• All mothers should be offered information on expressing their colostrum antenatally as part of the antenatal feeding conversation.

• Benefits of antenatal expression should be discussed and, if the mother wishes to do this, then she should be taught how to hand express and provided with equipment to collect her colostrum from 36 weeks onwards.

• Mothers should be made aware of correct storage of any colostrum obtained.

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Abbreviations

To explain, advise and support all women on the appropriateness of antenatal hand expressing of colostrum, including where there are special circumstances meaning antenatal expression would be especially beneficial.

Antenatal colostrum collection should be encouraged for all mothers.

• staff to be able to explain to women why it may be useful/ appropriate to hand express

• staff will be able to teach women the principles of effective hand expressing

• staff to be able to discuss how the woman can safely store her colostrum at home prior to the birth of her baby

• to enable the woman to become familiar with her own breasts

• staff to know how colostrum can be safely stored in hospital until it is needed for the baby

• to identify women where hand expressing antenatally would be especially suitable

• to identify infants for whom this would be especially beneficial

Breast milk is the healthiest option for a baby to receive after birth ^1,2,3,4,5,6.

Antenatal hand expressing of colostrum provides the infant with an additional supply of colostrum to complement the infant’s feeds/needs in the first 24 hours after birth, where this is appropriate and may avoid the need for artificial formula with its potential adverse effects.

It is beneficial for women to know how to hand express their colostrum⁷.

Special circumstances when antenatal expression would be particularly beneficial

Between 28-34 weeks of pregnancy a discussion should be had with all mothers about the benefits of antenatal colostrum collection. The following special circumstances require additional information as to why antenatal colostrum collection would be especially beneficial.

Women with diabetes ^8,9,10,11

Delayed lactogenesis (onset of lactation) is a known phenomenon in diabetic women with poor diabetic control. Delayed lactogenesis, a higher risk of interventional delivery and admission to Neonatal Unit (NNU) are all potential factors leading to a reduced milk supply and long term reduced breastfeeding capacity.

Furthermore, infants born to diabetic mothers are at increased risk of developing hypoglycaemia in the first 24 hours of birth and require early and regular 3 hourly feeding with monitoring of blood glucose levels.

Colostrum given in addition to breastfeeds can help to maintain blood glucose levels, promote ketogenesis and avoid the use of artificial formula.

Infants who receive artificial formula are more likely to develop childhood diabetes.

Antenatal diagnosis of cleft lip or palate¹²

Following detection of an abnormality on ultrasound, the woman should be referred to the Regional Cleft Specialist Nurse.

A feeding plan should be developed in the antenatal period with the Infant Feeding Specialist/Regional Cleft Specialist Nurse.

Infants with a cleft of the lip may, with assistance of positioning and attachment, be able to breastfeed.

An infant with a cleft of the palate is unlikely to be able to feed from the breast, as he/she is not able to create the vacuum needed to feed effectively.

Antenatal diagnosis of an infant with Trisomy 21 (Down’s Syndrome)¹³

Referral to the Infant Feeding Specialist should be considered so that a feeding plan can be developed.

Infants with Trisomy 21 (Down’s Syndrome) may be sleepier and often have a poor sucking reflex. They are prone to respiratory infections and digestive problems; the immune factors present in colostrum and breast milk are especially valuable.

Previous history of poor/ delayed lactogenesis, excessive weight loss of the neonate

Referral to the Infant Feeding Specialist should be offered. The aim will be to discuss the previous concern(s) and to develop a feeding plan with the woman as appropriate.

Maternal obesity

Studies have demonstrated that obese women are less likely to breastfeed. Obese women may also experience delayed lactogenesis leading to a poor milk supply and early cessation of feeding¹⁴.

Multiples

Anecdotal evidence shows that women of multiple pregnancies may worry about their ability to nourish more than one infant. Colostrum harvesting may reassure the mother that milk will be available for her babies.

Midwives should identify and give information at booking to all known women with Type I and Type II diabetes, to discuss the benefits of breastfeeding and colostrum harvesting.

Any woman identified as being of high risk of developing GDM (Gestational Diabetes Mellitus) should be given information on the benefits of breastfeeding and colostrum harvesting at the time of blood glucose monitoring.

By 34 weeks, all women who elect to give birth at Frimley Park Hospital or Wexham Park Hospital should have received individual discussion/information on the benefits and management of breastfeeding. This includes information on hand expressing and colostrum harvesting. This should then be documented on EPIC under the Infant Feeding Conversation AN.

• wash hands, and then gently massage the breast. Avoid sliding fingers over the skin, as this will cause discomfort

  • roll the nipple briefly between thumb and finger

  • cup the breast and feel back from the base of the nipple to where the texture of the breast feels different

  • using thumb and finger, gently squeeze this area – it should not hurt

  • release the pressure and repeat again and again, building up a rhythm. With the right technique the colostrum should start to drip

  • once the flow slows, change the position on the breast to a third of the way round and repeat the gentle squeezing; reposition again for the third part of the breast

  • when the colostrum slows, express from the other breast as above. If the colostrum does not flow, try moving fingers towards the nipple or further away, try gentle breast massage again.

A warm flannel on the breast tissue for a minute might help the colostrum to flow.

Show women the information about the technique for hand expressing using the Department of Health and UNICEF leaflet ‘Off to the best start’. Breastfeeding leaflet (unicef.org.uk)

Teach mothers to hand express using a hands-off approach, using the leaflet and a knitted breast model. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/video/hand-expression/

A mother can express twice daily from 36 weeks of gestation, unless contraindicated.

Colostrum should be stored in a small, sterile, purple/oral syringe and put in a bag with identity labels showing the mother’s name, hospital number, her date of birth, date and time when expressed and when frozen¹⁵. All equipment needed, to be supplied by the hospital. Frozen EBM should be stored at home until the birth of the baby¹⁶. The mother can bring up to 5 labelled syringes of frozen colostrum into hospital when attending in labour / for induction / for elective caesarean. These must be immediately stored in the freezer on the postnatal ward and can be defrosted when needed. EBM will be discarded 48 hours after discharge from hospital.

This information is provided for guidance and will not be monitored.

If there are communication issues (e.g., English as a second language, learning difficulties, blindness/partial sightedness, deafness) staff will act appropriately to ensure the patient (and her partner, if appropriate) understand the actions and rationale behind them.

This guideline has been subject to an Equality Impact Assessment.

1. WHO Evidence for the Ten Steps to Successful Breastfeeding. WHO, Geneva 1998.

2. Williams A. Hypoglycaemia of the Newborn. Review of the literature. WHO, Geneva 1997.

3. Identification and Management of Neonatal Hypoglycaemia in the Full-Term Infant: Framework for Practice. British Association of Perinatal Medicine, 2017.

4. www.babyfriendly.org.uk Guidance on the development of policies and guidelines for the prevention and management of hypoglycaemia of the newborn. BFI; 2007. http://www.babyfriendly.org.uk/pdfs/hypo_policy.pdf

5. Lucas A, Boes S, Bloom SR, Aynsley-Green A. Metabolic and endocrine responses to a milk feed in six-day old infants. Differences between breast and cows formula feeding. Acta Paediatric Scandinavia 1981; 70:195-200.

6. NICE Donor breast milk banks. NICE clinical guideline 93; 2010.

7. Renfrew MJ, Woolridge MW, Ross McGill H. Enabling women to Breastfeed, - A review of practices. London: The Stationery Office.

8. CEMACH Diabetes in Pregnancy; Caring for the baby after birth. CEMACH; 2007 http://www.cmace.org.uk/getattachment/d985a10d-a7d8-4cc2-b6b4-44052d6662af/Diabetes- in-Pregnancy--Caring-for-the-baby-after-b.aspx

9. Clay T. Colostrum harvesting and type I diabetes. Journal of Diabetes Nursing 2005; 9(3):111- 116.

10. Finigan V. The challenges of breastfeeding faced by women with diabetes. Journal of Diabetes Nursing 2006; 10(9):332-337.

11. Karjalainen J, Martin JM, Knip M et al. A bovine peptide as a possible trigger of insulin- dependent diabetes mellitus. New England Journal of Medicine 1992; 327:302-307.

12. Martin V, Bannister P. Cleft Care: a practical guide for health professionals on cleft lip and/or palate. Salisbury, APS publishing; 2004.

13. Spender Q, Stein A, Dennis J et al. An exploration of feeding difficulties in children with Down’s Syndrome. Dev. Med. Child. Neurol 1996 Aug;38(8):861-94.

14. Turcksin R, Bel S, Galjaard s et al. Maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review. Matern Child Nutr 2014 Apr;10(2):166-183.

15. personal communication April 2010.

16. Hands A. Safe storage of expressed breast milk in the home. MIDIRS Midwifery Digest 2003; 13(3):378- 385.

17. Unicef UK Baby Friendly Initiative education refresher sheet 4

Forster DA, Jacobs S, Amir LH, et al. Safety and efficacy of antenatal milk expressing for women with diabetes in pregnancy: protocol for a randomised controlled trial. BMJ Open 2014;4:e006571. doi:10.1136/bmjopen-2014-0065

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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