This document provides guidance to BHS staff in facilitating antenatal expression of colostrum. The National Health and Medical Research Council (NHMRC) and the World Health Organisation (WHO) recommend exclusive breastfeeding as the ideal for newborn infants. Colostrum is the optimum source of nutrition for the newborn as it is antibody rich, has high bio-availability, increases gut peristalsis and aids the passage of meconium. Colostrum also aids in the activation of early protective immunological responses in the infant's gut and therefore should ideally be the first food given to infants.

Challenges to exclusive breastfeeding in the early postnatal period include pregnancy complications, maternal diabetes, thyroid disease, hormonal imbalances, unwell infant/mother, feeding difficulties, infant abnormalities and medical conditions such as prematurity and hypoglycaemia. In these situations, some infants may require medically indicated supplementation of breastfeeding in the first few hours and days after birth. Expressed breast-milk (EBM) is the preferred choice for supplementation, but in the absence of enough EBM, antenatally expressed and stored colostrum is the next best choice before infant formula is used.

Antenatal expression of colostrum will:

• allow storage of colostrum which may reduce the use of infant formula in at risk infants.
• assist to increase the mother's awareness of how her breasts function and increase confidence with breastfeeding.
• reduce the need for admission to Special Care Nursery which will
  • avoid mother/infant separation
  • enhance mother/infant bonding
  • facilitate the early establishment of breastfeeding
  • reduce health care costs

Colostrum - is the first milk produced by the breasts from around 16 weeks of pregnancy and during the first few days after birth. It is thicker and more yellow in colour than mature breast-milk, reflecting a higher content of proteins, many of which are immunoglobulins, fat-soluble vitamins and some minerals.

Midwives and doctors working with pregnant women should follow this guideline when teaching women how to express colostrum antenatally.

Concerns are often raised regarding nipple stimulation and its effect on uterine contractions. However, the following points should be noted:

• Women successfully breastfeed whilst pregnant.
• There is no evidence of any significant relationship between nipple stimulation and inducing labour.
• Nipple stimulation has not been shown to augment labour.
• Nipple stimulation at term may assist with cervical ripening (up to 45 mins 3 x day).

Use of stored colostrum in the postnatal period.

When the use of expressed breast-milk is indicated postnatally, the mother should express and use freshly expressed colostrum first, and only use stored colostrum if there is not enough fresh colostrum. This is to ensure the woman's breasts are well stimulated in the first few days after birth. Reliance on stored colostrum without regular breast expression may negatively impact on early milk production.

Indications for the antenatal expression of colostrum may include:

• Maternal indications
  • diabetes( type 1, type 2, gestational) in pregnancy
  • thyroid disease
  • obesity
  • hormonal imbalances
  • breast hypoplasia.
  • hyperandrogenesis (polycystic ovarian disease)
  • history of any breast surgery
  • multiple sclerosis
  • significant poor breastfeeding history
  • history of significantly delayed lactogenesis
  • strong family history of dairy intolerance
  • strong family history of inflammatory bowel disease
  • any other maternal condition which may negatively impact on the establishment of breastfeeding

• Obstetric factors
  • established premature labour where birth is expected to proceed.
  • past history of macrosomic baby
  • past history of more than one infant being admitted to Special Care Nursery
  • elective caesarean birth

• Infant indications
  • intrauterine growth restriction
  • suspected macrosomia >4kg
  • antenatally diagnosed congenital conditions e.g.
    • cleft lip and/or palate
    • Downs syndrome
    • cardiac conditions
  • any other infant condition which may negatively impact on the establishment of breastfeeding

The antenatal expression of colostrum is contraindicated in the following circumstances;

• History of threatened or actual premature labour.
• Current threatened premature labour where the mother is having tocolytic/suppressive treatment.
• Cervical incompetence.
• Cervical suture insitu.
• Placenta praevia.
• Multiple pregnancy - this is a relative contraindication. If the woman is term, or early birth is planned, some antenatal expression may be considered on a case by case basis.

Equipment:

When teaching how to hand express;

• Knitted breast
• Diagram of the breast (optional)

For the storage of colostrum at home;

• 1ml --2.5ml oral syringes
• Zip-lock bags
• Printed Bradma labels

Initiation of expressing;

• Commence expression at 36 weeks gestation.
• Start with 3-5 minutes on each breast, 2-3 times a day.
• The total time expressing when proficient should only be 5-10 mins up to 3 times per day.
• Stop expressing if having uterine contractions associated with expressing.
• Expressing can be commenced after admission to hospital: e.g. induction of labour, established preterm labour which is expected to proceed, unless there are contraindications as above.

Patient Education - How to hand express and store colostrum.

1. Provide the woman with the pamphlet "The Antenatal Expression of Colostrum" included in the pre-prepared antenatal expression kit in Maternity Outpatients and the Maternity Ward.
2. Wash and dry hands before beginning.
3. Remove the syringe from its packet. Keep the packet to store the syringe in afterwards. Write the mothers name and date of birth and the date of expressing on the back of the packet or use a Bradma label.
4. Ensure mother is sitting comfortably and upright. Ensure privacy.
5. Apply warmth to breast.
6. Gently stroke the breast towards the nipple to stimulate the let-down reflex. Include stroking the areola.
7. Place the finger and thumb about 2-3 cm behind the nipple, on either side of the areola.
8. Gently press the finger and thumb pads back towards the chest wall, then gently squeeze them together through the breast tissue, and then release the pressure.
9. Fingers should be well back from the nipple. Don't squeeze or pinch the nipple.
10. Repeat the action in a rhythm similar to a baby's sucking.
11. When colostrum drips/flows easily start collecting in the syringe.
12. When colostrum flow slows, rotate the position of the fingers and thumb around the areola and repeat the expressing action.
13. Swap to the other breast when flow slows right down or stops.
14. Use both breasts at least twice each session.
15. When finished expressing, place the syringe back into its bag and place into the fridge.
16. Colostrum can be collected 2-3 times on the same day and stored in the same syringe.
17. Start with a new syringe each day.
18. At the end of the collecting day place the syringe into a zip lock bag and place into the freezer. Ensure labeled with mothers name and date of birth..
19. The frozen colostrum can be stored for 3 months in the freezer or 6-12 months in a deep freezer.
20. Instruct the mother to bring frozen colostrum in to hospital when she is admitted for the birth of her baby and hand to staff as soon as she is admitted for storage.
21. Store labeled colostrum in Postnatal Milk Room freezer (or Special Care Nursery Milk Room freezer if SCN admission is anticipated), and communicate this to other relevant staff.
22. If a syringe is difficult to manage , the colostrum can be collected into a clean small receptacle like a medicine cup and drawn into a syringe after expressing.