expressing colostrum antenatally

Have you noticed lots of Instagram posts about expressing colostrum antenatally?

There are even people jumping on the bandwagon and selling “kits”.

I have been around long enough to have seen many fads in this space and I can’t help thinking this is one of them. (NB: Be on the lookout for fear-based messaging, this is always a 🚩)

To be fair, there was a good study done on antenatal expression in 2017 called the DAME (Diabetes and Antenatal Milk Expressing) Trial, but it only studied a specific subset of women…635 diabetic women who were otherwise low-risk.

The DAME Trial did show that AME (Antenatal Milk Expression) caused no signs of harm to mothers and babies (again in this very specific group) and that their babies were more likely to have only breast milk (and no infant formula) while in hospital.

The trial concluded:

We found that there is no harm in advising women with diabetes in pregnancy who have a low risk pregnancy to express breast milk from 36 weeks of pregnancy. (Forster et al, 2017).

But is this good enough evidence to now suggest all women need to antenatally express colostrum and are there easier ways to get hospital staff to stop giving formula to babies in hospital 🤔

 

Importantly, the “no harm” they looked at was very specific too :

  • Women with diabetes in pregnancy who were taught hand expressing after 36 weeks did not give birth any earlier than women who did not express during pregnancy
  • Babies of women with diabetes in pregnancy who were taught expressing were no more likely to need admission to the special or intensive care nursery and were more likely to receive only breast milk in the first 24 hours after birth and during their hospital stay. ((Forster et al, 2017)

But are there other potential harms?

As with most things suggested to pregnant women (and new mothers), you have to ask yourself:

1. How did we survive as a species for so long, before ‘experts’ decided they knew more about our bodies than we do? 🤦🏻‍♀️

2. Are there any risks and do the benefits outweigh the risks or vice versa in my unique situation? 🧐

Some women will decide to antenatally express and others will decide to not worry about it.

The choice is yours.

(I always send my workshop participants a link on how to do it and what equipment they actually need so they don’t need to buy expensive ‘kits’ if they decide it is right for them.)

 

Sometimes the benefits of AME are overestimated or not supported by evidence.

Despite what you might have been told AME does not:

  • Speed up lactogenesis II (your milk coming in)
  • Reduce postpartum breast engorgement (frequent, flexible, and efficient breastfeeding does this)
  • Increase exclusive breastfeeding

 

Even when it comes to babies not getting formula in hospital The DAME Trial found:

Women who did AME had only a 10% greater chance of their baby only having breast milk in their first 24 hours. This went down to 7% for the rest of their postnatal stay and we do not know if this was their mother’s antenatally expressed colostrum or colostrum expressed after birth.

Couldn’t we just support women whose bodies need expressed colostrum to express postnatally?

This has the double benefits of the colostrum the baby gets being fresh and therefore biospecific, and establishing milk supply post-birth.

The DAME Trial also found:

  • There was no difference in milk coming in for women who expressed antenatally and those who didn’t.
  • There was no difference in exclusive breastfeeding in the longer term.

 

So should all women be told to express colostrum antenatally?

As with every intervention it is all about weighing up the risks and benefits of your unique situation

Most providers will list the above benefits (whether they are backed by evidence or not) and the fact that it may increase confidence in women who can antenatally express, but you need to weigh this against the risks.

So here are some potential risks.

 

Risk 1: Induces contractions

Some large contractions were seen during AME during the DAME Trial. This may lead to significant stress for compromised babies (all babies in the trial were low-risk with healthy placentas).

Using pumps for antenatal expression is therefore not advised.

 

Risk 2: Babies might get antenatally expressed milk rather than establish breastfeeding

This is actually my main concern on busy postnatal wards.

I worry that having antenatally expressed colostrum makes it too easy for staff to keep mums and babies separated in this critical window for breastfeeding journies.

Although the DAME Trial found that AME made no difference in milk coming in and no difference in exclusive breastfeeding in the longer term, both these rates are below par in hospital births and I feel we should be looking at ways of improving them rather than just not impacting them

Wouldn’t it be far better to:

  • Help the mother establish breastfeeding
  • Plus give the baby freshly expressed milk rather than milk that has been in a freezer if they need can’t feed directly from the breast

 

Risk 3: It may cause psychological harm to women who can’t get any or only little amounts of colostrum.

25% of women in the study got less than 1 ml and 50% got less than 5 ml for all the AME they did. Some women got no colostrum at all.

And even though these women were told repeatedly that this was completely normal and had no bearing on their ability to breastfeed successfully, many of these women said not being able to express large amounts did decrease their confidence.

So although one of the reasons care providers suggest AME is to increase women’s confidence with hand expression and therefore their ability to breastfeed, for a large percentage of women it can have the opposite effect.

Many studies have shown that breastfeeding self-efficacy (a woman’s confidence in her ability to breastfeed her new baby) is positively associated with breastfeeding duration and exclusivity of breastfeeding, so I really worry about all the women’s breastfeeding self-efficacy that is undermined so early in their breastfeeding journey.

Risk 4: Negative impact on milk supply

Again although the DAME Trial found no impact on milk coming in and a longer duration of exclusive breastfeeding, this is not necessarily a good thing.

As research has shown that interventions can impact breastfeeding (See Dr. Sarah Buckley’s Research) and more and more women are having interventions, I think we should be doing all we can to positively impact milk supply.

Nipple stimulation and milk (and colostrum) removal are the primary control mechanisms for milk supply. Frequent milk removal (>10 times) in the 1st 24 hours is critical for establishing a healthy milk supply.

There is a risk of this not happening if babies are given antenatally expressed colostrum as many care providers still believe hormones are the main mechanism (endocrine control)  at this point and underestimate the importance of milk removal (autocrine control).

Milk (colostrum) removal from the breasts from the very first day is critical in a woman establishing her optimal milk production levels.

*Remember: If your baby does end up getting your antenatally expressed colostrum (which is much preferable to formula for a few reasons but a big one, that is often not explained, is the incredible protective properties of colostrum, but that’s a whole different blog) make sure your breasts also still get at least 10 ‘colostrum removals’.

 

If you want to learn more about getting breastfeeding off to the best start then come along to one of my workshops.

I am also available for individual consults prenatally and postnatally at the Perth Baby Clinic

 

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