Prevalence and Outcomes of Breast Milk Expressing in Women With Healthy Term Infants

A Systematic Review

Helene M Johns; Della A Forster; Lisa H Amir; Helen L McLachlan


BMC Pregnancy Childbirth. 2013;13(212) 

In This Article


Although data are collected about the proportion of women breastfeeding on discharge from hospital, little is known about how many women are expressing to provide breast milk feeds in addition to, or as an alternative, to feeding directly at the breast. There has been some discussion about increasing numbers of women in Australia, United States of America, the United Kingdom and Singapore expressing to give breast milk feeds rather than breastfeeding directly from the breast.[1–6] Only two studies, one conducted in Australia and one in Singapore,[2,6] measured expressing over time. Both reported an increase.[2,6]

From an historical point of view, Fildes' 1986 publication about the history of infant feeding provides a comprehensive insight into infant feeding practices from antiquity and describes related medical practices, popular customs and beliefs.[7] The 'drawing off' of breast milk was discussed by Avicenna (AD 980–1036) in the context of milk that was believed to be unpleasant smelling or too thick for the baby to drink.[7] Subsequent references to expressing describe the sucking glass, first mentioned in the mid-16th century.[7,8] The mother applied a glass cup to her breast and sucked on the end of its long glass stem to express milk when her nipples were cracked, or her breast inflamed or infected. During a time when there was concern about the undesirable effects of feeding colostrum to the newborn in pre-industrial Europe, the sucking glass was used as an alternative to employing children or puppies to remove this early milk while the baby was fed by a wet nurse.[7]

Developments in breast pump design and uptake over the last century are reflected in changes in 'brand' or company names during the same period. A collection at the Powerhouse Museum in Sydney, Australia includes the Breast Exhauster (1892), the Breast Reliever (1947), the more recent Kaneson hand pump (1973)[9] and the water operated Ellis Expressor (1970), locally designed to be connected to a kitchen tap.[10] By the early 1980s, breast pumps were transformed, as the red rubber tubing and glass apparatus and, in the case of the electric breast pump, the noisy motor, were substituted for more appealing designs. Pastel colours, discreet motors and less angular shapes became the norm and these pumps are now promoted with names that are arguably designed to enhance market acceptability. In addition to those mentioned in the previous paragraph, examples in name and design are seen in the earlier Lopuco and Egnell electric[11] and their successors, the Diana, Freestyle, Pump-in-style, Symphony, Swing, Harmony, Elite and Purely Yours pumps.[12,13]

In the world of parenting print media, breast pumps have a growing advertising presence. A hand search of the catalogue of Essence, the bi-monthly member magazine of the Australian Breastfeeding Association (ABA) demonstrates a change in the focus of consumer discussion about breastfeeding over time. Breastfeeding is convenient, and advertising for breast pumps may be interpreted as suggesting that expressing is equally so. Blum writes of "the new regularized, fetishized breastfeeding … exemplified in the widespread advertising of pumps"[14] (p. 55). Breast milk expression appears to have become more popular as the associated equipment has become more sophisticated and readily available.

Many of the studies about expressing breast milk focus on premature and/or unwell infants[15–17] reflecting the main reasons women expressed to feed their infants in the past. It is likely that up until the last 20 years healthy term infants were either breastfed or bottle fed with infant formula. Although more recent literature has discussed the prevalence of breast milk expression and suggested that more women are expressing their milk,[1,5] measurement of this phenomenon is limited and the consequences relatively unknown.

Defining breastfeeding is complex. Discussion has previously focused on the accurate measurement of breast milk feeding; its exclusivity and duration.[18] That is, breastfeeding was the term used to describe any breast milk intake regardless of the mode of its delivery. The focus of recent debate has shifted and the emerging popularity of expressing presents another complexity; the need to find out how breast milk is given, directly at the breast, or otherwise.[19] In addition, Geraghty and Rasmussen have recommended a need to identify at what age the infant is exposed to expressed breast milk, and whose milk is being used.[20]

In this paper expressing (also known as pumping) is used to describe using a pump to obtain breast milk, and hand expressing is used for instances where expressing is done by hand. Breastfeeding is used to describe the act of feeding directly from the breast, and breast milk feeding includes any means by which breast milk is given to the infant.

The aim of this paper is to systematically explore the literature related to breast milk expressing by women who have healthy term infants, including the prevalence of breast milk expressing, and the reported reasons for, methods of, and outcomes related to expressing.