Decreasing Breast Milk Volumes in the NICU: What Can Clinicians Do?

Irene Murphy Zoppi, RN, MSN, IBCLC / July 2017


How often have you heard mothers of infants in your unit comment that they aren’t producing enough breast milk?

Have you witnessed mothers’ milk supplies initially appear sufficient, but then seem to decrease when nutritional needs of their infants increase?

Although mothers work diligently to keep up with the demands of producing milk, they continue to struggle with producing adequate volumes of breast milk. Decreasing milk supply is just one issue many mothers who express breast milk for their NICU infants often encounter.1,2,3,4

Meier suggests expressed daily milk volumes be greater than or equal to 500 milliliters within the first two weeks post birth to ensure the provision of exclusive human milk over the length of the NICU stay.5 Hill demonstrated correlation of milk volumes expressed on day 4 post-partum with milk volumes 6 weeks post birth.2

But the questions that beg for answers are:  Can the decrease in expressed breast milk volumes be prevented, and what strategies can be implemented to prevent a decrease in production?

Pumping early and often

More and more mothers of NICU infants desire to provide their own breast milk for their infants.

Unfortunately, due to the health issues these infants experience, direct breastfeeding is not possible.  As a result, mothers choosing to provide milk for their infants find it necessary to employ breast expression techniques that allow the provision of breast milk to their infants.

Early milk expression after delivery seems to make a difference in initial and subsequent milk volumes. Parker’s research demonstrates mothers who delivered VLBW premature infants and began milk expression within 1 hour of delivery produced significantly more milk during the initial days after birth as well as through six weeks post birth than mothers who initiated milk expression after 1 hour post delivery.6,7,8

A delay in initiating milk expression can interrupt the onset of copious milk, referred to as Secretory Activation or Lactogenesis II.  Such a delay can lead to a secondary failure of milk production if not managed well, meaning mothers may find it difficult to ever achieve full milk production and/or, over time, may experience a decrease in milk production.9

The first step in helping to prevent declining milk production then, is to get off to a good start by pumping as soon as possible after delivery, preferably within the first 1-3 hours.

The right technology

The use of a multi-user, evidence-based double electric breast pump has been recommended for mothers exclusively pumping milk for their hospitalized infants.10,11,12 A double-electric breast pump may help mothers who are exclusively pumping for their hospitalized infants to stimulate milk production in the most effective and efficient manner.5

A breast pump that utilized suction patterns mimicking the unique sucking action of healthy term infants used in the first five days post birth has demonstrated increased volumes of expressed milk for mothers whose infants are unable to directly breastfeed.12,13,14,15

Using hands to express milk

Hand expression has been mentioned to aid in the retrieval of the small quantities of colostrum produced during the initial days of lactation.16 It’s a great way for pumping mothers to obtain colostrum that can be used for oral care in the NICU and can be used in conjunction with breast pump usage.

Hand expression of colostrum should be viewed as an adjunct to pumping for mothers of VLBW infants, but not as an alternative to pumping. Hand expression removes breast milk by compressing the milk ducts within the breast. But healthy term infants don’t remove breast milk by compression; research tells us that healthy term infants and breast pumps remove milk by using vacuum.17,18

These two therapies (early hand expression and the most effective, efficient breast pump outfitted with the right technology) can make a difference in early milk volumes and subsequent milk production.

Double pumping

Mothers know exclusively pumping can be time consuming. One suggestion to combat ‘pumping fatigue’ is to instruct mothers to double pump.

There is research that demonstrates double or simultaneous pumping is more efficient, increases the volume of milk expressed, and produces milk that is higher in fat than sequential pumping.19 Another technique to improve efficiency while pumping is to instruct mothers to use the highest, yet comfortable vacuum, known as Maximum Comfort Vacuum™.

A pumping diary

By encouraging mothers to keep a daily journal or diary documenting pumping sessions and milk volumes, they are actively engaged in providing nutrition to their infants.  It also enables them and clinicians to identify when milk volumes start to diminish.5,10

What you need to know about breast shields

Breast shields that are either too small or too large can cause physical discomfort and/or injury. What a lot of mothers don’t know is that their breasts undergo multiple changes in the early post birth period, and an ill-fitting breast shield can impact milk removal and lead to milk volume issues.5

Some of the issues resulting from ill-fitting breast shields can be eliminated by assessing their fit daily during the first two weeks after birth. Another helpful technique is to have mothers warm the breast shields before pumping; warmed breast shields can improve the efficiency of milk removal.20


The early days after birth are critical in establishing a plentiful milk production. Early, frequent, and effective removal of the first milk secreted determines future production potential. Exclusive pumping is hard work! Every exclusively pumping mother deserves the opportunity to meet her lactation goals.

What better way to get each pumping mother off to the best start possible in meeting her lactation goals than with methods that make a difference!  Perhaps with bedside education, support, and use of the right technology, both initial milk volumes and subsequent milk production will not be jeopardized. Maybe we can put an end to the decreasing milk production many NICU mothers experience.



1 Hill PD, Aldag HC, Chatterton RT. Effects of pumping style on milk production in mothers of non-nursing preterm infants. J Hum Lact. 1999; 15(3): 209-215.

2 Hill PD, Aldag HC, Chatterton RT, Zinaman M. Comparision of milk output between mothers of preterm and term infants: the first 6 weeks after birth. J Hum Lact. 2005; 21(1):22-30.

3 Cregan MD, De Mello TR, Kershaw D, McDougall K, Hartmann PE. Initiation of lactation in women after preterm delivery. Acta Obstet Gynecol Scand. 2001; 81():870-877.

4 Meier PP, Engstrom JL. Evidence-based practices to promote exclusive feeding of human milk in very low-birthweight infants. NeoReviews. 2007; 8(11):e467-e477.

5 Meier PP, Engstrom JE, Patel AL, Jegier BJ, Bruns NE. Improving the use of human milk during and after the nicu stay. Clinic Perinatol. 2010; 37(1):217-245.

6 Parker LA, Sullivan S, Kruegger C, Kelecchi T, Mueller M. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. J of Perinatol. 2012; 32(3):205-209.

7 Parker LA, Sullivan S, Krueger C, Muellerl M. Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med. 2015; 10(2): 84-91.

8 Parker LA, Mueller M, Sullivan S, Krueger C. Optimal time to initiate breast milk expression in mothers delivering extremely premature infants. The FASEB J. 2017; 31(1).

9 Czank C, Henderson JJ, Kent JC, Lai CT, Hartmann PE. Hormonal control of the lactation cycle. In: Hale TW, Hartmann PE, eds. Textbook of human lactation. 1 ed. Amarillo, TX.:Hale Publishing, L.P.;2007.

10 Spatz DL. Ten steps for promoting and protecting breastfeeding for vulnerable infants. J Perinat Neonat Nurs. 2004; 18(4):365-396.

11 ABM – Clinical Protocol #7: Model Breastfeeding Policy (Revision 2010). Breastfeed Med. 2010; 5(4

12 Meier PP, Patel AL, Hoban R, Engstrom JL. Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology. J Perinatol. 2016; 36(7):493-499.

13 Meier PP, Engstrom JL, Janes JE, Jeiger BJ, Loera F. Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants. J Perinatol. 2012; 32(2):103-110.

14 Torowicz DL, Seelhorst A, Froh EB, Spatz DL. Human milk and breastfeeding outcomes in infants with congenital heart disease. Breastfeed Med. 2015; 10(1):31-7.

15 Post ED, Stam G, Tromp E. Milk production after preterm, late preterm and term delivery: effects of different breast pump suction patterns. J Perinatol. 2016; 36(1):47-51.

16 Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining had techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol. 2009; 29(11):757-764.

17 Kent JC, Mitoulas LR, Cregan MD, Geddes DT, Larsson M, Doherty DA, Hartmann PE. Importance of vacuum for breastmilk expression. Breastfeed Med. 2008; 31(1):11-19.

18 Geddes DT, Kent JC, Mitoulas LR, Hartmann PE. Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev. 2008; 84(7):471-477.

19 Prime DK, Garbin CP, Hartmann PE, Kent JC. Simultaneous breast expression in breastfeeding women ins more efficacious than sequential breast expression. Breastfeed Med. 2012; 29(11):757-764.

20 Kent JC, Geddes DT, Hepworth AR, Hartmann PE. Effect of warm breastshields on breast milk pumping. J Hum Lact. 2011; 27(4):331-338.


About the Author

Irene joined Medela in 1999 as a clinician for the Breastfeeding Division. She currently serves as a Clinical Education Specialist focusing on Advocacy Outreach. In this role, she acts as a vital resource for groups assisting breastfeeding mothers and infants. She has been frequently interviewed on radio and online regarding breastfeeding issues for mothers and clinicians.

Irene spent many years caring for new families in antenatal, labor and delivery, postpartum and NICU settings and was involved in direct patient care and family-based education. Irene has extensive experience teaching in a variety of nursing education programs.  She produced a video presentation on nursing students’ involvement in Community Health Nursing for the National League of Nursing.