1. Steurer, Lisa M. PhD, RN, CPNP-PC, CLC
  2. Smith, Joan R. PhD, RN, NNP-BC

Article Content

Both term and preterm infants in the neonatal intensive care unit (NICU) often need to rely on expressed breast milk due to their inability to adequately latch and empty the breast effectively. For this reason, breast milk feeding in the NICU often depends upon the mother's ability to initiate and maintain an adequate milk supply through expression, through manual (eg, hand expression) or electric pumping. Typically, a hospital-grade electric pump is the gold standard for NICU mothers. However, mothers are often challenged immediately postpartum, after a high-risk delivery, to establish milk production with the use of a hospital-grade electric pump. This may not be the most effective strategy to set the stage for future milk production. Manual expression can be an appropriate supplement to electric pumping. Manual expression refers to the use of the mother's hand to express milk from the breast. This should not be confused with manual pump expression, which is the use of a device that operates manually without the use of electric or battery power. Manual expression is thought to be advantageous over either manual or electric pumps in the first few days after delivery.1 In addition, manual expression is often more effective in removing thick colostrum that is present in the first few days after delivery, thus priming the breast for the onset of lactogenesis III when the full milk supply is available.


Lactogenesis III is a highly vulnerable time, and nurses are in a unique position to educate and support NICU mothers for breastfeeding success. Ideally, breastfeeding methods, including manual expression, should be taught in the antenatal period when the mother may be more ready to receive information with fewer periods of distraction, fatigue, or feelings of being overwhelmed from the birth experience. At-risk pregnant women on the antepartum unit are often confined to the hospital for extended periods prior to delivery; this provides an opportune time for nurses to intervene and discuss their breastfeeding plans. Neonatal nurses can also learn this simple technique to reinforce and answer questions that NICU mothers may encounter. The technique of manual expression can be easily taught using a breast model or videotape demonstration. A readily available video on the Internet by Jane Morton, MD (titled Early Hand Expression Increases Later Milk Production2), can be viewed on most electronic devices (eg, smartphone, tablets, laptop). Most women find the technique easy to perform with fairly brief instruction. In addition, this technique can be easily taught by neonatal or perinatal nurses and does not rely on specialty training from a certified lactation consultant.


Manual expression is not a new technique, and up until the development of battery and electric pumps, it served as the only available alternative for milk expression during infant separation. This form of expression should be combined with electric pump expression for each session. However, there are circumstances wherein mothers who are discharged from the hospital and separated from their infants do not have a hospital-grade electric pump available at home. The Affordable Care Act requires mothers to have access to a pump and breastfeeding supplies,3 although there may be a time lag between the mother's hospital discharge and when the pump becomes available. Manual expression can be maintained when these unfortunate lapses in pump access occur. This is critical since the first 72 hours after birth set the stage for milk production and breastfeeding success. In fact, women who manually express colostrum a minimum of 6 times per day have more milk later on than those who manually express 1 to 2 times per day in the first 3 days following delivery.1 While the frequency of manual expression is important, so is its effectiveness. Manual expression aids in complete emptying of the breast, resulting in a greater future milk production supply.


Teaching mothers how to manually express is part of the Baby-Friendly Hospital Initiative (BFHI), an ongoing global commitment to implement practices that protect, promote, and support breastfeeding.4 Hospitals providing maternity care throughout the world are interested in obtaining BFHI designation to demonstrate such a commitment to breastfeeding. The Global Criteria for the Baby-Friendly Hospital Initiative serve as the standard for measuring adherence to each of the Ten Steps to Successful Breastfeeding.4 The Ten Steps are the minimum criteria for hospitals/birthing facilities to receive and retain Baby-Friendly designation. Step 5 requires mothers to be shown how to breastfeed and maintain lactation, even if they are separated from their infants. Staff must report they teach mothers manual expression and be able to describe or demonstrate the correct technique or refer appropriately to lactation consultants. In addition, mothers must report they were taught how to hand express and be able to describe or demonstrate an acceptable technique or describe the subsequent referral process.4


The Baby-Friendly designation is auditing for a limited period of time and only in maternity hospitals. For freestanding pediatric facilities with NICUs, this same standard can be applied as part of an ongoing quality improvement initiative to improve quality of breastfeeding care for mothers separated from their infants. Expanding the Baby-Friendly initiative for all hospitals providing breastfeeding consultation to mothers could result in improved and sustained breastfeeding rates for NICU infants. In addition to mothers being taught, there should be ongoing evaluation of their experience with manual expression to determine the number of days mothers may most benefit from manual expression. At this time, evidence suggests the first 3 to 5 days, or when the mother's milk comes in, as the most beneficial time for manual expression. For some, this could be longer since not all women reach full milk production at the same rate.


When mothers are separated from their infants, there is a sense of loss and grief. Breastfeeding is an example of one thing they can do for their infants during this time. As nurses, we are obligated not only for the health and well-being of the infant but also for the emotional integrity of the mother to provide optimum resources and education about the breastfeeding experience in this situation. Teaching techniques such as manual expression in addition to electric pump may be most beneficial in those vulnerable days after delivery when breast milk stimulation to increase production is imperative. Both maternity and pediatric hospitals should be consistent in their breastfeeding practices to provide for the most successful breastfeeding outcomes and allowing mothers of premature infants who are separated from their infants to achieve their breastfeeding goals.


-Lisa M. Steurer, PhD, RN, CPNP-PC, CLC


-Joan R. Smith, PhD, RN, NNP-BC


St Louis Children's Hospital


St Louis, Missouri




1. Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol. 2009;29(11):757-764. doi:10.1038/jp.2009.87. [Context Link]


2. Morton J. Early hand expression increases later milk production. Web site. Accessed January 9, 2018. [Context Link]


3. Health Resources and Services Administration. Women's preventative services guideline. Web site. Updated October 2017. Accessed January 9, 2018. [Context Link]


4. World Health Organization. The global criteria for the Baby-Friendly Hospital Initiative. Web site. Updated 2009. Accessed January 9, 2018. [Context Link]