How would you react to finding bottles of breastmilk in your office fridge? Or to the sight of a woman using a breast pump in a public place?

It is now generally accepted that breastfeeding, where and when possible, is the best option for mother and baby. For babies, it lowers the risk of cot death, and reduces the incidence of a wide range of major and minor ailments, from asthma and eczema to diabetes and glue ear. It aids the development of brain, nervous system and eyesight. For mothers, simply the act of continuing to produce breastmilk for the months after the birth reduces the risk to her of breast cancer, ovarian cancer and osteoporosis.

The popularity of breastfeeding waned in the middle of the 20th century: at a time of increasing attempts to standardise childbirth, bottle-feeding was promoted by health professionals, as it was possible to measure how much the baby received, and the quality of the baby’s food. Now breastfeeding is promoted again, in part at least for the reasons listed above. Public services such as shopping malls and cafes are encouraged to accept breastfeeding mothers and to provide facilities where possible. People are becoming more tolerant of a woman breastfeeding a child in public.

But there is one aspect of breastfeeding which is still shunned, misunderstood or even treated with revulsion - expressing.

Expressing is when the milk is removed from the breast by another process, to be fed to the baby then, or at a later time. The milk in such situations is often referred to as EBM - Expressed Breast Milk.

There are a number of reasons why a mother may choose to - or be obliged to - express breastmilk. These are some of the most common:

The baby

• A premature baby may not yet developed the sucking reflex or stamina required for breastfeeding. In these situations the EBM may be given to the baby by gastrointestinal tube, or orally by bottle, syringe or cup (bottles are avoided where it is hoped the baby will start natural breastfeeding at a later stage - as the change from teat to nipple may confuse the child)
• A baby who has been forced onto the breast in the early days may refuse to breastfeed for some time
• The baby may have a birth condition such as a cleft palate
• The baby has any condition which requires him to be hospitalised away from his mother

The mother

• The mother may be spending time away from the baby, whether just for an evening out, or to return to work
• The mother may simply be taking a much-needed rest. This can have the added benefit of giving the father a chance to feed the baby - a lovely bonding opportunity
• The mother may be producing more milk than the baby needs, leading to painful swollen breasts - a condition known as engorgement - which can in turn lead to infection. Expressing is the only guaranteed way to remedy this without drying up the milk entirely¹
• The mother may have flat or inverted nipples, making it difficult for the baby to ‘latch on’. Some babies will be able to cope with this, and after a little determined feeding, to bring the nipple out. However, for babies without the stamina to do this, the act of expressing may cause these nipples to reshape themselves, allowing natural breastfeeding to begin at a later stage.
• The mother may be beginning a course of medication which would not allow her to continue breastfeeding, as the medication could be passed to the baby through the milk
• The mother may be weaning the baby, and is using breastmilk as an ingredient in cooking first foods.

How it's done

Breastmilk is expressed manually or using a pump. There are many tips and techniques relating to expressing, but basically, manual expression involves massaging the breast to stimulate milk production and then using the fingers on the aureola surrounding the nipple to squeeze out the milk and stimulate further production. Manual expression can be convenient, in that it requires no equipment other than a clean container to catch the EBM. However, many women find it to be slow and messy. The nipple contains not one, but many duct outlets, these can spray milk in all directions, meaning that as much milk drips up the woman’s wrist or squirts in her eye as goes in the bowl!

Breast pumps come in all shapes and sizes. They work by applying a vacuum to a funnel placed over the breast to squeeze the aureola and surrounding flesh. Hand-held, electronic and battery-operated pumps are not expensive and can easily purchased in large branches or pharmacists and even supermarkets.

Electric and battery-operated pumps may seem like the easy option, but they can be very noisy and it can be hard to regulate the pressure. Hand-held pumps are quiet and surprising efficient, but excessive use can lead to repetitive strain injury. Larger breast pumps, including the robust models used in hospitals, allow both breasts to be expressed at the same time. These are expensive, but can be hired for home use.

EBM can be fed immediately to the child, while still at body temperature. It can be stored in the coldest part of the fridge (usually the back of the bottom shelf) for up to 72 hours. EBM can also be frozen, and kept in the freezer for around three months.² It should always be gently warmed to body temperature before being given to the baby,³ and warmed milk cannot be refrozen.

Some women find it very easy to express milk; others find it difficult or even impossible. No woman expresses milk for fun, and in most cases a woman does not wish to feed her baby EBM, but is doing so because it is the only practical route open to her if she wishes her baby - and herself - to receive the benefits of breastfeeding. For a woman in this situation, it is impossible to exaggerate how much difference can be made by the support and understanding of those around her.

Attitudes to Expressing and EBM

People who are supportive of a breastfeeding woman can react negatively to expressing. Even other breastfeeding mothers may recoil. Why? What is it that makes breastfeeding in public acceptable, but almost no-one would express while sitting at a cafe table? These are some of the reactions received to expressing:

Breastfeeding is a natural process, but expressing is unnatural

Feeding a baby EBM is far more natural than feeding baby formula through a bottle, but bottle-feeding is thoroughly socially acceptable. Expressing is a natural answer to the situations encountered by a breastfeeding mother, and has been used by women throughout history ⁴ - how is that unnatural?

Why can't you wait till you're in your own home?
As the body produces breastmilk on a demand and supply basis, milk will be produced automatically following the last time the baby fed. If the milk is not removed, the mother risks inflammation and possibly infection, and if the milk is not removed regularly, the body can take this as a sign that the milk is no longer needed, drying up the woman's breastmilk entirely

If youre back at work, shouldn't you be giving up breastfeeding anyway?

The UK Department of Health recommends that babies are exclusively breastfed for the first four months of life. The World Health Organisation extends this to six months; yet the UK statutory paid maternity leave is only eighteen weeks, between one and eleven weeks of which must be taken before the birth of the child. This means that if a mother is to follow recommendations on what is best for her baby, and keep her job and income, expressing is probably the only option.

All that breast massage and gadgetry must be kinky

Breasts may be secondary sexual organs, but their primary and original purpose is feeding babies. If you find this hard to cope with, that’s your problem, not the mother’s. Expressing breastmilk, whether it involves massaging the breast by hand, or hooking up to a gadget, is not sexually stimulating. Any pleasure or satisfaction derived from it is the fundamental satisfaction of being able to do the best for your baby.

Breast milk is gross - I don’t want to even see it, and you’re not putting bodily fluids in my fridge

Breastmilk just looks like full cream milk - there’s nothing weird about it. As for storing bodily fluids: Forget Howard Hughes ⁵: breastmilk may be a bodily fluid, but so is cows' milk, found in most fridges. Expressing mothers are scrupulous about hygiene - you can be assured that the breast milk is probably far more hygienically produced than other products in the fridge!

Please take a supportive attitude to expressing - the constructive attitudes of a few enlightened people could begin to change the attitudes of others, and make a world of difference to mothers everywhere.

Related links

• The Baby Friendly Initiative
  
  is a global programme of UNICEF and the World Health Organisation. It works with health services to ensure that parents are enabled and supported to make informed choices about how they feed and care for their babies.
• The National Childbirth Trust
  offers support in pregnancy, childbirth and early parenthood and runs a breastfeeding support service in the UK with breastfeeding counsellors and a free helpline available to all.
• La Leche League is an international organisation with the sole purpose of helping breastfeeding mothers

Equipment for expressing and storing breastmilk can be supplied by:

• Avent
• Ameda