Hand Expressing Method – When Milk Flow is Insufficient While Pumping

Mothers use a breast pump to supplement their baby's nursing for many different reasons.

In the clinical context, pumps are used to express breast milk for a premature or sick baby while the baby is unable to nurse at the breast.¹ In these cases, the mother expresses regularly, starting as soon as possible after the birth, in order to build up her milk production.² Professional electric breast pumps are generally provided for this purpose. 

However, breast pumps are also used in a normal domestic setting with a healthy breastfed baby.^1,3

• Some mothers want or have to leave their babies occasionally and need to express their milk so that the caregiver is able to feed the child.
• Others do not enjoy nursing in public, so they take expressed milk with them in a bottle when they leave the house with their baby.
• Occasionally, the mother's milk supply does not meet the child's needs at that time. This is when pumping can help to stimulate greater production or remove surplus milk.
• Sick babies may have temporary difficulties nursing and need help with their feeding to ensure they continue to drink enough milk.
• The mother may have to undergo medical treatment that requires her to take a break from nursing.  

In all of these cases, pumping can ensure that nursing does not have to stop and the baby can continue to receive the mother's breast milk. 

Mothers should ideally contact their midwife if they experience problems expressing milk. Some women have the impression that their breast is not letting down the milk while they are pumping. Others are surprised at how little milk they obtain from pumping and wrongly conclude that their milk supply is too low.

What can be done if the mother has the impression that she is unable to empty the breast using the pump? 

In actual fact, a lot of women are unable to empty their breast fully or satisfactorily simply by using a breast pump. You can tell when a breast is fully empty because, after pumping, only a few drops can still be expressed. It is clear when a breast is fully empty because none of the milk glands feel full. (A few drops can also be expressed if the pump is not working correctly).

To make pumping more successful, there is a helpful method known as hands-on pumping by those who promote breastfeeding.⁴ The method is used when the milk does not flow while pumping, even though it can be felt in the milk glands. By using hands-on pumping much more milk can be obtained since the aim is to almost fully empty the breast.⁵ This method is also useful for building up a stock of milk; it can equally be applied after nursing successfully.

For the mother there are three steps to the hands-on pumping method:

• Massage: Before pumping, the milk let-down reflex is stimulated by massage, e.g. using the Marmet technique. The first few drops are expressed by hand. The portal of the Global Health Media Project has some very clear and useful videos.⁶
• Express with a breast pump: The pump is first used to express as much milk as possible. Ideally use a double pump set with well-fitting breast shields or, if you only have one set of shields, alternate between breasts.⁷

• Additional hands-on support: As you continue to pump, use your fingers to apply targeted massage to the milk glands that you can feel in order to stimulate let-down. Alternatively, you can empty the breast with your hand. With your free hand, hold your breast between thumb and fingers from below or above. Squeeze your thumb and fingers together over the milk glands in a slow rhythm while you are pumping. You should never reach or exceed your pain limit. A video by Dr Jane Morton, Stanford, demonstrates a number of effective options.⁸ The pump shields should not be pressed too hard against the breast to avoid the risk of blocking the milk ducts.

The result is up to twice as much milk

¹Lawrence, R. A. (2016): Breastfeeding. A Guide for the Medical Profession. 8th edition. Maryland Heights, Missouri: Elsevier Mosby Inc.
²Hill, P. D.; Aldag, J. C.; Chatterton, R. T. (2001): Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants. In: Journal of human lactation: official journal of the International Lactation Consultant Association 17 (1), p. 9–13. DOI: 10.1177/089033440101700103.  
³Kämmerer, B.; Nindl, G.; Bier, A. (2018): Gewinnen von Muttermilch per Hand und Milchpumpe. Script 4-005. Prod. by the Europäisches Institut für Stillen und Laktation. Available online at www.stillen-institut.com/media/05-MM-Gewinnung-20180926.pdf, last checked on 01/03/2020.  
⁴Morton, J (2017): How to use your hands when you pump. Maximizing milk production. Available online at med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html, last checked on 01/03/2020.  
⁵Morton, J.; Hall, J.Y.; Wong, R.J.; Thairu, L.; Benitz, W.E.; Rhine, W.D. (2009): Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. In: J Perinatol. 29 (14), p. 757–764. DOI: 10.1038/jp.2009.87.  
⁶Global Health Media (prod.): How to express breast milk. Global Health Media Project (Breastfeeding Series). Available online at globalhealthmedia.org/portfolio-items/how-to-express-breastmilk/, last checked on 01/03/2020.  
⁷Hill, P. D.; Aldag, J. C.; Chatterton, R. T. (2001): Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants. In: Journal of human lactation: official journal of the International Lactation Consultant Association 17 (1), p. 9–13. DOI: 10.1177/089033440101700103.  
⁸Maximizing Milk Production | Newborn Nursery | Stanford Medicine (2020). Available online at med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html, last updated on 18/01/2020, last checked on 01/03/2020.  
⁹Morton, J.; Wong, R. J.; Hall, J. Y.; Pang, W. W.; Lai, C. T.; Lui, J. et al. (2012): Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. In: Journal of perinatology: official journal of the California Perinatal Association 32 (10), p. 791–796. DOI: 10.1038/jp.2011.195. (8).