The best start

A guide to expressing and breastfeeding

your premature baby

With support from

M U M I N S P I R E D . H O S P I TA L T R U S T E D .
 Why give my baby breast milk?
Helps with
my baby’s
growth
What does
breast milk do?
• Protects against
bacteria and viruses
Who can help?
• Helps protect against • Breastfeeding
life-threatening gut co-ordinators
infections • The Bliss freephone
• Provides antibodies Helpline
that are present in • Other mums on the unit
breast milk and help
strengthen your baby’s • Speech and language
immune system therapists

“Looking back, I am very proud of our

achievement. It was the encouragement of the
midwives, NICU nurses, and other mums who got
us there. Nathan had such a difficult start and
I’m so pleased I was able to give him the best
food possible and contribute to his recovery. The
medical support in the hospital was brilliant, but
milk was something only I could provide.”
Michaela, mum to Nathan, born 24 + 1 weeks

2 Bliss 2012 - Breastfeeding your premature baby

 Expressing your milk
Unlike a fully-grown newborn, your premature baby will not
have had time to build up energy reserves in their body. This
will mean that they will need food in some form very soon
after their birth and then at frequent, regular intervals.
Your baby may be too small or too sick to begin
breastfeeding, but you can still give them the best
start by expressing your breast milk. This can be done
by hand or by using a pump. It can take time to learn
this skill but with patience and some encouragement
you can begin to give your baby the best start.

Breastfeeding your baby

Breastfeeding is the healthiest way to feed your baby. The time will come
when your baby will be ready for you to breastfeed. Premature and sick
babies get tired easily, but they enjoy your closeness and smell of your milk
and gradually they will begin to take an interest and learn how to suck. It may
take patience, but with encouragement and guidance, you will both master
this skill. Any amount of breastfeeding has a positive effect. The longer you
breastfeed, the longer the protection lasts and the greater the benefits.

Building a bond
By using close contact techniques such as skin-to-skin
Kangaroo Care, you can help to build a loving bond with
your baby, stimulate your milk supply and boost your
immune system to produce more antibodies.
Kangaroo Care can help you feel more confident in
caring for your baby and benefits your baby by making
them feel calm, encouraging less crying and more deep
sleep which is vital for their development. Ask the team
caring for your baby to help you do this.

Bliss 2012 - Breastfeeding your premature baby 3

 Express Your Love....
From the start, the love and protection you give your baby is vital for their health
and wellbeing.
The health benefits from breastmilk are well documented and because you have
decided to give your baby breastmilk, we wish to support your choice.

About Ameda
Ameda know how much breastfeeding matters to you and your baby. Ameda’s
story starts with a passion for breastfeeding.
More than 60 years ago, engineer Einar Egnell invented the first truly comfortable
and effective breastpump. He also created the vacuum and cycle standards that
today’s lactation consultants use to assess breastpump efficiency.
Because every mum and baby is different, Ameda breastpumps are designed to be
more adjustable than other hospital-grade breastpumps:

CustomControlTM Vacuum and cycles can be adjusted to your personal preference

offering optimal results every time – giving you increased milk supply
and reduced pumping time.
CustomFitTM 7 funnel sizes to provide optimal convenience during your
breastfeeding experience – giving you greater comfort and better
milk flow.
HygieniKitTM Our unique anti-viral barrier keeps your breastpump clean and free
from bacteria and viruses – giving you peace of mind.

Ameda breastpumps, are available as hospital-grade, single and double electric

and manual models. Our hospital-grade model (Ameda Elite) is available for
hire should your hospital unit not have one to loan to you. We also provide other
breastfeeding accessories to make your breastfeeding experience as comfortable
as possible.
Ameda ‘Purely Yours’ personal breastpumps with hospital technology, are available
from leading breastfeeding and baby specialist retailers.
Everything Ameda offers, our breastpumps and accessories, our breastfeeding
education and the support of lactation professionals, reflects our passion for
breastfeeding. We know how much breastfeeding means to you and your baby.
For Ameda hospital breastpumps and breastpump rental: Central Medical Supplies
Ltd Tel: 01538 399 541 www.ameda.co.uk
For Ameda personal breastpumps:
Hardenberg&Co Ltd Tel: 0845 009 1789
www.ameda.co.uk

4 Bliss 2012 - Breastfeeding your premature baby

Contents
Introduction 6
Preparing to express or breastfeed 9
Expressing your milk 12
Breast massage technique 14
Some problems that may occur when expressing 22
Breastfeeding your baby 24
Breastfeeding step-by-step 28
Lisa’s story 32

Bliss 2012 - Breastfeeding your premature baby 5

 Introduction
While you were pregnant, you protective antibodies to their babies
probably imagined what life would through the placenta during the last
be like once your baby arrived, and three months of pregnancy. This
how you would care for your baby. process is interrupted when a baby
The fact that your baby has been is born prematurely. For this reason,
admitted to a neonatal unit may premature babies are especially
have come as an enormous shock. vulnerable to infections. Breast milk
provides antibodies that protect your
However, the good news is that you baby against bacteria and viruses.
can still do many of the things you
Helps your baby grow
have planned. It is still possible to
feed your baby your breast milk even Breast milk is extra rich in antibodies
if your baby has been born very early. and growth factors and also
Providing breast milk for your baby is provides nutrients, special fats and
your unique contribution to their care. hormones that are important for
No one else can do this and it may growth and development during the
help you feel closer to your baby. crucial early months after birth.
Easy to digest
All newborn babies are different when
it comes to feeding, whether they were Breast milk is very easy to digest and is
born at term or prematurely. A baby’s absorbed more easily than formula milk.
ability to breastfeed can depend on
Building a bond with your baby
many factors, including how early
the baby was born and their medical Being part of your baby’s care is
condition. For premature babies, important for you and your baby.
there is usually step-by-step progress Kangaroo Care (or ‘skin-to-skin’) can
towards ‘ordinary’ breastfeeding. help nurture your baby and give you
more confidence in taking part in
Benefits of breast milk your baby’s cares. Kangaroo Care
holding relaxes your baby making
Feeding your baby your breast milk
them less anxious, cry less and
This has benefits for both you and your experience more time in deep sleep.
baby and can also encourage and
develop a bond between you both. This is especially beneficial when you
are trying to establish breastfeeding.
Breast milk protects against germs
Once your baby is strong enough and
The body manufactures specialised stable, ask the team caring for them
proteins, called antibodies, to fight to show you how to begin Kangaroo
off infections. Mums transfer these Care. Not only does this special care

6 Bliss 2012 - Breastfeeding your premature baby

help build a bond between you, it also weeks until your baby grows and
encourages the production of breast becomes strong enough to breastfeed.
milk. Although your baby may be too
Supplemented feeds
small to breastfeed, place them close
to your nipple and let them nuzzle you Sometimes, it can be difficult to express
so they can smell and lap tiny drops enough milk to supply all your baby’s
of your milk. See page 8 for more needs, especially if you have been ill
information on Kangaroo Care. during your pregnancy. In the early
days, you may need to supplement
Good for you too
(top-up) your colostrum to ensure your
Breastfeeding is good for your health baby receives enough energy and
too. It can help you regain your pre- fluids to get well quickly (see page 13
pregnancy figure, since any extra fat for more information on colostrum).
stored by the body during pregnancy is
used as energy to produce breast milk. Two short-term options are to use
additional breast milk donated to some
There is also some evidence that hospitals by other new mums, or to use
breastfeeding reduces your risk of formula. Nursing and medical staff will
breast cancer and ovarian cancer. discuss these options with you. It will
only be a temporary measure, since
Intravenous and tube feeds
you should soon be able to produce
At birth, feeding may have to be delayed enough milk for all your baby’s needs.
for a short period. If your baby has Every step is taken to ensure that feeds
breathing complications, they may need from the hospital’s breast milk ‘bank’ are
to be fed through a drip (a device for safe for your baby. Breast milk donors
giving fluid, drop by drop, into a vein). are screened and donor breast milk is
tested and heat-treated before use.
If this is the case, the sooner you start
to express your milk the better. As your
baby continues to improve, they will
gradually progress from drip feeds
to breast milk, which at first is given
through a tiny tube inserted through
their nose or mouth and into their
stomach. With supervision from the
nursing staff, it may be possible for
you to help with tube feeding. This can
help you bond with your baby. You may
have to express your milk for several
 Kangaroo Care (skin-to-skin contact)
As soon as your baby’s condition Care may help to boost your
becomes stable, you may be milk production, especially if
encouraged to practise Kangaroo your baby is held near to your
Care, which allows you to hold breast. Kangaroo Care can also
and cuddle your baby as much stimulate your immune system
as possible. If appropriate, your to produce more antibodies.
baby will be dressed in a nappy These then appear in your
only and will be placed on your breast milk and help to protect
chest, skin-to-skin, inside your your baby against infection.
clothing. It is useful to wear
a loose shirt or blouse with In the longer term, Kangaroo
buttons, so that the drips and Care can also help both
monitor leads are not disturbed. mum and dad to feel closer
to their babies and more
Close contact with your baby confident caring for them.
also stimulates your breasts to
make more milk. So Kangaroo

8 Bliss 2012 - Breastfeeding your premature baby

Preparing to express or breastfeed
Why not try it and see? other tasks, such as making a meal.
Feeding your baby breast milk gives Milk expression takes up a lot of your
them a good start in life. If you’re not time, and added stresses can make it
sure yet about the best way to feed more difficult and frustrating. Try to tell
your baby, you could try expressing for your partner what you need them to do
a little while, just to see how it goes. to ensure that your expression sessions
are as calm and productive as possible.
Support from your families
and friends Looking after yourself
For many people, breastfeeding is
unknown territory. Important people
Rest and sleep
in your life, your partner, your family This may be a stressful time, but it is
or friends for example, may not important to look after yourself and
understand how much hard work is keep your own strength up. Make sure
involved in expressing milk for a sick you take sufficient rest and sleep so you
baby, particularly after a long and have the energy to look after your baby.
tiring day. They may not know about Expressing milk (discussed on page 12)
the worries you have or the extra is also easier when you are well rested.
time you need. It might help to share
this booklet with your partner so they If you look after yourself, your body will
understand what is happening and do a more efficient job of producing milk.
feel more involved in decisions and
Diet
the care of your baby. Partners can
all too easily feel helpless and left During breastfeeding, mums need
out during this time, because only a healthy diet to provide for their
the mum can produce breast milk. It own needs as well as those of their
is worthwhile talking through these baby. When you were pregnant, soft
feelings with your partner and family unpasteurised cheese and liver were
and reminding them how much you ‘off limits’, but now that your baby has
and the baby really need them. They been born, it is safe to eat these foods
can become involved and support you while breastfeeding. There is no need
in many ways; for example, by setting to avoid spicy foods. Try to eat regular
up your equipment before expressing meals – including breakfast, a snack
or sterilising the equipment afterwards. meal and a main meal – each day.
Having some privacy
Milk and dairy products provide
Many women value privacy while protein, calcium and vitamins. Fruit
expressing their milk. Ask your partner, and vegetables provide vitamins and
friends or family to help you out with help your body take in iron from your

Bliss 2012 - Breastfeeding your premature baby 9

 diet. Bread, potatoes and cereals have drinking within the limits recommended
energy, fibre and vitamins. Meat, fish for pregnant women. That is, no more
and vegetarian alternatives (such as than one or two units a week.
beans, pulses, high-protein grains
and soya) provide protein and iron. If you regularly drink more
than this amount:
Try to include at least one helping of
oily fish a week, such as fresh, smoked • Your milk may smell different
or tinned mackerel, salmon, herring and put your baby off feeding
or sardines. Tuna is also nutritious,
but is best fresh. Oily fish will boost • The alcohol may make your
the level of a special group of fats, baby too sleepy to feed
called long-chain polyunsaturated
fatty acids, in your milk. These fats are • Your baby may have difficulties
thought to contribute to your baby’s with digestion and problems
long-term growth and development. with sleeping patterns.

Drinking Extra alcohol of any type will not

Whilst it is unlikely that having an improve your milk production and
occasional drink while breastfeeding may actually reduce it.
will harm you or your baby, alcohol does
pass through to the baby in your breast
milk. As such, it is advisable to keep your Smoking
This is an opportunity to stop smoking.
Reducing the number of cigarettes you
smoke each day may help, if stopping
altogether seems too stressful. Your
milk will contain nicotine if you smoke.
Smoking may also slow down the flow
of your milk and make it more difficult
to express. Exposing your baby to
second-hand smoke can also greatly
increase their risk of chest infections.

It is extremely important not to

smoke directly before you express
breast milk. Nicotine levels increase
in breast milk immediately after

10 Bliss 2012 - Breastfeeding your premature baby

smoking, and the nicotine will remain Medication
in your milk for about 95 minutes. Avoid taking drugs or medicine,
including herbal remedies, without
If you feel you can’t stop smoking right advice from your doctor or pharmacist.
now, it is a good idea to breastfeed
anyway. The health benefits of breast Remember to tell health professionals
milk are so great that they outweigh the that you are breastfeeding when they
risks of exposing your baby to nicotine. are recommending any medication for
you. If you discuss birth control with
For help and advice to stop smoking, try your doctor, remember to mention
the NHS Smoking Helpline on 0800 169 that you are breastfeeding as this
0 169 or visit www.gosmokefree.co.uk may affect the method you choose.

Bliss 2012 - Breastfeeding your premature baby 11

 Expressing your milk
Your baby may not be ready to feed this does not mean that your milk is
directly from the breast straight away. any better or worse, just different.
So while they are getting stronger, you
can pump the milk from your breasts In the early days, if you are expressing
using a technique called expressing. colostrum, you may only obtain a few
drops. Gradually, over the following
Expressing breast milk is a skill that few days, the volume will improve and
can take time to learn, and the staff expressing should get easier. Try to
looking after your baby will give you remember that this stage only lasts for
positive support and practical help with a few days, and that the milk will flow
this. It is important to start expressing more freely as the volume improves.
your milk frequently as soon as
possible after the birth of your baby. You may notice that your breasts have
not changed much since you gave birth.
Only a small amount of milk is produced This is because your more mature breast
in the first few days after a baby is milk comes after three or four days.
born. This is perfectly normal. Later When your milk comes in, it is a gradual
on, the amount of milk you express process, and you will notice your breasts
may change depending on the time feeling tender and getting fuller.
of day and how you feel. Expressing
can feel like a big pressure and it is Some mums of premature babies can
important to remember that no matter take a little extra time to establish a
how much or little you are able to milk supply. During the last stages of
express, your baby will benefit. pregnancy, hormones prepare the
breasts to start producing milk, and this
Breast milk changes over time. During process may have been cut short if your
the time that you spend expressing baby was born early. You will eventually
your milk, you will notice many changes ‘catch up’, so don’t lose heart, and do
in its flow, colour and consistency. ask for support from breastfeeding
One mum’s breast milk may look very experts who are there to help you.
different to another’s, but don’t worry,

“My son, Nathan, was very sick and not expected to

live. Despite this, a very brave midwife asked me if I was
intending to breastfeed, and showed me how to express
milk. If she hadn’t made that suggestion then that would
have been the end of my breastfeeding story.”
Michaela, mum to Nathan, born 24+1 weeks

12 Bliss 2012 - Breastfeeding your premature baby

 reflex. In the early days, this takes a
Colostrum (first milk) few minutes to appear, but later on
All mums produce a special it will occur within a few seconds.
first milk, called colostrum,
in the first three or four days Milk ejection feels different to different
after delivery. Colostrum is women. You may have tingling or
thicker than breast milk and prickling in your breasts and nipples,
yellow in colour. It contains a or a feeling as if the milk is rushing in
rich mix of proteins, including to fill them. Some mums describe a
antibodies, that help to protect slight pain and some mums have no
a newborn against infection. sensations at all but notice that milk
starts to drip from both breasts.
How often to express Methods of expressing milk
It is best to express milk eight to ten There are various options available to
times in 24 hours and to try to avoid help you express your milk – from the
leaving gaps of more than three hours high tech to the very basic. You may
during the day. At night, try not to leave wish to use a combination of methods
a gap longer than five to six hours. This to suit your needs:
pattern will ensure that you maintain a
milk supply that will satisfy your baby’s • Electric pumps – Hospital-grade
needs. The more you can express electric breast pumps are a good
the better. Later on, you may be able choice if you will have to express for
to express less often, depending on a long time. There are several types,
how much milk you are producing. and most can be adapted to allow
single or double pumping. Electric
Obviously this can be very tiring and breast pumps can be rented .
you may feel that expressing is adding
extra pressure to an overwhelming • Hand pumps – Manual or electric
and stressful situation. Try to give hand pumps are a cheaper option
your self as much time as possible and are easily available. With
to relax, try to establish a routine manual hand pumps, suction is
and allow time for preparation created by squeezing a handle,
before you begin expressing. Your which can prove quite tiring after
body may respond to certain things a while. The battery or mains-
you do, leading to expression by operated versions can save you
triggering your milk ejection reflex. both time and energy.
The milk ejection reflex
• Hand expression – This is the
Each time you express milk or sit simplest way of expressing your
down to breastfeed your baby, milk, and it is an important skill to
you may notice a sensation in your learn. Do ask for help if you have
breasts called the ‘milk ejection’ any questions or problems.

Bliss 2012 - Breastfeeding your premature baby 13

 Breast massage technique
Gentle breast massage can help A
your milk to flow and make it
easier to express milk. Begin
by applying a warm flannel or
towel to your breasts. You can
stroke the area with gentle,
feather-like movements (A).

Or you can massage your breast B

with a hand action that rolls the
knuckles downwards over the
breast (B), beginning at the top of
your breast and working towards
the areola (darker-coloured skin
around the nipple), gradually C
going over the whole breast (C).
Don’t forget to include nipple stimulation.
The nipple can either be rolled gently
between the thumb and forefinger, or the
palm of the hand can be gently moved back
and forth over the tip of the nipple.

Then stroke the area under the D

nipple and areola with flat hands
in an upward movement (D).
Massage should feel comfortable,
so remember to be gentle. If
it is painful, stop and ask for
professional advice. It can also
be helpful to ask your partner or
a friend to massage your back
before you express, as this can
also stimulate your milk flow.

14 Bliss 2012 - Breastfeeding your premature baby

Put your feet up
time-consuming to express. It does not
Sit down and put your feet up for five mean that you will find breastfeeding
minutes before you start to express equally difficult. After all, nature has
your milk. Relax your arms and back, equipped babies with a very efficient
and take several slow, deep breaths. system of getting milk from the breast.
Concentrate on feeling the tension
leave your body. Maybe even listen It may be helpful to express in short
to your favourite relaxing music. bursts. Try expressing either once an
hour, over a period of eight hours in
Encouraging the flow
a row, for 15 minutes each session, or
Many mums find that having a photo every two hours for about 30 minutes
of their baby to look at helps them each session, if you can manage it. You
while expressing. You could also try may need to set some time aside and
recording a video of your baby on your plan your expressing routine, especially
mobile phone or camera. Borrowing if you have other children or other
a cuddly toy from your baby’s cot, commitments. This can really help your
or a piece of clothing your baby has milk flow and establish your pattern.
worn, can also help the milk to flow
by providing powerful memories of
your baby. Warm flannels or towels
placed on the breasts can help the
milk to flow more easily, especially if
your breasts are very full on the third
and fourth days. Breast massage
before and during expressing can also
help to drain your breasts. This gentle
action will trigger the milk ejection
reflex, stimulating your milk flow.
Expressing some milk by hand before
using a breast pump may also help.
Everyone is different
Some mums find it very easy to express
milk and they produce more milk than
their baby requires; others need more
time and may produce just enough to
feed their babies. Don’t think that you
are a failure if you are finding it very

Bliss 2012 - Breastfeeding your premature baby 15

 Getting the timing right
• It can be helpful to take one-minute to relax while you express. If you have
breaks during pumping sessions. a large supply of frozen breast milk that
You can take these breaks every your own baby will not be able to use,
three or four minutes. Massaging it may be possible to donate your milk
both breasts during these rest to a milk bank. For more information
periods may also help to make please contact the UK Association
expressing more efficient. for Milk Banking www.ukamb.org
As your baby moves on to
• It is very important to express your
the breast
milk regularly. At first, it’s best
to express at least eight to ten When your baby starts to establish
times within every period of 24 breastfeeding, you may find it confusing
hours. Later on, you may be able knowing when to express and when
to express less often, depending to breastfeed. The tip is to continue
on how much milk you produce. to express so that your supply does
not dwindle. It is important not to
• Try to express first thing in the express just before a breastfeed.
morning, ideally before there However, if your breasts are very full,
are any interruptions. it can be useful to express by hand
briefly in order to soften your breast.
• You will need to express during
the night. Your body’s milk
production will be boosted by
night-time sessions.

If you have a large milk supply, it is

very important not to limit the number
of times you express or the amount of
milk you remove at each expression.
This is because as the bottle fills, the
volume of milk in the breast goes down
and the fat content gradually rises.
Therefore, the milk at the end of the
feed contains the highest amount of
fat and it is essential that your baby
receives the extra calories. Also, when
you know you have a good supply of
milk, it gives confidence and helps you

16 Bliss 2012 - Breastfeeding your premature baby

 • Expressing with your baby nearby,
or using breast massage and
Kangaroo Care, are helpful ways
to increase your milk supply.

• Sometimes changing the method

you use to express can also help.
For example, if you are double-
pumping, try single-pumping with
Twins and multiples extra massage, or vice versa.
Most mums are able to produce more
than enough milk for twins or triplets • Hand expression will give you
without any supplementation. For more control over the way your
multiple births, you may need to use milk is expressed.
formula as well, but this will depend
on your milk supply, your confidence • Some mums say that having a
and the amount of support you have photo of their baby, or keeping
from the people around you. an item which has their baby’s
smell nearby, while they are
For more detailed information about expressing will also help.
breastfeeding twins and multiples,
Drugs to increase milk supply
contact the Twins and Multiple
Births Association (TAMBA) through You may be advised to ask your GP
their website www.tamba.org.uk to prescribe a drug to increase your
milk supply. Although some mums
If your supply decreases
have found this type of medication
Occasionally, when mums have been helpful, there is no firm evidence that
expressing for several weeks, the milk it is effective, and it is best to avoid
supply will suddenly reduce for no any unnecessary medication when
apparent reason. Usually, this is just breastfeeding. Therefore, we would
temporary. It does not necessarily mean always advise using techniques
that you are losing your milk supply. described above, such as massage
Try not to focus on the amount of milk and regular feeds and expression, to
gathered when you express, but do increase milk supply. However, this
ensure you are expressing eight to ten is an area where local opinion and
times per day. Concentrate on relaxing practice vary. You will need to ask
and take practical steps to trigger for specific advice from the doctors
milk production such as: caring for you and your baby.

Bliss 2012 - Breastfeeding your premature baby 17

 Hand expression
Be easy on yourself
Hand expression is a very important
skill to learn, and is a useful ‘first aid’ You are going through so
technique to drain blocked milk ducts. much at the moment, and
When milk ducts (tubes through which it is important to relax as
the milk is carried) are not emptied much as possible. Try to
properly, they can become blocked give yourself plenty of time
and feel uncomfortable. Restoring to express your milk. Make
the milk flow as soon as possible sure you leave enough time
can help to prevent infection (see for preparation, as this can
page 22). Hand expression will also become an important part of
help you to encourage your baby to the whole expressing routine.
feed. You can do this by expressing
a few drops of milk on to the end of
Technique
the nipple for them to taste while
you are doing Kangaroo Care. 1. Cup your breast and feel back from
the end of the nipple to where the
Getting ready
texture of your breast feels different.
Have a clean towel ready to catch Using your thumb and index finger
any spills. A wide-mouthed container squeeze this area – this shouldn’t hurt.
is also essential, as milk may spurt
in several directions at one time. 2. Release the pressure and then
repeat again and again, building up a
rhythm. Avoid sliding your fingers over
the skin. Milk should start to flow.

3. When the flow slows down,

express the other breast. Keep
changing the breasts until the
milk stops or drips very slowly.

4. If the milk doesn’t flow, try

moving your fingers slightly towards
the nipple or further away. Or
try gentle breast massage.

18 Bliss 2012 - Breastfeeding your premature baby

Expressing your milk
with a pump
Breast pumps do not pump, suck or pull
milk out of the breast. The breast pump
removes milk as it flows into the nipple.
Therefore, you should make sure you
understand fully the following guidelines
about milk expression before you begin.
Getting ready
• Give yourself plenty of time to
prepare the equipment and where the breast meets the
express your milk. ribs. This supports the breast
tissue forward into the funnel.
• Make sure you have all the bits and
pieces you will need close at hand. • Make sure that the nipple is
You will need lids for the bottles, central to the funnel.
water to drink, a pen to complete
the label and a table to put the • Keep the funnel close enough to
bottle on whilst you disconnect the breast to maintain a vacuum,
from the tubing. Tips on sterilising but do not press it too firmly or the
equipment and storing breast breast tissue will be squashed
milk can be found on page 30. and the milk will not flow freely.

• Make sure you wash your hands • Be careful not to set the suction
before you start. level on an electric or battery pump
too high, since this may make your
Getting comfortable
nipples sore. Try increasing the
• Try to sit comfortably, with your vacuum on the pump slowly until
back straight. A sturdy chair it starts to feel a bit uncomfortable
with arms can make expressing and then reduce it slightly. It is
much more comfortable. a good idea to make a note of
the best suction level so you can
• Support your breast from use the same setting the next
underneath, with fingers flat on time you sit down to express.
your ribs and the index finger

Bliss 2012 - Breastfeeding your premature baby 19

 • Do not try to remove the collection How to do breast compression
funnel whilst pumping since the (deep breast massage)
vacuum can be strong. It can
hurt if you pull away while the 1. Hold your breast pump with
pump is running. one hand.

• Try gently massaging your breasts 2. Hold the breast with the other
when expressing, as this can hand, thumb on one side of the
encourage milk flow (see page breast, finger on the other side,
14 for more information about fairly far back from the nipple.
breast massage technique).
3. Do not roll your finger along
• Use breast compression to the breast, just squeeze.
help stimulate the milk ejection
reflex, helping your milk to flow 4. Do not squeeze so hard that it
more quickly. hurts and try not to change the
shape of the nipple area (areola).
• When you start pumping, you
might find that the funnel makes 5. When the milk stops flowing,
your nipple very sore. release the squeeze and
wait for a short time before
• If this happens, it could be the compressing the breast again.
wrong size for you. In this case,
Getting more milk
it is worth discussing it with your
breastfeeding adviser or nurse. While expressing your milk, changing
Larger funnels are available, from one breast to another can help to
which will make expressing more stimulate the milk ejection reflex which
comfortable. Availability depends can make your milk flow more quickly
on the pump that you are using. or come out in spurts. Carry on with
one breast until the milk flow slows
to the occasional drip. The amount of
Helpful hint
fat in your milk rises as the breast is
You may find one breast emptied, so it is important not to restrict
produces more milk, or that the time taken to express milk. Double-
one breast flows faster. This pumping/expressing from both breasts
is perfectly normal and means at the same time can save a lot of time.
that your baby might latch on
to one breast for longer Research has shown that double-
when feeding. pumping may increase your milk
supply, especially if your baby is born

20 Bliss 2012 - Breastfeeding your premature baby

very early. It will also save a lot of time. Underwired bras should not be worn,
Some mums can find it a bit daunting as they can damage the tender breast
but it can be very helpful to express tissue and may cause blocked milk
beside your baby’s cot or incubator. ducts, which can result in mastitis.
Expressing close to your baby will
Getting into a routine
help the milk to flow more quickly.
It will help to get into a routine for
expressing as soon as possible. You
Helpful hint
may find that your milk flow responds
If you are sterilising or cleaning to a fixed routine to get you ready for
your equipment, make sure expressing. These can be very ordinary
that the inside of your funnel actions, like removing equipment from
is thoroughly dried, as this will the steriliser, or putting together the
give better suction (see page pump. The sound of a breast pump
30 for more information on or even the smell of disinfectant may
sterilising). trigger your breasts to release milk. The
preparation time is an important part of
expressing milk. Your body may learn
A comfortable bra that certain things you do leading to milk
expression will trigger a milk ejection
It may help to buy a comfortable reflex, making it easier to express.
bra, since your breasts will need
Taking care of your equipment
extra support during this time. Many
nursing bras, with openings in the If you are using a breast pump
cup to help you access your breasts for extended periods of time, it is
more easily, are available on the high important to maintain your machine
street from specialist baby stores. and equipment. It is always a good
idea to check the tubing and funnels,
For double pumping, wearing a halter- as a milky residue can slowly build up,
neck that has been adapted to hold making points of connection less snug.
both funnels securely may be useful, Making sure that equipment is extra
since it will free your hands while you clean after every session can reduce
express. Some mums find that adapting loss of pressure and will ensure that
a sports bra can also work. You can do your milk is not contaminated by germs.
this by cutting slits along the seams in
the end of the cups just large enough
to ensure that the narrow point of the
funnel can slip through, and ensure
that the widest part of the funnel can be
placed more snugly against the breast.

Bliss 2012 - Breastfeeding your premature baby 21

 Some problems that may
occur when expressing
The most common pumping problems Small amounts of milk
with milk expression are sore nipples It is common for mums to express only
and small amounts of milk. You might small amounts of milk especially to
find that the diagram on page 28 helps begin with. There are many reasons
you understand some of the terms used for this and they can include being
here to describe parts of the breast. in a hurry, feeling stressed or under
pressure, or a collection set (funnels)
Sore nipples
that are too small. Try some relaxing
To help prevent sore nipples, make techniques and allow yourself
sure the funnel is the correct size. If enough time for milk ejection reflex
friction is created while expressing, to appear before using a pump.
you may need a larger-size breast
Infections of the breast
shield. Ask your nurse, midwife or
lactation consultant for advice. Always Thrush is a yeast infection which can
apply the lowest vacuum setting cause pain when expressing, and
that will produce milk. High vacuum can be passed from baby to mum
won’t make the milk flow any faster when breastfeeding. The symptoms
and may make your nipples sore. are painful breasts, or a burning
feeling. The nipple can also become
red and shiny. If you think you have
thrush, it can be easily treated. It is
best to seek advice from the nurses
on the neonatal unit. Both you and
your baby should be treated.
Mastitis
Mastitis is a breast infection which
can be caused by blocked milk ducts,
but this is not always the case. It can
also be caused by cracked nipples,
since infection has a route to enter
the breast. If you have mastitis, you
may have some of the symptoms of
blocked ducts (see page 23). However,
mastitis also causes flu-like symptoms
and a general feeling of being unwell.

22 Bliss 2012 - Breastfeeding your premature baby

It may need treating with antibiotics There are many things you can do:
and therefore it is important that you
consult your doctor. It is also very • Massage the affected area
important not to stop expressing, as this before and during expressing
can make the symptoms worse. Don’t
worry – your milk is still safe to use. • Use a hot towel on the affected
area or take a hot shower
Blocked ducts
Milk travels to the nipple through • Express milk with a pump
tubes called ducts. Sometimes the
milk ducts can become blocked. • Avoid underwired bras and
Symptoms are pain or redness in tight clothing.
the area around the blocked duct
Engorged breasts
or a hard lump in the breast.
Sometimes the breasts become too
Blocked ducts can occur when the full, hard and painful. If engorgement
breast is not well drained, and becomes a problem, you need to
therefore can be more of a risk for increase the number of times you
mums who are expressing their milk. express in a day and ensure that
you continue to express until the milk
stops dripping. Expressing more
often will also lower the risk of a
breast infection such as mastitis.

“After my son was born at 27 weeks, weighing only 1lb 4oz,

breastfeeding was the last thing on my mind. However, I came
to understand the importance of breastfeeding for my tiny son.
I followed this booklet’s advice and expressed at least every
three hours, even at night, to try to stimulate my milk supply.
Since he came home, he has only had one minor cold and he’s
also no longer on oxygen. I like to think that his good health is at
least partly as a result of breastfeeding.”
Rachel, mum to Tal, born 27 weeks

Bliss 2012 - Breastfeeding your premature baby 23

 Breastfeeding your baby
Eventually, the time will arrive when arms and talk to them. Your baby will
you can put your baby to the breast. be comforted by the skin contact and
This section of the booklet will help you by the sound of your voice, which they
prepare for that very precious moment. heard whilst growing in your womb.
First cuddles
When you do put your baby to the
When your baby is well enough to breast, they may not actually suck, but
come out of the incubator, they may be they will enjoy your closeness and the
able to be undressed and held against taste and smell of the milk expressed on
your skin (this is called Kangaroo Care, to your nipple. It may be helpful to use
see page 8 for more details). The first pillows to support your back and arms,
time you hold your baby, there is no and to raise your baby so that they are
need to concentrate on feeding. Just level to the breast. Your baby will feel
cuddle your little one gently in your most comfortable if their head and body
are in a straight line and support is
given to their neck, shoulders and back.
Starting to breastfeed
Encourage your baby to enjoy being
at the breast. Tiny babies love to
lap milk and to catch dribbles of
milk in their mouths. At the first
feed, do not expect too much, since
premature babies get tired easily
and must gradually learn to suck.
Capturing your baby’s interest
Initially, your baby may not show any
interest in the breast, particularly if
they are being fed every hour, since
it is the feeling of hunger that will
trigger a baby’s demand for milk.
Touching their lips and jaw gently
may help. You can also express a
little milk directly into their mouth.

24 Bliss 2012 - Breastfeeding your premature baby

 at the breast. You can start as soon as
Helpful hint your baby’s breathing tube is removed.
Remember to move your baby This method is described as ‘dry’
towards your breast, rather than breastfeeding. This involves expressing
your breast towards your baby. milk which is then tube fed to your baby
while your baby suckles on a drained
breast. In this way, your baby will learn
Using a breast pump briefly before a to associate sucking with a full stomach.
feed will also make the milk flow more When your baby can co-ordinate
easily and stretch your nipple, helping sucking and swallowing with breathing,
the baby to latch on to the breast. you can partially express beforehand to
Reassure them with gentle handling. trigger the milk ejection reflex so your
baby gets the milk without too much
Making it easy for your baby
effort. The next step is to put your baby
Try not to be discouraged if your baby to the breast without expressing first.
appears too sleepy to feed. Placing
How much milk is enough?
your baby on one breast and using
the breast pump at the other will help If you have a very large milk supply it
your milk to flow more easily, since can be tempting just to remove enough
you get milk ejection on both breasts milk for your breasts to feel comfortable.
at the same time. This will help your This is particularly tempting if you are
baby save energy, since all they will in a hurry. If you don’t remove all the
have to do is suck and swallow. You will available milk your milk supply can be
need an extra pair of hands for this. down regulated. It is important that
you drain the breast you are feeding
Non-nutritive sucking (NNS)
from, as this will ensure that your baby
Many hospitals use this as a method benefits from the fat rich milk at the end
of supporting and encouraging early of a feed (see page 16). Also remember
sucking experiences in babies. This that as your baby grows the amount of
is called non-nutritive sucking, as the milk he will need will increase steadily.
baby is not getting nutrition (milk) while
Nipple shields
sucking. Dummies are offered to babies
to suck while they are being tube fed. Nipple shields are made of soft silicone
and fit over the nipple. They can be
Babies can also learn to suck by a useful tool when breastfeeding a
practising non-nutritive sucking directly premature baby with a weak suck. They

Bliss 2012 - Breastfeeding your premature baby 25

 How will I know my baby is getting
are also sometimes used as a solution
enough breast milk?
for sore nipples, which can be caused
by pumping too hard or using the Premature babies who are getting
wrong position during breastfeeding. enough to eat have at least six to
eight wet nappies every 24 hours,
However, they do have drawbacks and pale urine that does not have a
should only be used under professional strong smell, and regular bowel
advice and as a short-term measure. movements. A breastfeeding baby
that is feeding well should not be
With nipple shields, the baby is not constipated and should pass at least
positioned directly on the breast. This two soft, yellow stools in 24 hours.
means less milk may get to the baby, as
it has to flow through the shield before Your baby will seem content and happy
it reaches their mouth. Since the nipple after a breastfeed and grow steadily.
is not being stimulated directly, milk For any specific questions, you should
ejection may be a little more difficult talk to the team caring for your baby.
to achieve. It is important to express
How will I know
following a breastfeed using a nipple
my baby is hungry?
shield to make sure that all the milk has
been removed from your breast. If you The key is listening to your baby. If they
are using nipple shields, you should give you a hunger cue, feed them. If you
try to persuade your baby to latch on offer the breast and your baby starts
without them after a few weeks. to feed, they must be hungry. However
some premature babies don’t wake
Finding additional guidance
when they are hungry. The desire to
Ask your midwife or health visitor for sleep over rides the desire to feed.
a copy of the DVD entitled From bump
to breastfeeding. This resource was Look out particularly for:
sponsored by the Department of Health
and provides step-by-step guidance • Rooting
about establishing breastfeeding,
how to position your baby effectively • Hand to mouth movements
and specific breastfeeding problems.
The DVD is available in English, • Sucking movements
English with subtitles, sign language,
Urdu, Bengali, Somali and Polish. • Sucking on fingers and hand

• Opening of the mouth in

response to touch.

26 Bliss 2012 - Breastfeeding your premature baby

Watch your baby closely while they feed, developing. This is a commitment
so you can be sure they are swallowing to your baby and a real benefit to
and sucking well. You may have to both of you.
remind them to keep sucking and
swallowing by stimulating them gently. Initially, you might decide that your short-
term goal is to continue breastfeeding
Do keep expressing
or expressing until your baby reaches
It is very helpful to continue pumping the date when they should have been
until your baby is able to breastfeed born. The longer you breastfeed, the
well, as it will help you maintain your greater the benefits will be to you and
milk production. Some babies may find your baby. However, it is your choice
it easier to develop a good sucking how long you breastfeed for. You are
rhythm when their mum has a good milk still doing a lot of good for your baby’s
production since the milk flows freely. health and development, even if you
provide milk for just a few weeks.
Long-term goals
It is worth all the effort of expressing
milk and establishing breastfeeding
when you see your baby growing and

Bliss 2012 - Breastfeeding your premature baby 27

 Breastfeeding step-by-step

1 2
Start by holding your baby She’ll reach towards your
close to you with her nose nipple, her mouth will open
level with your nipple. wide and you may see her
putting her tongue out.

3 4
When her mouth opens really Well latched on, her chin
wide, and she will open wider will be against your breast
if you wait a little, bring her and there will be a little
shoulders in close so that gap between your breast
her head tilts backwards as and her nose. You should be
she come to your breast. comfortable and feel no pain.

28 Bliss 2012 - Breastfeeding your premature baby

5 6
3
When she first starts to suck, If it hurts, you can take her off
your milk may begin to flow by slipping your little finger
very quickly and she may gently into the corner of her
come off. Don’t worry about mouth to release the suction.
this. Just start again.
After some quicker suckling,
she will slow down into a
deeper slower rhythm and
she should be relaxed and
swallowing.

7
Babies come off the breast
spontaneously when they
have had enough. Then
you can offer the second
breast if she’s still awake.

Bliss 2012 - Breastfeeding your premature baby 29

 Getting help to establish the manufacturer’s instructions,
breastfeeding and check that your equipment
is microwave-friendly). Utensils
If your baby is receiving your freshly can also be soaked in a cold
expressed milk from a feeding bottle water sterilising solution.
and you really want to establish
breastfeeding after your baby has
Storing milk
been discharged from hospital,
additional support and assistance • Many units supply sterile
will be available from one of the disposable bottles.
breastfeeding support groups.
• Label each container with your
Sterilising your equipment
baby’s name, date and time
Breast milk is a complex fluid, which of collection.
requires careful collection and handling.
• Always leave at least one
• Always wash your hands centimetre of free space at the
thoroughly before collecting milk. top of the milk container, as milk
will expand when frozen.
• Wash the milk collection attachments
and bottle in warm soapy water • Breast milk will keep for 48 hours
when you have finished expressing (unless defrosting) in a refrigerator,
and scrub with a bottle brush. as long as it is not stored in the
fridge door (the temperature in
• In hospital; follow the hospital the door compartments goes
guidelines for sterilising. up and down when the fridge
is opened and closed).
• At home; sterilise the milk collection
attachments and bottle by heat • Milk can be deep-frozen for up
sterilisation with a steam unit to three months.
or microwave kit (always follow

30 Bliss 2012 - Breastfeeding your premature baby

• Breast milk that has been to add the time and date when you
supplemented with additives removed the bottle from the freezer.
should be used immediately. It
Breastfeeding support at home
is not suitable for freezing and
defrosting. Your neonatal staff Just because you have left hospital
will be able to manage this. does not mean you must manage
breastfeeding alone, with no help.
• Milk stored in a freezer with a Ask the staff on the neonatal unit to
self-defrost cycle may have a put you in touch with nurses in the
slightly soapy smell. It is not community and with volunteer groups
harmful to your baby. However, that support breastfeeding mums, or
if it smells sour, do not use it. contact the Bliss freephone Helpline
for support groups in your area.
Leaving hospital
Many mums feel uncertain about
expressing milk on their own once they
leave hospital. Here are some practical
tips to make things easier. You will
need your own breast pump at home.

If you need to go home before your

baby is discharged from hospital,
you will need to ask where you can
get a breast pump. You will have got
used to the pump that you used in
hospital, so if it is working well for you,
it may be worthwhile either buying
or renting the same machine.
Transporting your milk
While your baby has been in hospital
you might have accumulated a large
supply of expressed milk. With care
you can use this milk at home. An
insulated cool box is useful to transport
milk on your journeys to and from
hospital. Don’t forget to label each
bottle with your name, and the time
and date you expressed your milk. If
the milk is defrosted, you will also need

Bliss 2012 - Breastfeeding your premature baby 31

 Julie’s story
My experience of
breastfeeding
by Julie Ebrey

showed no signs of being

ready to produce milk. The
nurse gently explained to
me that colostrum was
the most natural thing for
such a tender fragile baby
like Marc to digest – and
that it would prepare his

O
ur lovely baby son Marc gut for when he was ready to take my
was born at 24 weeks, milk. I was supported by a fabulous
weighing only 620 midwife through this time, who gave
grams. His twin brother me great confidence and helped me
was born moments before but he to understand what a special job I was
was so poorly and sadly died. doing for my son, by giving him a good
start to his very early life. Although
From the moment I entered the my feelings were upside down, I
neonatal unit, I was in complete started to feel secure in the care of
shock. All my hopes and dreams were the nursing staff and was happy for
shattered. All I had wished for was a my actions to be guided by them.
healthy, strong baby whom I could hold.
I had to pump eight times a day
When I took that first look at Marc, he (including during the night), to make
was hardly recognisable. Behind the sure that I built up my milk supply
coloured strands of wires and tubing sufficiently to be able to feed Marc
lay what seemed to be our helpless when, or if, he would be strong enough
little boy. The first day in the neonatal to feed from me. It was such a huge
unit was scary and I was completely commitment. For the first two months
overwhelmed by what I saw. To top it of Marc’s life it was very much touch
all, I was asked by the nurse looking and go as to whether he would even
after Marc if I would express some survive. Expressing my milk was the
colostrum for him. I thought that this one thing that only I could do; and that
was a big joke, since I did not even made it important for me to succeed.
know if I could express – my breasts

32 Bliss 2012 - Breastfeeding your premature baby

I tube fed Marc as much as possible. I realised that I could donate any
It helped me to bond. I was told unneeded milk to a local milk bank.
that my milk would adapt to suit
the environment Marc was in and Marc continued to be exclusively
protect him even further. I got into breastfed until I started to wean him
the habit of expressing just before I at eight months (from his birth date).
tube fed him. I wanted to make sure It was important to me that he had all
he had the freshest milk possible. the protection possible from my milk.
He took to solids really well and had
When Marc was about 34 weeks a good appetite. Breastfed babies are
gestation, we tried him on the breast. used to the taste changes of breast
Although he only lasted moments, milk (depending on what mum eats),
I had an overwhelming sense of and so adapt easily to new foods.
achievement; we had reached a
real milestone. He slowly continued Marc grew well, developed nicely and
to make progress and the hospital enjoyed a night-time breastfeed until
feeding adviser showed me some good he was a few years old. Long-term
techniques to help me feed Marc. breastfeeding is not for everyone; it’s
a choice you and your baby make.
In time, we moved towards three hourly It takes commitment from the mum,
feeds. Together, with the neonatal real strength from the baby and total
staff, we worked out a schedule encouragement from everyone around.
so that I would tube-feed him and
breastfeed him at every alternative
feed. During the times at night when I
could not be there, the nurse cup-fed
him (to help him to build on his suck,
breathe, swallow coordination).

I had built up my milk supply so much

through pumping, that I had a lot
of milk in store. I was thrilled when

Bliss 2012 - Breastfeeding your premature baby 33

34 Bliss 2012 - Breastfeeding your premature baby
This booklet was produced for Bliss
Designed by Megan Sayers
Edited by Mark Gorman, Communications Officer
Reviewed by Carmel Bartley, Bliss Family Support Manager
Written by Liz Jones, Neonatal Breastfeeding Coordinator, Julie Ebrey, mum to Marc, and
Andy Spencer, Consultant Paediatrician, University Hospital of North Staffordshire

With help from Annie Aloysius, Specialist Speech and Language Therapist, Hammersmith Hospital;
Carmel Duffy, Deputy Programme Director, UNICEF UK Baby Friendly Initiative; Caroline King, Chief
Paediatric Dietitian, Hammersmith Hospital; Heather Naylor, Clinical Nurse Specialist, Queen
Charlotte’s and Chelsea Hospital; Gillian Weaver, Milk Bank Manager, Queen Charlotte’s and
Chelsea Hospital; Bliss Medical and Nursing Advisory Panels.

8th edition, 2012

© Bliss – the special care baby charity
No part of this booklet may be reproduced without prior permission from Bliss
The information contained in this booklet on feeding and Kangaroo Care is supported by UNICEF
UK Baby Friendly Initiative. www.babyfriendly.org.uk

Bliss
9 Holyrood Street
London SE1 2EL
t 020 7378 1122 f 020 7403 0673
e enquiries@bliss.org.uk
www.bliss.org.uk
Bliss Publications 01933 318503
or order online at www.bliss.org.uk
Registered charity no. 1002973 Scottish registered charity SC040878

Bliss 2012 - Breastfeeding your premature baby 35

To access support please call our
freephone Helpline

0500 618140
or visit our parent messageboard
www.blissmessageboard.org.uk

To volunteer your time or to join our local

network of support groups visit

www.bliss.org.uk
RNID typetalk 018001 0500 618140
Bliss is a member of Language Line, the telephone interpreting service,
which has access to qualified interpreters in 170 languages.

Bliss is the UK charity working to provide the best possible care and
support for all premature and sick babies and their families.
We support parents, we work directly with doctors and nurses and
we campaign to ensure the needs of babies and their families are
always heard.

Bliss relies on voluntary donations to fund its services and your support
would be greatly appreciated. To find out how to donate, please contact
020 7378 1122 or visit our website

Bliss
9 Holyrood Street
London, SE1 2EL
t 020 7378 1122 f 020 7403 0673
e enquiries@bliss.org.uk
www.bliss.org.uk

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Registered charity no. 1002973
Scottish registered charity SC040878