Hand expression is a technique in which breastfeeding mothers or care providers use one or two hands to apply gentle pressure to the breast to express milk (Flaherman 2013, KellyMom.com)

Maximize hand expression efficiency by first stimulating the letdown reflex. A “let down” is a reflex that is initiated when the nipple is stimulated, sending a signal up to the brain to release the hormone oxytocin, which then travels through the bloodstream until it reaches the mammary gland. There oxytocin binds to small muscles surrounding the milk-producing cells leading toe milk secretion through the milk ducts towards the nipple.

While nursing, a baby stimulates the let down reflex via a combination of suction and compression of the nipple. A pump stimulates a let down only through suction. Mothers who are hand expressing can stimulate a let down by tapping, gently rolling or pinching or pulling on the nipple (Australian Breastfeeding Association).

Initiating a let down can take a few minutes, because it takes oxytocin about 90 seconds to be released from the brain and travel to the mammary tissue to squeeze the milk-producing cells.  It helps to alternate the ‘nipple tapping and pinching’ with hand expression movements while waiting for milk to start flowing.  (Australian Breastfeeding Association)

Each mother’s breast anatomy is unique, so there is likely a special place on your breast where you should place your fingers to yield the most milk in the shortest amount of time.

One version of hand expression involves the following actions: a mother forms a “C-shape with her ipsilateral hand (on the same side as the breast she wants to express milk from), places her thumb 2–3 cm above her areola and her fingers 2–3 cm below her areola. To initiate expression, the mother presses gently back towards her chest wall, exerting continuous pressure without eliciting any pain. This is key. Hand expression should not hurt, although the fingers and hand might get tired. The thumb and fingers are pressed toward the chest wall, and then brought together and pressed gently forward, so that they push on the ducts beneath the areola.  Ideally, when compressing the breast tissue the fingers should meet together in the place where the baby’s gums would fall while nursing. 

Milk should be expressed as the fingers come together when compressing the breast tissue. Using a cycle of pressing and releasing and rotating her fingers around the areola, a mother can aim to capture all of the ducts until a maximum volume of milk has been expressed (Flaherman 2013). It is not always necessary to rotate the fingers around the areola and many mothers feel their breasts empty without ever moving their fingers from one position. 

According to La Leche League, there are a variety of techniques that can be used to express breastmilk, but the key is that hand expression should not be painful for the mother.

If you have questions about hand expression and would like a live video consultation with our CEO, an international board-certified lactation consultant, please let us know.  

For more information on teaching hand expression to increase early milk production, view Dr. Jane Morton’s videos on the Stanford Medicine Newborn Nursery webpage. You can also view instructional videos on hand expression and breast massage from Maya Bolman, RN, IBCLC here.

For women at risk for delayed lactogenesis II (delayed milk coming in), formula supplementation can be avoided if colostrum is expressed during pregnancy. Consult your physician to learn if you may be at risk for delayed lactogenesis II. (Australian Breastfeeding Association, Forster et al, 2017; Soltani & Scott, 2012; East et al., 2012

Why might a mother want to hand express colostrum antenatally?

  • A mother with diabetes during pregnancy may experience a delay in the onset of lactogenesis II (the increase in milk production in the days following birth), thus her infant may be at increased risk of exposure to artificial formula. A baby born to a mother who has diabetes during pregnancy is at risk of low blood sugar after birth. Providing colostrum to the infant after birth may help stabilize blood sugar levels . Other conditions related to insulin sensitivity (eg. polycystic ovarian syndrome and obesity) also place mothers at greater risk for delayed lactogenesis II.(East et al., 2012)
  • Infants with oral anatomical variations like cleft lip and/or palate or with neurological or cardiac conditions may struggle with breastfeeding after birth(Australian Breastfeeding Association). If these conditions are diagnosed antenatally, the mother can express colostrum to feed her infant after birth. It also gives her practice at expressing before her baby is born (Australian Breastfeeding Association).

In the Diabetes and Antenatal Milk Expressing (DAME) study (2017), pregnant women were taught how to hand express colostrum and encouraged to express twice daily for no more than 10 minutes from 36 weeks until being admitted to hospital to give birth. Exclusive breastmilk feeding was more likely in the first 24 hours of life when expressed colostrum was available (Forster et al, 2017).

It’s a good idea for mothers to discuss their desire to feed their newborn stored colostrum to healthcare providers as part of their birth plan to make sure hospital staff are aware of their plans and prepared to assist.

To prepare for their hospital stay, families should be given clear guidelines for storing and transporting colostrum. In general, mothers should be advised to express colostrum into a clean container such as a medicine cup or syringe. Colostrum can be collected two to three times a day in the same container and stored sealed in the refrigerator between uses. At the end of a collection day, the syringe or container can be placed in a zip-lock bag before storing in the freezer. Expressed colostrum (2-3 containers to begin) should be transported to the hospital in a cooler with ice packs to maintain the temperature. If there is a fridge available (in your room, or centrally located on the ward), keeping colostrum refrigerated is preferred. Frozen colostrum will defrost in the refrigerator, and once fully defrosted it must be used within 24 hours (ABM Clinical Protocol #8: Human Milk Storage). 

75% of mothers in the United States stop breastfeeding before reaching the 6-month recommendation for exclusive breastfeeding (Soltani & Scott, 2012). Although women discontinue breastfeeding for a variety of reasons, some of the most commonly cited barriers to breastfeeding are low  breastfeeding self-efficacy, perception of insufficient milk, and early, in‐hospital formula supplementation (Demirici et al, 2019). Antenatal milk expression has been identified as a potential intervention to address premature breastfeeding cessation as it can increase maternal commitment to and confidence in breastfeeding (Demirici et al, 2019; O’Sullivan et al.; 2019).

“Breastfeeding mothers use a variety of home management strategies when they experience symptoms of engorgement. Maternal engorgement peaks at postpartum day 5. Mothers find it helpful when education on engorgement and techniques of hand expression and massage are provided at this visit. This education provides targeted breastfeeding support and specific skills that empower mothers to self-manage their engorgement symptoms (Witt et al.; 2016).”

For all mothers, early hand expression of colostrum may increase breastmilk production and, in turn, increase their self-efficacy for breastfeeding and the likelihood of breastfeeding success (Australian Breastfeeding Association). 

In the United States, approximately 60% of women participate in the labor force. One third of mothers return to work within 3 months of giving birth and two thirds return within 6 months. Unfortunately, maternal employment is associated with a decrease in breastfeeding duration (Angeletti, 2009; Meek, 2001). Breastfeeding duration drastically decreases when mothers return to work because they often can’t find time or space to express their breastmilk. (Meek, 2001).

Breastfeeding mothers who find it inconvenient to use, clean, and transport a breast pump may prefer to hand express their breastmilk. 

  • Hand expression may also be preferable to mothers who work part-time, don’t have access to electricity, or have limited financial resources to purchase or rent a breast pump (Angeletti, 2009). 
  • Breast pumps are noisy and have many parts that need daily cleaning (La Leche League). 
  • Hand expressing or using hands-on breast pumping techniques can provide more stimulation to the breast and provide more breastmilk to the baby than breastfeeding or pumping alone and can increase milk production (Droplet;  Imagine, a Way to Collect Breast Milk Without a Pump).  

Do you want to ditch the pump and learn how to hand express at work? The LiquidGoldConcept CEO has been hand expressing at work since 6 months postpartum! Would you like more information about hand expression at work tips and tricks? Yes No

The WHO and UNICEF launched the Baby-friendly Hospital Initiative (BFHI) to motivate maternity and newborn healthcare facilities to implement the Ten Steps to Successful Breastfeeding – a package of policies and procedures to ensure each facility supports breastfeeding. Today, there are more than 20,000 Baby-Friendly designated facilities worldwide.

How does teaching hand expression align with the Ten Steps?

  • Step 2: Training all maternity staff to teach and assist mothers with hand expression of breastmilk. 
  • Step 3: discussing the importance and management of breastfeeding with pregnant women and families
  • Step 5: support mothers to initiate and maintain breastfeeding and manage common difficulties
  • Step 6 “do not provide breastfed newborns any food or fluids other than breastmilk, unless medically indicated” (Soltani & Scott, 2012).

The EMPower training designed by the Carolina Global Breastfeeding Institute (CGBI) to assist maternity hospitals achieve Baby-Friendly accreditation lists “teaching hand expression and safe storage of breast milk” as one of four key competencies for hospital staff breastfeeding education. Simulation is a critical part of effective breastfeeding education. The WHO and CGBI recommend using breast and baby models to train staff in hand expression and positioning and attaching an infant at the breast. 

In the 2013 Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, the WHO recommends expansion of the original Ten Steps to encompass the different situations that impact successful breastfeeding in preterm and sick infants and their mothers. These recommendations include training healthcare professionals (OBGYN/pediatric physicians, nurses, and midwives) in lactation and breastfeeding support to promote antenatal breastfeeding education for families and the use of mother’s own expressed breast milk or donor milk (when available) to feed the infant.