How NICU Clinicians Can Assist Mothers with Breast Milk Expression

Michelle A. Krauklis, RNC-NIC, MSN / July 2016


(This article was originally published in the Spring 2016 issue of Neonatal Intensive Care) Undeniably, human milk is the preferred nutrition for all infants. This is especially true for fragile, premature infants in the NICU as human milk provides protection from multiple prematurity-specific morbidities. Evidence demonstrates greater protection to the infant with the delivery of exclusive mother’s own milk (Meinzen-Derr 2009; Sisk 2008; Vohr 2006; Vohr 2007). However, infant prematurity poses many challenges that prohibit direct feeding at the breast. Mothers choosing to provide milk for their infants face an often unexpected reality of breast pump dependence.

Practice Guidelines Rationale
1.  Assess mother’s intention to provide breast milk for her infant. 1.  A mother may have questions about providing pumped milk for her infant. The provision of scientific information regarding the value of human milk allows the mother to make an informed decision regarding pumping milk for her infant (Spatz 2012).
2.  Educate mother on the importance of early initiation of pumping. 2.  In the absence of effective infant sucking, mechanical methods of milk expression should be employed to provide appropriate and adequate mammary gland stimulation and milk drainage. Without sufficient stimulation, milk volumes may be affected (Neville 2001; Chapman 2001).
3.   Assist mother to initiate pumping as soon as possible after delivery,
preferably within one hour of delivery.
3.   Early breast expression increases early and long-term milk volumes (Hill 2001; Parker 2012, 2015). Pumping within one hour (compared to 1-6 hours) of delivery was found to significantly increase maternal milk output at different time points from in the first few days after birth through six weeks postpartum. Average milk volumes were increased by approximately 100% (Parker 2012).
4.   Provide a hospital-grade (multi-user), double electric breast pump with Initiation Technology™. 4.    Initiation Technology™  mimics sucking patterns of healthy term infants during the colostral phase of lactation. In a randomized controlled trial, pumping mothers of preterm babies produced on average43% more milk by day four and 67% more milk by day seven. Milk increases were sustained throughout the study with women pumping 124 fewer minutes during the first two weeks (Meier 2011). Similar results were found in other studies regardless of infants’ gestational age (Torowicz 2015; Post 2016; Meier 2016).
5.   Demonstrate the set-up and use instructions of the breast pump. 5.   Patients should have clear, specific operating instructions when using a medical device (Swayze 2011).
6.   Instruct mother to double pump. 6.   Research demonstrates double or simultaneous pumping is more efficient, increases volumes of milk expressed, and produces milk that is higher in fat than sequential pumping (Prime 2012).

Lactation best practices are changing to reflect scientific evidence related to optimal milk production outcomes with increasing attention to lactation initiation practices and technologies.

Nurses in labor and delivery, on other baby units, and in special care nurseries are critical to mothers’ lactation success because they support, educate, and assist new mothers with breast milk expression from the first minutes after birth until both mother and infant are discharged home. The following practice guidelines
summarize evidence-based practices to best assist pump-dependent mothers with milk expression.

7.  Teach mother how to pump using Maximum Comfort Vacuum™. 7.  Maximum Comfort Vacuum™ is the mother’s highest, yet comfortable vacuum setting used while pumping. Use of Maximum Comfort Vacuum enhances milk flow rate and milk yield (Kent 2008).
8.  Assist mother to initially pump a minimum of eight times daily. 8.   Mothers should be instructed to pump at the same frequency healthy term infants would normally breastfeed (Walker 2010). Frequent breast/nipple stimulation causes prolactin and oxytocin release while emptying the breast stimulates ongoing milk production (Kent 2012).
9.  Inform mother she may need to initially include a night time pumping session. 9. Around-the-clock pumping sessions provide necessary mammary gland stimulation, simulate the normal feeding patterns of term infants, and help to prevent a decline in milk volumes (Kent 2013; Spatz 2004).
10. Once milk volumes increase, instruct mother to pump for two minutes after the last droplets are noted. 10. Ensures all available milk and high-fat milk has been removed. Well-drained breasts will produce more milk than breasts that are only partially drained (Meier 2010; Daly 1996).
11. Provide mother with appropriate size containers to collect milk. 11. The healthy, term infant ingests minimal amounts of colostrum in the first twenty-four hours-approximately 15 mL. Providing small containers to collect colostrum and subsequent milk sets realistic expectations for the mother. Large containers may intimidate the mother to think her milk production is abnormal (Santoro 2010; Spatz 2012).
12. Encourage mother to keep a daily journal documenting her pumping sessions and milk volumes. 12. A milk journal enables mothers and clinicians to identify milk volume issues early so that interventions can be implemented (Spatz 2004; Meier 2010; Wu 2015).
13. Provide pumping target volumes. 13. Providing target volumes helps set expectations of the volume of milk the mother should be producing. Ideal target volumes should reach 750-1000 mL within the first two weeks post-birth. This volume of expressed milk is aligned with meeting the breast milk intake for the infant over the entire NICU stay (Meier 2010).
14. Assess for risk factors associated with delayed lactogenesis. 14. Multiple risk factors have been identified that may significantly impact the onset of copious milk production (Secretory Activation). These include; diabetes mellitus, preterm labor, pregnancy-induced hypertension, excessive maternal blood loss, prolonged bed rest, maternal stress during labor and delivery, an unscheduled Cesarean delivery, obesity, and the use of selective serotonin re-uptake inhibitors (SSRIs). Many mothers have more than one risk factor and should be carefully followed for a delay in lactogenesis (Nommsen-Rivers 2010; Marshall 2010; Hurst 2007).
15. Assess breast shield fit daily during the first two weeks after birth. 15. Mothers’ breasts undergo multiple changes in the early post-birth period. A too large or too small breast shield may cause physical discomfort and/or injury. An ill-fitting breast shield can also impact milk removal and lead to milk volume issues (Meier 2010).
16. Support bedside pumping. 16. Pumping at the infant’s bedside provides the mother the opportunity to visit her infant while she pumps. It also allows staff to correct any incorrect pumping techniques. Providing a bedside pump in L & D  and for each mother on post-partum facilitates pumping. Staff should not have to spend valuable time searching for a pump when needed (Meier 2007; Spatz 2011).
17. Provide frequent opportunities for skin to skin holding. 17. Studies have demonstrated mothers are able to express significantly more milk after a skin to skin session (Furman 2002; Hurst 1997; Spatz 2004; Meier 2007). Skin to skin care results in improved breastfeeding, milk production, parental satisfaction, and bonding (Baley 2015).
18. Assist with the transition for the infant to begin tasting breast milk. 18. Nonnutritive sucking can be initiated once the infant is no longer intubated and has demonstrated improvement in the transition to direct breastfeeding and longer breastfeeding rates (Narayanan 1991; Briere 2015; Wilson 2015).


The process of initiating and maintaining adequate volumes of human milk for premature infants requires dedication from mothers and commitment from clinicians. Bedside nurses can have a significant impact on pumping experiences of pump-dependent mothers by integrating lactation best practices — starting with milk expression initiation- into their care and unit policies. With the encouragement, guidance, and support of clinicians, pump-dependent mothers can successfully initiate and maintain milk supplies for their infants.



Baley, J., Committee On, Fetus, & Newborn. Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU. Pediatrics. 2015; 136(3), 596-599.

Briere CE, McGrath JM, Cong X, Brownell E, Cusson R. Direct-breastfeeding premature infants in the neonatal intensive care unit. J Hum Lact. 2015; 31(3):386-92.

Chapman DJ, Young S, Ferris AM, Perez-Escamilla R. Impact of breast pumping on lactogenesis stage II after cesarean delivery: a randomized clinical trial . Pediatrics. 2001; 108(6):E94.

Daly SEJ, Kent JC, Owens RA, Hartmann PE. Frequency and degree of milk synthesis. Exp Physiol. 1996; 81:861-75. doi:10.1038/jp.2016.14

Furman L, Minich N, Hack M. Correlates of lactation in mothers of very low birth weight infants. Pediatrics. 2002; 109(4)e57-64.

Hill PD, Aldag JC, Chatterton RT. Initiation and frequency of pumping milk and milk production in mothers of non-nursing preterm infants. J Hum Lact. 2001; 17(1):9-13.

Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L. Skin-to- skin holding in the neonatal intensive care unit influences maternal milk volume. J Perinatol. 1997; 17(3):213-7.

Hurst NM. Recognizing and treating delayed or failed lactogenesis II. J Med and Women’s Health. 2007: 52-6.

Kent JC, Hepworth AR, Sheriff JL, Cox DB, Mitoulas LR, Hartmann PE. Longitudinal changes in breastfeeding patterns from 1 to 6 months of lactation. Breastfeed Med. 2013; 8(4):401-7.

Kent JC, Mitoulas LR, Cregan MD, Geddes DT, Larsson M, Doherty DA, Hartmann PE. Importance of vacuum for breast milk expression. Breastfeed Med. 2008; 3(1):11-19.

Kent JC, Prime DK, Garbin CP. Principles of maintaining or increasing breast milk production. JOGNN. 2012; 4(1):114-20.

Marshall AM, Nommsen-Rivers LA, Hernandez LL, Dewey KG, Chantry CJ, Gregerson KA, Horseman ND. Serotonin transport and metabolism in the mammary gland modulates secretory activation and involution. J of Clin Endocrin. 2010; 95(2):837-46.

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

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. 2011; 31:1-8.

Meier PP, Engstrom JL. Evidence-based practices to promote exclusive feeding of human milk in very low-birthweight premature infants. NeoReviews. 2007; 8(11):e467-77.

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: online, 25 February 2016

Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of human milk in extremely low birth weight infants’ risk of necrotizing enterocolitis or death. J Perinatol. 2009; 29(1):57-62.

Neville MC. Anatomy and physiology of lactation. Pediatr Clin North Am. 2001; 48:13-34.

Nommsen-Rivers LA, Chantry CJ, Peerson JM, Cohen RJ, Dewey KG. Delayed onset of lactogenesis among first time mothers is related to maternal obesity and factors associates with ineffective breastfeeding. Am J Clin Nutri. 2010; 92(3):574-84.

Parker LA, Sullivan S, Kruegger C, Mueller 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.

Post EDM, 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.

Prime DK, Garbin CP, Hartmann PE, Kent JC. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression. Breastfeed Med. 2012: 29(11):757-64.

Santoro W, Martinez FE, Ricco RG, Jorge SM. Colostrum ingested during the first day of life by exclusively breastfed healthy newborn infants. J Pediatrics. 2015; 156(1):29-32.

Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O’Shea TM. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infnats. J Perinatol. 2007; 27():428-33.

Sisk PM, Lovelady CA, Gruber KJ, Dillard RG, O;Shea TM. Human milk consumption and full enteral feeding among infants who weigh ≤ 1250 grams. Pediatrics. 2008; 121(6):e1528-33.

Spatz DL. Innovations in the provision of human milk and breastfeeding for infants requiring intensive care. JOGNN. 2012; 41():138-43.

Spatz DL. Ten steps for promoting and protecting breastfeeding for vulnerable infants. J Perinatol Neonatal Nurs. 2004: 18(4):385-96.

Swayze SC, Rich SE. Promoting safe use of medical devices. The Online Journal of Issues in Nursing. 2011, 17(1). doi:10.3912/OJIN.Vol17No)1PPTOI

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

Vohr BR, Poindexter BB, Dusick AM, McKinley LT, Higgins RD, Langer JC, Poole WK. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics. 2007; 120(4):e953-959.

Vohr BR, Poindexter BB, Dusick AM, McKinley LT, Wright LL, Langer JC, Poole WK. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 2006; 118:e115-123.

Walker M. ‘Breast pumps and other technologies.’ pp 381-86, Ch. 12 in Breastfeeding and Human Lactation, 4th edition, 2010 by Jan Riordan and Karen Wambach, Jones and Bartlett Publishers, Sudbury, MA.

Wilson E, Christensson K, Brandt L, Altman M, Bonamy AK. Early provision of mothers’ own milk and other predictors of successful breast milk feeding after very preterm birth: a regional observational study. J Hum Lact. 2015; 31(3):393-400.

Wu B, Zheng J, Zhou M, Xi X, Wang Q, Hua J, Hu X, Liu JQ. Improvement of expressed milk in mothers of preterm infants by recording breast milk pumping diaries in The Neonatal Center in China. PLoSOne. 2015; 10(12):e0144123.


About the Author

Michelle Krauklis is a Neonatal Intensive Care nurse at Loyola University Medical Center in Maywood, Illinois, functioning as a permanent charge nurse. She is an independent Educational Consultant for Medela, Inc.