How to get ready to make enough milk if you are expecting a high-risk baby

Breastfeeding has important health benefits for almost all babies. And it helps you and your baby bond. The benefits are even higher for babies who are born high-risk. Babies in the NICU need a mother's breastmilk to help support their immune systems, improve their digestion, and decrease the risk of a serious condition called NEC (necrotizing enterocolitis). If you are expecting a high-risk baby, providing your child with breastmilk is something only you can do. Below are some suggestions for how you can get ready to make enough milk for your high-risk baby:

• If possible, start pumping within 60 minutes of delivering your high-risk infant. Evidence shows that this can help make more milk than if you start later.

• Use breast massage and warm your breasts before you pump.

• Start expressing milk by hand to get your milk started, then use a pump as needed.

• Listen to relaxing music as you pump. Evidence has shown that this can help women to make more milk, possibly by reducing stress.

Methods for expressing milk

You will have to depend on milk expression to establish and then maintain milk production until your high-risk baby is ready to breastfeed. Most mothers find they get more milk in less time when using a hospital-grade, electric breast pump with a double collection kit when providing milk for high-risk newborns.

Developing a milk expression routine

You will want to pump at least 8 times in 24 hours (about every 2 to 3 hours). It's helpful to learn hand expression in case you are ever without some of the equipment pieces for the electric pump when it is time to express milk. This is true even if using a good electric pump. Sometimes in the early days of milk expression, mothers find they get more colostrum through hand expression than they do with the breast pump. 

Don't put off or stretch the time between pumping sessions during the first 3 to 5 days after giving birth. You may not see any milk during the first several pumping sessions. And you may only get a couple of drops for several sessions after that. It is important to keep expressing. The milk made before day 3 to 5 after birth is called colostrum, and it is normally made in small amounts. Colostrum is especially rich in the anti-infective properties that can help your high-risk baby. If you are able to pump or hand express even one drop, it may be helpful to your baby. Drops can be drawn up, and stored, in syringes specially labeled as colostrum.

Helpful equipment

Breast pump

It's important to use the right kind of pump when long-term milk expression is necessary. Not all breast pumps are created equal. Most mothers with high-risk infants find that a hospital-grade, electric breast pump is needed for frequent and prolonged milk expression. These pumps automatically cycle suction with release of suction. This is very much like a baby's sucking action. Studies find mothers who must pump for several weeks, or even months, make a larger amount of milk when using this type of pump.

There are a variety of good breast pumps on the market for personal use. Including battery-operated, rechargeable double electric breast pumps. Some mothers produce a good amount of milk with these pumps. There are some pumps on the market that were not designed for frequent or long-term use, but work well for occasional use. Some of these smaller pumps take more time to obtain a good amount of milk and discomfort is possible with prolonged use. If you are unsure of what type of pump to use, discuss this with a knowledgeable healthcare provider or lactation consultant.

Getting a pump

Most maternity units and newborn intensive care units (NICU) have hospital grade double electric breast pumps available. So you can start pumping right away. They will also provide a double collection kit you can use at home and when spending time with your baby in the NICU, so you won't have to miss any pumping sessions.

Most healthcare benefit plans, including Medicaid, cover the cost of a breast pump or breast pump rental and collection kit for home use. Most states WIC (Women, Infants and Children) programs will provide a hospital grade breast pump as well if insurance is not an option. You may need a prescription from your or your baby's healthcare provider. Because of the many benefits of a mother's own milk, health insurance companies know they ultimately save money if you pump your milk for your baby. Contact your health insurance company to find out if they cover the cost of a breast pump or breast pump rental and collection kit. If health insurance won't cover the cost, remember that the equipment needed to maintain milk production still costs less than the infant formula you'll have to buy if you don't pump. (A high-risk baby is more likely to be given a more expensive, special formula for a longer time, too.)

Breast pump collection kit

A breast pump collection kit includes tubing, breast flanges, and collection bottles. The tubing attaches to the pump itself and transfers suction to the breast flange, which may also be referred to as the breast shield or milk funnel. The flange is the piece that is in direct contact with the breast. It is centered over the nipple and areola of the breast. A hard plastic bottle connects to the breast flange piece and collects milk flow. Clean collection bottles should be used for each pumping session.

Double collection kit

A double collection kit allows you to pump both breasts at once. Studies have shown that mothers tend to make more milk in less time when they use this type of collection kit with a hospital-grade, electric breast pump. This may be because mothers find it's easier to pump often enough when using this combination of breast pump equipment. Many mothers also like to use a hands-free bra. This allows you to have the flanges held for you so that you can do other activities with your hands.  

How often and how long?

A full-term, healthy newborn typically breastfeeds for the first time an hour or two after birth. And they will want to eat about 8 to 12 times in 24 hours for the next few weeks or months. A milk expression routine should closely follow this pattern. So you'll want to start pumping as soon after your baby's birth as possible.

8 times a day

Pump at least 8 times, or for a total of at least 100 minutes, in every 24-hour period. The more pumping sessions, the better. More frequent sessions may be needed if you're pumping milk for twins, triplets, or more.

Freeze any extra milk

At first you may find frequent pumping makes more milk than your high-risk baby needs. But extra milk can be frozen for later use. It's better to stay ahead of your baby's current intake. If you pump less than 8 times a day, you may find milk production begins to drop after several weeks. Then, 10 to 12 daily pumping sessions may be needed for several days or weeks if you want to increase production to meet your baby's growing appetite.

A typical cycle

Most mothers pump for about 15 to 20 minutes, every 2 to 3 hours during the day, with one, 4- to 5-hour stretch of uninterrupted sleep at night. Some women pump longer than 15 to 20 minutes and wait until there has been no milk flowing from the breasts for about 1 minute before stopping. This can cause sore nipples if pumping longer than 20 minutes. 

Single vs. double

Some mothers prefer single pumping of each breast separately, especially when first learning to use the breast pump. These mothers pump one breast for 5 minutes (or until milk flow slows), then pump the second breast for 5 minutes (or until milk flow slows). Then they repeat the whole process but continue to pump until a minute passes without any milk flow for either breast. Single pumping lets a mother massage each breast as she pumps. This can increase milk flow. If a mother wants to massage both breasts at the same time, she can use a hands-free bra or hook to hold the flange to the breast while she massages the breast tissue. 

How much milk?

After 7 to 10 days of frequent pumping sessions--at least 8 times a day and for a daily total of 100 minutes or more--expect to make between 16 to 32 ounces (about 500 to 1,000 ml or cc) of breastmilk a day. This may be more milk than your high-risk baby needs just now. But you will be glad to have extra milk in the freezer if milk production drops at some point. This is not abnormal after several weeks. 

Don't be surprised if you get more milk at some pumping sessions than others. Many mothers find they get more milk earlier in the day. You can expect some variation in the total amount pumped from day to day. But if you find the daily total keeps dropping for several days in a row, talk with a certified lactation consultant, your baby's healthcare provider, or a breastfeeding support leader.

Helpful hints

Mothers of high-risk newborns have found some or all of the following suggestions helped them create and stick to a routine when expressing their milk for days, weeks, or months:

Stick to a schedule

Many mothers find their milk lets down more quickly and they soon get larger amounts of milk when they pump at about the same times every day. But don't be concerned if there is some variation in the schedule from day to day.

Set a timer

It's easy for time to slip away and for pumping sessions to get a late start. It's helpful to set an oven timer, a digital watch, or cell phone to remind you when the next session is to start. If a session is delayed, pump a little earlier next time.

Chart pumping sessions

Keep track of when you pump, how long you pump, and how much milk you get by using a simple checklist chart to note pumping sessions. Keeping a record of pumping sessions will help you pick up any drop in number of sessions, time spent pumping, or volume of milk obtained, so you can make changes before a real problem develops. There are free Apps for your phone that can help track this information.

Get comfortable

You are more likely to continue a routine if you pump in a comfortable, yet convenient, spot. Have a snack and a drink in reach. Listening to relaxing music has been shown to increase breastmilk production. You could distract yourself by talking with someone over a speakerphone or watching TV. You can also use the hands-free pumping equipment and do other activities at the same time as you are pumping. 

Create a ritual

Follow the same routine for most or all of your pumping sessions. Your ritual might include:

• Pumping in a certain place

• Putting warm compresses on your breasts and doing breast massage before pumping

• Dimming lights

• Turning on soft music

• Using relaxation methods, such as slowing your breathing and imagining a beautiful waterfall that turns to milk after a minute or two of pumping

Include your baby in the ritual

You might want to look at a picture of your baby or breathe in the scent of a blanket or cap they have worn as you pump. Some mothers listen to audio of their babies' cries when they begin to pump. Others simply think of their baby while pumping. Skin-to-skin contact with your baby (called kangaroo care) in the NICU has been found to increase milk production.

Plan ahead for night sessions

Nighttime pumping sessions will seem less annoying if the pump and collection kit are set up and ready to go when it's time to wake up to pump. Some mothers save steps at night by placing bottles in an insulated cooler with an appropriately sized freezer pack to keep milk chilled correctly until morning.

Be positive

It's easy to get discouraged, bored, or frustrated when pumping at least 8 times, or more than 100 minutes, in 24 hours for day after day. This is especially so if you are having any trouble making milk. There may be moments when you'd like to throw the breast pump out the window. Know that such feelings are normal., But don't throw that pump away. It's an expensive machine, and it's allowing you to provide the most valuable food your baby can get. Remember, by providing your high-risk baby with this exceptional milk, you are a vital member of your baby's healthcare team. It also maintains your milk supply so that you can bond with your baby through nursing when they come home from the hospital.