Effective Initiation

Frequent expression – Effective initiation interventions

Time to read: 3 min.

When the infant is not able to breastfeed, stimulating the mother’s breast by frequent milk expression is an evidence-based intervention that helps the mother initiate and build sufficient milk volumes for the long term.

What is frequent expression?

Expressing at least 8 or more times in 24 hours, inclusive of a nightime expression.

When the infant is not able to breastfeed, the mother needs to stimulate the breast and express milk frequently to initiate, build and maintain milk volumes.1

Why is frequent expression important?

During the first days after birth, frequent breast stimulation through suckling or vacuum2,3 enhances hormone concentrations and supports the closure of the cellular junctions between the lactocytes and the transition into secretory activation by 72 hours (known as milk 'coming in').4,5

During the critical window of the first 14 days, when breast milk is removed frequently (8 or more times in 24 hours), the breast milk-making cells are programmed to initiate, build and establish milk supply, enabling mothers to achieve the required milk volumes for their infant’s long-term needs.4

Pumping regimes must mimic the pattern of a healthy breastfed term born infant and thus pumping sessions need to occur 8-12 times per 24 hours.6

How to implement frequent expression

  • Ensure mothers receive education and assistance to initiate, build and maintain supply:
    • Initiate early within 3 hours of birth and expressing every 3 hours on day of birth1
    • Expressing 8 or more times every 24 hours1,7
    • Expressing at least once during the night between the hours of 00:00-07:00am7
    • Double pumping with the use of correctly sizedbreast shields whilst applying breast massage before, during and after pumping.8,9
  • Provide mothers with pumping logbooks to document pumping frequency and volume.1,3,7,10 Ensure monitoring of pumping records is carried out daily during the first critical 14 days, then twice per week or as required.1
  • Implement cohesive lactation practices within maternity and NICU services to support frequent expression for pump dependent mothers.
  • Provide access to pumps and kits in all maternity and NICU areas to support frequent pumping
  • Provide support to pump-dependent mothers following discharge home11

How to monitor frequent expression

Collect data on frequent expression with a data collection tool

  • Review pumping logbooks and collect daily frequency of pumping data 

  • Carry out monthly audits of the data to measure the average daily frequency of pumping during the first 14 days postpartum

  • Identify hospital practices where mothers may not achieve frequent expression

  • Identify contributing factors such as availability of home-use pumps, time etc that reduce pumping frequency

  • Communicate findings and recommendations regularly to all departments to improve and sustain best practice


1. Spatz DL et al. Pump early, pump often: A continuous quality improvement project. J Perinat Educ. 2015; 24(3):160–170.

2. Lussier MM et al. Daily breastmilk volume in mothers of very low birth weight neonates: a repeated-measures randomized trial of hand expression versus electric breast pump expression. Breastfeed Med. 2015; 10(6):312–317.

3. Meier PP et al. Supporting breastfeeding in the Neonatal Intensive Care Unit: Rush Mother's Milk Club as a case study of evidence-based care. Pediatr Clin North Am. 2013; 60(1):209–226.

4. Neville MC, Morton J. Physiology and endocrine changes underlying human lactogenesis II. J Nutr. 2001; 131(11):3005S-3008S.

5. Hoban R et al. Human Milk Biomarkers of Secretory Activation in Breast Pump-Dependent Mothers of Premature Infants. Breastfeeding Medicine. 2018; 13(5):352–360.

6. Spatz DL. Ten steps for promoting and protecting breastfeeding for vulnerable infants. J Perinat Neonatal Nurs. 2004; 18(4):385–396.

7. UNICEF, WHO. Protecting, promoting and supporting breastfeeding: The baby-friendly hospital initiative for small, sick and preterm newborns. Geneva, New York: WHO; UNICEF; 2020. 42 p.

8. Prime DK et al. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression. Breastfeed Med. 2012; 7(6):442–447.

9. Sakalidis VS et al. Breast shield design impacts milk removal dynamics during pumping: A randomised controlled non-inferiority trial. Acta Obstet Gynecol Scand. 2020; 99(11):1561-1567.

10. Takako H et al. Improving Human Milk and Breastfeeding Rates in a Perinatal Hospital in Japan: A Quality Improvement Project. Breastfeed Med. 2020; 15(8):538–545.

11. Bower K et al. "I Had One Job and That Was To Make Milk". J Hum Lact. 2017; 33(1):188–194.

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