The Significance of Teaching Hand Expression to All Breastfeeding Mothers

By: Julie Murphy, RN, BSN, IBCLC
Specialty Nurse and Pediatric Lactation Consultant at The Johns Hopkins Hospital, Bloomberg Children’s Center
Disclosure: Member of Lansinoh’s Clinical Advisory Network

Over the last year the importance of and impact of healthcare workers has been highlighted repeatedly. Support from healthcare leaders and clinicians can make all the difference in a patient’s outcome. This is especially true when it comes to a mother providing breast milk to her infant. Therefore, it is imperative for healthcare leaders and clinicians to embrace breastfeeding as the biological norm for a human mother and her baby and to provide the necessary and appropriate support as early as possible (1).

The benefits of breastfeeding are well-documented and supported by many leading professional organizations including the Academy of Breastfeeding Medicine, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists. Suboptimal breastfeeding practices are unequivocally associated with a greater risk of infant morbidity and mortality. Optimal infant and young child feeding according to the Academy of Breastfeeding Medicine includes “immediate and continued skin-to-skin contact, early initiation of baby-led breastfeeding (within 1 hour of birth), exclusive breastfeeding for 6 months, and continued breastfeeding for at least 1 and up to 2 years or longer, with age-appropriate complementary feeding.” (2)

Breastfeeding also has a positive impact on the health of the mother. Women who do not receive adequate breastfeeding support are at risk for shorter durations of breastfeeding associated with a higher risk of breast and ovarian cancers, type 2 diabetes, hypertension, and cardiovascular disease (2).

Supporting the breastfeeding mother and her infant should have the attention of all leaders and clinicians due to the substantial and longitudinal impact breastfeeding has on maternal, child, and societal health (2).

Julie Murphy

Julie Murphy, RN, BSN, IBCLC

A mother’s breastfeeding journey is a multifaceted process. From the first moments after birth, mother and baby enter this breastfeeding journey as novice, highly invested learners attempting to find the ideal breastfeeding rhythm. The mother is invested in providing her breast milk for her baby to thrive and her baby is striving for “optimal self-regulation” (3).

Despite a mother’s desire to provide breast milk to her infant, we know one of the most common reasons for discontinuing breastfeeding is the mother’s perceived or actual low milk supply (4). Acting upon this knowledge with crucial support as soon as baby is born can influence breastfeeding success (1). Human milk production is a complex physiological process involving physical, emotional, and hormonal factors (4); the general principle of more frequent and thorough draining of the breasts typically results in an increased rate of milk production (4). Similarly, low milk supply is often related to suboptimal milk removal from the mother’s breasts (4). Suboptimal milk removal may be related to baby learning how to effectively breastfeed, general breastfeeding management, mother or infant illness, or mother-infant separation (4). Whatever the reason may be for perceived or actual low milk supply, as a preventive measure, hand expression should be discussed with every breastfeeding mother in advance of baby’s birth and practiced by the mother as soon as baby is born to signal her breasts to produce milk (1)(3)(5). Hand expression is a low cost, low risk, proactive measure with the potential to produce significant benefits for mother and baby (5). In teaching hand expression, clinicians can empower mothers to signal their breasts to produce colostrum and increase milk volume for baby (3)(6).  Ideally, hand expression should be taught within the first hours after birth (7). During this time, clinicians can reassure the mother that obtaining only a few milliliters of colostrum at each session does not signify a low milk supply (1). This teaching experience builds the mother’s confidence and skills related to hand expression and breastfeeding with knowledge of her own body. (1). The use of new, cost-efficient tools including a hand expression funnel that connects directly to a feeding syringe can also be helpful to improve a mother’s confidence in hand expression and reduce wasted colostrum collected in the early days, as well as improve ease of use for the clinician over traditional collection methods (8).

It can be extremely encouraging for breastfeeding mothers to know that frequent hand expression, especially in the first 3 days after the birth, can have a significant effect on her milk volume – lasting up to 8 weeks postpartum (7). In addition, any drops of colostrum or breast milk the mother expresses can be fed directly to her baby.  This supports her baby’s milk intake to prevent excessive weight loss while also providing time for baby to learn how to breastfeed effectively and reduce a need for formula supplementation (3)(6)(7).

Breastfeeding is the biological norm for a mother and her baby, and human breast milk is the preferred nutrition for the premature infant (1)(9). For the vulnerable NICU baby who is separated from the mother due to illness, prematurity, or other medical reasons, and in situations where direct breastfeeding is impossible or undesired, hand expression can be an important proactive skill to teach for more effective colostrum removal than using pump suction alone (109). Hand expression may be more effective at removing colostrum due to the viscosity (thickness) of colostrum (7). For the pumping mother, as maternal milk volume increases in the days following baby’s birth, a combination of pump suction and breast massage and compressions while pumping (referred to as “hands-on pumping”, HOP) may all be advantageous (9)(10). The benefits may include increased overall milk volume and removing more of the nutrient rich, high fat, and high calorie hind milk than by using pump suction alone (98). This addresses two major limitations in using human breast milk for premature infants: inadequate milk supply and suboptimal nutrients for the infant to achieve optimal growth (9).

Hand expression is a preventive and proactive technique that is simple, low cost, low risk, and has the potential to produce significant benefits for mother, baby, and society (1)(2)(3)(5)(7). As expert leaders and clinicians in maternal healthcare, we should teach every mother who desires to breastfeed and provide any amount of breast milk the technique of hand expression.


  1. Hernández-Aguilar, M. T., Bartick, M., Schreck, P., Harrel, C., & Academy of Breastfeeding Medicine (2018). ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine13(9), 559–574.
  2. Chantry, C. J., Eglash, A., & Labbok, M. (2015). ABM Position on Breastfeeding-Revised 2015. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine10(9), 407–411.
  3. Morton J. (2019). Hands-On or Hands-Off When First Milk Matters Most?. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine14(5), 295–297.
  4. Brodribb W. (2018). ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine13(5), 307–314.
  5. Morton J. (2012). The importance of hands. Journal of human lactation : official journal of International Lactation Consultant Association28(3), 276–277.
  6. Kellams, A., Harrel, C., Omage, S., Gregory, C., & Rosen-Carole, C. (2017). ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine12, 188–198.
  7. Morton, J., Hall, J. Y., & Pessl, M. (2013). Five steps to improve bedside breastfeeding care. Nursing for women’s health17(6), 478–488.
  8. Kristensen-Cabrera, Alexandria & Sherman, Jules & Lee, Henry. (2018). A prospective clinical study of Primo-Lacto: A closed system for colostrum collection. PLOS ONE.13. e0206854. 10.1371/journal.pone.0206854.
  9. Morton, J., Wong, R. J., Hall, J. Y., Pang, W. W., Lai, C. T., Lui, J., Hartmann, P. E., & Rhine, W. D. (2012). Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. Journal of perinatology : official journal of the California Perinatal Association32(10), 791–796.
  10. Morton, 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. Journal of perinatology : official journal of the California Perinatal Association29(11), 757–764.

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