Your High-Risk Baby and Expressing Milk

How to get ready to make enough milk if you are expecting a high-risk baby

Breastfeeding has important health benefits for almost all babies. And, it helps you and your baby bond. But the benefits are even higher for babies who are born high-risk. Babies in the NICU need a mother's breast milk to help support their immune systems, improve their digestion, and decrease the risk of a serious condition called NEC (necrotizing enterocolitis). If you are expecting a high-risk baby, providing your child with breast milk is something only you can do. Below are some suggestions for how you can get ready to make enough milk for your high-risk baby:

• If possible, start pumping within 60 minutes of delivering your high-risk infant. Evidence shows that this can help make more milk than  if you start later.

• Use breast massage and warm your breasts before you pump.

• Start expressing milk by hand, then use a pump as needed, to get your milk started.

• Listen to relaxing music as you pump. Evidence has shown that this can help women to make more milk, possibly by reducing stress.

Techniques for expressing milk

You will have to depend on milk expression to establish and then maintain milk production until your high-risk baby is ready to breastfeed. Most mothers find they get more milk in less time when using a hospital-grade, electric breast pump with a double collection kit when providing milk for high-risk newborns.

Developing a milk expression routine

You will want to pump at least 8 times in 24 hours. Even if using a good electric pump, it is helpful to learn hand expression in case you are ever without some of the equipment pieces for the electric pump when it is time to express milk. Sometimes in the early days of milk expression, mothers find they get more colostrum through hand expression than they do with the breast pump. 

Do not put off or stretch the time between pumping sessions during the first 3 to 5 days after giving birth. You may not see any milk during the first several pumping sessions, and you may only get a couple of drops for several sessions after that. Keep expressing. The milk produced before day 3 to 5 after birth is called colostrum, and it is normally produced in small amounts. However, colostrum is especially rich in the anti-infective properties that can help your high-risk baby. If you are able to pump or hand express even one drop, it may be beneficial to your baby. Drops can be drawn up, and stored, in syringes specially labeled as "colostrum."

Helpful equipment

Breast pump

It is important to use the right kind of pump when long-term milk expression is necessary, and not all breast pumps are created equal. Most mothers with high-risk infants find that a hospital-grade, electric breast pump is necessary for frequent and prolonged milk expression. These pumps automatically cycle suction with release of suction--similar to a baby's sucking action. Studies find mothers who must pump for several weeks, or even months, produce a larger amount of milk when using this type of pump.

Although there are many good mini-electric, battery-operated and hand (manual) breast pumps on the market, these pumps were not designed for frequent and long-term use. These pumps were designed to obtain milk for an occasional "relief" feeding. Most of these smaller pumps require a mother to invest more time and effort to obtain an adequate amount of milk. Many do not cycle suction automatically, which often lead to complaints of breast soreness or tenderness. The motors of mini-electric pumps can burn out with frequent use. Frequent changes of batteries are necessary when battery-operated pumps are used frequently, and these pumps become sluggish and less effective at milk removal as batteries wear down.

Getting a pump

Most maternity units and newborn intensive care units (NICU) have electric breast pumps available, so you can begin pumping immediately. They will also provide a double collection kit, which you should take with you when you leave the hospital. The collection kit is then used with the hospital-grade, electric breast pump you will rent for use at home. You can also bring your collection kit with you when spending time with the baby in the NICU, so you will not have to miss any pumping sessions.

The NICU staff, a lactation consultant (IBCLC--International Board of Certified Lactation Consultants), or a breastfeeding support leader will know of breast pump rental stations in your area. Many healthcare benefit plans, including Medicaid, cover the cost of breast pump rental and collection kit purchase when a letter from a neonatologist or a lactation consultant explaining the baby's need for milk expression is sent with the request for reimbursement. Because of the many benefits of a mother's own milk, health insurance companies know they ultimately save money if you pump your milk for your baby. Contact your health insurance company to learn if they have specific requirements for reimbursement or pump rental station referral. Should health insurance not cover the cost, remember that the equipment needed to maintain milk production still costs less than the infant formula you will have to buy if you do not pump. (A high-risk baby is more likely to be given a more expensive, special formula for a longer period, too.)

Breast pump collection kit

A breast pump collection kit includes tubing, breast flanges, and collection bottles. The tubing attaches to the pump itself and transfers suction to the breast flange, which may also be referred to as the "breast shield" or "milk funnel." The flange is the piece that is in direct contact with the breast. It is centered over the nipple and areola of the breast. A hard plastic bottle connects to the breast flange piece and collects milk flow. Clean collection bottles should be used for each pumping session.

Double collection kit

A double collection kit allows you to pump both breasts at once. Studies have shown that mothers tend to produce more milk in less time when they use this type of collection kit with a hospital-grade, electric breast pump. This may be because mothers find it is easier to pump often enough when using this combination of breast pump equipment. Many mothers also like to use a hands-free bra or hook. This allows you to have the flanges held for you so that you can do other activities with your hands.  

How often and how long?

A full-term, healthy newborn typically breastfeeds for the first time within an hour or two of birth and will want to eat about 8 to 12 times in 24 hours for the next several weeks or months. A milk expression routine should closely imitate this pattern, so you will want to begin pumping as soon after your baby's birth as possible:

8 times a day

Pump at least 8 times, or for a total of at least 100 minutes in every 24-hour period. The more pumping sessions, the better. More frequent sessions may be necessary if pumping milk for twins, triplets, or more.

Freeze any extra milk

At first you may find frequent pumping produces more milk than your high-risk baby needs, but excess milk can be frozen for later use. It is better to stay ahead of your baby's current intake. If you pump less than 8 times a day, you may find milk production begins to drop after several weeks. Then, 10 to 12 daily pumping sessions may be necessary for several days or weeks if you want to increase production to meet your baby's growing appetite.

A typical cycle

Most mothers pump for about 15 to 20 minutes, every 2 to 3 hours during the day, with one, 4- to 5-hour stretch of uninterrupted sleep at night. You could pump for about 15 minutes without interruption. However, you may find it helps to take a "massage" break when milk flow slows after 5 to 10 minutes. Stop, massage your breasts, and then reapply the pump until a minute passes without any milk flow. Some women pump longer than 15 to 20 minutes and wait until there has been no milk flowing from the breasts for approximately 1 minute before stopping. 

Single vs. double

Some mothers prefer single pumping of each breast separately, especially when first learning to use the breast pump. These mothers pump one breast for 5 minutes (or until milk flow slows), then pump the second breast for 5 minutes (or until milk flow slows), and repeat the whole process but continue to pump until a minute passes without any milk flow for either breast. Single pumping lets a mother massage each breast as she pumps, which can increase milk flow. If a mother wants to massage both breasts at the same time, she can use a hands-free bra or hook to hold the flange to the breast while she massages the breast tissue. 

How much milk?

After 7 to 10 days of frequent pumping sessions--at least 8 times a day and for a daily total of 100 minutes or more--expect to produce between 16 to 32 ounces (about 500 to 1,000 ml or cc) of breast milk a day. This may be more milk than your high-risk baby needs just now, but you will be glad to have extra milk in the freezer if milk production drops at some point, which is not unusual after several weeks. Then any stored milk can be used.

Don't be surprised if you get more milk at some pumping sessions than others. Many mothers find they get more milk earlier in the day. Also, expect some variation in the total amount pumped from day to day, but talk to a certified lactation consultant, your baby's healthcare provider, or a breastfeeding support leader if you find the daily total keeps dropping for several days in a row.

Helpful hints

Mothers of high-risk newborns have found some or all of the following suggestions helped them develop and stick to a routine when expressing their milk for days, weeks or months:

Stick to a schedule

Many mothers find their milk lets down more quickly and they soon get larger amounts of milk when they pump at about the same times every day. Don't be concerned if there is some variation in the schedule from day to day, however.

Set a timer

It is easy for time to slip away and for pumping sessions to get a late start unless you set an oven timer, a digital watch, or cell phone to remind you when the next session is to start. If a session is delayed, pump a little earlier next time.

Chart pumping sessions

Keep track of when you pump, how long you pump, and how much milk you get by using a simple checklist chart to note pumping sessions. A written record will help you pick up early any drop in number of sessions, time spent pumping, or volume of milk obtained, so you can make changes before a real problem develops.

Get comfortable

You are more likely to continue a routine if you pump in a comfortable, yet convenient, spot. Have a snack and a beverage within reach. Listening to relaxing music has been shown to increase breast milk production. Or, you could distract yourself by talking with someone over a speakerphone or watching TV. You can also use the hands-free pumping apparatus and do other activities at the same time as you are pumping. 

Create a ritual

Follow the same routine for most or all of your pumping sessions. Your ritual might include:

• Pumping in a certain place

• Putting warm compresses on the breasts and doing breast massage before pumping

• Dimming lights

• Turning on soft music

• Using relaxation techniques, such as slowing your breathing and imagining a beautiful waterfall that turns to milk after a minute or two of pumping

Include your baby in the ritual

You might want to look at a photograph of your baby or breathe in the scent of a blanket or cap he or she has worn as you pump. Some mothers listen to an audiotape of their babies' cries when they begin to pump, and others simply think of the baby while pumping. Skin-to-skin contact with your baby, which is sometimes called Kangaroo Care, during visits to the NICU has been found to increase milk production.

Plan ahead for night sessions

Nighttime pumping sessions will seem less bothersome if the pump and collection kit are set up and ready to go when it is time to wake up to pump. Some mothers save steps at night by placing bottles in an insulated cooler with an appropriately sized freezer pack to keep milk properly chilled until morning.

Be positive

It is easy to become discouraged, bored, or frustrated when pumping at least 8 times, or more than 100 minutes, in 24 hours for day after day--especially if you are having any difficulty producing milk. There may be moments when you would like to throw the breast pump out the window. Accept such feelings as normal, but don' throw that pump away. Not only is it an expensive machine, it is allowing you to provide the most valuable food your baby can get. Remember, by providing your high-risk baby with this exceptional milk, you are a vital member of your baby's healthcare team. It also maintains your milk supply so that you can bond with your baby through nursing when he or she comes home from the hospital.