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Is Pumping Out of Hand? Why Hand Expression in the First 3 Postpartum Days is Important

Stanford trained, Jane Morton, became a partner at the Palo Alto Medical Foundation, where she practiced general pediatrics and was repeatedly recognized by her colleagues as
one of the top pediatricians in the Bay Area.  She was invited to join the Stanford neonatology faculty to develop their Breastfeeding Medicine Program. She designed a nationally recognized educational program, published her original research and traveled extensively and internationally as an invited speaker.  At the 2011 ILCA Conference in San Diego, CA, Jane presented this plenary session titled, “Is Pumping Out of Hand?”

Jane Morton, MD
Cl Professor of Pediatrics
Stanford Pediatrics

A low milk supply is the most common reason for mothers to stop breastfeeding. (1.)  We have learned that what we do (or do not do) in the first 3 days after delivery can have a major impact on future milk production potential.  In our research, we found that milk production in pump-dependent mothers of preterm babies depended on the frequency they used hand expression in the first 3 days after delivery. (2.)  Mothers who used hand expression more than 5 times a day in the first 3 days yet pumped with the same frequency as other study mothers, expressed an average of 955 mls, about a quart a day by 8 weeks. This is more than a term 4 month old would need. Mothers also found consistent increases in production when they did not rely solely on pump suction alone to remove milk, but used “hands-on pumping”. This technique combines breast massage, compression and hand expression with electric pumping and does not require more time.  Of the 67 study participants, several volunteered to demonstrate hand expression and hands-on pumping on the Stanford website.  (3.)

For mothers of term and late preterm babies, there is an important role for an alternative way to remove colostrum when the infant has not yet learned to latch on and nurse effectively.  About 50% of mothers will have some difficulty getting their babies to latch on well in the first day. (4.) While providing a mother with a pump may be the easiest solution from the nursing standpoint, a recent study suggests it is more effective to teach her to hand express milk after breastfeeding. (5.) At 2 months, mothers assigned to hand expression were more likely to be breastfeeding (96.1%) than mothers assigned to breast pumping (72.7%). (p=0.02)

A smaller study suggests more milk can be removed with manual expression than with a new, double rental-grade pump in the first 48 hrs post partum. (6.) Given the feasibility and safety of spoon feeding, (7.) perhaps the routine practice in the first several days for infants at risk for suboptimal intake and/or mothers at risk for suboptimal milk production should be to encourage hand expression and spoon feeding after breastfeeding. This provides more milk for the baby and more stimulation to the breasts than breastfeeding alone. There seems to be no cost or risk and only potential benefit in this approach.

  1. Ruowei Li, Fein SB, Chen J,
    Grummer-Strawn L. Pediatrics 2008; 122(2):S69-S76.
  2. Morton J, J
    Perinatol. 2009 Nov;29(11):757-64. Epub 2009 Jul 2
  3.  See: Hand
    Expressing Milk — video
    and Maximizing via Katy TX
    Milk Production — video
    . Complete video, Making Enough Milk, the Key to Successful Breastfeeding, can be
    previewed and purchased at
    . Soon available in Spanish
  4. Dewey KG.
    Risk Factors for Suboptimal Breastfeeding Behavior, Delayed Onset of Lactation
    and Excess Neonatal Weight Loss. Pediatrics 2003;112:607-619
  5. Flaherman VJ, Archives of Disease in
    Childhood 2011
  6. Ohyama M. Pediatr Int. 2010
  7. Kumar A. J Perinatology 2010;

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10 Responses to Is Pumping Out of Hand? Why Hand Expression in the First 3 Postpartum Days is Important

  1. Roberta Graham de Escobedo 6 September 2011 at 18:27 #

    Going back to basics has been very beneficial, especially for the mothers of premies. In my private practice setting I have found it to be an empowering practice which allows the mothers to feel more in control of their production, instead of feeling so dependent on a piece of equipment, whether a manual or a high-end fancy schmancy doublepumping electric pump. In truth, their plentiful milk production capacity is literally, “in their hands”. Dr. Morton’s research and more importantly her clear way of teaching this technique has been a breath of fresh air in a world which apparently values THINGS more than PEOPLE.

  2. Gail Martel, RNC,IBCLC 7 September 2011 at 03:21 #

    Excellent information!! Thank you!

  3. elleandsam 8 September 2011 at 22:28 #

    I hand expressed when my son was in NICU and found it very effective. Almost 8 months on and he is still nursing and has never struggled to gain weight.

  4. flamidwyfe 9 September 2011 at 06:16 #

    I don’t totally agree with this. In fact, I totally DISAGREE with the 1st sentence in the article’s 2nd paragraph… the most common reason women stop breastfeeding is LACK OF SUPPORT. When we encourage hand expressing or pumping in normal term babies or late preterm babies, we are telling mother’s that they aren’t designed to make the right amount of milk! By showing gentle breast massage and spending 20 minutes at the bedside actually GIVING PATIENT CARE, your patient will feel as if she has support and will gain confidence! I know that it’s difficult to give basic care in this day of HIS systems and such, but we must get back to the basics and empower our patients to do what’s best for their baby.
    My 2 cents, from many years of practice.

    • lactationmatters 13 September 2011 at 03:40 #

      Thank you for your comments and we appreciate you taking the time to post your reply.
      Dr Morton has shared her findings in her research and you will find the referenced article below. It is ILCA’s objective to share the latest in evidence-based research with the IBCLC community.

      Flamidwyfe you raise an important issue for IBCLCs everywhere, now with the shorter hospital stays and with reduced staffing levels, performance indicator needs, and clinical competencies guidelines. This is becoming a constant dilemma faced by all health professionals, especially us IBCLC’s.

      Dedicating quality time to women, within these restraints, enabling their empowerment and outlining the principles of ‘the basics’ in this very important beginning for a mother and her new baby is paramount.

  5. Lenore Hoyt 9 September 2011 at 14:44 #

    Thanks for this post! It was shared on Facebook by The Breast Idea and Milk Smart Mama. I really appreciate your making this information available–it reframes my own experience and gives me something to share with other mamas!

    • lactationmatters 13 September 2011 at 03:41 #

      Lenore, thank you for your reply. We are pleased this is confirming for you . Keep up the great work.

  6. Jennifer Rosenberg 13 April 2012 at 09:31 #

    This was a valuable thing to read during pregnancy, how valuable I didn’t learn until later. When my son was born, he appeared to latch well, but I massaged and milked my breasts while he nursed until my milk came in. He seemed to swallow more when I did so, so I continued. His weight gain was excellent, and it was not until he was 2 1/2 months old that his deep, submucosal grade 3 posterior tongue tie was discovered, and then only because my nipples were sore, he was still gaining very well. The tie was cut, my pain disappeared, and my milk remains plentiful. For me, the ultimate gift of hand expression is that I can see where the “sweet” spots are on my breast to get the most milk, which helps me help my baby when the sucking skills are less than optimal.

    I was successful nursing my 7 year old, despite a neurological condition secondary to a chromosome problem that left her unable to suck well or swallow in a coordinated fashion, by milking my breasts into her mouth, but I think if I’d known how important those first days are, we would have had a much, much easier time of it.

  7. Emma 22 May 2020 at 08:42 #

    Buying a breast pump?
    I’ve started doing some research about breast pumps. I am due in 8 weeks and I plan to breast feed–but after a while I want to pump and feed so that I’m not physically attached to my baby. Just wondering if anyone has a brand or model of breast pump they absolutely recommend or that I should definitely not buy. Thanks!
    I’m not saying I don’t want or intend to bond with my baby. But after I while, I have to go back to work, I’d eventually like my husband to feed the baby once in a while, and maybe on occasion I’d even like to leave the house for a few hours on my own!!! So I need a decent breast pump that’s going to help provide my baby with what he needs for a year, and offer me just a teensy bit of independence when I need it!


  1. How do I make enough breastmilk for my baby? ⋆ The Boob Geek - 11 May 2016

    […] hand expression, or pumping—in the first few days, the more milk you will have overall. (One study found a large difference between pumping output at 8 weeks between mothers who pumped or pumped and […]

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