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Review
. 2016 Sep 29;9(9):CD006170.
doi: 10.1002/14651858.CD006170.pub5.

Methods of milk expression for lactating women

Genevieve E Becker  1 , Hazel A Smith, Fionnuala Cooney
Affiliations
Review

Methods of milk expression for lactating women

Genevieve E Becker et al. Cochrane Database Syst Rev. .

Abstract

Background: Breastfeeding is important, however not all infants can feed at the breast and methods of expressing milk need evaluation.

Objectives: To assess acceptability, effectiveness, safety, effect on milk composition, contamination and costs of methods of milk expression.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2016), handsearched relevant journals and conference proceedings, and contacted experts in the field to seek additional published or unpublished studies. We also examined reference lists of all relevant retrieved papers.

Selection criteria: Randomised and quasi-randomised trials comparing methods at any time after birth.

Data collection and analysis: Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

Main results: This updated review includes 41 trials involving 2293 participants, with 22 trials involving 1339 participants contributing data for analysis. Twenty-six of the trials referred to mothers of infants in neonatal units (n = 1547) and 14 to mothers of healthy infants at home (n = 730), with one trial containing mothers of both neonatal and healthy older infants (n = 16). Eleven trials compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and pump types. Twenty studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols, pumping frequency, provision of an education and support intervention, relaxation, breast massage, combining hand expression with pumping and a breast cleansing protocol.Due to heterogeneity in participants, interventions, and outcomes measured or reported, we were unable to pool findings for most of the specified outcomes. It was not possible therefore to produce a 'Summary of findings' table in this update. Most of the included results were derived from single studies. Trials took place in 14 countries under a variety of circumstances and were published from 1982 to 2015. Sixteen of the 30 trials that evaluated pumps or products had support from the manufacturers. The risk of bias of the included studies was variable. Primary outcomesOnly one of the 17 studies examining maternal satisfaction/acceptability with the method or adjunct behaviour provided data suitable for analysis. In this study, self-efficacy was assessed by asking mothers if they agreed or disagreed with the following statement: 'I don't want anyone to see me (hand expressing/pumping)'. The study found that mothers who were using the electric pump were more likely to agree with the statement compared to mothers hand expressing, (mean difference (MD) 0.70, 95% confidence interval (CI) 0.15 to 1.25; P = 0.01, participants = 68). Mothers who were hand expressing reported that the instructions for expression were clearer compared to the electric pump, (MD -0.40, 95% CI -0.75 to -0.05; P = 0.02, participants = 68). Descriptive reporting of satisfaction in the other studies varied in the measures used, did not indicate a clear preference for one pump type, although there was satisfaction with some relaxation and support interventions.We found no clinically significant differences between methods related to contamination of the milk that compared any type of pump to hand expression (risk ratio (RR) 1.13, 95% CI 0.79 to 1.61; P = 0.51, participants = 28), manual pump compared to hand expression, (MD 0.20, 95% CI -0.18 to 0.58; P = 0.30, participants = 142) a large electric pump compared to hand expression (MD 0.10, 95% CI -0.29 to 0.49; P = 0.61, participants = 123), or a large electric pump compared to a manual pump (MD -0.10, 95% CI -0.46 to 0.26; P = 0.59, participants = 141).The level of maternal breast or nipple pain or damage was similar in comparisons of a large electric pump to hand expression (MD 0.02, 95% CI -0.67 to 0.71; P = 0.96, participants = 68). A study comparing a manual and large electric pump, reported sore nipples in 7% for both groups and engorgement in 4% using a manual pump versus 6% using an electric pump; and in one study no nipple damage was reported in the hand-expression group, and one case of nipple damage in each of the manual pump and the large electric pump groups.One study examined adverse effects on infants, however as the infants did not all receive their mothers' expressed milk, we have not included the results. Secondary outcomesThe quantity of expressed milk obtained was increased, in some studies by a clinically significant amount, in interventions involving relaxation, music, warmth, massage, initiation of pumping, increased frequency of pumping and suitable breast shield size. Support programmes and simultaneous compared to sequential pumping did not show a difference in milk obtained. No pump consistently increased the milk volume obtained significantly.In relation to nutrient quality, hand expression or a large electric pump were found to provide higher protein than a manual pump, and hand expression provided higher sodium and lower potassium compared to a large electric pump or a manual pump. Fat content was higher with breast massage when pumping; no evidence of difference was found for energy content between methods.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.

Authors' conclusions: The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Variation in nutrient content across methods may be relevant to some infants. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings. Independently funded research is needed for more trials on hand expression, relaxation and other techniques that do not have a commercial potential.

PubMed Disclaimer

Conflict of interest statement

Genevieve Becker works in the general area of infant and young child feeding, but is not specifically connected with the topic of this review. She is not in receipt of any financial relationship with any commercial entity.

In October 2012 Hazel A Smith registered as a PhD student to study the effects of infant's milk diet at two months of age on their body composition, growth and neurodevelopment in the first 2 years of life. Hazel is the Research Coordinator for the Paediatric Intensive Care Unit in Our Lady's Children's Hospital, Ireland. Hazel is not in receipt of any financial relationship with any commercial entity.

Fionnuala Cooney works as a Specialist in Public Health Medicine. She received no funds for work on this review, has no relationship to any commercial organisation involved in research on this topic, and has no known conflict of interest to declare.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Any type of pump versus hand expression, Outcome 1 Adverse effects for mother or infant.
1.2
1.2. Analysis
Comparison 1 Any type of pump versus hand expression, Outcome 2 Transfer to feeding at breast.
2.1
2.1. Analysis
Comparison 2 Any manual pump versus hand expression, Outcome 1 Adverse effects for mother or infant.
2.2
2.2. Analysis
Comparison 2 Any manual pump versus hand expression, Outcome 2 Quanity of milk expressed.
2.3
2.3. Analysis
Comparison 2 Any manual pump versus hand expression, Outcome 3 Nutrients (potassium, energy) in milk.
2.4
2.4. Analysis
Comparison 2 Any manual pump versus hand expression, Outcome 4 Nutrients (sodium, protein) in milk.
3.1
3.1. Analysis
Comparison 3 Any manual pump versus any other manual pump, Outcome 1 Quantity of milk expressed (mL/24 hours).
4.1
4.1. Analysis
Comparison 4 Any battery or small electric pump versus any other battery or small electric pump, Outcome 1 Quantity of milk expressed.
4.2
4.2. Analysis
Comparison 4 Any battery or small electric pump versus any other battery or small electric pump, Outcome 2 Change in 24 hour milk production (g).
4.3
4.3. Analysis
Comparison 4 Any battery or small electric pump versus any other battery or small electric pump, Outcome 3 Time taken to express.
4.4
4.4. Analysis
Comparison 4 Any battery or small electric pump versus any other battery or small electric pump, Outcome 4 Maternal physiological effects ‐ hormone levels.
5.1
5.1. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 1 Maternal satisfaction (self‐efficacy) measured using BSES, Breastfeeding Self‐Efficacy Scale..
5.2
5.2. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 2 Maternal satisfaction (with instructions) measured using BMEE, breast milk expression experience.
5.3
5.3. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 3 Adverse effects for mother or infant.
5.4
5.4. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 4 Quantity of milk expressed.
5.5
5.5. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 5 Nutrients (protein, nitrogen) in milk.
5.6
5.6. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 6 Nutrients (potassium) in milk.
5.7
5.7. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 7 Nutrients (sodium, energy) in milk.
5.8
5.8. Analysis
Comparison 5 Any large electric pump versus hand expression, Outcome 8 Nutrients (protein, carbohydrate, fat, energy) in milk.
6.1
6.1. Analysis
Comparison 6 Any large electric pump versus manual pump, Outcome 1 Adverse effects for mother or infant.
6.2
6.2. Analysis
Comparison 6 Any large electric pump versus manual pump, Outcome 2 Quantity of milk expressed.
6.3
6.3. Analysis
Comparison 6 Any large electric pump versus manual pump, Outcome 3 Time taken to express milk.
6.4
6.4. Analysis
Comparison 6 Any large electric pump versus manual pump, Outcome 4 Nutrients (sodium, energy) in milk.
6.5
6.5. Analysis
Comparison 6 Any large electric pump versus manual pump, Outcome 5 Nutrients (potassium) in milk.
6.6
6.6. Analysis
Comparison 6 Any large electric pump versus manual pump, Outcome 6 Nutrient (protein) in milk.
7.1
7.1. Analysis
Comparison 7 Any large electric pump versus battery or small electric pump, Outcome 1 Quantity of milk expressed (one expression).
7.2
7.2. Analysis
Comparison 7 Any large electric pump versus battery or small electric pump, Outcome 2 Quantity of milk expressed (g/one day).
7.3
7.3. Analysis
Comparison 7 Any large electric pump versus battery or small electric pump, Outcome 3 Time taken to express.
7.4
7.4. Analysis
Comparison 7 Any large electric pump versus battery or small electric pump, Outcome 4 Maternal physiological effects ‐ hormone levels.
8.1
8.1. Analysis
Comparison 8 Any method with a specified protocol of simultaneous versus sequential pumping, Outcome 1 Quantity of milk expressed.
8.2
8.2. Analysis
Comparison 8 Any method with a specified protocol of simultaneous versus sequential pumping, Outcome 2 Time taken to express milk.
8.3
8.3. Analysis
Comparison 8 Any method with a specified protocol of simultaneous versus sequential pumping, Outcome 3 Maternal physiological effects ‐ hormone levels.
9.1
9.1. Analysis
Comparison 9 Any method with a specified relaxation technique versus no specified relaxation technique, Outcome 1 Quanity of milk expressed.
9.2
9.2. Analysis
Comparison 9 Any method with a specified relaxation technique versus no specified relaxation technique, Outcome 2 Nutrients in milk (g/L).
9.3
9.3. Analysis
Comparison 9 Any method with a specified relaxation technique versus no specified relaxation technique, Outcome 3 Nutrients in milk (%).
10.1
10.1. Analysis
Comparison 10 Any method plus specific instruction or support provided versus any method with no specific instruction provided, Outcome 1 Transfer to feeding at breast.
10.2
10.2. Analysis
Comparison 10 Any method plus specific instruction or support provided versus any method with no specific instruction provided, Outcome 2 Quantity of milk expressed.
10.3
10.3. Analysis
Comparison 10 Any method plus specific instruction or support provided versus any method with no specific instruction provided, Outcome 3 Nutritents in milk.
10.4
10.4. Analysis
Comparison 10 Any method plus specific instruction or support provided versus any method with no specific instruction provided, Outcome 4 Time taken to express.
11.1
11.1. Analysis
Comparison 11 Any method plus breast massage versus no breast massage, Outcome 1 Quantity of milk expressed (mL from two expressions).
11.2
11.2. Analysis
Comparison 11 Any method plus breast massage versus no breast massage, Outcome 2 Nutrients in milk.
12.1
12.1. Analysis
Comparison 12 Any method plus warming the breast versus not warming the breast, Outcome 1 Quanity of milk expressed (mL).
13.1
13.1. Analysis
Comparison 13 Any vacuum protocol versus vacuum protocol, Outcome 1 Quantity of milk expressed (EXP‐EXP vs EXP‐STD).
13.2
13.2. Analysis
Comparison 13 Any vacuum protocol versus vacuum protocol, Outcome 2 Quantity of milk expressed (EXP‐EXP vs STD‐STD).
13.3
13.3. Analysis
Comparison 13 Any vacuum protocol versus vacuum protocol, Outcome 3 Quantity of milk expressed (EXP‐STD vs STD‐STD).
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD006170.pub4

References

References to studies included in this review

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Hill 1999 {published and unpublished data}
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    1. Chan CS, Stellwagen LM, Vaucher YE, Montminy TD, Kim JH. Hand expression combined with pumping does not change the nutrient content of human milk from mothers of very low birthweight infants. Pediatric Academic Societies' 2010 Annual Meeting; 2010 May 1‐4; Vancouver, Canada. 2010.
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Vasan 2004 {published data only}
    1. Vasan U, Joseph S, Mathews J, Engstrom J, Meier P. Maternal milk volume (MMV) and milk transfer (MT) for low birth weight (LBW: <2500G) infants in Ecuador: comparison of electric breast pump and hand expression. 11th Conference of the International Society for Research in Human Milk and Lactation (ISRHML); 2004. 2004.
Yiğit 2012 {published data only}
    1. Yiğit F, Cigdem Z, Temizsoy E, Cingi ME, Korel O, Yildirim E, et al. Does warming the breasts affect the amount of breastmilk production?. Breastfeeding Medicine 2012;7(6):487‐8. - PubMed
Zinaman 1992 {published and unpublished data}
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References to studies excluded from this review

Alekseev 1998 {published data only (unpublished sought but not used)}
    1. Alekseev NP, Ilyin VI, Yaroslavski VK, Gaidukov SN, Tikhonova TK, Specivcev YA, et al. Compression stimuli increase the efficacy of breast pump function. European Journal of Obstetrics & Gynecology and Reproductive Biology 1998;7:131‐9. - PubMed
Batista 2014 {published data only}
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Chapman 2001 {published data only}
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Fewtrell 2006 {published data only}
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Flores‐Huerta 1995 {published data only}
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Forster 2011 {published data only}
    1. Forster DA, McEgan K, Ford R, Moorhead A, Opie G, Walker S, et al. Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial. Midwifery 2011;27(2):209‐14. - PubMed
Fujimoto 2006 {published and unpublished data}
    1. Fujimoto S, Yokoo K, Nakagomi S, Murakami M. Mothers' experiences of expressing breast milk for neonates in the NICU ‐ difference between hand and electric breast pump expression. Journal of Health Sciences, Hiroshima University 2006;6(1):65‐70.
Green 1982 {published data only}
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Junior 2008 {published data only}
    1. Junior WS, Martinez FE. Effect of intervention on the rates of breastfeeding of very low birth weight newborns. Neonatal Intensive Care 2008;21(2):37‐41.
Kent 2003 {published data only (unpublished sought but not used)}
    1. Kent JC, Ramsey DT, Doherty D, Larsson M, Hartmann PE. Responses of breasts to different stimulation patterns of an electric pump. Journal of Human Lactation 2003;19(2):179‐86. - PubMed
Kent 2008 {published and unpublished data}
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Kimani‐Murage 2013 {published data only}
    1. Kimani‐Murage EW, Kyobutungi C, Ezeh AC, Wekesah F, Wanjohi M, Muriuki P, et al. Effectiveness of personalised, home‐based nutritional counselling on infant feeding practices, morbidity and nutritional outcomes among infants in Nairobi slums: study protocol for a cluster randomised controlled trial. Trials [Electronic Resource] 2013;14:445. - PMC - PubMed
Lang 1994 {published data only (unpublished sought but not used)}
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Lewis 2005 {unpublished data only}
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Mennella 2010a {published data only}
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Mennella 2010b {published data only}
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Morton 2009 {published data only (unpublished sought but not used)}
    1. Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology 2009;29:757‐64. - PubMed
    1. Morton J, Wong RJ, Hall JY, Pang WW, Lai C, Hartmann P, et al. Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. Journal of Perinatology 2012;32:791‐6. - PubMed
NCT00393640 {published and unpublished data}
    1. NCT00393640. Early and regular breast milk expression to help establish lactation after delivery: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT00393640 Date first received: 27 October 2006.
NCT01802047 {published data only}
    1. Dollberg S. Milk volume production in mothers of preterm infants: electric pumping modalities. clinicaltrials.gov/ct2/show/NCT01802047 Date first received: 19 February 2013.
Ohyama 2010 {published data only}
    1. Ohyama M, Watabe H, Hayasaka Y. Manual expression and electric breast pumping in the first 48 h after delivery. Pediatrics International: Official Journal of the Japan Pediatric Society 2010; Vol. 52, issue 1:39‐43. - PubMed
    1. Ohyama M, Watabe H, Hayasaka Y. Which is more effective, manual‐ or electric‐expression in the first 48 hours after delivery in a setting of mother‐infant separation? Preliminary report. Breastfeeding Medicine 2007;2(3):179.
Pepino 2008 {published data only}
    1. Pepino MY, Mennella JA. Effects of breast pumping on the pharmacokinetics and pharmacodynamics of ethanol during lactation. Clinical Pharmacology and Therapeutics 2008;84(6):710‐4. - PMC - PubMed
Pound 2015 {published data only}
    1. Pound CM, Moreau K, Rohde K, Barrowman N, Aglipay M, Farion KJ, et al. Lactation support and breastfeeding duration in jaundiced infants: a randomized controlled trial. Plos One 2015;10(3):e0119624. - PMC - PubMed
Slusher 2012 {published data only}
    1. Slusher TM, Slusher IL, Keating EM, Curtis BA, Smith EA, Orodriyo E, et al. Comparison of maternal milk (breastmilk) expression methods in an African nursery. Breastfeeding Medicine 2012;7(2):107‐11. - PubMed
Thompson 1997 {published data only}
    1. Thompson N, Pickler RH, Munro C, Shotwell J. Contamination in expressed breast milk following breast cleansing. Journal of Human Lactation 1997;13(2):127‐30. - PubMed
Waller 1946 {published data only}
    1. Waller H. The early failure of breast feeding. Archives of Disease in Childhood 1946;21:1‐12. - PubMed
Williams 1985 {published data only}
    1. Williams AF, Akinkugbe FM, Baum JD. A comparison of two methods of milk sampling for calculating the fat intake of breast‐fed babies. Human Nutrition. Clinical Nutrition 1985;39:193‐202. - PubMed
Yoshidome 2014 {published data only}
    1. Yoshidome A, Hayashi I. Comparison of triglyceride and calcium levels before and after lactation and breast massage. International Confederation of Midwives 30th Triennial Congress. Midwives: Improving Women’s Health; 2014 June 1‐4; Prague, Czech Republic. 2014:P174.
Zhen 1990 {published and unpublished data}
    1. Zhen H, Qian A. Breast massage to promote milk secretion for pregnant and parturient women. Chinese Journal of Nursing 1990;25(9):454‐5. - PubMed

References to studies awaiting assessment

Raguindin 2015 {published data only (unpublished sought but not used)}
    1. ACTRN12614000218695. Kangaroo mother care and its lactogenic effects. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365839&isReview... Date first received: 28 February 2014.
    1. Raguindin PF, Uy ME, Dumalag JA. Prolactin level and breast milk volume among mothers of low birth weight infants admitted to Level II neonatal intensive care unit who underwent kangaroo mother care. Breastfeeding Medicine 2015;10(Suppl 1):S‐4.
Yu 2014 {unpublished data only}
    1. Yu R. Philips AVENT Relaxation Study. http://www.healthcare.philips.com/pwc_hc/main/shared/Assets/Documents/av... (accessed May 12 2014).

References to ongoing studies

Fewtrell NCT02128295 {published data only}
    1. NCT02128295. Trial of two electric breast pumps in mothers of term infants. clinicaltrials.gov/ct2/show/NCT02128295 Date first received: 29 April 2014.
Parker NCT01892085 {published data only}
    1. NCT01892085. Early initiation of milk expression in mothers of very low birth weight infants. clinicaltrials.gov/ct2/show/NCT01892085 Date first received: June 28 2013.
Sahler NCT01893047 {published data only}
    1. NCT01893047. Effect of quiet or listening to music while breastfeeding on the production and lipid and sodium content of the milk. clinicaltrials.gov/ct2/show/NCT01893047 Date first received: June 20 2013.
Sisk NCT01167517 {published data only}
    1. NCT01167517. Lactation education study in mothers of very low birth weight infants. clinicaltrials.gov/ct2/show/NCT01167517 Date first received: 20 July 2010.

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