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Breast milk expression for the preterm infant

Breast milk expression for the preterm infant
Literature review current through: Jan 2024.
This topic last updated: Jun 29, 2022.

INTRODUCTION — Human milk is widely recognized as the optimal feeding for virtually all infants because of its proven health benefits to infants and their mothers [1-4]. It has particularly important health benefits for preterm infants. However, premature birth also poses several unique challenges to breast milk production and feeding. Mothers of premature infants need early and ongoing support to ensure optimal human milk feeding through breast milk expression and transitioning to direct breastfeeding when the infant is ready.

Breast milk expression for the premature infant will be reviewed here. Breastfeeding the premature infant, the nutritional composition and fortification of human milk, and the approach to enteral feeds in the preterm infant are discussed separately. (See "Breastfeeding the preterm infant" and "Nutritional composition of human milk and preterm formula for the premature infant" and "Human milk feeding and fortification of human milk for premature infants" and "Approach to enteral nutrition in the premature infant".)

EFFECTS OF PREMATURITY — Human milk is widely recognized as the optimal feeding for all infants because of its proven health benefits to infants and their mothers [1,2,5,6]. (See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)

Importance of human milk feeding — For preterm infants, human milk feeding has particularly important health benefits, including protection from infection and necrotizing enterocolitis, improved tolerance of enteral feeding with shorter hospital stay, possible protection from severe retinopathy of prematurity, and improved neurodevelopment [7]. Moreover, mother's own milk appears to have additional health benefits relative to human donor milk. (See "Human milk feeding and fortification of human milk for premature infants", section on 'Benefits of mother's milk'.)

Challenges — Premature birth also poses several unique challenges to breast milk production and feeding. Because infants with gestational age <28 weeks are unable to breastfeed effectively for at least six weeks after birth, their mothers must establish and maintain milk production by expressing milk, typically by using a breast pump [8]. Moreover, mothers who deliver prematurely have difficulty in establishing an adequate milk supply [9-11].

The following factors are associated with decreased likelihood that mother's milk will be used for infant feeding [9,10]:

Extreme prematurity – Milk production decreases with lower gestational age. Milk production is particularly reduced in mothers of extremely preterm infants (gestational age <28 weeks) [10,12]. Extremely preterm infants typically are also unable to breastfeed effectively for some time after birth, which requires their mothers to establish and maintain milk production by milk expression either by hand or by use of a pump.

Delay in initiating breastfeeding (eg, beyond six hours after birth) [13].

Irregular and infrequent emptying of the breast, especially in very preterm infants (gestational age <34 weeks).

Increased maternal-infant separation.

Decreased skin-to-skin contact. (See 'Skin-to-skin contact' below.)

Other factors include maternal fatigue and stress, young maternal age, and low maternal annual income (ie, less than $50,000). An expert lactation support service helps to overcome the above factors. (See 'Lactation support service' below.)

PARENTAL COUNSELING AND SUPPORT — In many cases, mothers who deliver prematurely have not made a final decision on whether to breastfeed their infant and may not have the necessary information to make an informed decision. Mothers who are educated about the benefits of human milk and breastfeeding usually opt to feed their infant breast milk and are willing to express their milk for at least one to two weeks until the infant is able to breastfeed directly [14]. Universal prenatal education ensures that all mothers, including those who will deliver preterm, are informed about the benefits of breastfeeding prior to infant's birth.

Because many preterm infants cannot initially feed at the breast, mothers need instructions regarding expression and collection of milk. When the infant is mature enough to breastfeed, mothers will require additional instructions on how best to initiate breastfeeding [15,16].

Lactation support service — Lactational counseling improves breast milk expression and, ultimately, the rates of breastfeeding for preterm infants [11,17-19]. Efforts to promote breastfeeding should be directed and coordinated by a clinician with expertise in both lactation and intensive neonatal care to capture the benefits of human milk feeding and a comprehensive understanding of how to address the unique challenges in this population. Optimal care practice policy, which promotes breastfeeding, is outlined in the criteria required for the Baby-Friendly Hospital and is discussed separately. (See "Initiation of breastfeeding", section on 'Hospital policy and environment'.)

Additional support should be directed towards subgroups of women who are less likely to breastfeed, and counseling should focus on the specific maternal issues that negatively impact breastfeeding. (See "Breastfeeding: Parental education and support".)

Goals — The goals of educational and supportive counseling include:

Initiating milk expression within the first six hours following birth because many preterm infants cannot initially feed at the breast

Optimizing milk production by encouraging frequent milk expression (every two to three hours, even at night, during the first two weeks after birth)

Maintaining milk production with regular milk expression (approximately six times per day)

Teaching the mother how to properly collect and store expressed milk

Determining when to initiate oral feeds and teach the mother proper breastfeeding techniques

The following sections discuss strategies to fulfill of these goals.

MILK EXPRESSION — Mothers of infants with gestational age <34 weeks usually need to express their milk after birth because the infant is not sufficiently mature to completely feed at the breast.

Mechanical versus manual expression — Milk expression with a mechanical breast pump is the best way to empty the breasts thoroughly and efficiently. Several randomized trials demonstrate the superiority of electric breast pumps over hand expression for optimal milk removal [20,21].

Supplementary manual milk expression ("hand expression") during the first 48 hours after birth, in addition to mechanical pumping, provides additional breast stimulation and yields higher volumes of colostrum [22]. Ongoing combined manual and mechanical milk expression over the first eight weeks after birth helps to establish sustainable daily milk volumes (>500 mL) [23].

Breast pump and shield selection — For mothers who are totally dependent upon expression of their milk to initiate and maintain their milk production, we recommend a hospital-grade electric breast pump. Electric pumps programmed with suction patterns that mimic the human infant during breastfeeding result in greater milk output in less time spent pumping [24]. Pumping both breasts simultaneously (double pumping) is more effective than sequential pumping in the first two weeks after birth [20,25]. Compared with single pumping, double pumping stimulates more milk ejections and yields higher milk volume and with higher energy content [26]. Mothers should be advised to use the maximum comfortable vacuum, which has been found to enhance milk flow rate and milk yield compared with vacuum pressures above this comfort threshold [27].

A hospital-grade double pump may be rented through hospitals, pharmacies, lactation consultants, and home health agencies. For women in the United States who are participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), these pumps are available at no charge in most states. A single-user (personal) double pump can be used as an alternative. However, it is important to note that the hospital-grade double pump has been shown to be more effective than the personal use pump during the "coming to volume" lactation phase. For mothers who do not have access to an electric pump, manual pumping can be successful, although the pumping time is longer [28].

Selection of the correct-size breast shield is important in order to maximize the amount of milk expressed. If a breast shield is too small, the nipple will rub against the sides of the tunnel, causing discomfort and possible nipple trauma, which can inhibit milk ejection and reduce milk flow [29]. If a breast shield is too large, this can cause air leakage and reduced suction, resulting in ineffective stimulation, milk ejection, and milk flow. A properly fitted shield allows the nipple and areola to move in and out of the shield freely without touching the sides of the tunnel (figure 1). Mothers should be reevaluated for proper shield size following several weeks of pumping to ensure that the fit is still appropriate.

Timing, frequency, and duration

Initiation – Mothers who are unable to breastfeed directly should be advised to initiate milk expression within the first six hours after birth. Initiating milk expression between three and six hours after birth results in greater milk volumes at one, two, and eight weeks postpartum [30-33].

Frequency – During the first two weeks after birth, milk expression should be performed at intervals not greater than three hours, even at night. Subsequently, the breasts should be pumped at least six times a day to ensure an adequate milk supply. This frequency is associated with higher milk volumes during the first six weeks after birth [23,34]. The optimal number of daily milk expressions will vary with each mother, and hospital staff should monitor milk production closely and make adjustments in the pumping schedule as needed. (See 'Target volume for milk production' below.)

Duration of pumping session – Mothers should be advised to pump the breasts simultaneously for 15 minutes prior to the onset of lactogenesis II (defined as the first of two consecutive pumping sessions for which the total milk output is >20 mL, which typically occurs around the third or fourth day after birth). After the onset of lactogenesis II, each pumping session should continue until only drops are expressed, with a minimum of 15 minutes [24]. Typical duration for a pumping session is approximately 15 to 25 minutes [23]. Once lactation is fully established, some mothers may find that less time is required to achieve satisfactory breast emptying.

Emptying the breast completely is important to stimulate milk production and also to maximize fat content of the expressed milk, which increases from the beginning to the end of an expression session. The final drops of milk (hindmilk) have the highest fat and caloric content and contribute disproportionately to the infant's calorie intake [35,36]. Breast massage during the final minutes of pumping can increase breast emptying and assist in extraction of hindmilk. This technique also allows the mother to locate and drain alveoli containing residual milk, thereby reducing the potential for developing plugged ducts and mastitis. (See "Nutritional composition of human milk and preterm formula for the premature infant", section on 'Total fat content' and "Common problems of breastfeeding and weaning".)

Maximal interpumping intervals — After the first two weeks after birth, once milk production is established, some mothers can extend the interpumping intervals for convenience (eg, at night), although they should still pump at least six times in every 24-hour period. For other mothers, extending the interpumping interval will interfere with milk production because the response to milk stasis during interpumping intervals varies [37]. If a mother's milk production is inadequate or at risk, it may be helpful to evaluate her optimal interpumping interval by comparing milk production with different pumping schedules. (See 'Evaluate response to interpumping intervals' below.)

Target volume for milk production — The single most important factor predicting breastfeeding success is the ability of the mother to produce enough milk to meet the requirements of her infant at hospital discharge [14,38,39]. Most mothers of preterm infants, including those born extremely preterm (gestational age <28 weeks), can produce sufficient amounts of breast milk for the nutritional needs of their infants using a combination of mechanical and hand expression, supported by ongoing lactation counseling [23].

At discharge, most preterm infants require approximately 150 to 170 mL/kg per day of milk (300 to 500 mL per day for an infant weighing 3 kg). Some preterm infants will take as much as 200 mL/kg per day, which is tolerated in the absence of significant chronic pulmonary diseases such as bronchopulmonary dysplasia. Volumes on the higher end of the above range may be needed for larger preterm infants and for infants who are preparing for hospital discharge who will be fed human milk exclusively after discharge. (See "Approach to enteral nutrition in the premature infant", section on 'Discharge planning'.)

Mothers of premature infants who produce less than approximately 350 mL of milk per day by days 10 to 14 postpartum are at risk of producing insufficient milk to feed their infants at discharge [40]. Efforts to increase production should be initiated at that time and continued during the infant's hospitalization. (See 'Specific measures to optimize milk production' below.)

Lactation can be optimized by providing mothers with a method to document the frequency and volume of milk expression in the first few weeks after birth (table 1) [41]. These records reflect volume patterns following different lengths of interpumping intervals, which we use to adjust pumping frequency and optimize volume production. Daily monitoring of maternal milk volume during this early critical period provides objective, quantifiable information to optimize lactation outcomes. In our practice, we use a simple assessment score to monitor risk factors for low milk volume during the first 14 days postpartum; this is modified from the "coming to volume" log [40]. (See 'Specific measures to optimize milk production' below.)

MILK COLLECTION AND STORAGE — Improper collection, storage, and preparation of expressed human milk for feeding can negatively impact the antimicrobial and nutrient properties of human milk. As a result, it is important that hospitals have policies and procedures to ensure optimal handling of expressed milk, as discussed in the following sections.

Milk collection — No human milk is sterile when collected [42,43]. Mothers should learn the following collection technique to reduce further bacterial growth [44]:

Wash hands prior to each milk expression

Disassemble all pump parts, and use a bottle brush in small crevices

Wash all milk collection equipment that comes in contact with the milk with hot soapy water, and rinse thoroughly following each use

Sterilize milk collection equipment once daily, either by using a microwave sterilizing bag or by boiling it in water for 15 to 20 minutes

Transport containers (coolers or ice chest) should be thoroughly cleaned, inside and outside, on a regular basis. Individuals transporting milk should wash their hands before picking up and delivering the milk to prevent inadvertent contamination of milk containers. This is particularly important when the family has pets or family members who work in contaminated environments. Further details are provided in this guidance from the Centers for Disease Control and Prevention [44].

Milk storage

Containers — Glass (Pyrex) and hard plastic (polypropylene) containers are recommended for human milk storage because they provide stability for water-soluble constituents and are easy to handle [45,46]. When a hard plastic container becomes scratched with use, it will be more difficult to clean and should be replaced.

Storage materials that should be avoided include flexible polyethylene bags, which are not recommended for milk collection and storage, because they cause more loss of the cellular component of the milk (maternal macrophages and lymphocytes) and also leak during storage and handling [45]. Transparent plastic containers or bottles that contain bisphenol A also should be avoided because exposure to bisphenol A, an endocrine-disrupting chemical, may have adverse effects on infant development. These containers often are marked with the recycling number 7 or the letters PC, which stand for "polycarbonate" plastic.

Each container should be labeled with the infant's name, medical record number, date and time of collection, and current maternal medications, if any. Mothers should be provided with labels for this purpose and instructed to use pens/markers that will not smudge or wash off when exposed to water. If the milk is to be transferred to another container by the nurse or other designated staff prior to feeding, each individual syringe/bottle should be labeled appropriately. Prior to feeding, the information from the labeled milk should be verified against the infant's name band. To reduce errors of feeding milk to the wrong baby, some hospitals are using barcode scanning labels in place of manual verification processes [47]. A container of unlabeled milk should never be administered to an infant under any circumstance.

Temperature — The temperature at which milk is stored depends upon the intended duration of storage prior to feeding. Many of the protective antimicrobial properties of human milk are temperature sensitive. Heating, freezing, thawing, and prolonged storage result in some loss of bioactivity [48,49]. Although stored and frozen milk remain superior to formula in their protective antimicrobial and nutrient properties, milk that is fed immediately after expression offers the highest degree of natural bioactivity. Due to these beneficial components in fresh milk, whenever possible, we recommend that at least one daily feed include fresh milk (never frozen and pumped within 96 hours).

The Human Milk Banking Association of North America [50] provides the following temperature recommendations for the storage of expressed breast milk for hospitalized infants. Temperature depends upon the length of time from expression and when the milk will be used.

Room temperature (25 to 27ºC; 77 to 79ºF), used within four hours

Refrigeration (1 to 4ºC; 35 to 40ºF), used for up to 96 hours

Frozen (-18 to -20ºC; -4 to 0ºF), used between 48 hours and 9 months

The guideline for storage of refrigerated milk is supported by a study in which milk storage for up to 96 hours at 4ºC did not significantly change its osmolality, total bacterial colony counts, or concentrations of secretory immunoglobulin A (sIgA), lactoferrin, and fat [51]. There was a 16 percent decrease in the white blood cell concentration and a decrease in pH from 7.21 to 6.68, but neither change was clinically significant. In another study, lactoferrin concentration was stable in human milk samples that were refrigerated for five days but decreased on average by one-third in samples that were frozen for over three months at -18 to -20ºC [52]. Freezer storage of human milk for nine months at -20°C is associated with decreasing pH and bacterial counts, but key macronutrients and immunoactive components are preserved [53]. Based on a study of repeated freeze-thaw cycles, unpasteurized milk that has thawed in the refrigerator for up to eight hours may be safely refrozen [54].

Prolonged home storage of milk or storage outside of the supervision of hospital staff should be discouraged to reduce the possibility of inadvertent freeze-thaw or contamination.

Routine culturing of milk is not recommended, because results were not predictive of infection when evaluated prior to the occurrence of infection [55].

Aliquoting — If milk from a single expression is divided into multiple aliquots, mothers should mix the milk thoroughly but gently before distributing it into the storage containers. Fat distribution in expressed milk is uneven not only because of changing lipid content as the breast is emptied but also because milk fat (cream) rises to the top after expression. If the milk is not mixed, the infant can receive feedings with markedly different fat and caloric values, which might affect metabolic processes and overall weight gain [56].

It is also acceptable to pool the milk expressed over 24 hours into one container before separating into aliquots for storage. This approach leads to less variability in caloric and nutrient content and no differences in bacterial growth compared with using individual containers at each pumping [57].

Warming — Milk can be warmed gradually to approximately 98ºF (37ºC) in a warm water bath (not to exceed 20 to 30 minutes). One should avoid submerging bottles in water when using the warm water-bath method. In hospital milk labs that process large volumes of human milk, the use of a laboratory bead bath is an effective and safe method for milk thawing [58]. Rapid heating or microwaving adversely affects the breast milk's immunologic and nutritional properties [48,59]. If the infant is in an incubator, the feeding syringe can be placed inside the incubator for gradual warming (for no more than 30 minutes prior to the feed). The bottle should be labeled with the date and time when the milk was thawed.

SPECIFIC MEASURES TO OPTIMIZE MILK PRODUCTION — If milk production is deemed inadequate or at risk, strategies to stimulate milk synthesis should be initiated immediately. Interventions during the early postpartum period generally lead to the most rapid increases in milk production, but milk production can be increased at any point in lactation [11,30,40].

Strategies to increase milk volumes include:

Identifying any risk factors associated with decreased milk production.

Ensuring complete breast emptying at least six times a day, enhanced by bedside pumping, proper use of the breast pump and pump shield, and combining hand expression and breast massage with mechanical milk expression.

Tactile nipple stimulation and skin-to-skin contact with infant, and measures to reduce maternal stress.

Uninterrupted maternal sleep of five and six hours after the first two weeks postpartum, if volume can be maintained.

Use of galactagogues as a second-line approach for selected patients, in conjunction with the mother's health care provider.

Address maternal factors that decrease milk production — A thorough history is important to identify maternal factors associated with decreased milk production, including [60]:

History of breast surgery

Endocrine disorders (eg, hypothyroidism, polycystic ovary syndrome)

Extended bedrest prior to birth

Maternal medication (eg, pseudoephedrine)

Some mothers with previously adequate milk volumes experience a decrease in production; this pattern may be identified by monitoring maternal milk volumes throughout the hospitalization. In this case, the history should explore changes that might cause diminished milk volumes, including:

Return to work, resulting in altered milk expression frequency

New stressors related to infant's condition and/or other life events

Changes in pumping frequency, including when direct breastfeeding is initiated

New medications

Ensure breast emptying — Following secretory activation, maintenance of milk production depends upon the removal of milk on a regular basis. Failure to remove milk results in excessive and prolonged accumulation of milk within the alveolar lumen, leading to alveolar distension and elevation of intramammary pressure, which result in decreased milk production.

Mothers who are dependent on pumping – For mothers who are exclusively pumping, several strategies help to optimize milk production:

Complete emptying of the breast should be done on a regular and frequent basis, at least six times a day. If milk extraction techniques are performed efficiently, increasing the frequency of breast emptying by two sessions per 24 hours results in an average milk volume increase of 80 mL per day over a two-week time period [30]. The pumping schedule should be individualized based upon the maternal milk production response to milk stasis during interpumping intervals. (See 'Evaluate response to interpumping intervals' below.)

Pumping at the infant's bedside is beneficial because it allows clinical staff to directly observe and correct (as needed) the mother's technique, including the use of breast shields and ability to completely empty the breasts, and also to monitor the mother's pumping schedule. It enables physical contact between the mother and infant during milk expression, which augments release of lactogenic hormones (eg, oxytocin) [14,61].

Diversionary strategies (eg, listening to music) may also be helpful to promote milk expression while pumping [62,63].

Mothers who are primarily breastfeeding – During the transition from partial to exclusive breastfeeding, mothers should continue pumping after nursing to ensure complete breast emptying. This is because preterm infants are often unable to withdraw milk from the breast effectively until their oral feeding ability matures. (See "Breastfeeding the preterm infant".)

Suckling to provide tactile nipple stimulation — Nonnutritive sucking, in which the preterm infant suckles the emptied breast after the mother has pumped, provides tactile nipple stimulation, which enhances milk production and the infant's transition from tube to oral feeding. Although the hormonal regulation of lactogenesis and milk ejection is complex and not completely understood, it is known that nipple stimulation early after birth increases the number of secretory cells and the density of prolactin receptors in the mammary epithelial cells. (See "Neonatal oral feeding difficulties due to sucking and swallowing disorders", section on 'Sucking' and "Breastfeeding the preterm infant", section on 'Readiness'.)

Skin-to-skin contact — Limited data suggest that skin-to-skin (STS) contact, also referred to as kangaroo care, improves milk production in low birth weight preterm infants (birth weight <2500 g), similar to data reported in term and late preterm infants [61,64-67]. STS contact has been safely performed even for extremely preterm infants (gestational age <28 weeks), including those who were mechanically ventilated [68-72]. Regular sessions of STS contact are optimally continued throughout the hospitalization.

STS is performed with the mother positioned reclining at an angle of 45 to 60 degrees. Using reclining chairs and foot stools provides an appropriate and comfortable position for the mother and infant. Infants are placed prone and upright between the mother's breasts with the head turned so that the side of the face rests against the surface of one breast. Mirrors positioned to allow mothers to observe their infant's face enhance the maternal experience. For optimal results, sessions should last for two or more hours.

Additional reported benefits of STS in preterm infants include longer duration of breastfeeding, promotion of maternal sense of competence, and reduced maternal stress [64,65,73-76].

Evaluate response to interpumping intervals — If a woman's milk volume is inadequate or marginal, it may be helpful to assess whether her milk production varies with short versus longer interpumping intervals. The response to extending the interpumping interval varies among women, depending on individual sensitivity to milk stasis.

The following approach determines milk production rates between feeds and over a 24-hour period and uses this information to adjust the pumping schedule, as needed [77,78]:

Determine the overall rate of milk synthesis over a 24-hour period, calculated as the measured 24-hour volume/1440 minutes

Determine and compare the rates of milk synthesis for interpumping intervals of long and short duration

Compare the rates of long interpumping intervals (six hours or greater) with the 24-hour synthesis rate

Mothers who demonstrate similar milk production during short and long interpumping intervals can safely extend the interpumping interval at night. In contrast, mothers whose milk production decreases with longer interpumping intervals should not extend the interpumping interval, to optimize their milk production. The daily pumping log should reveal the impact of changes in the interpumping interval on the 24-hour milk supply and allow the mother to make necessary adjustments.

Galactagogues — Galactagogues (or lactagogues) are medications or other substances believed to assist initiation, maintenance, or augmentation of maternal milk production. Data are generally inconclusive regarding whether these drugs significantly increase milk production, based on small studies. Therefore, galactagogues are not routinely recommended, due to limited efficacy and potential side effects of the available agents. However, we occasionally offer a galactagogue to selected mothers with low breast milk volume who failed to increase their milk production despite expert lactation counseling.

The agents most commonly used are dopamine receptor antagonists (eg, metoclopramide and domperidone) [79]. If a galactagogue is used, we prefer domperidone because it does not cross the blood-brain barrier, it has fewer side effects than metoclopramide, and there is some evidence for efficacy, albeit very limited [80]. Metoclopramide is associated with central nervous system side effects in the mother, including headaches, diarrhea, mood swings, and depression [81]. We do not suggest use of prolactin as a galactagogue, because data are limited regarding its efficacy and safety. Data on the use of herbal galactagogues are even more limited. Fenugreek is the most widely used herbal agent, but data are insufficient to determine its efficacy and safety, especially for preterm infants, and therefore it is not recommended.

Further information about the use of these drugs during lactation is available from the LactMed database, which is maintained by the National Library of Medicine. (See "Common problems of breastfeeding and weaning", section on 'Management'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breastfeeding and infant nutrition".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Pumping and storing breast milk (The Basics)")

Beyond the Basics topics (see "Patient education: Pumping breast milk (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Benefits of human milk feeding – Human milk is the optimal feeding for virtually all preterm infants. Compared with preterm formula, human milk feeds are associated with reduced rates of comorbidities including necrotizing enterocolitis and late-onset sepsis, as well as improved neurodevelopment. (See "Human milk feeding and fortification of human milk for premature infants".)

Parental counseling and support – For mothers of hospitalized premature infants, lactational counseling improves the rate of breastfeeding. The goals include early initiation of milk expression within the first six hours following birth, optimizing milk production by encouraging frequent milk expression every two to three hours, and assisting with the transition to direct breastfeeding when the infant is sufficiently mature. (See 'Parental counseling and support' above.)

Milk expression – Mothers of preterm infants below 34 weeks gestation generally need to express their milk because their infant is unable to completely feed at the breast. (See 'Milk expression' above.)

Techniques to optimize milk expression and production include:

Breast pump selection – Milk expression is most often performed using a mechanical breast pump because of its efficiency in removing milk within a reasonable time period and its ability to thoroughly empty the breast. In most cases, the optimal device is a hospital-grade electric breast pump to stimulate and empty both breasts simultaneously. (See 'Breast pump and shield selection' above.)

Early and frequent pumping – For mothers with preterm infants who are unable to feed at the breast, we suggest early and frequent milk expression to ensure optimal milk supply in the first weeks of life (Grade 2B). Milk expression should be started within the first six hours after birth and performed every two to three hours for the first two weeks and at least six times a day thereafter. (See 'Timing, frequency, and duration' above.)

Other measures – Thorough breast emptying optimizes milk production and ensures expression of hindmilk, which has the highest fat and caloric content of human milk. Milk production is also enhanced by bedside pumping, skin-to-skin contact, and tactile nipple stimulation. (See 'Specific measures to optimize milk production' above.)

Milk collection and storage – Optimal handling of expressed milk reduces bacterial growth and protects the antimicrobial and nutritional properties of human milk. The temperature at which milk is stored depends upon the intended duration of storage prior to feeding. (See 'Milk collection and storage' above.)

Galactagogues – We suggest against the routine use of galactagogues to increase milk production because of limited data on efficacy and safety for both mother and infant (Grade 2B). (See 'Galactagogues' above.)

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Topic 5044 Version 40.0

References

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