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
www.burgesspediatrics.com
drjane@burgesspediatrics.com

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. http://newborns.stanford.edu/Breastfeeding/  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 www.breastmilksolutions.com
   . 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
   Feb;52(1):39-43
7. Kumar A. J Perinatology 2010;
   30:209-217