maintaining a milk supply for the
premature or ill infant

Most mothers don’t anticipate having a premature or ill infant, and are not prepared for the experience of establishing or maintaining a milk supply for their babies. But because your baby is premature or ill, your breastmilk is one of the most important things you can give him. This pamphlet is designed to help you continue to produce milk until you and your baby are able to establish or re-establish a breastfeeding relationship.

There are several things you should do to ensure adequate milk production. You need to eat a well-balanced diet, drink an adequate amount of fluid (2–2 ½ quarts per 24 hours), get a sufficient amount of rest, and provide frequent stimulation to the breasts and nipples. The breasts should be stimulated six to eight times a day by either hand or mechanical expression. Expressing milk every two to three hours for approximately 10–15 minutes on each breast is usually enough to maintain a milk supply. You may take a six-hour stretch between expressions at night. The quantity of milk is not as important as the frequency and regularity of expressing it.

expressing milk

A hospital-quality electric breastpump can be very effective at stimulating the breasts to establish and maintain milk production. A double-pumping system that pumps both breasts simultaneously may be recommended, especially for twins. Many mothers produce more than their babies can consume with electric pumps.

There are several types of hand pumps available at moderate prices. Those pumps that use a rubber bulb to create suction are generally ineffective, uncomfortable and may allow bacteria to grow in the bulb. A cylinder-shaped pump is usually more effective and is simple to clean and use. This pump is comprised of two all-plastic cylinders, which fit inside one another. A shield on the inner cylinder accommodates the nipple and areola, and when the other cylinder is extended a vacuum is created.

Manual expression can be very difficult and tiring when mothers need to express frequently to establish milk production. Second-time mothers experienced in manual expression may have better success.

Some hints that may help when expressing milk are as follows:

  • patience and persistence are key in expressing milk, and you will become more efficient at manual or pump expression. The first few times you may obtain only a few drops, but the regularity of stimulation gradually increases the milk production.
  • establish a pattern It may take time for the milk ejection reflex (letdown) to adjust to artificial stimulation, so don’t become discouraged.
  • apply moist heat to the breasts A hot shower, hot bath or hot wet towels on the breasts may encourage the milk ejection reflex.
  • gently massage the breasts in a repeated circular pattern around the breast with the fingertips. Then cup the hands around the breast and gently stroke toward the nipple.
  • relax to encourage the milk ejection reflex Exercises involving deep breathing or contracting muscle groups and letting them go may help, as well as thinking about the baby. Look at some pictures of your baby. Listen to tapes of baby sounds. In some cases you may need to consult with a physician regarding the temporary use of synthetic oxytocin, a nasal spray hormone, which may encourage the milk ejection reflex.
  • as the flow from one breast decreases, you may proceed to the second breast, switching back and forth. For example, express 7 minutes on each side, then 5 minutes, then 3 minutes.

The color and consistency, as well as the amount of breastmilk, can vary. Factors that may affect the color and consistency are the time of day the milk is expressed, or what you may recently have eaten. Variations range from a pale, transparent color, to a thicker, somewhat yellow or greenish color. The foremilk (milk produced at the beginning of an expression) is lighter in color and in fat content than the hindmilk (last milk expressed) which is higher in fat and creamier.

Be aware that anything you ingest is transferred to your baby through your breastmilk. Medications, whether over-the-counter or prescribed by your doctor, can pass through your breastmilk. It is important that your physician knows that you are providing milk for your infant should you need to take any medication. The baby’s doctor should also be made aware of any medication you are taking, even pain relievers such as aspirin, cold remedies and laxatives.

In addition to medications, the effects from alcohol, caffeine, and cigarettes are also transferred to your baby via your breastmilk. Avoid these or consult with your physician regarding their effects on your baby.

Use a separate container for each expression. Do not “layer” (add newly expressed milk to previously frozen milk) as long as your baby is hospitalized or ill.

sterilizing pumps and bottles

A premature or ill infant is very vulnerable to infection and every precaution should be taken to give him milk that is as uncontaminated by bacteria as possible. Breastmilk is sterile when it leaves the breast. Discarding the first few squirts lowers the bacterial count by flushing bacteria from the skin or just inside the nipple.

Begin by washing your hands thoroughly. Use a scrub brush on your nails and dry your hands on a clean towel. Don’t put your fingers inside the bottle or in the cap.

Any sterile bottle with a screw-on lid may be used. The nursery at your hospital may provide bottles for your milk. Be sure that your baby’s physician approves of your bottles and sterilization methods.

All pump parts that come in contact with milk should be washed immediately with liquid dish soap and hot water. Air-dry on a clean towel. Immediate washing is the key to reducing bacterial growth.

Once a day all pump parts and nipples should be sterilized by one of the following three methods:

  • Cover items with water in a pot and boil for 5 minutes. (To prevent breakage put a washcloth in the bottom of the pot.) After 5 minutes remove from the heat, cover the pot and save until ready to use. Excessive boiling builds calcium deposits, which create a medium for bacterial growth.
  • Sanitize in a dishwasher with a hot wash/dry cycle.
  • Soak in a 1% sodium hydrochloride solution for one minute. (Put one teaspoon of household bleach in one gallon of water.) Do not rinse, then air-dry.

storing, transporting and using breast milk

Swirl milk bottle in ice water to cool and place in the freezer immediately. Leave at least ½-inch air space and do not cap the jars tightly as milk expands when it freezes. To transport milk, pack in ice and deliver as soon as possible.

To use at home, remove from freezer, loosen cap and place in a bowl of warm water or thaw in the refrigerator. After thawing, gently swirl to distribute cream (vigorous shaking damages the milk cells). Do not microwave. Thawed milk should be used immediately or refrigerated for no more than 24 hours. Frozen milk may be kept for six months in the back of a 0°F freezer. Use a freezer thermometer. Never refreeze thawed milk.

while your newborn is in the hospital

Spend as much time as possible with your infant. He will benefit from having you caress or hold him if that is possible. Remember, though, that once the infant is home, you will be very busy taking care of him, so don’t allow yourself to become overly tired. Leave the hospital early enough so that you can get a good night’s rest as often as possible.

You may feel as if you need someone to mother you a little. This is quite normal. In the days past, we had our mother, sister, aunts, etc. to help us out and give us a shoulder to lean on. Today, many of us are left alone feeling alone and isolated. Don’t be afraid to ask for help when you need it. Find an organization, such as a group that counsels breastfeeding mothers, who can give you the support and encouragement you need. If you feel low, try to talk to someone about it. Often, just expressing your feelings can make you feel better.

Keep in touch with your baby’s nurses and/or physicians. Let them know your feelings about breastfeeding and that you are working to maintain a milk supply. Find out when your baby can have your milk or colostrum. If the baby is not able to breastfeed yet, your colostrum or milk can be fed to the baby via gavage (tube).

in the nursery

clothing You will be asked to wear a gown. If you are ill a mask and/or cap will be required. You will be more comfortable in a lightweight, two-piece outfit which you can easily manipulate. Try to wear convenient nursing bras and pads.

putting the baby to the breast A premature or ill infant may not have a strong sucking reflex and he may not be able to nurse vigorously, if at all. Even if the baby does not nurse well, he learns the smell and feel of your skin.

positioning Your baby’s mouth may seem tiny compared to your nipple size. The “dancer hand” position is effective for the premature or neurologically impaired infant. The baby’s jaw needs to be steadied. The baby’s chin also needs support by cupping your hand under the breast and using the index finger and thumb on each side of his jaw. Make sure the baby’s head des not tilt back, but is tucked down in this position. When lying down or using the football hold continue to support the baby’s jaw and chin.

If your baby is reluctant to nurse, you may wish to roll out your nipple between your fingers until it is erect. Express a few drops of milk for the baby to taste and smell. Stroke the baby’s lips with your nipple. When the baby’s mouth is wide open, insert the nipple as far back as possible. Often the baby will not suck until he feels the nipple well back at the top of his mouth.

it is not unusual for a newborn to suck a time or two and then lose interest or fall asleep To awaken a sleepy baby, try tickling his feet, stroking his forehead, spine, or under his chin. AS your baby grows and becomes stronger, he will do better. You and your baby will become a team but teamwork takes time and practice. Keep trying.

once the baby has finished nursing express manually or with a pump in order to encourage an ample milk supply.

do not use a rubber nipple shield Its use compounds difficulties if the baby becomes nipple confused.
Your patience and perseverance will reward you. Once your baby is stronger and his appetite improves, he will begin to nurse more. You may have to help him along, but don’t despair. Some babies are tube-fed and/or bottle-fed for weeks before they begin to breastfeed. As long as you express milk frequently and regularly you can keep up your milk supply.

references

Asquith, Maria Theresa, Ronald Sharp, RS, and David K. Stevenson, MD, Decreased Bacterial Contamination of Human Milk Expressed with an Electric Breast Pump, Journal of the California Perinatal Association, Volume IV, No.2, 1986.

Asquith, Maria Theresa, Chairperson of the Human Milk Banking Association of Norht America, Director of Mothers’ Milk Bank of the Institute of Medical Research, San Jose, CA.

Harrison, Helen, and Kositsky, Ann, The Premature Baby Book: A Parents Guide to Coping and Caring, St. Martin’s Press, New York, NY, 1983.

Huggins, Kathlenn, RN, MS, Nursing Mothers Companion, 1986.

Nance, Sherrie, Premature Babies: A Handbook for Parents by Parents, Arbor House Publishing Co., New York, NY 1984.

The information in this pamphlet was prepared and revised by Nursing Mothers Counsel, Inc., a non-profit organization, according to the policies, procedures and approval of the Mothers Milk Bank of the Institute of Medical Research, San Jose, CA, which has been providing mothers’ milk for premature or ill infants since 1974. IT has been approved by the following members of the NMC Medical Advisory Board: Stephen J. Buchner, MD, Kenneth Castor, Jr., MD, James A. Cisco, Md, Emily Earl, MD, Donald B. Lathrop, MD, Frederick A. Lloyd, MD, Philip Sunshine, MD

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