October 2018 Newsletter: When Hand-Expressing Trumps Breast Pumps

By BMSG Editorial Team

While breast pumps might be a no-brainer purchase for working mothers when they return to work, for others, hand-expressing appears to be an easier option. We speak to three breastfeeding mothers, who are also our breastfeeding counsellors, who hand-express at work and on-the-go, doing away with the conventional breast pump.

CL Chan, a junior doctor, rushes to a toilet cubicle at the hospital she works in. She is on call and is anticipating a beep from the hospital at any time. CL, who is still breastfeeding her youngest baby, flips open a clean milk bottle and starts hand-expressing her milk. In just under ten minutes, she has a bottle filled with breast milk, which makes up one of the next day’s feeds for her baby.

For CL, a mother of three, working in a pressure-cooker environment compelled her to pick up hand-expressing as a skill. “For my first and second babies, I relied on my portable double pump, but often had difficulty finding a clean, private spot to set up my gear, put on my pump bra and start pumping,” CL added.

CL also found it cumbersome to bring along her pump with her on her rounds. “There was the added stress of dragging the pump, cooler bag and flanges around with me as I moved from ward to ward.” Feeling frustrated at having to cut short her pumping session many times due to the hectic and sudden nature of her job, CL chose to hand-express out of necessity.

Mummy CL Chan with her youngest daughter, Ellie, whom she is still breastfeeding. [Photo courtesy of CL Chan]

Convenience of hand-expressing a Strong Motivation

For Jasmine Tan, 35, being an exclusively-pumping mother for her second child triggered much exhaustion. It was her first day back at work, lugging her heavy breast pump and work bag despite on a part-time contract, that forced her to look for other options. It was not until later on, during a three-week holiday, that she decided enough was enough and figuratively threw out her breast pump in frustration.

“I didn’t want to always be stuck in the nursing room while on holiday, always having to worry about milk storage and warming it up,” said the corporate relations manager, whose baby had poor milk transfer while latching, due to a tongue tie.

As she got better at hand-expressing during the vacation, she began to realise that the convenience was the best motivation for her. “Gaining mastery at hand-expressing just before a baby’s feed did it for me; no washing, sterilising, pumping, storing, or warming was required. It was the best alternative to my baby to direct latching,” she added.

For Jasmine Tan (right), hand-expressing seemed to her to be the only viable option for her as an exclusively pumping (EP) mum. [Photo courtesy of Jasmine Tan]

Jasmine was also the only lactating mother at work and there was no nursing room at her workplace. She also had to travel frequently for work, giving her the extra push to rely on hand-expressing especially when time was tight. Jasmine also frequently thought about how mothers coped in the past. “I was always thinking what the last few generations of mothers would have done in my situation. With no pumps back then, hand-expressing came to mind,” Jasmine said.

Correct Technique Key to Maximum Output

For the uninitiated, hand-expressing may sound cumbersome. Some mothers who have attempted it may also complain of poor output the first few times. But according to Nur Hafizah Rafie, who hand-expressed her breast milk for her two children for almost four years, it helped her produce more than when she was using a breast pump.

The family researcher, who was working in an office setting previously, experimented with multiple breast pumps. From electric to manual pumps, and even single and double pumps, Hafizah found that her output from hand-expression trumped what she got when using pumps. “It took me a longer time to have a good output,” she said, adding that she got better at hand-expressing from practicing.

Hafizah has grown so adept at hand-expressing that she would complete two of her three hand-expressing sessions at her desk instead of the nursing room. This also saves her time at work. “I hand-express at my desk with just a nursing cover,” she added.

Hafizah with her two daughters, both of whom she had hand expressed for to provide them with breastmilk when she was at work. [Photo courtesy of Hafizah Rafie]

Jasmine, who did not hand-express for her first child, understands that the first few tries might be difficult especially for one who has just started out. But like the other mothers, she found practice makes perfect. “No doubt, it was at first tiring for the hands and my breasts were bruised in the initial stages as I was trying too hard. But after hand-expressing eight to ten feeds a day, over weeks and months, it just became second nature,” said Jasmine.

For CL, watching a video from Stanford University won her over to hand-expressing. “It was life-changing for me. Using their technique of placing your fingers, pushing back into the chest wall then rolling forward, hand-expression is virtually painless!”

Indeed, successful hand-expressing requires the right technique and pressure, and is often a chosen way to help new mothers provide colostrum and breast milk to newborns at the hospital. While we are inclined to assume that lots of hard pressing is required to extract milk from the breasts, it is actually the exact opposite. According to the World Health Organization (WHO), hand-expressing should be painless and comfortable. There should be no rubbing or sliding fingers along the skin, and the nipples should not be pinched. It is also recommended to switch sides a few times during each hand-expressing session until milk flow is slow from the start.

Triggering a Letdown

Similar to using a breast pump, the key to producing enough for a feed when hand-expressing is to trigger a letdown. A letdown occurs when the brain receives the necessary stimulation from the breasts to open the floodgates to express breast milk out from the milk glands in the breasts. This is always more successful when the environment and stimulation at the breast are when mothers are at their most comfortable.

For Hafizah, being relaxed is helpful. “I will make sure my chair is comfortable by using a good cushion to support my back. I drink a hot drink before I begin and then massage my breasts to prepare for hand-expressing. I also place a warm compress on my breasts to help trigger a letdown,” she said.

Fear and anxiety may hinder a letdown, so Hafizah also sometimes watches a drama while hand-expressing to keep her mind off how much milk she is making. “The thing with hand-expressing is that you can do other things like watching television without looking at the bottle. By not looking at the bottle, it prevents me from thinking about how much output I should get in one session. When I was still using a pump, I kept staring and checking the bottle to see if I have gotten enough for the session. It somehow added more stress for me instead,” said Hafizah.

Finding a comfortable spot is a proven challenge for CL as she is always on the move in the hospital. But viewing videos of her baby given to her from home helps her to achieve a letdown when she is able to get a bit more time to sit down and hand-express. “I also found being gentle and rhythmic in the initial part of a session, even if you don’t yield a significant amount, helped stimulate a letdown much like the massage mode on a pump. Once you achieve a letdown, then not much work is needed to extract the milk. Switching sides two to three times per session also helped increase my yield,” said CL.

CL took this picture for her husband on her first day being posted to work at a location away from the hospital. Despite having to sit in an empty storage room, CL is grateful for being able to hand-express as it still allows her to provide breast milk for her baby . [Photo courtesy of CL Chan]

Not a Popular Choice, Yet These Mums Won’t Choose Otherwise

All three mothers concur that people’s reactions to them hand-expressing were always one of shock and disbelief. “Many people will go on to share their extremely painful or bruising experience with hand-expressing, or comment about how tired your hands must be. But as I mentioned earlier, with the right technique to trigger a letdown, no “force” is needed to squeeze the milk out,” CL said. “Some people are just shocked. I guess it is something that my body is used to and it is faster and fuss-free for me because all I need is just a bottle and a milk storage bag,” chips Hafizah. Jasmine agrees, too, that it was not easy to begin with but became easier as time went by. “The pros definitely outweigh the cons,” she added.

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Tips for Comfortable hand-expressing
(adapted from the WHO Publication Infant and Young Child Feeding – Model Chapter for textbooks):

The mother should:

  1. Have a clean, dry, wide-necked container for the expressed breast milk;
  2. Wash her hands thoroughly;
  3. Sit or stand comfortably and hold the container under her nipple and areola;
  4. Put her thumb on top of her breast and her first finger on the underside of her breast so that they are opposite each other about 4 cms from the tip of the nipple;
  5. Compress and release her breast between her finger and thumb a few times. If milk does not appear, re-position her thumb and finger a little closer or further away from the nipple and compress and release a number of times as before. This should not hurt – if it hurts, the technique is wrong. At first no milk may come, but after compressing a few times, milk starts to drip out. It may flow in streams if the oxytocin reflex is active;
  6. Compress and release all the way around her breast, with her finger and thumb the same distance from the nipple;
  7. Express each breast until the milk drips slowly;
  8. Repeat expressing from each breast 5 to 6 times;
  9. Stop expressing when milk drips slowly from the start of compression, and does not flow;
  10. Avoid rubbing or sliding her fingers along the skin;
  11. Avoid squeezing or pinching the nipple itself.

Mothers may also want to massage their breasts, stimulate their nipple, or get someone else to massage their back in order to stimulate the oxytocin reflex to kickstart a letdown.

Sept 2018 Newsletter: Breast pumps – A Useful Tool, Not a Silver Bullet

By BMSG Editorial Team

When Susan Chen gave birth to her firstborn, she did not expect to face any trouble with breastfeeding. Having read up a lot on breastfeeding during her pregnancy, Susan was surprised when she struggled to latch her baby. The lactation consultant (LC) at the hospital she birthed at had diagnosed her as having short nipples. She was also told that one of her nipples was almost inverted, a reason she was made to believe caused her baby difficulties in latching.

After the initial struggle, she discovered that her baby was diagnosed with jaundice. At a loss, she gave in to pressure from the people around her to feed her baby formula milk; she was made to believe that formula could bring her baby’s jaundice down. Wanting to  attempt breastfeeding, she began pumping milk at home to kickstart her milk supply as well as to manage engorgement. When she tried to latch her baby a few days later, however, she still refused to latch.

“By the time I sorted out my painful engorgement, my daughter had gotten so used to bottle feeding that getting her to latch was a struggle,” said Susan. Still adamant on attempting to breastfeed, she went thrice for LC consultations and also purchased nipple shields and a Supplemental Nursing System (SNS), which are tools to help babies latch. Unfortunately, latching continued to be a struggle.

After suffering from a bout of postnatal blues and feelings of failure, Susan sought support on several Facebook groups on pumping milk for her daughter. “(It) slowly made me realize that I could exclusively pump for my baby and that would not make me less of a mother.” Coupled with the fact that her daughter had multiple allergies, including being allergic to cow’s milk, she pressed on to continue providing breastmilk despite the challenges of exclusive pumping. She managed to provide breastmilk to her daughter, who is now four years old, for 13 months.

Susan and her children. While she started off exclusively pumping, Susan has managed to latch her son when he turned 10 weeks old.

Like Susan, teacher Jessica Xie, a mother of two, also resorted to breastpumps when she had no support for breastfeeding after the birth of her first child. Struggling with an overactive letdown, her baby struggled to latch and Jessica exclusively pumped, although she still needed to supplement with formula during this time.

Breastfeeding was also tough for Jessica as she was experiencing Dysphoric Milk Ejection Reflux (D-MER), an anomaly of the letdown reflex in lactating women. This is a physiological reflex where a mother experiences depressive thoughts, due to an imbalance of brain chemicals, when oxytocin levels rise during letdown. While D-MER is a fairly rare condition, it is a difficult one to live through, and it drained Jessica. With her struggles in pumping and getting enough milk, she gradually stopped pumping after six months when her supply dried up.

Better postpartum support a growing demand to help initiate breastfeeding

For mums like Jessica, Susan, and many others who struggle to breastfeed during the initial days post-birth, breastpumps are a lifesaver for those who still want to provide breastmilk for their babies. It is, however, a signal that more needs to be done in helping mothers initiate breastfeeding right after birth.

For her second baby, Jessica obtained the right breastfeeding support from the hospital during birth. “(The hospital) insisted on one hour of skin-to-skin and latching right after delivery, which wasn’t insisted on during my first delivery. It helped a lot in allowing my baby to latch well, myself to gain confidence in latching instead of relying on pumping and for the milk to kick in on the second day.”

Her experience with her first child made her prepare better this time around. On top of getting good support, she also purchased a hospital-grade pump which worked better for her. She was also motivated to establish a good supply of milk for her baby, to help her sustain breastfeeding more easily after returning to work, so she focused her efforts on feeding exclusively at the breast during her maternity leave. Furthermore, she also had to return to work earlier this time and she was motivated to ensure that her supply was in good shape. In the end, she was able to establish good milk flow and supply with the help of a good diet, which included lactogenic foods, as well as being consistent in stimulating her milk supply through nursing on demand and pumping extra for storage.

Despite still experiencing D-ME, with stronger bouts of depressive thoughts the second time round, the positive experience of successfully latching her baby and her eagerness to breastfeed for as long as possible motivated her to continue. “I usually try to distract myself with happy thoughts during those times or tell myself that it has nothing to do with me, and that it’s just an emotion due to hormones,” Jessica added, when asked how she coped with her condition.

Jessica (left) with her family. Jessica had a better post-birth experience for her second baby, which gave her more confident to initiate breastfeeding right from birth.

Postpartum support at the hospital is especially important in determining successful rates of breastfeeding. When maternity wards are not aware of steps to help initiate breastfeeding, as lined out by the Baby-Friendly Hospital Initiative (BFHI), breastfeeding can go downhill. For example, giving the bottle runs the risk of nipple confusion for a newborn baby. Nipple confusion occurs when a baby has difficulty latching on, or may even reject latching completely, and develops a preference for the quick flow of the bottle teat. Latching at the breast requires more work for the baby as compared to sucking from a bottle, since milk can flow from the bottle teat without much effort. However, since we know that direct latching is still superior to the bottle, the best alternative to bottles when a baby has to be supplemented is cup, syringe or even finger feeding.

While some parents may still prefer to use a bottle at some point in a baby’s life, it is recommended that babies only be introduced to bottles when breastfeeding has been well established.

Nipple confusion, lack of stimulation of mums’ milk supply common reasons for breastfeeding relationships to suffer

Early introduction to bottles was once again the cause of difficulties in latching when Susan gave birth to her second baby. While she had sought advice from an LC before giving birth on how she could do better in latching this time around, her son had to be admitted to the Neonatal Intensive Care Unit (NICU) for respiratory issues at birth. There, he was also given formula via bottles and subsequently struggled to latch when they reunited. Just like her first baby, she resorted to pumping again when he became impatient at the breast.

“I was resigned to the fact that maybe, because of my short and inverted nipples, I was not meant to breastfeed. At that point, I just wanted him to have breast milk and if that means exclusively pumping again, then it’s OK,” said Susan.

Things took a surprising turn, however, when Susan managed to latch her son at ten weeks. After following a pumping routine, she decided one day that she wanted to try to latch her son. “I thought maybe I should just try putting him at the breast and see what happens. He was sleepy and after an initial period of confusion, he latched on and fed from the breast and fell asleep. I was on cloud nine!”

She gradually increased his feeds via direct latch till she was able to replace all his feeds at the breast, dismissing the myth that mothers with short or inverted nipples are unable to latch their babies. It also shows that nipple confusion can be overcome, though not without some effort.

Michelle Ng, a mother of three, agrees that the lack of robust breastfeeding support right after birth makes it difficult for new mothers to start breastfeeding on the right note. She ended her nursing relationship with her firstborn just after two months. “I had no support at all,” said Michelle, who also struggled to learn the ropes of breastfeeding and pumping back then.

She eventually managed to breastfeed her second child for up to six months, citing better support as a reason for success. “I even had a friend who came over to my house to teach me how to direct latch my baby while sitting up and lying down.” Indeed, many mothers find that comfortable and suitable positions are helpful in sustaining breastfeeding, especially since a lot of time is spent at the breast in a newborn’s early days of comfort latching and cluster feedings.

Pumping is a learned art, requires the right support

Mothers who pump also need the right support and knowledge, as well as a pump that fits well and that which they can respond well to. It is important for mums who exclusively pump to understand that the use of the pump must mimic that of direct latching, especially when it comes to the frequency of emptying the breasts. Michelle, who is already back at work after the birth of her third baby, said that she struggled to exclusively pump previously as she was unaware that she needed to pump so frequently to provide sufficient milk for her two older children.

She has been breastfeeding her third child since birth for more than six months now, and pumps regularly at work. “Now, I try to pump every three hours. I also try to pump on time.” Pumping at the time baby would feed and providing the necessary stimulation of the breasts to sustain the supply of breastmilk in the body are crucial when a mother pumps for her baby. This is especially important because the pump is not able to extract as much milk as a latching baby can. Hence, consistent  and frequent pumping helps to send signals to the body that it needs to make milk.

Michelle (left, in black) initially struggled to breastfeed as she did not receive ample support in the early days after giving birth. She was finally able to exclusively breastfeed her third baby.

Mothers who pump also face the arduous and repetitive process of setting up their pumps, washing and sterilising bottles and pump parts, and then having to feed baby as well. “Exclusive pumping got a bit tiresome after 1 year,” said Susan, who stopped pumping when her daughter reached the one year mark. Mums who exclusively pump may also require accessories to help ease the backbreaking work of frequent pumping throughout the days and nights. Susan could not imagine how she was able to pump for 13 months for her firstborn without a handsfree bra. “I was literally holding on to the bottles for each pump session, which lasted 15 minutes each time, up to six times a day.”

With the prevalence and ubiquity of breastpumps now, coupled with mothers’ mobile lifestyles, the breastpump is here to stay and proves to be helpful for mothers who need to provide breastmilk when they are away from their babies. The price points of breastpumps have also widened, as with the specifications, to provide for the differing and evolving needs of mothers. Nonetheless, its growing demand also signals and necessitates the need for every mother to receive accurate and encouraging breastfeeding support for herself and her newborn that they truly deserve right from the birth of her baby.