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Hand Expression: Q & A with #ILCA15 Conference Speaker Jane Morton

Copy of Journal of Human Lactation (5)Dr. Jane Morton, MD is a plenary speaker at the upcoming 2015 ILCA Conference, 22-25 July in Washington, DC, USA. Her plenary address will be Updates on Game-Changing Research about Breast Milk Expression: Early Hand Expression and Hands-On Pumping. Dr. Morton will also present during a breakout session on Prevention, Availability and Sustainability: What Baby-Friendly Bedside Care for Low- and High-Risk Infants Must Offer.

Dr. Morton was recently interviewed by Marie Hemming, IBCLC, a member of the International Lactation Consultant Association® (ILCA®) Medialert Team.

MH: In September 2011, your overview of pumping appeared in an article entitled Is Pumping Out of Hand. Many of us working with new mothers get the impression that all mothers want to have a breast pump and health care practitioners want to give them one. Why do you think that has gotten a little out of hand, so to speak?

JM: Pumps (used most effectively) are a vital part of lactation support. The high number of mothers discharged from the hospital with their babies and pumps is most often twofold, sending mothers home who will not produce enough milk to feed their babies, and sending babies home who risk not getting enough breast milk.

We need to ask ourselves why this is and how we can leverage the time spent in the hospital to prevent problems. Commonly, in medicine, rather than thinking preventatively, we offer episodic, problem-oriented care, waiting for excessive weight loss, excessive jaundice, etc. before more urgent measures are taken. The question that needs to be addressed is how can we better prevent these problems?

MH: Breast pumps are not particularly convenient, given the need for sterilization, perhaps a source of electricity, and the unwieldy size and weight. Hand expression seems so much simpler. How do you think we can guide mothers prenatally to teach them that hand expression is almost mandatory postpartum?

JM: From Picasso to Steve Jobs, artists and inventors have found that keeping things simple is worth striving for. Building simplicity, repetition, and logic into a didactic setting is key. Learning prenatally the benefits of hand expression gives expectant mothers the answer to many typical “what if” concerns and preparation for whatever the outcome may be. Unlike a machine, a mother’s touch is quite natural and does not suggest a problem or medicalize milk expression.

MH: What are the benefits of hand expression?

JM: Our research and subsequent studies [to be presented at the ILCA15 Conference] suggest hand expression of colostrum increases milk production, onset of lactogenesis, and breastfeeding rates.

MH: What’s the most surprising thing you’ve found in your research on hand expression?

JM: I have been teaching hand expression to mothers from the beginning and referred mothers to IBCLCs if they needed a pump. This research project required the use of a pump, but I found that they were not as effective as hand expression. I went back to the Internal Review Board to change the protocol to incorporate hand expression as part of the tools and [to] add a tally of how frequently milk was hand expressed.

The first surprising thing to me was that the data showed that [there was a] difference [in] milk production, depended[ing] upon how often milk expression happened in the first three days. The second surprise was how very simple it is to express colostrum in the first hour after birth and how much more difficult it was for the same mother to express colostrum later.

A new study I just reviewed will be coming out in Academy of Breastfeeding Medicine in a couple of months, and the results show precisely that the timing of the expression of colostrum is much more important than we thought. That first hour after birth we have known is very critical to the success of breastfeeding, and, again, this reiterates the significance of hand expression of colostrum in the first hour.

MH: Do you have a teaching method you prefer to use to teach hand expression, and how long does it take?

JM: The World Health Organization, the American Academy of Pediatrics, and other well recognized supporters of breastfeeding recommend every mother learn hand expression prior to discharge, for a myriad of reasons. How long it takes and how easy it is to teach will, of course, vary from one mother to the next. When the oxytocin level is highest (within the first hour after delivery), colostrum is quite easy to express; mothers are delighted to see their milk, and research supports this may be a critical window of time to maximize the benefits [of expressing]. In fact, hand expression and helping a baby latch work well together.

At the [ILCA15] Conference, we [will] discuss ways of integrating this into our practice, [while] respecting the constraints of time, skills, and resources. The more frequently hand expression is used, the easier it becomes, the earlier milk comes in, and the more milk mothers make. Mothers who use hand expression can make up to 80% more milk. Teaching hand expression needs to be incorporated into the first hour following birth to maximize the benefit.

A video from Stanford University’s School of Medicine on hand expression and Dr. Jane Morton’s research.

MH: What kind of clinical guidelines need to be in place so that all mothers can receive timely teaching of hand expression prenatally and following the birth of their babies?

JM: In my mind, the question is not whether mothers need to learn this, but how often they may need to practice this technique prior to discharge. We certainly don’t have all the answers and, at the conference, I [will] share how some hospitals are managing this.

MH: Have you considered incorporating the teaching of hand expression into the Baby-Friendly Hospital initiative (BFHI)?

JM: Given the increasing number of dyads at risk for preventable complications of breastfeeding, I think a stronger case for this will become clear. With more randomized clinical trials addressing outcome measures, we would have a stronger case to recommend just this.

At the [ILCA15] conference, [I] will discuss why Baby-Friendly care, as wonderful as it is, may fall short of providing truly preventative care to all dyads.

ILCA15 register now button

 

Dr. Jane Morton, MD is a Professor of Pediatrics at Stanford University School of Medicine. Her particular interest is preventing breastfeeding problems by training new mothers, their partners, and their providers simple, doable but critical steps from the first day, no matter what the challenges may be.

 

Marie ipad photoMarie Hemming, IBCLC is the mom of three breastfed children (now 21, 17, and 16 years of age). She developed and taught a 20-hour breastfeeding class at the Florida School of Traditional Midwifery. She is currently volunteering as an IBCLC and lay community counselor at Birthline of San Diego, serving families living in poverty.

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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
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
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