IF THE BABY CANNOT

FEED AT THE BREAST

Session 11

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

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.

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.

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

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.

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

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.

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.

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.

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.

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.

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.

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.

MILK EXPRESSION BASICSGoal: 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.

LET’S PUMP IT UP!

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.

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.

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.

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.

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.

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.

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.

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.

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.