When lactation (mature milk) is established: signs and stages

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Mature lactation is one of the stages of natural feeding. The longest period when the production of mother's milk occurs in consistently equal portions exactly in the volume that the child needs. Lactation begins on average 3 months after birth and lasts until the end of feeding.

What is mature lactation

The formation of lactation is a complex process, the final result of which is the adjustment of milk production by the mammary gland to the needs of the child. During mature lactation, milk does not flow in rushes, but is produced stably in equal quantities without interruptions.

Therefore, mothers often confuse mature lactation with lactation crises or think that the milk has disappeared, since they no longer feel bright milk flows. The breasts become soft and do not fill out as before.

Stages of lactation formation

The milk production process has several stages. It begins during pregnancy and ends with the involution stage. Only 1.5–3 months after the birth of the child does mature lactation begin. Moreover, in primiparous women this process takes longer than in women who have given birth.

Preparatory stage

This stage of preparing the mother's breast for feeding begins during the period of gestation before birth. A number of hormones are involved in this process, each of which performs its own function.

Changes in the mammary gland occur under the influence of estrogen, prolactin and progesterone. Hormones provoke the growth of milk ducts and their branching. Thanks to the influence of prolactin, the lobes and alveoli of the gland develop. Lactocytes (milk-producing cells) increase. Colostrum appears around the 28th week of pregnancy. Milk production begins immediately after birth.

During this period, a woman may notice external changes in her breasts. It may increase in size and the nipple areola may darken. The nipple itself becomes more elastic, sometimes more sensitive.

The formation of the lactation process

The process of establishing lactation begins after the birth of the child. Strong hormonal changes provoke the onset of milk production. The process of separation of the placenta takes place, and the baby is placed on the breast. This is accompanied by a significant decrease in progesterone levels and the release of oxytocin. Early breastfeeding promotes uterine contraction and colostrum production. This is important for the speedy recovery of the female body and the establishment of the lactation process.

After 2–3 days, colostrum is replaced by transitional milk, its amount is several times greater. The woman notes the fullness of her breasts, sometimes density and heaviness. In some cases, fever and redness may occur.

At this time, the process of breastfeeding is controlled by the endocrine system. Therefore, milk production occurs even if the mother does not breastfeed. At this stage, it is important to put your newborn to the breast frequently. This promotes the formation of a large number of receptors for the hormone prolactin. They affect the production of sufficient milk volume. The number of receptors remains constant throughout all stages of lactation.

2–3 weeks after birth, the final transition to mature milk is observed. The amount of prolactin decreases. This occurs as the process of establishing lactation completes. Milk production is no longer carried out under the influence of hormones, but under autocrine control. This means that the volume of milk produced depends on the amount of milk the baby drinks.

Mature lactation

This period lasts from 3 months after birth until the end of lactation. Milk production is completely under autocrine control. Milk is produced as much as the baby needs. The amount of prolactin stops at a level almost equivalent to what it was before pregnancy. An increase in prolactin occurs at night and as a result of more active sucking movements of the child. A sufficient level of prolactin receptors allows you to regulate the amount of mature milk produced in accordance with the child’s increased needs for it.

This property is especially important during lactation crises. They appear as a result of an increase in the need for milk in a growing baby. At this time, it is important to give the baby the opportunity to breastfeed for as long as he sees fit. This way it signals the breasts to produce more milk. After 3–7 days, the body adapts to the increased needs of the baby and milk becomes sufficient.

Involution

A physiologically justified cessation of natural feeding is called involution. Milk continues to be produced even after the baby stops breastfeeding. According to WHO, the period of involution in the female body lasts for 40 days. At this time, it is possible to restore breastfeeding if the baby is often put to the breast.

Involution begins as the number of breastfeedings decreases or as a result of a complete cessation of feeding. In the case of the natural course of lactation, the process of involution begins after the child reaches 2.5 years.

The main signs of involution are:

The chest stops filling.
Prolactin levels decrease, and milk-producing cells are destroyed.
The milk becomes similar in appearance to colostrum. It has a translucent appearance and a more liquid consistency.
The glandular tissue of the breast is replaced by fatty tissue.
Closing of the gland ducts is observed, the breast returns to its pre-pregnancy size.

Even if the break between feedings is a day, no noticeable breast enlargement is observed. During this period, stopping the baby's feeding is painless for the mother's body. There is no excess milk or breast fullness in the absence of feeding.

Stages of lactation

How your body prepares for breastfeeding:

During the first trimester, breast tissue begins to multiply to support milk production. When this happens, you may notice that your breasts become tender.
As the second trimester of pregnancy begins, your breasts begin to develop milk ducts and glands that allow you to produce colostrum. You may experience milk leakage from time to time, but don't worry. This is another sign that your body is making the right changes to prepare for feeding your baby!
The birth of a baby causes the first hormonal changes necessary to prepare for the first feeding. The pituitary gland in your brain produces the hormone prolactin, which stimulates the mammary glands in your breasts.
When your baby begins to breastfeed, sucking movements cause your brain to release oxytocin. This hormone stimulates milk production.

Breast milk production consists of several stages

Colostrum
Colostrum, also called “first milk,” has more benefits than most people think. The first drops of colostrum after birth will strengthen the baby's immune system. Each feeding over the next 3-5 days will be rich in proteins, vitamins, prebiotics, immunoglobulins and fatty acids, especially suitable for your newborn. Colostrum is yellowish or cream-colored and thicker than transition milk.

Transition milk

Colostrum turns into “transition milk”, which lasts for about 2 weeks. The levels and types of fats, carbohydrates and proteins adjust to meet your baby's growing nutritional needs. During this time, the levels of vitamins and minerals, enzymes, and protective antibodies in transition milk also change.

Mature milk

From about the time your baby is 4 weeks old, your breast milk will be fully mature and generally won't change much from then on. It has a higher water content for hydration, but with the right balance of proteins, fats and carbohydrates needed for your baby's growth. Breast milk changes over the course of a feeding, so that the first milk, called foremilk, becomes thinner, and the milk produced at the end of the feeding, called hind milk, contains more fat.

Breastfeeding schedule

Each mother and baby have their own breastfeeding relationship, which matures with each feeding. Here's a typical timeline of what you two might experience.

Week 1: Frequent feedings

Your breasts will produce colostrum for 3-5 days after giving birth. After 3-5 days of breastfeeding, transitional milk is formed. This marks the transition from first milk to mature breast milk. As your milk matures, your breasts may become very full and tender. Continuing to breastfeed every 2 to 3 hours for at least eight feedings a day will help maintain good nutrition. Try not to skip feedings or wait too long between feedings. Frequent feedings are important because they help your body adjust its milk production and sync up with your baby's needs.

If you have trouble getting your baby to breastfeed or have questions about your milk supply, contact a lactation consultant or ask your obstetrician for help determining your milk supply. Your child's pediatrician may also have resources that can help you.

Week 2: Introducing to Breastfeeding

You will feel more comfortable because your baby will latch onto your breast better, your position will be more comfortable, and your milk supply will increase. This will happen around the time of your baby's first growth spurt, so be prepared for increased feeding needs.

Week 6: You're recovering

By the sixth week, you will feel physically stronger and have a reasonable recovery from childbirth. Feeding only breast milk for the first six weeks allows your body to produce the right amount of breast milk at each feeding. You will begin to feel less breast fullness and tenderness between feedings.

Week 12: Breastfeeding becomes second nature

At this point, you are a breastfeeding pro, but don't worry when your baby starts demanding more frequent or longer feedings. Your baby's periodic growth spurts will cause an increased appetite and your body will respond by producing the amount of milk your baby needs.

How to determine the maturity of lactation

You can understand that lactation has been established by the following signs:

The breasts become softer, it seems that they have lost their elasticity. The heaviness in the chest disappears.
When feeding a baby, milk comes in response to sucking movements; it does not accumulate in reserve in the chest, as before.

Typically, mature lactation is fully established by the age of three months. It is often at this time that a nursing mother experiences some difficulties when feeding. The baby may begin to refuse the breast, spit it out and become capricious while eating. This is due to the fact that it takes a little more effort for the baby to get mature milk. Therefore, accustomed to the flow of milk, which flows out with pressure, the child is capricious due to the need to suck out food.

Also during this period, the baby begins to intensively pay attention to the objects around him. Therefore, the baby can often be distracted by what is happening, ignoring his mother’s breast. This is not due to a lack of milk or lack of milk, but is a period of natural development of children's curiosity.

The process of lactation in a woman is not a simple matter. Preparation for it begins during pregnancy, goes through several stages, requires the participation of many hormones and depends on many factors. Let's try to figure out how lactation and breastfeeding happen step by step.

Already during pregnancy, a woman’s body begins to undergo changes that will ensure milk production after the birth of the child. Right now, thanks to hormonal changes, the formation of milk ducts and special alveoli cells that produce milk occurs in the mammary gland. Due to the changes that occur, the breast may increase in size, and the area around the nipple - the areola - may become darker. The nipple itself becomes more elastic, and sometimes its sensitivity to touch or pressure from clothing increases. Beginning in the second half of pregnancy, some women may experience fluid discharge from the breasts. This is normal and should not worry you. Only in some cases, if the discharge is very heavy, breast pads may be required to protect the underwear. What should a woman do to prepare for breastfeeding? You don’t need anything special, now nature itself does everything for you. Even if you have a flat nipple, you should know that the baby will suck on the areola area, and in this case it is only important to pay special attention to the correct attachment to the breast. With the exception of very rare cases, when there are physiological characteristics of the breast that may complicate the process of breastfeeding, special measures for hardening or training the breast are not required. Moreover, in late pregnancy, nipple irritation can cause uterine contractions and lead to premature birth. It is much more useful for an expectant mother to learn more about breastfeeding itself, perhaps talk to nursing mothers, read, or listen to special lectures.

Immediately after the birth of a child, the body experiences a strong hormonal “explosion”, which is a signal to start the process of milk formation. In the first days, this special milk is colostrum, a thicker liquid, yellowish or even orange in color. Colostrum, although it is released in small quantities, is very beneficial for a newborn baby. Its composition is characterized by a high protein content and a low fat level. Colostrum also contains a significantly higher content of the entire complex of natural antioxidants - vitamins A, E, beta-carotene, zinc, selenium, and many growth factors that stimulate development. The purpose of such nutrition is to help the baby adapt to new living conditions, to give him good immune protection, in particular, the immunoglobulins, lactoferrin, etc. contained in colostrum. At the same time, it contains little liquid so as not to overload the newborn’s kidneys. Colostrum also reduces the manifestation of physiological jaundice and has laxative properties, helping the child get rid of meconium - the original stool. What is important during the period of colostrum feeding, which lasts about 3 days? The main thing is to understand how valuable these first drops of colostrum are for a newborn. It is advisable that the baby be put to the breast 15-60 minutes after birth. It is important not to limit the duration of sucking, since it is breast stimulation that promotes the production of hormones responsible for the sufficiency of lactation. A newborn baby can suck chaotically, without a clear routine, and take pauses in sucking to rest. Do not be alarmed that your child does not have enough food - the nutritional value of colostrum is very high and he himself is not yet able to cope with large volumes. The weight loss of a newborn, which occurs in the first days and can amount to up to 10% of birth weight, is called physiological and is not an indication for the introduction of formula feeding or supplementary glucose supplementation. When foreign fluids are introduced, the baby does not receive many invaluable substances necessary for his health and development. What difficulties may arise in breastfeeding? Some women find it difficult to put their baby to the breast. Moreover, this is often even related to the shape of the breast or nipple itself; the whole point is simply a lack of breastfeeding skill. You should look in advance and learn how to breastfeed your baby. Or ask for help from experienced women - medical staff in the maternity hospital, lactation consultants, or any women who have successfully breastfed their children. If pain occurs when sucking, or even injuries appear (abrasions, cracks, blisters), this is a sign that the baby is not latching properly. In this case, it helps to keep the breasts in the open air as much as possible, using healing agents (it is better to select them individually in each specific case). And the most important thing is to correct the application. With proper latching, the nipple is located deep in the baby’s mouth, the areola is grasped approximately 2-3 cm, and there is no pain.

From the moment of high tide, when colostrum is replaced by transitional milk , the period of exclusive breastfeeding begins. Usually a hot flash occurs 2-4 days after the birth of a child, sometimes later, on 5-7 days. A lot of milk comes in at once, the breasts become full, heavy, dense. There may be redness or even fever. Usually, the overcrowding goes away within a day or two, and then less milk is produced, as much as the baby needs. Should I pump my breasts during hot flashes? Usually, a woman needs simpler measures: put the baby to the breast correctly as often as possible, let her breastfeed as much as she wants, and slightly limit her drinking. When your baby nurses on demand, it simultaneously stimulates the production of new milk and drains the milk that is already in the breast, preventing overfilling. If the mother pumps additionally at the time of the tide, the breast may decide that this milk has gone to the newborn and will continue to produce it in large quantities.

Transitional milk is produced in the breast before mature milk appears, that is, up to 3 weeks . Sometimes during this period a woman may experience repeated flows of milk. Mature human milk has its own unique properties, making it an ideal and unique nutrition for the baby. One of the main advantages of breast milk is its special composition. It contains all the nutrients necessary for a child’s growing body in sufficient quantities, the correct ratio and in an easily digestible form. For example, breast milk proteins are 80% alpha-lactoalbumin and lactoferrin, which are sources of all essential amino acids and are easily digestible, unlike cow's milk proteins, which contain 80% casein and 20% beta-lactoglobulins, which often cause allergic reactions in children 85% of carbohydrates in human milk are beta-lactose, which is slowly digested and thereby promotes the growth of beneficial microflora, in particular bifidobacteria. Fats in breast milk are represented by an optimal fatty acid composition (contain linoleic, alpha-linolenic, arachidonic and other fatty acids), and are sources of fat-soluble vitamins A, D, E. Human milk fats are easily most fully absorbed due to their form of finely divided particles, and the content of a special enzyme - lipase. The digestibility of iron from human milk is unique - 50%, while only 10% of iron is absorbed from infant formula. Thus, breast milk prevents the development of anemia in the baby. As for biologically active substances, mother’s milk has no competition at all. A huge number of hormones (prolactin, oxytocin, thyroid hormones, corticosteroids, etc.), enzymes (lipase and alpha-amylase), as well as protective ones (lactoferrin, immunoglobulin A, lysozyme, macrophages, antibacterial and antiviral factors, prebiotics, etc.) and growth factors simply cannot be replicated artificially. And finally, breast milk is unique in composition for each woman and each child will have its own unique balance of nutrients, suitable specifically for that child. How can a mother’s diet or health affect the composition of her milk? It is worth noting that, according to research, the content of calcium, zinc, iron, protein, energy and vitamin D in milk does not depend on the nutrition of a nursing mother. But the content of iodine, selenium, vitamin A, vitamin C and B vitamins does depend. In a varied diet, all these substances are supplied in sufficient quantities with food, so additional administration in the form of dosage forms is not required. Therefore, it is simply enough for a nursing mother to eat nutritiously and variedly, without overeating. It is important that a woman receives enough fluid as much as she wants. Only foods with a high degree of allergenicity (for example, fish, eggs, chocolate, citrus fruits, etc.) should be limited (not completely eliminated!) in the diet. If a woman gets sick, then her milk does not become dangerous for the baby. On the contrary, along with milk, the mother transfers antibodies to the baby, thereby helping his immature immune system and protecting him from diseases. Only in special cases with serious illnesses is it recommended to stop breastfeeding. Since medications pass into milk, if drug treatment is necessary, you should ask your doctor to prescribe a drug that is compatible with breastfeeding.

finally established 1-3 months after birth , depending on the individual characteristics of the woman and feeding conditions. When the breasts adapt to milk production, the sensation of hot flashes disappears. Externally, the breasts become soft, as if empty. It may seem to a woman that there is less milk, but the breast produces as much milk as the baby needs. The period of exclusive breastfeeding lasts until the baby is old enough to introduce complementary foods, which is associated with the maturation of enzymes in the gastrointestinal tract and the readiness of the digestive system to absorb other foods. What difficulties associated with breastfeeding may arise at this stage? So-called lactostasis may occur - stagnation of milk in the breast. Signs of lactostasis are: the appearance of a lump in any part of the mammary gland, soreness, redness of the skin, and often an increase in temperature, especially near the sore breast. Since the cause of milk stagnation is always a deterioration in its outflow from the breast, the main measures for the treatment of lactostasis and its prevention should be aimed at improving the outflow. It is important to breastfeed your baby often, not to limit the sucking time, and at the same time to monitor the correct attachment, since this allows the milk to be sucked out more efficiently. You need to be careful with the advice to “break up lumps” or “be sure to strain your breasts,” because breast tissue is very delicate and can be easily injured. You should also be careful when using various folk compresses on the breasts; many of them are intended to treat more serious problems with the breasts, and do not help against stagnation of milk, and may even cause harm. What to do if the baby doesn’t have enough milk? Sometimes women begin to suspect that they have a lack of milk: “I’m not a milk mother,” “The baby hasn’t gained much, there’s probably not enough milk or it’s low-fat,” “He cries a lot and often asks for the breast, apparently, hungry.” Most of these suspicions turn out to be false, since any mother is able to breastfeed her baby, and only in 3% of cases is lactation reduced and the child will need to supplement (and not replace!) nutrition with supplementary feeding. You can determine the sufficiency of nutrition by the number of urinations of the child and weekly weight gain. The daily norm is considered to be 10-12 urinations and a weight gain of 120-500 grams per week. Most often, a decrease in milk production is associated with improper feeding. A woman should know that lactation is ongoing, so there is no point in taking long breaks in feeding, trying to “accumulate” more milk. On the contrary, by frequently offering the baby the breast, the mother provides him with sufficient nutrition and at the same time stimulates milk production. Since milk is heterogeneous in composition and hindmilk contains more fat, it is important not to limit the duration of suckling on one breast, allowing the baby to get enough. And according to WHO recommendations, there is no need to supplement the baby with water or other liquids. With breast milk, he receives enough fluid, and any water reduces the amount of milk the baby sucks and has no nutritional value. By establishing proper breastfeeding, a woman is able to avoid problems with a lack of milk. And for a nursing woman, it is also important to have the support of others to increase confidence in her ability to breastfeed and to be confident in the naturalness of breastfeeding. Therefore, it is useful to communicate with mothers who breastfeed with pleasure and have successful experience.

Around 6 months with the introduction of complementary foods, the period of transitional nutrition begins . It is at this age that the child is ready to learn and assimilate new types of food, except milk. There is a gradual transition to regular food, which includes not only introducing the baby to new types of foods, but also mastering chewing skills and techniques for handling dishes and cutlery. The child’s task is to gradually move from liquid food to a regular family diet. During the transition period, the introduction of food products adapted for age in consistency and composition is required. Therefore, complementary foods should, on the one hand, be denser in consistency than breast milk, and on the other hand, such that the child can swallow it. The need for transitional foods continues until approximately 1 year of age, until the child is mature enough to eat regular home-cooked foods. At the same time, milk does not lose its value and continues to be a complete nutrition for the baby. Breastfed babies may develop a positive response to solid foods more quickly than formula-fed babies because the former are accustomed to the different flavors and smells passed on through breast milk. Should the introduction of complementary foods mean the end of breastfeeding? No, because with milk the child continues to receive many important substances that cannot be obtained from food. In particular, these are growth factors necessary for the development of the baby’s growing body, taurine, which promotes the growth of the neuroretina of the eye and brain, as well as vitamins and microelements. Throughout the second year of life, 448 ml of breast milk provides 29% of energy needs, 43% of protein needs, 36% of calcium needs, 75% of vitamin A needs, 76% of folate needs (folic acid derivatives), 94% of needs in vitamin B12, 60% of the needs for vitamin C. The role of breast milk in protection against diseases due to the immune factors it contains remains important. For example, the content of secretory immunoglobulin A in human milk per year is 1 mg/ml, and at 2 years - 1.1 mg/ml, that is, increases compared to 6 months (0.5 mg/ml). By continuing breastfeeding after a year, the mother helps the baby grow healthy and develop.

The stage of completion of feeding ideally occurs after the child is 2 years old, as his need to attach to the breast decreases, and proceeds smoothly. The amount of milk produced decreases, and at the same time its composition changes. Even if the baby does not breastfeed for 12-24 hours, milk overflow does not occur, and the breast remains soft. Completion of feeding during this period will take place physiologically, naturally and without traumatic consequences for mother and child. How does breastfeeding end naturally? Gradually, the child is put to the breast less and less often, during the day he eats with everyone at the table, sucking remains for falling asleep and for psychological comfort, for example, calming, which also go away over time. By the age of 3-4 years, the baby’s needs to satisfy the sucking reflex fade away and he no longer needs his mother’s breast as an object for sucking. In parallel, the final maturation of the child’s digestive, nervous, immune and other systems occurs. He grows up and is able to eat, be satisfied and absorb regular food from the family table. Having accumulated immunoglobulins obtained from mother's milk, the child receives a supply to protect against harmful factors. And also, by about 3 years, he realizes himself as an individual, strives for independence and is ready for psychological separation from his mother. At the same time, the woman’s lactation decreases and stopping feeding does not lead to problems with the breasts and will not affect her health. For each mother-child pair, the end date for breastfeeding will be different, depending on their personal psychological and physiological readiness. At the completion stage, the baby can be attached to the breast 1-3 times a day, usually these are night feedings. Sometimes he may forget to take a nap before falling asleep, then he may suddenly remember about the breast after a few days of break. As a result, with the natural completion of feeding, a woman may not notice the exact date of termination of feeding, since everything happens very gently and as if by itself.

Note: This article does not claim to be complete and comprehensive and is more of an overview. Its purpose is to provide brief information on lactation and the stages of breastfeeding, as well as answer the most frequently asked questions among nursing mothers. You can learn more about breastfeeding or solve any problems that arise by contacting lactation consultants by phone or online. We will be happy to help you!

Elena Shmakova, lactation consultant, member of the Interregional Public Organization “Association of Breastfeeding Consultants” (AKEB), mother of five children

How to speed up development

The timing of lactation is individual for each organism. There are no recommendations for accelerating its formation, but there are general rules, adhering to which, it is easier to ensure that the process of establishing natural feeding is as comfortable as possible for both mother and child.

Firstly, feeding on demand is the key to providing the baby with a sufficient amount of milk and producing milk in proportion to the infant’s needs. You should avoid supplementary feeding and resort to pumping only if necessary. Secondly, it is necessary to maintain a normal drinking regime. Thirdly, the mother’s good psychological state and the absence of stress will ensure normal lactation and sufficient milk production.

Maintaining effective lactation and organizing breast milk expression

Ryumina Irina Ivanovna
Narogan Marina Viktorovna
Orlovskaya Irina Vladimirovna
Sharipova Kamila Ravshanovna
Zubkov Viktor Vasilievich

Summary
The need for breastfeeding for both full-term and preterm newborns is now obvious. Effective lactation and successful breastfeeding largely depend on the organization of care for mother and child in the hospital and proper counseling of the mother on breastfeeding issues. The introduction of modern organizational technologies to encourage, support and protect breastfeeding, along with the most complex treatment measures, is one of the main tasks of a modern obstetric institution and neonatology hospital. The article discusses the basic principles of organizing expressing breast milk in a hospital, which allows you to feed sick newborns and premature babies with mother's milk from the first days of life, as well as maintain lactation while the mother or child is sick or they are separated.

The main differences between different models of breast pumps - electric and manual, stationary and individual, are presented, and the advantages of the modern Symphony electric stationary breast pump are described, which allows expressing simultaneously from both mammary glands, which effectively stimulates lactation. Creating conditions for effective, safe and comfortable expression of breast milk in a neonatology hospital not only ensures the preservation and efficiency of lactation, but also has a positive effect on the psychological state of the mother, her ability and desire to independently care for the child.

Key words: newborn, pumping, breastfeeding, breast pump

For quotation:

Ryumina I.I., Narogan M.V., Orlovskaya I.V., Sharipova K.R., Zubkov V.V. Maintaining effective lactation and organizing the expression of breast milk // Neonatology: news, opinions, training. 2021. T. 7. No. 4. P. 85-92. doi: 10.24411/2308-2402-2019-14007

The priority of breastfeeding is undeniable for both full-term and premature newborns. The only exceptions are children with some rare congenital diseases, such as the classic variant of galactosemia, congenital lactase deficiency, impaired oxidation of long-chain fatty acids and related disorders, etc. The introduction of modern organizational technologies to encourage, support and protect breastfeeding, along with complex therapeutic measures, is one one of the main tasks of any obstetric institution and neonatology hospital [1-7].

Not all newborns are able to breastfeed. Successful breastfeeding is possible if the baby has a mature sucking reflex and coordination of sucking, swallowing and breathing. Violation of these coordinated functions can lead to apnea, bradycardia, and aspiration. Healthy full-term newborns are able to coordinate sucking, swallowing and breathing well, but in sick children and premature babies born before the 32nd week of pregnancy, the sucking reflex is weak, the coordination of sucking and swallowing is impaired, so they need feeding through a tube [8, 9]. If the child has coordination of sucking and swallowing, but the sucking reflex is weak, then feeding is carried out from the nipple. To preserve and maintain lactation in cases of feeding from a nipple or through a tube, as well as in conditions where the child cannot be in the ward with the mother, it is necessary to create all opportunities to provide the child with breast milk as much as possible [10-13].

Effective lactation and successful breastfeeding largely depend on the organization of care for mother and child in the hospital and proper counseling of the mother on breastfeeding issues. A necessary condition for supporting breastfeeding is the presence of the child and mother together, and if this is not possible, the creation of comfortable conditions for communication between mother and child.

If the baby cannot be put to the breast after birth, the mother should be advised to begin expressing milk within the first 6 hours after birth. Only a few drops of colostrum will be expressed at first, but expressing will stimulate milk production later on. Colostrum, which is synthesized in small quantities in the first few days after birth, is essential for the baby. Colostrum contains the highest concentration of all bioactive and immunological components, which contribute to the child’s adaptation to extrauterine life, the maturation of all its organs and systems, and provide protection against infectious diseases and the development of immunity [14].

Mother's illnesses, as a result of which it is temporarily necessary to take medications that are not recommended during breastfeeding, are not an obstacle to continuing breastfeeding after discontinuation of medications. In these cases, breastfeeding is stopped only for the duration of treatment, during which breast milk must be expressed regularly. If diagnostic procedures using narcotic and radioactive drugs are indicated for the mother, breastfeeding is stopped only for the duration of the action of these drugs. Even with an active form of tuberculosis, breastfeeding can be resumed after treatment of the mother, but not earlier than 2 weeks and in the absence of pathogen isolation.

Thus, expressing breast milk makes it possible to feed sick newborns and premature babies with mother's milk, as well as maintain lactation while the mother or child is sick or separated [15, 16].

In addition to early pumping immediately after birth, effective lactation requires regular pumping throughout the day (6-10 times) and, if possible, including pumping at night. If a mother expresses milk only a few times a day or at long intervals, this will result in a decrease in milk production. During lactation crises, when the amount of milk decreases, it is necessary to express milk more often, and not wait for milk to accumulate in the mammary gland.

Limiting breastfeeding and improper latching of the baby to the breast can lead to blockage of the milk ducts, the formation of a hard, painful lump in the breast tissue; If at this time the outflow of milk from the mammary gland is not established, mastitis will develop. You can prevent mastitis and improve a woman’s condition by frequently putting the baby to the breast. If the baby does not completely empty the breast, then it is necessary to express all the milk remaining after feeding. Sometimes feeding a baby can be difficult due to lactostasis. In this case, the mother is advised to relax before feeding, gently massage the breasts and partially express milk so that the breasts become softer and the baby can suck on them.

The need to express milk is not limited to cases of illness of the mother or baby, it can also arise in situations where mother and baby are healthy and breastfeeding occurs without any difficulties. If a mother is forced to go to work or continue her studies, pumping will help maintain the process of feeding the child with breast milk.

When it is necessary to express milk, the question always arises as to how best to express it - by hand or using special breast pumps [17].

You can express milk with your hands without special equipment at any time and anywhere, but the lack of manual expression skills can lead to trauma to the mammary gland and the risk of microflora getting from your hands in cases of poor hygiene. Expressing engorged and painful breasts manually is quite difficult, and sometimes impossible on your own. For more comfortable and efficient pumping, there are specially designed breast pumps, the sterilization of funnels, containers and other parts of which allows you to express milk hygienically. Breast pumps can be electric or manual, and can also be stationary or individual. The choice of breast pumps is now extremely wide. There are breast pumps for frequent and occasional use, for use at home or at work. Models have been developed with classic rhythmic expression (according to Egnel) or with more modern two-phase pumping technology, which was developed in 2000. Electric personal breast pumps can be powered by mains power or replaceable batteries.

Stationary clinical breast pumps provide the opportunity to select the vacuum level that is most comfortable for the mother, while being as effective and pain-free as possible, and are also equipped with special programs for expressing milk in mothers of premature newborns. They must be reliable and wear-resistant, which ensures intensive, uninterrupted operation of the breast pump without loss of performance over a long period of time. Processing kits for expressing stationary clinical breast pumps in dry-heat ovens and autoclaving eliminate the risk of contamination with microorganisms. The alternative use of ready-made sterile pumping kits completely eliminates any processing of breast pumps, which significantly saves the time and effort of medical personnel in a medical institution.

Individual breast pumps are intended for use by only one mother, since sterilization of individual breast pumps is carried out in steam (household) sterilizers [18]. The presence of its own microflora in traces of milk, which can remain in the units and mechanism of an individual breast pump, does not have any consequences for the single user and does not pose any danger. However, the use of such a breast pump by another woman is not allowed.

Before using any sterilization method, you must ensure that the method can be used for your specific breast pump model [19].

Recommendations for choosing different models of personal breast pumps (electric double pump, single electric breast pump, manual breast pump) depend on how often you express milk, every day or occasionally, at what speed, whether you plan to continue pumping at home, and the level the complexity of the tasks of supporting lactation facing the mother [20-24].

There is a model of electric breast pump that allows you to pump simultaneously from both mammary glands, which increases the degree of stimulation of lactation, increases hormone levels and promotes successful lactation [25].

The Symphony stationary clinical breast pump, in addition to such characteristics as prevention of cross-contamination, reliability, has an Initiate program for quickly establishing lactation, even if the baby has not yet been put to the breast, and also provides the possibility of double pumping with two-phase technology, which gives maximum results [26, 27].

With double pumping, each breast produces an average of 18% more milk in 15 minutes than with single pumping. After 15 minutes of double expression, the fat content of the total volume of expressed milk is 8.3%. This is significantly higher than the 7.3% figure obtained with single pumping. This indicates that double pumping releases hindmilk faster, which contains more fat and provides the baby with energy. During double pumping, unlike single pumping, additional milk separation occurs. Thus, double pumping promotes faster and more voluminous expression of breast milk and allows you to obtain milk that is higher in calories and rich in fat.

Double pumping in a hospital setting is recommended to quickly increase milk volumes during hypogalactia, lactation crises, to stimulate lactation in mothers of premature infants, in mothers with a delayed start to latching the baby to the breast, in case of difficulties with latching that make it difficult to extract milk. In addition, this method of pumping is recommended to increase the fat content of milk when feeding premature infants and children with postnatal growth retardation. Breast milk fats not only increase the energy value of the diet, but also perform numerous other physiological functions important for newborns, and especially for premature infants. Long-chain polyunsaturated fatty acids are necessary for the construction of membranes, the development of the nervous system and the retina. The components of the membrane of milk fat globules (in which fats are structured) are involved in the development of the brain, the peripheral nervous system, the immune system, the formation of intestinal microbiota, the synthesis of hormones, the transport of lipid complexes across cell membranes, the transmission of cell signals, the regulation of cell permeability and many others. Cholesterol, which is contained in the membrane of milk fat globules, structures cell membranes and participates in the synthesis of bile acids, lipoproteins, vitamin D, and steroid hormones. It is also very important for the functioning of neurons both during development and beyond. In addition, lipids are carriers of fat-soluble vitamins (A, D, E, K).

To make expressing more effective, it is necessary to use additional techniques that improve milk separation. Lightly massaging the breasts before pumping increases the synthesis of prolactin, which increases milk production, and also stimulates the release of oxytocin, which makes milk easier to let go. Skin-to-skin contact between mother and baby (kangaroo care) also promotes more efficient milk expression [20, 28]. To increase lactation, it is advisable for the mother to express milk while looking at the baby, even if she is not breastfeeding; sometimes a photograph of the baby in front of her eyes helps. A warm shower, a warm soothing drink about half an hour before pumping, and a comfortable position while pumping are important for effective milk extraction. The design of breast pumps is constantly being improved, taking into account not only the efficiency of expression, but also ease of use. The new oval-shaped Personal Fit Flex™ breast shield, which has an opening angle of 105°, allows you to use it for a variety of breast shapes and express milk in a more comfortable position, which is also facilitated by the new technology (closed system) used in the Medela Flex™ breast pump, which Prevents milk from spilling and getting into the breast pump motor.

In order for pumping to be not only effective, but also safe, it is important to comply with certain hygiene requirements. Immediately before pumping, a nursing mother must wash her hands. It is important that with modern clinical breast pumps, as well as with some personal breast pumps, you can use the same bottle from which the baby is subsequently fed to collect milk. This eliminates transfusions and is the best way to hygienically collect milk for subsequent feedings. If the containers for pumping and feeding are different or it is intended to feed from a syringe, then the milk is carefully poured and immediately used to feed the baby. In a hospital setting, the remaining milk can be stored in a special refrigerator for expressed milk for 3 hours and, after preheating to 37 ° C (using a special warming device), can be used for the next feeding. Each portion of milk must be labeled with the mother's name, the baby's date of birth, and the date and time of pumping. Sterile or disinfected parts of the breast pump should be stored in a separate container in a specially designated place (in cabinets). Medical staff teach mothers the rules of hygiene when using breast pumps and monitor their implementation, and also provide practical assistance to mothers when expressing [29]. It has been noticed that if the mother performs the first expression with a breast pump in the presence of a medical professional, she is calmer, more confident and gets better results, and subsequently, as a rule, successfully uses the breast pump on her own. If the mother uses an individual sterilizer, then after each expression the breast pump must be completely disassembled, cleaned using special detergents, rinsed under running hot water and sterilized using a steam sterilizer. After sterilization, it is necessary to dry all parts of the breast pump thoroughly and store them in an individual locker. Cleaning and sterilization of the breast pump is carried out by the mother, but staff must provide training and clear instructions using demonstrations and an illustrated manual. All instructions must be clear and written (spoken) in simple and accessible language. If necessary, staff trained in breastfeeding can help the mother in case of difficulties - advise and teach proper breast massage and pumping techniques.

Stress is one of the significant factors that adversely affects lactation [30]. The birth of a sick or premature baby, especially with very low and extremely low body weight, causes strong negative feelings in the mother: anxiety, fear, feelings of inferiority, guilt, helplessness and disappointment. Stress and discomfort can interfere with the production of the hormone oxytocin, which is necessary for the release of breast milk. The faster the child’s condition stabilizes and the faster he is transferred to the department of pathology of newborns and premature infants, the faster the stress in mothers is leveled, which helps to increase lactation. The opportunity to be with the child or to care for him most of the time in a general ward has a beneficial effect not only on the development of the child, but also on the psychosomatic state of the mother. At this time, it is very important to encourage parents to communicate with the child, care for them, and pay attention to signs by which the mother can assess changes in the child’s condition [31]. However, if the mother does not know how to care for and is afraid to touch the child, being together between mother and child without training and training in caregiving skills can be additional stress. Anxiety, fatigue and emotional stress are powerful inhibitors of lactation, while anything that has a positive effect on the psychological state of the mother/parents has a positive effect on lactation. It should be emphasized that the joint stay of a very premature baby with his mother, especially in the first days, requires increased attention and assistance from staff. To reduce the level of anxiety and stress, you can use various simple techniques: dim lighting in the room, relaxing music, physical contact with the child, the Kangaroo method [32-34]. Kangaroo Care promotes a mother's sense of well-being and a close bond with her baby. Mothers who practice the Kangaroo Method feel more confident and better understand the nuances of their child’s behavior than mothers who do not maintain long-term tactile contact with their children [35, 36]. Tactile contact between mother and child, when the mother holds the child in her arms, is in close contact with her skin for a long time, has a positive effect on children: they are less susceptible to infections, less excitable, gain weight faster and are discharged from the hospital earlier [31, 37].

Thus, creating conditions for effective, safe and comfortable expression of breast milk in a neonatology hospital not only ensures the preservation and efficiency of lactation, but also has a positive effect on the psychological state of the mother, her ability and desire to independently care for the child.

Conflict of interest.

The authors declare no conflict of interest.

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