thumb and forefinger
… when no more drops of milk are expressed, move
hand position and repeat
… when the milk flow decreases to an occasional
droplet, stop, massage and express from other
breast
 Mothers will adapt technique to
their comfort. Frequent practice
will improve yield.

9. HAND PUMPS
 Rubber bulb pumps are not recommended.
 Hand pumps are suitable for use by
mothers with a well established milk
supply for occasional expression.
 Hand pumps may not give adequate
stimulation for establishing a milk supply.
 All hand pumps are not equal in
performance.

10. SMALL ELECTRIC BREAST
PUMPS
 Battery pumps and small electric pumps which are not fully
automatic are intended for occasional use. Such pumps are
not usually considered suitable for establishing milk supply
in a situation of mother/baby separation.
 Manufacturer’s instructions should be read and followed
with care.

11. RENTAL GRADE ELECTRIC
PUMPS
 Rental grade pumps with dual
collecting kits are recommended for
mothers who must establish and
maintain a milk supply for
hospitalized infants. Each mother
should have her own personal
collecting kit.
 Dual collecting kits are considered
helpful for women separated from
their baby by full-time employment
outside the home.

12. ESTABLISHING AND MAINTAINING
MILK SUPPLY WHEN INFANT
CANNOT FEED AT THE BREAST
 Expression with rental grade pump should be
implemented as soon as possible, preferably
within 6 hours of birth.
 Delays in initiating milk expression may
decrease early milk volume.
 Frequency of pumping should imitate the
pattern of a healthy newborn. Intervals of
more than 3 hours between pumping sessions
should be avoided.

13. WHEN INFANT CANNOT
FEED AT BREAST II
 Combining pumping and hand expression
may increase milk volume for mothers of
preterm infants. Increased frequency of
pumping is more effective in building milk
supply than increased duration of each
pumping session.
 Early milk production is positively associated
with more pumping sessions in 24 hours, with
total duration of more than 100 minutes/day.
 Use of relaxation, massage and visualization
are valuable in facilitating let-down.

14. RECOMMENDED PUMPING
PROTOCOL
 Optimal pumping: 8 pumping sessions per
day with duration of 15-20 minutes per
session when double collecting kit is used.
 Pumping both breasts simultaneously may
result in higher prolactin levels and
greater total milk volume than single
pumping.
 If a single collecting kit is used, milk can
be collected from the other breast in a
suitable container.

15. MILK EXPRESSION BASICS
Goal: to provide milk that is as safe and clean as possible
 Wash hands thoroughly
 Routine breast cleansing is not necessary
 Every mother needs her own collection kit
 Wash collecting kits in hot soapy water after each
use and rinse thoroughly. Parts of kit which do
not come in contact with milk need not be cleaned
 Aseptic preparation of kit and storage containers
is adequate.

16. LET’S PUMP IT UP!

17. STORING EXPRESSED MILK
 Different storage requirements apply
to hospitalized infants and healthy
term infants.
 Milk should be placed in the coldest
part of the refrigerator or freezer.
 Antibacterial properties of human
milk help prevent bacterial growth.
 Package milk in feeding sized portions
to minimize waste. Milk that has
been partially fed should not be
reused.

18. STORAGE
RECOMMENDATIONS
Healthy Term Hospitalized
Infant Infant
Room Temp 4 - 6 hours never*
Refrigerator 3 days 48 hrs.
Freezer 3 months 3 months
(in self-defrosting freezer)
6-12 months
(in deep freeze)
*unless continuous feed - change syringe set-up every 4 hrs.

19. CONTAINERS
 Hard-sided, self-supporting
containers with air-tight caps are
best.
 Plastic bags are a poor choice,
particularly in NICU because of
loss of fat and risk of contamination
due to difficulty in handling.
 Label containers with infant’s name
and date of expression. Use oldest
milk first.

20. THAWING FROZEN MILK
 Never microwave human milk. This may
damage milk components altering anti-
infective properties.
 Thaw milk rapidly by running lukewarm
water over container or setting container
in pan of warm water.
 Thawing may also be done in the
refrigerator overnight or by using
manufactured human milk defrosting
devices.
 Excessive heat should be avoided.

21. WARMING HUMAN MILK
 Warm milk by holding container under running warm water or
in a pan of warm water.
 Some hospitals use controlled hot air incubators to warm milk.
 Too much warming may initiate bacterial growth.
 Gentle shaking of warmed milk is advised to re-suspend milk
fat globules.

22. SUPPLEMENTAL
FEEDING METHODS
 Several options may be considered for
supplementary feedings when they are
indicated: at breast feeders, cup feeding,
spoon, bottle and cup feeding.
 Newborn intensive care units have developed
protocols for feeding infants without bottles.
 Breastfeeding is less physiologically stressful
than bottle feeding.
 Cup feeding is less stressful than bottle
feeding.
 Cup feeding can be helpful for older term
infants who refuse bottles.

23. USE OF MILK FROM ANOTHER
MOTHER
 If a baby cannot feed at the breast, the next best choice is to
receive his or her own mother’s milk. If the baby’s own mother’s
milk is not available, milk from another mother47 is more
suitable than milk from a cow, goat, camel or other animal, or
milk from a plant (soy milk).
 When a woman breastfeeds a baby to whom she did not give
birth, it is called wet nursing.
 Expressed milk from another mother is called donor milk.
 Some places may have breast milk banks to provide milk for
babies who are preterm or ill.
 In a milk bank, the donor mothers are screened for HIV and
other illnesses and the milk is also pasteurised (heat-treated).
Using donor-banked milk is usually a short-term option, as the
supply may be limited, and another way of feeding will need to
be discussed.

24. ARE GLOVES REQUIRED WHEN
HANDLING HUMAN MILK?
 According to the Centers for Disease Control, it is
not necessary to wear gloves when feeding a baby
expressed human milk. The only situation where
gloving is warranted is when handling human
milk in donor milk bank settings.
 Human milk is not specifically mentioned as a
body fluid of concern by OSHA.

25. EXPECTATIONS FOR
HOSPITALS
 Must have a policy that specifies how to handle
breast milk so that one mother’s milk is not
mistakenly given to another woman’s baby.
 The policy should specify what to do if an incident
occurs.