Tips for Exclusive Expressing
The below information aims to support you to initially express 100% milk supply for your baby. Though many families will plan for longer term combination feeding with some formula feeds (FF) alongside expressed breast milk (EBM), long term expressing can be more robust and effective in later weeks if you have established a strong and robust supply early on.
The information here is written for a generic audience, and all information may not be appropriate for you - please refer to your personalised plan and contact Heidi Hembry IBCLC if further clarification is needed.
Expressing to Establish an Effective and Robust Supply
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Aim to express a minimum of 8 times per day. More is better. The more often you drain your breasts, the more they want to make to refill. As a minimum, if your baby is gaining weight well, you should express as often as your baby feeds. If your baby is not yet gaining weight well, you may need to express more often.
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Express both breasts each time. If you are consistently making significantly more milk per day than your baby needs, you may only need to express one breast as some/all sessions.
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Planning to express every 2 hrs from 7 am to 11 pm will mean that you get 9 expressings completed, and then you don’t need to do so many at night (aim for every 3-4hrs overnight eg, 2 am, 5 am, or when your baby wakes)
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Night expressings are important as most mums have higher levels of prolactin at night. It also means your breasts are not being left unstimulated for a long period. The longer your breasts are left unstimulated (day or night), the slower they are to make milk.
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Hand expressing is an essential skill for collecting colostrum. It gets easier with practice. You can move to a pump when your more mature milk is made on top of your colostrum, usually on days 3-5.
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If you have a single pump, express one breast until you notice the flow has slowed to a drip. This may only be a few minutes at first, or 10-20mins. Then switch to the second breast and repeat. As the flow slows again, switch back to the first breast, and again, switch to the second breast a 2nd time. Massage and jiggle your breasts during expressing sessions to encourage more milk to flow.
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You can continue this for as long as it feels productive, though it’s good to aim for a minimum of 4 breasts when establishing a supply, or sometimes 6 breasts when working to build from a low supply.
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If you are using a double pump, express both breasts until the flow slows to a drip. Set your pump down for a few minutes. Massage and jiggle, then return for a second pumping session. This might look like 10mins on, 5 off, 5 on, or something similar. However, a few mums find that they do not need to take breaks and their flow remains constant and strong across many minutes. See below for more on pump fit and styles.
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Hands On expressing an also improve yield - massaging before and during expressing can help some mums collect up to 50% more milk.
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Hand expressing can also be effective when pumps struggle to get fatty milk out - a few minutes of hand expressing at the end of a pumping session can add a few extra mls to your stash!
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Different expressings can be added together to make a top-up or full feed as needed, freshly expressed milk can be added to fridge cold milk expressed earlier in the same day.
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Aim to use Responsive Bottle-feeding techniques (regardless of EBM of FF) to better replicate the ebb and flow a breastfeeding milk flow, and allow baby to realise when they are full. Our babies are small versions of us, not robots who need the same volume of milk at each intake, exactly spaced apart. Some feeds will be big meals, some feed small drinks just a short while after a meal. https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2019/04/Infant-formula-and-responsive-bottle-feeding.pdf
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For healthy, full term babies, to help minimise work whilst expressing regularly, there is no need to sterilise kit that is only used for breastmilk. You can wash in hot soapy water and rinse in fresh water and leave to dry. Alternatively, many mums expressing very frequently to build supply will keep their expressing kit in a clean Tupperware box/Ziplock bag in the fridge and only wash or sterilise once a day to reduce time.
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For preterm or unwell babies, cleaning/sterilising after each feed is recommended. There is no research (and therefore no clear guidance) on when it becomes unnecessary to clean/sterilise after each use, this is down to parental judgement and health professional input as your baby grows.
BFN - expressing and storing
http://www.breastfeedingnetwork.org.uk/wp-content/pdfs/BFN%20Expressing%20Leaflet%202019.pdf
https://www.breastfeedingnetwork.org.uk/breastfeeding-help/expressing-storing/
VIDEOS - hand expressing
Reducing Expressing Frequency - Later Weeks
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Some families will find they are easily able to make 100% of their baby's milk needs, increasing volumes expressed as their baby increases volumes of intake. Other families may have a longer journey, including the use of galactagogues (see below), and some families may find they always need (or wish) to supplement with formula.
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When you feel you have a good/maxium supply that has established and stabilised, you may find you are able to reduce your expressing frequency and duration.
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You should experiment by dropping just one expressing first, and seeing if your overall milk production remains stable over several 24hr periods.
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You may find that you need to express for a few more minutes to gain extra milk volume at you remaining sessions.
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If your supply remains intact, you can drop a second expressing session. It is advisable to select a session at an opposing, rather than consecutive time of day. Eg if your first session dropped was 1am, then your next one might be a day time one between 10am -2pm.
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Some families find that, much like with breastfeeding, expressing gets quicker and more efficient in later weeks. You may be able to get as much in 15mins at 3 months as you we able to get in 30+minutes at 6 weeks. However, some families expressing long term find yields dropping in later weeks as breasts switch from storing large volumes, to making milk on demand (less engorgement, more biological efficiency), and will need to introduce power pump sessions and/or power pump days as needed to bost supply.
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A reduction in supply is not a problem if your intention is to introduce some FF bottles.
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Your maximum previous EBM supply can often be re-established simply by spending a few days expressing more often again. This is easier and quicker to achieve if the drop is recent, and a more prolonged process if the drop in supply has been established over a longer period.
Expressing can be Psychological
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Though flange fit and pump patterns/frequency and style of pump all play their part in comfy expressing, your brain is a powerful tool too.
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Stress and anxiety (and pain) can all inhibit your milk flow, making for lower expressing yields.
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Not all pumps will work for all mums, regardless of fit. If you hate the look or sound of your pump, this may be enough to inhibit your milk flow. Finding a pump you are happy with and that is comfy to use is vital.
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Some mums (particularly those worried and constantly checking if they have collected enough) may find that covering their pumps with a muslin whilst pumping allows them to focus on something else and relax, and therefore promotes a better letdown.
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Skin to skin before an expressing session can help your body's oxytocin levels to rise and promote a good letdown and flow.
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Stroking your baby or looking at your baby whilst expressing can help yield volumes improve. You can use videos and picture on your phone, or hold and smell clothing your baby has been wearing.
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Visualisation and mindfulness can be powerful tools for some mums. Imagining your collection bottles filling with milk, visualising jets of milk, waterfalls of flowing milk etc.
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Relaxing is important if your stress/anxiety is high. Lighting candles, having a back or foot rub, talking to someone who makes you laugh on the phone, or watching your favourite sitcom, listening to your favourite playlist or podcast can all help.
Pump/Expressing Options
Having a well fitting flange/flange adapter can make a huge difference to your expressing comfort, volume expressed, and efficiency. Though fit seems to be the most important aspect, there is some early research that suggests hard flanges are more effective than soft inserts. Soft inserts are often easier and cheaper to purchase in a set of sizes. Once you have found your best fit, you can purchase the correct hard flange if desired.
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Hand Expressing: Free, and can be used in emergencies at any time of day or night. Essential for expressing colostrum. Can be more efficient than electric pumps when mums have practised and honed their skills. However, can be tiring and achy (especially if RSI already present in hands or wrists). Needs skilled support to make sure you are working well with your unique anatomy.
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Single piece silicone pumps: Low cost and can be used anywhere any time. Work by vacuum alone, and the vacuum reduces as the receptacle fills, slowing down flow also. Takes more than 'drip milk', but for the overwhelming majority of mums, will not be anywhere near effective to remove enough milk to create a full supply. Can be helpful if you have a single pump and you can collect milk on one side whilst pump-collecting on the other, then switch.
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Hand Pump: single pump with manual handle to provide vacuum and pull. Low cost, and can be effective to start a supply on the first couple of weeks when volumes required are small. However, most families looking to exclusively express will need to move to an electric (ideally double) pump. Some mums will get on with this pump very well if they dislike the noise of an electric pump. Being manual, you are in direct control of how strongly and how frequently the vacuum pulls, and this works well for mums with very sesnsitive breasts.
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Single/double battery powered pumps (This includes 'bottle collection' styles and in-bra styles): Range of costs - you do not necessarily get a better product for a higher price. These pumps can be great for on the go pumping when you have an established supply via frequent pumping with a double electric pump early on. For many mums they are not strong or efficient enough to build and establish a supply in the first few weeks. Can be great if you feel you cannot leave the house due to your pumping schedule - it's better to pump out and about with a portable pump than to miss a session entirely . Be careful - they are designed to be used on the move, but in a steady and upright position. If you lean over to pick up your baby, or empty the dishwasher, you can loose all of your hard worked for breast milk down your top. A few mums are able to build, establish and maintain a great supply with in-bra pumps alone.
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Double plug in pumps (including 'hospital grade'): These are reliably the best pumps for building a supply in the early weeks, and can be a great time saver. Hospital grade pumps tend to be the most efficient - it is often possible to hire one for a month from ether your local hospital/community breastfeeding service, or from a private company, moving to a less expensive model for maintaining your supply. These pumps all tend to have a stimulation phase, followed by a letdown phase where you manually select the Suction/Volume. Some models have an additional Cycle control that alters the frequency of the pull. In general you want high frequency, low volume during the letdown phase and low frequency, high volume during the letdown/collection phase. Models that have both of these as manual controls allow your to better tailor the session to your needs/comfort/efficiency
Herbs & Medications to Improve Supply
The most effective way to improve your milk supply is to improve milk removal, either by improving breastfeeding efficiency and/or improving expressing volume/frequency. When these things have been addressed, if supply remains sub-optimal, one of the below herb/medications may be suitable to try alongside maintaining effective feed/express patterns. It is not advisable to try multiple interventions at the same time. Please consult Heidi Hembry IBCLC to discuss which may be the most appropriate intervention for you.
Fenugreek to Increase Supply
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Fenugreek may not be a suitable supplement if you are asthmatic, take insulin or warfarin, have a peanut/chickpea allergy, or if you have a history of thyroid issues.
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Fenugreek, when taken in high doses can improve milk production in about 70% of women who take it. A few women report a reduction in supply, particularly if there is a history of hypothyroidism for you or in your maternal family.
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If you have 500/600mg capsules, you need to take 9-12 per day, ie 3-4 in the morning, 3-4 in the afternoon and 3-4 in the evening.
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If fenugreek is going to work for you, when taken in these doses you will generally notice a difference in 3 days, but give it a week to be sure.
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Fenugreek works best when taken in conjunction with additional milk removal, either through increased frequency/efficiency of feeding or expressing.
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When you feel your milk supply is raised and stabilised, wean off the capsules gently. Ie drop from 4 x 3 times per day to 3x3 per day. Wait for a few days and drop to 2x3 per day. Wait again, etc etc.
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Most mums find that when their supply has stabilised they no longer need to take the capsules, but for a few mums, continuing to take them for several weeks seems necessary.
Goats Rue
https://www.ncbi.nlm.nih.gov/books/NBK501817/
Blessed Thistle
https://www.ncbi.nlm.nih.gov/books/NBK501775/
Helpful Blog on Herbs
https://sarahoakleylactation.co.uk/wp-content/uploads/2021/03/Galactagogues-info-sheet.pdf
https://www.mahmee.com/articles/herbal-supplements-and-milk-production
Domperidone
Domperidone is an anti-sickness drug that is not regulated for milk production, though it is a common side effect of taking the drug. Some GPs are happy to prescribe, others are not, so these information sheets below (particularly the Breastfeeding Network one as it is put together by internationally recognised and respected pharmacist Wendy Jones) can be useful when talking to your GP:
https://ibconline.ca/information-sheets/domperidone/