• Breast milk feeding, even partial, reduces risk of necrotising enterocolitis (NEC), retinopathy of prematurity (ROP) and sudden infant death (SIDS) and improves cognitive outcomes in preterm babies
• Human milk is important in establishing enteral nutrition
• Any amount of mother’s breast milk is valuable 

• Early initiation (within 2 hr of birth) is associated with adequate milk supply at 2 weeks
• Recognise that building a milk supply is a challenge for mothers who are separated from their babies and they will require consistent face-to-face support 
• All mothers should have access to an electric hospital grade breast pump with the following characteristics:
  
  • easy to assemble and disassemble with all parts able to withstand sterilisation methods
  • fully automatic, with a cyclic suction rhythm that mimics baby suckling
  • vacuum strength ≤250 mmHg, and easily regulated
  • separate drive and suction system to ensure no contamination from milk spillage can enter pump
  • collection system enabling milk to be pumped directly into storage container with universal thread, to avoid need to transfer milk to another container for storage or administration
• Advise mothers to:
  
  • bath or shower daily
  • wash hands thoroughly with soap and running water before expressing 
  • gently massage breast and stimulate nipple to trigger milk ejection reflex before milk expression
  • have regular prolonged skin-to-skin contact with their baby
  • stimulate oxytocin release by expressing next to baby where possible 
  • complete expressing log and seek help if concerned about milk supply

• Sterilise milk collection kit before use
• Commence hand expression as soon as possible following delivery (preferably within 2 hr)
• Frequency of expression: 8–10 times/24 hr (not leaving a gap >6 hr overnight)
• Teach all mothers hand expression
• Use hand expression to express colostrum and collect milk obtained via a syringe (see Nutrition and enteral feeding guideline for advice on colostrum collection and administration)
• When milk obtained is sufficient to flow easily into storage container or by day 3 of life, teach mother to use electric breast pump
  
  • continue to hand express after using pump to help release higher fat milk and maximise supply
• Encourage simultaneous (double) pumping of both breasts. Tubular support bandage or an inexpensive bra with small holes made for funnels can be used to hold both kits in place
• Ensure mother has a properly fitting breast shield (funnel); nipple should fit comfortably in shield
  
  • may require different shield sizes as lactation progresses and to prevent nipple trauma caused by ill-fitting shield

• Ensure mother seated in a comfortable chair and keep clothing away from breast while expressing milk 
• Position breast pump shield (funnel) centrally over nipple with gentle pressure to obtain seal
  
  • if nipple rubs on walls of shield it is too small
  • if breast tissue drawn into shield it is too large
    
    • measuring tools available from some manufacturers
• Adjust suction control to increase vacuum slowly until slightly uncomfortable (not painful), then reduce until comfortable
• Use gentle pressure to obtain patent seal between breast and shield. Firm pressure will inhibit milk flow by compressing ducts
• Use gentle breast compression during expressing to increase efficacy of electric pump
• Express breasts as thoroughly as possible since fat content increases as breast is drained. Express until milk stops flowing
• If using a single pump, switch to second breast when milk stops flowing 
• Use a new bottle for each expression
• Leave a space of 1–2 cm at the top of each bottle to allow for expansion during freezing
• After expression, wash equipment in hot soapy water with a bottle brush and rinse under cold running water, dry thoroughly with paper towels. Sterilise before next use 
• Encourage mothers to practice ‘kangaroo care’ also known as skin-to-skin holding (see Kangaroo care guideline)
• Encourage mothers to express where they feel most comfortable; either close to baby or with baby picture/memento
• Complete expressing assessments at least once within the first 12 hr following delivery and ≥4 formal expressing assessments in the first 2 weeks (optimise milk production and address any issues related to expressing) See www.unicef.org.uk/babyfriendly/assessment-of-breastmilk-expression-checklist 

Problems related to milk expression

Sore nipples

• Centre milk expression shield
• Try a variety of shield sizes
• Check pump vacuum and expressing technique 
• Stop pump before removing shields
• Do not use plastic-backed breast pads
• Change breast pads frequently
• Consider infection

Improving milk supply

• Complete BFI or unit expressing assessment

• Increase kangaroo care (skin-to-skin)

• Express close to baby

• Check frequency of pumping, ensure including night-time expression

• Hand express after using the breast pump 

• Check shield (funnel) size

• Encourage breast compression during expression

• Increase frequency of expression sessions

• Consider cluster expressing – mother expresses 2 or 3 times in a 4 hr period 
  for 3–4 consecutive days

• Refer to infant feeding team for support

• Consider enhancing prolactin secretion using domperidone

• Praise provision of expressed milk, no matter how small

• See www.unicef.org.uk/babyfriendly or www.bestbeginnings.org.uk/watch-small-wonders-online