Time to first expression - Effective initiation interventions

Early pumping is an evidence based intervention to achieve effective initiation of lactation. When the infant cannot breastfeed effectively, pumping within 3 hours after birth has been shown to have a significant impact on future milk supply, infant feeding and subsequent health outcomes.

Woman who uses double breast pump looking at healthcare

What is time to first expression?

Time between delivery and a mother’s first pumping session. For healthy term infants who have normal births, the first breastfeed should occur within the first hour.1

The focus of this measure is early pumping, this is defined as within 3 hours of delivery.2-4

Why is time to first expression important?

Early breast stimulation (feeding or pumping ) after birth has significant impact on future milk supply and subsequent feeding outcomes.2,3,5

Studies highlight that NICU mothers who initiate pumping within 3 hours after birth significantly:

  • reduce the time to secretory activation (milk ’coming in’)6

  • have higher daily and cumulative milk volumes over time 2,3

  • are more likely to be pumping at 6 weeks after birth2
  • have infants more likely to breastfeed on discharge and for extended periods6

How to implement time to first expression

  • In the antenatal period, identify and provide women with known risk factors women with known risk factors, information around importance of early initiation within 3 hours of birth

  • Support mothers whose infants cannot breastfeed in the first hours or have a poor, ineffective breastfeed to commence pump expression within 3 hours of birth

  • Ensure that early expression commences within the delivery theatre, recovery room

  • Start with a hospital-grade double pump with researchbased initiation technology7,8

  • Implement strategies to identify a delay in time to first expression greater than 3 hours

  • Support cohesive lactation practices within maternity and NICU services to initiate expression within 3 hours of birth

  • Track and document time of first expression in a pumping log

  • Track and document the reasons for delayed first expression in maternal medical records

How to monitor time to first expression

Collect data on time to first expression after delivery with a data collection tool

  • Review maternal midwifery records, medical records, pumping logbooks and data for the ‘time to first expression’ after delivery
  • Regularly audit the data to measure the % proportion of mothers who initiate expression within 3 hours of delivery
  • Identify hospital practices that result in a delay in time to first expression
  • Identify associated risk factors such as caesarean section, which may influence time to first expression
  • Communicate findings and recommendations regularly to all departments to improve and sustain best practice

1 WHO, UNICEF. Global strategy for infant and young child feeding. Geneva: World Health Organization; 2003. 1-30 p.

2 Spatz DL et al. Pump early, pump often: A continuous quality improvement project. J Perinat Educ. 2015; 24(3):160–170.

3 Meier PP et al. Evidence-based methods that promote human milk feeding of preterm infants: An expert review. Clin Perinatol. 2017; 44(1):1–22.

4 UNICEF, WHO. Protecting, promoting and supporting breastfeeding: The baby-friendly hospital initiative for small, sick and preterm newborns. Geneva, New York: WHO; UNICEF; 2020. 42 p.

5 Parker LA. Optimizing Mother's Own Milk Production in Mothers Delivering Critically Ill Infants. J Perinat Neonatal Nurs. 2020; 34(1):13–15.

6 Parker LA et al. Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med. 2015; 10(2):84–91.

7 Meier PP et al. Which breast pump for which mother: An evidencebased approach to individualizing breast pump technology. J Perinatol. 2016; 36(7):493–499.

8 Prime DK et al. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression. Breastfeed Med. 2012; 7(6):442–447.