How Two Techniques to Express Human Milk Complement One Another

Irene Murphy Zoppi, RN, MSN, IBCLC / April 2019


Scientific research has continuously improved our knowledge about human milk and how infants breastfeed. Current research tells us that healthy, term babies use intra-oral vacuum to extract colostrum and milk from the breast.1,2

Understanding how infants apply an irregular vacuum pattern to stimulate the breast and extract colostrum and milk from the breast helps to understand the initial feeding behaviors of infants and how these relate to milk production. In the first few days post birth, in the presence of low colostrum volumes, infants feeding behaviors consists of short sucking bursts of varying intensities interspersed with pauses. Due to the normal, but low volumes of colostrum, infants use high sucking pressures; they suck harder to express the low volume available.  This infant sucking pattern does more than just “get the milk out of the breast”. It appears to program more secretory tissue and prolactin receptors under the influence of high concentrations of prolactin to program mothers’ breasts for later milk production and may play a greater role than milk removal in the initial stage of lactation.3,4,5 Hand expression uses compression rather than vacuum to extract milk, so although milk is expressed using hand expression, it may not fully stimulate further milk production. Yet, hand expression used in conjunction with an electric breast pump may facilitate the expression of colostrum and programming of secretory tissue in the first few days post birth.

Hand expression techniques were not the principle method of milk expression in the study conducted by Morton and colleagues.6  All mothers initiated milk expression using the standard 2.0 program of Medela’s Symphony® Breast Pump 8 times a day.  They continued to use the breast pump for the duration of the study.  Additionally, they performed hand expression for the first 3 postpartum days followed by hands-on pumping after lactogenesis II occurred. The study authors state that combining hand techniques with electric pumping may have an additive effect on milk production. They recommended a larger, prospective, randomized controlled trial would be needed to validate the observed benefits.

Do breast pump patterns matter?

Not only is vacuum suction important, the type of vacuum suction matters. The Symphony PLUS™ Breast Pump with the Initiation TechnologyTM pattern was developed to mimic the sucking behavior of term infants. Three clinical trials published in highly regarded peer reviewed journals evaluated the effectiveness of the Symphony PLUS Initiation Technology pattern.3,4,5 Although populations and methods were different, these studies yielded consistent results related to breast milk production.  Meier et al. reported the Symphony PLUS group achieved 67% more milk than the control group by day seven, with more than twice the number of mothers obtaining milk output goals of 500 mL/day by the end of two weeks. Post et al. reported daily milk production was significantly higher in the initiation program group at each time point from days three through 14. At two weeks postpartum, mothers in this group produced on average ~ 67% more milk (~750 mL/day compared to ~ 500/day in the standard program group). Post et al. also noted women using the Initiation Technology achieved lactogenesis on average by 3.3 days compared to 4.5 days for those who used a standard pump pattern. Torowicz et al. report mothers who used this technology attained average daily milk volumes above 600 mL by the end of the second week, levels that were maintained or increased in the next two weeks.

Best practice, then, is to combine hand expression with technology but not to exclude one over the other. Hand expression should be used in conjunction with the proven Initiation Technology to properly initiate a breast milk supply when mothers are unable to nurse or have breastfeeding risk factors.



1Geddes DT, Kent JC, Mitoulas LR, Hartmann PE. Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev. 2008 Jul;84(7):471-7

2Cannon AM, Sakalidis VS, Lai CT, Perrella SL, Geddes DT. Vacuum characteristics of the sucking cycle and relationships with milk removal from the breast in term infants. Early Hum Dev. 2016 May; 96:1-6.)

3Meier PP, Engstrom JL, Janes JE, Jegier 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.

4J Perinatol. Feb 2012;32(2):103-110. 14. Post ED, Stam G, Tromp E. Milk production after preterm, late preterm and term delivery; effects of different breast pump suction patterns.

5J Perinatol. Nov 5 2015. 15. Torowicz DL, Seelhorst A, Froh EB, Spatz DL. Human milk and breastfeeding outcomes in infants with congenital heart disease. Breastfeed Med. Jan-Feb 2015;10:31-37.) 

6Morton J, Hall JY, Wong RJ, Thairu L, Benit WE, Rhine WD. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol. 2009; 29(11):757-64).



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.