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This material was developed by Jane Morton, MD and produced for educational purposes only. Reproduction for commercial purposes is prohibited. Utilization of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

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This material was developed by Jane Morton, MD and produced for educational purposes only. Reproduction for commercial purposes is prohibited. Utilization of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

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If you are pregnant or breastfeeding, milk expression by hand is a useful technique to learn. It's a handy way to relieve engorged breasts. You can also use it to stimulate milk production and provide milk for a baby who is not breastfeeding well or needs more milk.

Why hand expression?
If you use a pump
Practice helps
How breasts work
Before you start
Relax and get comfortable
How to hand express Step by step How long will hand expressing take? Hand expressing shouldn't hurt

Why hand expression?

Skin-to-skin contact with hand expression encourages the milk ejection reflex (MER) or 'let-down reflex'.

Mothers usually get more milk using hand expression alone or combined with pumping than using just a pump.

It requires no special equipment and is always available, even in emergencies.

It's convenient and free.

Hand expression is particularly useful if you need to express colostrum during late pregnancy (see Antenatal Expression of Colostrum) or in the first few days after birth. It makes it easy to save every drop of precious colostrum.

If you use a pump

Whatever pump you may use, combining pumping with hand expression can help you express more milk more effectively.

Breast massage and hand expression can be used at the beginning to get your milk flowing.

Breast massage while pumping increases the amount of milk you can express.

Continuing to hand express can release milk remaining, even after the pump flow has stopped.

And if your pump breaks down, or there is no electricity, you always have your hands.

Practice helps

How breasts work

When milk is removed more often, your breasts feel soft and comfortable and produce milk faster. When milk is removed infrequently, your breasts may feel full but produce milk more slowly. Frequent milk removal is the key to maintaining milk production whether you are breastfeeding or expressing. Expressing stimulates your breasts-though not as effectively as a baby-to make and release milk.

For more information on how milk production works, click here.

Before you start

Wash your hands. Have a suitable clean container available to collect your milk: colostrum can be expressed into a small (5ml) container or even onto a teaspoon for immediate feeding. Once milk production has increased milk may spray in several directions so a bowl, wide mouthed container or a bottle with a funnel might be more practical.

Relax and get comfortable

Milk tends to flow better when you are feeling comfortable, relaxed and warm. Tension or anxiety inhibits milk flow. Relaxation techniques can help increase the amount of milk you can express. The sound of running water may help, or you could practise in the bath or shower.

Seek privacy; try the breathing exercises you learnt for use during labour; visualise flowing milk. Have your baby nearby, or think of him. Use photos or recordings of your baby and smell his clothing. All these will help stimulate milk flow. Take a few deep breaths, drop your shoulders and release tension with each exhalation. Bending forward with your breasts suspended means gravity can help milk flow.

How to hand express

One basic approach

1. Start by encouraging milk flow in both breasts.

2. Then hand express from each breast until milk flow slows right down. If you need to increase milk production, continue expressing for a couple of minutes after milk flow has stopped.

3. Repeat these two steps at least twice more. You will find milk flow slows or stops sooner each time you repeat.

4. Most mothers adapt the above approach to suit themselves, so experiment to find what works best for you.

Step by step

Encouraging milk flow
Stimulating your milk ejection reflex (MER or 'let-down') is the key to expressing. It can take a few minutes. You may see drops of colostrum or breastmilk, or even experience a tingling sensation, but many mothers don't see any milk until they start actually expressing. Experiment with the following suggestions to find out what works best for you.

Massage your breast starting at the top, using a firm circular pressure on one spot. After a few seconds, lift up your fingers to move to the next area on the breast. Spiral around the breast towards the areola and nipple.

Stroke your breast from the top of the breast to the areola and nipple. Light stroking with fingers is one option, or use a soft item with a light tickle-like stroke. Continue this stroking motion from the chest wall to the nipple around the whole breast.

Shake your breast gently while leaning forward so gravity can help your milk flow.

Hand position

You can use either or both hands on one breast, or express both breasts at the same time. Hold your hand in the shape of a letter 'C', with your thumb and forefinger behind the base of your nipple, feeling for the change in texture of your breast. Move you fingers closer to, or away from your nipple to find the best place for you.

To express

Start with the pad of your thumb at the top of your breast, and your finger pads below.

Support your breast, then press the breast towards the chest wall to put pressure on the milk ducts.

Now compress the breast between your fingers and thumb to move the milk forward towards your nipple.

Release and repeat rhythmically: press-compress-relax (like a baby breastfeeding) until milk flow stops

Then rotate your hand around the breast a little and repeat. Do this for each section of your breast until it feels soft and comfortable. Keep your fingers and thumb opposite one another as you rotate.

Remember that when a baby breastfeeds, milk doesn't flow immediately, so it's normal for it to take a little time for milk to start flowing when you express. Switch back and forth between breasts as the flow slows to encourage further MERs.

This video has a good demonstration of hand expression of breastmilk

How long will hand expressing take?
Allow plenty of time at first: the whole process may take 20 or 30 minutes, but you can always stop and start again later if you need to. Frequent short sessions are usually more effective than infrequent, longer expressing sessions.

Switching between breasts several times as milk flow slows can help trigger further milk ejection reflexes. The more MERs you stimulate, the more milk you will be able to express and make.

Hand expression shouldn't hurt
Squeezing, pulling and sliding fingers along the skin can cause discomfort, bruising and skin burns. Pain or discomfort inhibit the MER and are signs that something needs adjusting. If your breast feels engorged or tender try warm moist heat immediately before expressing. Start expressing from the most comfortable areas.

Removing milk from areas around a blocked duct can reduce the discomfort, making it easier to express from the tender area later.

Written by Sue Upstone, Karen Butler and mothers of LLLGB.

Further Reading
The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010.
Breastfeeding Answers Made Simnple. Mohrbacher, N. Amarillo, Tx: Hale Publishing, 2010.

Antenatal Expression of Colostrum
Birth and Breastfeeding
Expressing Your Milk
Engorged Breasts - avoiding and treating
My Baby Needs More Milk
Sleepy Baby - why and what to do
Storing Your Milk
Working and Breastfeeding
Bottles and other tools

You can buy this information in printed form from the LLLGB shop.

LLLI Resources
The Power of Hand Expression

Copyright LLLGB 2016

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Hand Expression of Breastmilk - La Leche League GB

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If you are pregnant or breastfeeding, milk expression by hand is a useful technique to learn. It's a handy way to relieve engorged breasts. You can also use it to stimulate milk production and provide milk for a baby who is not breastfeeding well or needs more milk. Why hand expression?

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The Basics of Breast Massage and Hand Expression

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The Basics of Breast Massage and Hand Expression

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The Basics of Breast Massage and Hand Expression

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"The Basics of Breast massage and Hand Expression" video by Maya Bolman, IBCLC and Ann Witt, MD, FABM, IBCLC

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Colostrum harvesting/expressingyour milk in the antenatal period

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Colostrum harvesting/expressingyour milk in the antenatal period

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Obs 050 Colostrum harvesting_expressing your milk in the antenatal period 07.21 v4

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ABM - Expressing your milk before your baby arrives

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ABM - Expressing your milk before your baby arrives

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This technique involves expressing colostrum in the final few weeks of pregnancy. It can also be referred to as 'colostrum harvesting' and is advocated by some NHS Trusts.

Mothers are normally advised to wait until around 36 weeks before starting antenatal expression. Mums who are having multiple births may sometimes start sooner as giving birth earlier is more likely.
Why do it?
For some mothers, it can be a useful tool that helps ensure their baby will start life without the need for formula supplementation. The importance of exclusive breastfeeding for all babies has been well-established by scientific research.

Colostrum contains vital immunological properties and helps to colonise the baby's gut with healthy bacteria that protect against allergy and disease.

It also contains the perfect balance of proteins, fats and micronutrients needed for human babies as well as acting as a laxative to help the passing of the first tarry meconium stools.

Some babies may experience difficulties with feeding or maintaining their blood sugar levels during the first few days after birth and therefore may require supplementary feeds.

These include babies:

whose mother had diabetes in pregnancy or who has a history of diabetes.

with a cleft lip or palate identified during pregnancy.

with congenital conditions e.g. Down syndrome or cardiac complications.

diagnosed with intrauterine growth restriction.

whose mother is taking beta blockers to control high blood pressure.

who are twins or triplets.

Where there is a family history of cow's milk protein sensitivity or type 1 diabetes, families may be particularly keen to avoid the use of early formula supplementation.

Some women may need to consider supplementing feeds from an early stage if there are concerns over their ability to make and/or secrete milk.

These include women:

who have a breast hypoplasia (limited breast development).

who have had previous breast surgery.

It is important for a mother to discuss her plans to express antenatally with her healthcare provider. It may not be recommended if you've been at risk of preterm labour in previous pregnancies, or have a surgical stitch, for example.

It is recommended to express antenatally by hand rather than use an electric or manual breast pump. Colostrum will be produced in quite small quantities and can easily stick to the bottles or pump parts and be harder to collect. A pump at this stage is likely to be more uncomfortable than gentle hands. Try hand expressing for a few minutes, 2 or 3 times a day.

If you hand express and use a syringe to draw up the individual drips of colostrum, you can use these syringes for storage prior to birth. Your health care provider may be able to supply you with sterile syringes.
How to hand express:

Always wash your hands before expressing.

Applying a warm compress to your breast or expressing after a warm bath or shower can help the flow of colostrum.

Get yourself comfortable. Perhaps seated and leaning slightly forward but find what works best for you.

Start with a gentle breast massage, stroking from the back of your breast towards the nipple to encourage the let-down reflex.

Put your thumb above the nipple and your first few fingers below the nipple. You will be cupping the breast in a 'C' shape.

With your thumb and fingers, feel a few centimetres back from the nipple.

Press back towards your chest, then compress (press your fingers together), and release.

Repeat this process, building up a rhythm. Press, compress, release.

It may be useful to look online for videos of hand expression techniques.

Colostrum should start to arrive drop by drop. Initially it may just be a glisten on the end of your nipple, and it may take a few days of practice before drops appear.

Collect the colostrum into a clean container, like a syringe (1ml or 2ml syringe). If nothing happens, adjust your finger position slightly to find the spot that works for you. Try not to pinch your nipple or slide your fingers uncomfortably over the skin.

Rotate the position of your fingers and thumb around the areola (imagine a clock face) and repeat the expressing process to stimulate and remove colostrum from different parts of your breast.

Express each breast twice during each session.

Colostrum can vary in appearance. Sometimes it may appear quite thick and yellow or orange and at other times paler and thinner. Expressing colostrum antenatally will not decrease or increase your milk supply after baby is born.
Storage of human breast milk
Colostrum can be collected two to three times each day in the same syringe. You will need to store the syringe in the fridge between uses.

At the end of the collecting day, the colostrum can be frozen - place the syringe into a zip-lock bag before putting into the freezer. Label the syringe and bag (separately) with the date and time of when you expressed.

The frozen colostrum can be stored for up to six months in the freezer. Once thawed, it should be used within 24 hours.
Is it safe?
The oxytocin hormone released when expressing, stimulates the uterus. Opinions differ on whether expressing colostrum antenatally is likely to induce labour. Those who advocate it do not believe that expressing would constitute sufficient stimulation to start labour. Sex while pregnant and breastfeeding through pregnancy both release oxytocin and both are generally considered safe while pregnant. If you experience any cramping in your uterus however, you should stop expressing and discuss your choice with your healthcare provider.
Transporting your frozen colostrum
You can take syringes of frozen colostrum into hospital using a freezer block and insulated bag. The colostrum can be defrosted under a running warm tap or at room temperature.

It's a good idea to mention your colostrum stores on your birth plan and make sure staff are aware in advance of your wishes in certain situations. The hospital may have access to a freezer for storage once you arrive.

After the birth, breastfeeding should usually be unrestricted. Ideally, a baby should feed successfully at the breast and the antenatally expressed colostrum would remain unused.

If your baby is experiencing difficulties with breastfeeding at this time, you may be encouraged to express some fresh colostrum to give to your baby. You may also use any colostrum you have brought into hospital with you in preference to using any formula.

If harvested colostrum ends up being 'wasted' because you are able to establish early exclusive breastfeeding, this is a cause for celebration rather than commiseration!

The process of antenatal expressing however, gives you a back-up if things don't go to plan which many families find reassuring. You'll also start your breastfeeding with a good sense of how to hand express and confidence about how your breasts work.

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Expressing your milk before your baby arrives - ABM

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Antenatal expressing is expressing colostrum in the final few weeks of pregnancy. Find out if it could be a useful tool for you.

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Antenatal Expression of Colostrum - La Leche League GB

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Mothers start to produce colostrum (early milk) while pregnant. Being able to express colostrum is a useful skill to have. Saving your expressed colostrum may also be beneficial if your baby is likely to need special care after birth. Why express while pregnant? Being familiar with your breasts and…

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Small volumes of colostrum (the first breast milk) are usually enough for most newborn babies until their mothers’ milk arrives

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Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME])

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Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME])

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Breastfeeding is the normal and natural way to feed and nurture a baby. If you have diabetes you may be concerned about whether you can breastfeed. The answer is yes.

All mothers experience metabolic and hormonal changes after giving birth. A mother with diabetes who breastfeeds has an advantage as breastfeeding reduces the impact of these changes. When you breastfeed, your body continues to support you and your baby, making your diabetes easier to manage in the days after birth. Later on, gradual weaning helps you to maintain control of your diabetes.

Gestational diabetes
Benefits of breastfeeding
What about medications?
Be prepared
Blood glucose control
Larger baby
Babies can have a hypo after birth
Antenatal expression of colostrum
Get breastfeeding off to a good start
Looking after yourself
Adjusting your diet

Gestational diabetes

It can be a shock if you are diagnosed with gestational diabetes during your pregnancy. This is usually a temporary condition in which your body fails to produce enough insulin to meet your extra needs while you are pregnant. It is usually diagnosed from the fourth month of pregnancy. Just like mothers who are on long-term treatment for diabetes, good control of blood glucose levels will minimise any problems for you and your baby. You may not need any extra medical care during labour and delivery. Diabetes treatment is usually unnecessary once you have given birth.

Benefits of breastfeeding
For you (as a diabetic mother)

Breastfeeding increases your insulin sensitivity and has long term positive effects on your glucose metabolism.
* For Type-1 diabetes, breastfeeding will reduce the amount of insulin you need.
* For Type-2 diabetes, breastfeeding will reduce the severity of your diabetes.
* For Gestational diabetes, breastfeeding significantly reduces your risk of developing diabetes later in life.

Breastfeeding suppresses your periods and monthly hormonal changes.

See our page Amazing milk for more information.

For your baby
Studies show that your baby will be healthier throughout their life if they are breastfed. Infant formula increases a baby's chance of developing diabetes.

What about medications

Insulin treatment is compatible with breastfeeding. Insulin molecules are too large to pass into your milk. Check with your doctor for up-to-date information on any other medications you take. If there is any concern over safety, an LLL Leader can obtain information on named medications for you.

Be prepared

Having diabetes can increase the risk of the following problems which may impact breasfeeding:
* Premature birth
* Caesarean birth
* Newborn hypoglycaemia (low blood sugar)
* Newborn jaundice.

See Further reading at the end of the page for a selection of resources to help avoid these problems and overcome difficulties. You may also like to find out about your local hospital's policies on the management of these and care of diabetic mothers during and after pregnancy.

Do ask if the hospital has an Infant Feeding Advisor who will be well informed about breastfeeding and a source of support in those early days.

Blood glucose control

This is the key to avoiding problems in pregnancy, labour and after birth. If you are planning a pregnancy, practise good diabetes management before you conceive too.
* Frequent antenatal and diabetes medical care will allow you to address any problems quickly.
* Discuss with the doctors, nurses and dieticians in your diabetes team how to control your changing needs for insulin, other medication and food while pregnant and after birth.
* You may be given a Continuous Glucose Monitor (CGM) which will notify you if your blood glucose levels get too high or too low.
* Monitor your blood glucose levels closely, so you can adjust your insulin, other medication and food intake.

You may need to eat frequent smaller meals a day to avoid hypos (hypoglycaemia or low blood glucose levels) and peaks in blood glucose levels.

Larger baby

Even with excellent control, diabetic mothers tend to have larger than average babies. Good blood glucose control will help limit how large your baby grows, making birth easier and reducing the risk of complications.

Babies can have a hypo after birth

Your baby will be prone to hypoglycaemia (low blood glucose levels) during the first 12 hours after birth, particularly if you have poor blood glucose control in pregnancy. Even with good control, your baby will have been used to relatively high levels of glucose before he was born. The extra insulin he produces can lead to a drop in blood glucose after birth. Skin-to-skin contact, and early frequent breastfeeding will help avoid problems.

Check your hospital's policy for testing blood glucose levels and treating a baby's hypo. Your colostrum (first milk) is the best food for your baby if he has a hypo. If your baby has not breastfed yet, stored colostrum can be given.

Antenatal expression of colostrum

In the last few weeks of pregnancy you can express some colostrum (early milk). This can be given to your baby if he can't breastfeed after birth, or he needs supplements for any reason eg hypoglycaemia. Our information sheet Antenatal Expression of Colostrum explains how to do this before birth so you have some of your milk immediately available for your baby should he need any supplement.

Get breastfeeding off to a good start

The first few days
For many mothers with diabetes, milk production increases later than for mothers who don't have diabetes. You can help your milk production increase normally on the third or fourth day with good control of blood glucose. Fluctuations in insulin levels will affect milk production, and increase the risk of your baby needing supplements. Get skilled breastfeeding help sooner rather than later to reduce the need for supplements. Your baby will need to stay in hospital for at least 24 hours after birth, until he is feeding well and maintaining blood glucose levels.

Breastfeeding basics
* Hold your baby against your skin after birth so he can breastfeed as soon as possible, ideally within the first hour after birth.
* Keep your baby with you unless separation is medically necessary.
* Try to breastfeed every hour for the first several hours, until your baby's blood glucose levels stabilise. Ensure your baby feeds at least 8-12 times each 24 hour period.
* Spend as much time as you can holding your baby and encouraging him to feed frequently.

Separation and supplements
Take action if you and your baby are separated or if your baby needs supplements for any reason.
* Hand express small amounts of colostrum frequently to give to your baby. This will also help you establish milk production.
* Once you can express larger amounts, you can use a hospital-grade pump.
* Your baby can be given your milk with a syringe, cup or spoon.

Being separated from your new baby will be hard for you. As soon as you can, spend as much time as possible with him to help make up for lost time. Even visiting him in the neonatal intensive care (NICU) or special care baby unit (SCBU) will help, as you will be able to touch, stroke and talk to him and take over some of his care. You can ask to give him kangaroo mother care, in which a baby is snuggled skin-to-skin against mum's chest. Kangaroo care helps to stabilise a baby's heartbeat, temperature and breathing, and encourages breastfeeding. The hormones produced will help you express your milk, even if you can't breastfeed straight away.

Looking after yourself

After birth
At first your blood glucose levels can change rapidly and you are at increased risk of having a hypo. Take suitable snacks into hospital so you have something readily available -and watch out for early signs of hypos.

Later you'll have to manage your own health while caring for your baby. Keep suitable snacks and drinks within arms reach in all the places you are likely to breastfeed your baby to treat hypos at the first signs.

Seek skilled help straight away if you experience sore nipples or breasts, to reduce the risk of an infection. You are more at risk from a thrush infection of the nipple area if you have diabetes.

Rest when you can
Lack of sleep can make it harder to manage your diabetes and be a cause of stress, which means youor blood glucose levels will run higher. Try to rest when your baby sleeps and accept offers of practical help from others when you need to.

Adjusting your diet

Breastfeeding helps your body adjust gradually to the metabolic and hormonal changes all mothers experience after birth.

You may need to eat many more extra calories a day while breastfeeding, eating regularly to maintain blood sugar levels. This will allow you to use your fat stores without the risk of ketones in your blood and urine.
Further support
Your local LLL Leader and Group can be a source of information and support. You may also find it helpful to meet with other mothers at your local LLL group. You will be able to share practical tips on breastfeeding and mothering and find out what is normal for a breastfed baby.

Written by Karen Butler and mothers of LLLGB

Further Reading
Positioning & attachment
Positioning & Attachment (Kindle publication)
Antenatal Expression of Colostrum
Birth & Breastfeeding
Beginning Breastfeeding
Caesarean Birth & Breastfeeding
Comfortable Breastfeeding
Hand Expression of Breastmilk
Is My Baby Getting Enough Milk?
Jaundice in Healthy Newborns
My Baby Won't Breastfeed
Sleepy Baby - why and what to do
Skin-to-skin

The Womanly Art of Breastfeeding, LLLI. London: Pinter & Martin, 2010.
Breastfeeding Answers Made Simple. Mohrbacher, N. Amarillo, TX: Hale Publishing 2010.

Benefits of skin-to-skin contact www.kangaroomothercare.com

References
Cox, SG. An ethical dilemma: should recommending antenatal expressing and storing of colostrum continue? Breastfeeding Review 2010; 18(3):5-7. http://pages.ca.inter.net/~jfisher/docs/ Ethical_BFR_-Sue_Cox.pdf Cox, S.

Expressing and storing colostrum antenatally for use in the newborn period. Breastfeeding Review Nov 2006. Oscroft, R.

Antenatal expression of colostrum. Pract Midwife 2001;4 (4): 32-5.

NICE Clinical Guideline 63: Diabetes in pregnancy management of diabetes and its complications from preconception to the postnatal period. National Collaborating Centre for Women's and Children's Health March 2008 (revised reprint July 2008): www.nice.org.uk/CG063

You can buy this information in printed form from our shop

Copyright LLLGB 2020

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Diabetes and Breastfeeding - La Leche League GB

# data[].attributes.attachment_link.description
Breastfeeding is the normal and natural way to feed and nurture a baby. If you have diabetes you may be concerned about whether you can breastfeed. The answer is yes. All mothers experience metabolic and hormonal changes after giving birth. A mother with diabetes who breastfeeds has an advantage as breastfeeding reduces the impact of [...]