Skin‑to‑skin contact, or kangaroo care, helps babies become ready to breastfeed earlier and supports a faster transition to exclusive breastfeeding. While lying skin‑to‑skin, the baby can smell the scent of breast milk and receives optimal support to feed at the breast. During the initial phase (non‑nutritive sucking), the baby experiences the taste of small drops of breast milk, which initiates practice of the suck‑swallow‑breathe coordination. Practice is essential, the more opportunities the baby has to practice, the more smoothly breastfeeding can progress.
Breast milk
Pumping
Pumping is necessary when a baby is unable to receive breast milk directly at the breast due to immature feeding skills. Pumping is also essential when the mother and baby are physically separated, allowing breast milk to be provided, for example, via bottle or feeding tube.
Pumping shortly after birth helps stimulate the onset of milk production. Ideally, this begins within the first hour after birth. If this is not possible, the aim is to start within 3 to 6 hours. The expressed milk can be stored and used for the baby. Regular pumping is important to optimize milk production. It is recommended to pump at least 8 times per day, including during the night. A maximum interval of about 5 hours between pumping sessions is advised. Pumping should continue until the breast feels empty, which usually takes 10 to 20 minutes per breast. More frequent pumping during the first days increases the likelihood of establishing a more robust and longer‑lasting milk supply.
How to manually express milk?
Here is the step‑by‑step approach to manual expression:
1. Make sure hands are clean and that all necessary items are within reach.
2. Prepare the breasts by masssaging them and, if helpful, applying warm compresses.
3. Support the breast with the hand, placing the thumb above the nipple and the index and middle finger below it, about 2.5 to 4 cm from the nipple. The hand forms a 'C' shape.
4. Gently press the fingers inward the chest wall, without sliding the fingers over the skin or moving them apart.
5. Roll the thumb and fingers forward at the same time, creating a gentle compression movement. Avoid pulling on the nipple.
6. This movement empties the milk ducts located behind the nipple. The finger position remains the same throughout.
7. Repeat the rythmical movement, rotating the hand around the areola to ensure that the entire breast is well emptied.
8. When the milk flow begins to decrease, switch to the other breast.
Often, the use of an electric breast pump alongside manual expression is necessary to help establish milk production when the baby cannot be latched at the breast. The use of a breast pump is explained in the section on supportive tools.
Storing expressed breast milk
Fresh breast milk has the highest nutritional value and can be kept at room temperature for up to 4 hours. In the refrigerator, it can be stored for 4 days. In the freezer, storage is possible for 6 to 12 months. Breast milk should be frozen as soon as possible. It is important to follow the practical guidelines provided by the midwife or nurse regarding freezing, transporting, and storing breast milk. Hospital guidelines may differ from those recommended for use at home.
Leftover milk
Leftover breast milk should not be reheated. For this reason, it is advised to store and thaw small portions. Fresh milk should also be warmed in small quantities. Milk should be stored in a well‑sealed container, bottle, or special breast milk storage bags.
Warming expressed breast milk
Breast milk should be warmed gently to preserve its antibodies. Avoid using the microwave. It is best to warm milk under running warm water or au bain‑marie, up to a maximum temperature of 37°C. Milk taken directly from the refrigerator can be warmed using these methods.
Freezing breast milk
If it becomes clear that breast milk will not be used within the next four days, freezing is recommended. Ideally, the milk should be frozen immediately after pumping. This helps build up a supply that can be used when the baby is ready to transition to oral feeding after a period of intravenous nutrition.
Human milk bank
There are two external human milk banks in Belgium. These donor milk banks collect breast milk from healthy mothers who produce more milk than their own baby requires. The donated milk is carefully screened and then heat‑treated (pasteurized) to eliminate bacteria. After processing, the milk is distributed to premature and critically ill babies who are unable to receive sufficient breast milk from their own mother. Every NICU in Belgium is supplied with a stock of donor milk.
Learn more?
Important: Breast milk obtained through unofficial channels is not safe. Such milk is not properly screened, which can pose significant risks to the baby.
Medication and breastfeeding
When medication is used during the breastfeeding period or while expressing breast milk, it is essential that this is carefully discussed with a physician or midwife. Although many medications are considered safe, some can be transferred to the baby through breast milk. The safety of medications can also be checked through reliable sources such as the MediMama and LactRx apps, as well as the e‑lactancia website. It remains important to review any information obtained from these sources with a healthcare professional.
Early Feeding Skills
Early feeding skills is a feeding scale designed to support and assess the feeding abilities of premature babies. The purpose of the EFS method is to help parents and healthcare professionals recognize the baby’s cues and adapt the feeding process to the baby’s individual needs.
One of the most important conditions for supporting the baby with the EFS method is determining whether the baby is ready to feed.
A baby who is ready to feed:
- is sufficiently alert and shows a stimulated rooting reflex*
- holds the body in a flexed position with hands/arms toward the midline
- has stable vital signs (heart rate/oxygen saturation/respiratory rate)
- has adequate energy
Only when these signals are visible the breast can be offered.
* The rooting reflex can be stimulated by gently stroking the baby’s cheek or corner of the mouth with a finger or nipple.
The feeding process can be assessed by asking three key questions:
1. Does the baby stop sucking independently to breathe?
A premature baby is not yet able to breathe between sucking and swallowing. Regular pauses are therefore needed so the baby can breathe. Premature infants often prioritize sucking over breathing, which may lead to alarms or choking. In such cases, temporary interruption of sucking, by briefly removing the baby from the breast or gently releasing the breast, allows the baby to pause and breathe. This technique is also known as pacing.
2. Is the milk flow not too fast?
If milk spills from the baby’s mouth, if coughing occurs, or if multiple consecutive swallows are seen, the milk flow is too rapid. This is common with a strong milk-ejection reflex. When the milk flow becomes too fast, releasing the latch briefly and re‑latching once the flow decreases can help.
3. Does the baby become tired during feeding?
When fatigue sets in, muscle tone decreases, causing the baby’s arms to fall loosely beside the body. Adequate muscle tone is essential for safe drinking, as it supports proper coordination of the upper airways. Muscle tone can be supported and energy loss minimized by positioning the baby on the side with good support of the torso, using a breastfeeding pillow or another supportive aid. The head and torso should always remain aligned.
Supportive tools
- Nipple shield
A nipple shield is a silicone aid shaped like a nipple. It can be used when breastfeeding difficulties arise. Nipple shields come in different sizes depending on the mother’s nipple size. However, before using a nipple shield, it is important to seek support and ensure that the baby is positioned correctly at the breast.
A nipple shield can help improve the positioning of the nipple in the baby’s mouth. It may also be useful when the baby has a weak suck. Phasing out the nipple shield is recommended once the baby drinks comfortably and effectively at the breast.
- Breastfeeding pads
Breast pads absorb excess breast milk, improve hygiene by keeping the nipples dry (when changed regularly), offer comfort, and can be warmed or cooled for pain relief. They are available as disposable or reusable options.
- Breast pumps
A breast pump is a device that creates suction to extract milk from one or both breasts. Both manual and electric pumps exist. To stimulate milk production, a double electric pump is the best choice. Double pumping saves time, stimulates both breasts simultaneously, increases milk production, and ensures efficient milk removal. To pump effectively, it is important to use a correctly sized breast shield. Combining manual expression with double electric pumping provides the best results, especially when initiating breastfeeding. This combination improves milk flow, increases the fat content of the milk, and reduces the risk of engorgement.
An effective pumping routine consists of three steps:
- Begin with manual breast stimulation or brief hand expression to trigger the milk-ejection reflex.
- Pump electrically, preferably with a double pump, to efficiently remove milk and stimulate production.
- Finish with hand expression to fully empty the breast and collect the last, fat-rich milk.
Breast pumps can be rented through health insurance funds or pharmacies.
Tips for breastfeeding challenges
Seek professional support as soon as the following problems arise. Assistance is available from midwives, nurses, or lactation consultants.
Flat or inverted nipples
With flat or inverted nipples, preparatory techniques such as gentle massage and softly drawing out the nipple can help immediately before latching. Correct positioning is essential, ensuring that the baby achieves a deep latch.
Delayed milk-ejection reflex
In mothers of premature babies, the milk-ejection reflex may be delayed. Stress, medical complications, or separation between mother and baby can also contribute. Skin‑to‑skin contact, the use of an (electric) breast pump, hand expression, and frequent feeding can help stimulate the milk-ejection reflex.
Nipple cracks
Nipple cracks are painful lesions that may lead to infection, difficulty feeding, reduced milk supply, and emotional distress. A correct latch usually prevents nipple cracks. Adjusting feeding positions may also help. After feeding, a drop of breast milk can be applied to promote healing, allow it to air dry completely to prevent fungal growth. Cold compresses and safe pain relief, such as paracetamol, can also reduce discomfort.
Engorgement or hard areas
Engorgement occurs when significant milk production is combined with incomplete breast emptying. Cold compresses between feeds can relieve swelling and pain, while warmth before feeding stimulates milk flow and helps clear blocked ducts. A well‑fitting, non‑tight bra can also reduce discomfort. Ibuprofen may offer additional relief.
Mastitis
Mastitis can develop due to several factors. A good breastfeeding technique helps prevent it. Regular feeding or pumping reduces the risk of blocked ducts and inflammation. Signs of infection, such as redness, warmth, pain, fever, or general malaise, require evaluation by a midwife or physician. Antibiotics may be needed.
Low milk supply
When milk production seems insufficient, several strategies can help increase supply. Feeding more frequently (8–12 times per day), ensuring thorough emptying of the breasts, and improving latch quality are important steps. A sleepy baby may benefit from breast compressions or switching sides. Pumping within 30 minutes after feeding can also stimulate production.
Breastfeeding twins
Breastfeeding twins requires preparation and support. Special feeding positions, such as the football hold, make it possible to feed both babies simultaneously. This saves time and helps coordinate feeds. Premature twins may have weaker sucking skills, making it necessary to combine breastfeeding with pumping to stimulate milk production and provide supplemental feeds when required.