Volume of Expressed Colostrum in the first 48 Hours Postpartum
by Anne Eglash MD, IBCLC, FABM
There are few studies that have evaluated the volume of colostrum produced in the first few days postpartum, before secretory activation (when the milk ‘comes in’) occurs. Most lactation consultants would likely say that there is wide variability between lactating individuals regarding colostrum volumes.
The publication for this week is an observational study of 105 mothers in Japan who were asked to manually express their colostrum for 10 minutes every 3 hours for 48 hours, with the goal of evaluating the change in colostrum volume during the first 48 hours. These mothers were unable to directly feed due to infant admission to the neonatal intensive care unit. The authors report that it is culturally acceptable in Japan to manually express milk in the initial postpartum phase with assistance and instruction from midwives.
Sixty-three women (60%) of the mothers began expression within 3 hours postpartum, and the frequency of hand expression ranged from 5-8 times in the first 24 hours, and 6-8 times between 24-48 hours postpartum. Midwives assisted mothers who had difficulty expressing their colostrum.
The total volume expressed in the first 24 hours ranged from 0.1-11.2 ml, and from 2.2-40ml between 24-48 hours postpartum. The lowest volume of colostrum occurred between 12-15 hours, and the volume stayed low until a sudden increase in volume at 30-33 hours postpartum. What else? See the question!
- In the first 30 hours postpartum, the multiparous mothers had significantly higher colostrum volumes than the primiparous women.
- The mothers who gave birth at gestational age 32-36 weeks had higher colostrum volumes as compared to those who gave birth at gestational age 22-31 weeks.
- Colostrum volume was higher among women who delivered vaginally as compared to those who delivered via cesarean.
- Colostrum volume increased earlier among mothers who began manual expression in the first 3 hours vs those who began at 3-6 hours postpartum.
See the Answer
Abstract
Objective
Colostrum, the first form of human milk, is strongly encouraged for infants due to its benefits. During the early postpartum (PP) period, the secreted colostrum volume can be minimal, causing concerns among mothers about sufficient milk supply. Few studies have examined temporal changes in the colostrum. This study aimed to elucidate the trajectory of expressed colostrum volume in the first 48 hours after delivery.
Materials and Methods
This was a cross-sectional observational study performed at Kagawa National Children’s Hospital. One hundred five mothers who did not directly breastfeed in the first 48 hours after delivery were enrolled in the study. Well-trained midwives instructed the mothers on how to express human milk, and mothers started to express as soon as possible after delivery. Mothers were advised to express human milk every 3 hours, and the milk volume was measured.
Results
Within 3 hours PP, 60% of mothers expressed milk, and the median frequency of expression was 14 (interquartile range, 11–16) times in the first 48 hours. At 0–3 and 3–6 hours PP, the volume of initially expressed milk was 0.4 (0.0–2.0) mL and 1.0 (0.0–6.0) mL, respectively. Subsequently, milk volume decreased. The volume remained low until 30 hours PP and increased dramatically; this phenomenon is termed secretory activation, which began later in primiparous women than in multiparous women.
Conclusion
The decline in expressed milk volume during the early PP period caused concern among mothers. Therefore, mothers should be informed of the PP trajectory of human milk volume.
The researchers found that multiparous mothers didn’t have higher colostrum volumes than primiparous mothers until after 30 hours, when the volume of colostrum greatly increased. At that point the rate of increase in milk volume was faster in multiparous mothers than in primiparous mothers.
Gestational age at birth and mode of delivery did not have an impact on colostrum volumes.
One important aspect to this study is the lack of adjustment for maternal BMI. There is increasing evidence that an elevated body mass index is associated with a delay in lactation, which would likely be associated with lower colostrum volumes.
The take-away from this study is that colostrum volumes are higher in the first 12 hours than in the next 18 hours. By 30 hours postpartum the volume of colostrum climbs exponentially.
This may explain why there may be more stools in the first 24 hours, followed by a slowing of stools after 24 hours until milk volume increases at 30 hours and beyond.
Nancy Bates
Thanks so much for this!! I am posting for Taft to see perhaps it will help them understand and quit putting a pump on kim to “see hou much baby is getting”! Grrrrr
Beth Lichy
Rarely, we see moms expressing much larger amounts (eg 40 mls) the first time a mom expresses. Is there evidence of a larger volume due to storage of colostrum during the pregnancy?
IABLE
I am not aware of the effect of antenatal expression on the volume of colostrum postpartum. We should do some research on this.
Cynthia Lucas
In my 20 years as a IBCLC, I have seen that trend with Moms who are separated and exclusively pumping.
They have told me it was a good volume then declined. Many of them have gotten discouraged and not wanted to pump. I have told them to keep pumping and hand expressing and it will go up.
I feel like this is the norm and glad to see there is a study to back it.
Kathryn Stagg, IBCLC
This is something we have seen frequently in Breastfeeding Twins and Triplets UK Facebook group. Parents are often reporting that they cannot get as much colostrum after the first day or so, and then within 24 hours after that their milk often begins to come in.
I am so glad somebody has now studied this phenomenon.
The next study that would be good to do as a follow up is whether antenatal hand expressing has any impact on whether this happens or whether because the breasts are used to regular stimulation before baby arrives, that the colostrum volumes stay more constant. That would be a fascinating study!!
Thank you so much for sharing
Nancy Bates
So much for my spelling. Posting for staff. pump on mom to see “How much”
Dee
Thank you for this. It does raise more questions.
– were these mothers just first timers or a mixture of pregnancies?
– were twin mothers involved in this?
– I have not known mothers to ‘lose’ colostrum after certain hours after birth.
– how would this be connected to mothers in other parts of the world?
IABLE
This was a combination of multiparous and primiparous mothers, and there was no difference in volumes of colostrum in the first 6-12 hours. They didn’t involve moms with twins. This study was done in Japan where manual expression is common in the first few days. Unclear how this would apply to populations that are not as familiar with manual expression, e.g. those that are more pump reliant.
Lynnette Hafken
I’m interested in what people think about the conclusion:
“The decline in expressed milk volume during the early PP period caused concern among mothers. Therefore, mothers should be informed of the PP trajectory of human milk volume.”
Chasta Hite
Agree. Informing parents this is normal often still does not reassure them and may deter them from continuing to breastfeed or pump.
Nina Torelli
I teach breastfeeding classes to L&D and postpartum nurses and am questioning about adding this information to my presentation. I love that this study was done and it’s reassuring to me that what I see on daily basis working with postpartum mom’s is indeed normal and natural, however, it’s not easy to instill reassurance in others with evidence-based research and facts.
Will providing this information give clarity and encouragement to postpartum moms to maintain their hand expression / pumping schedule (if not breastfeeding) or actually give mom’s/nurses a reason to supplement with formula unnecessarily because now they are expecting a decline in colostrum?
Edith Bryant
Great to read this.
I often noticed this in the postnatal ward and just kept on encouraging mothers to keep on expressing.
To me it makes sense from a perspective of lactogenesis 1 being controlled by hormones and lactogenesis 2 has the beginning of the autocrine control and increase in lactose
Can that be a reason?
But why exactly a decline by 12 hours
Not quite sure!?!
Chasta Hite
I think it’s important to note this is a decline in expressed milk not a decline in the total amount of available colostrum
That may be remaining in the breast. We often see this decline when a parent is pumping but with hand expression there is still colostrum available for the baby. When providing this information to a breastfeeding parent they could be deterred by thinking that the milk supply has dropped and their baby is hungry even if we tell them this is normal, that usually doesn’t convince them that their baby is not hungry. I think we need to be very careful how this information is presented. I would also suspect that postpartum edema is being created in the breast from early pumping that is further preventing the removal of milk.
IABLE
In this study, the participants only hand expressed. They did not pump.
Jan Edye
This is so interesting and relates and coincides well to the infant sleep pattern norms after delivery. Babies born alert remaining so for up to 2 hours post-delivery before moving into levels of sleep, become more wakeful after 20 hours or so. Clearly, support with attachment of babies needs skilled support straight after delivery to be sure that the optimum amount of colostrum is fed.
Ricardo Nunes
This research has raised a few more questions, mainly directed to the NICU population:
1) Have the authors used the Marmet Technique of hand expression?
2) Would it be possible to obtain an increase in the volume of colostrum by adding an electric pump with the INITIATION program simultaneously on both breasts for 15 minutes?
3) Would it be more effective before or after hand expression?
Shirley Donato
The way I see it, it’s a very well designed system. With the surge of oxytocin and prolactin hormones during the delivery process (Buckley, 2015), more colostrum is available for the newly delivered baby, who is generally awake and eager to nurse. Babies usually nurse very well in this initial “Golden Hour” after delivery, so this bolus of colostrum gives them the calories and nutrients needed to recover from the delivery and give them fuel for the next several hours. Babies then usually become very sleepy, and they may not eat much until they begin to be more awake after about 12-24 hours. After that initial bolus in the first few hours, the volume of colostrum produced settles to an appropriate volume for the nursling, and then gradually increases over the first few days until lactogenesis II occurs. As was stated in one of the responses, the study showed how much milk was expressed, not how much is available, and we all know that babies are much better at getting milk out of the breast than we are. Edema is not likely from early pumping, but rather due to the large volumes of IV fluids administered during the labor/delivery process accumulating in the tissues. Yes, we should be sure to explain the normal expectations for expressed milk/colostrum volume over the first few days, reassuring mom that it is normal to see very little milk volume in the first few days. Help mom to understand that continued frequent stimulation and breast-emptying is the best way to increase milk supply, whether by pumping, hand expression, or a combination of both (or frequent feedings, of course).
“Prolactin increases steeply as birth nears, likely due to peaks of beta-endorphins and oxytocin, both of which stimulate prolactin release. In addition, prolactin stimulates oxytocin release, contributing to oxytocin peaks in late labor and birth.”
Buckley SJ. Executive Summary of Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. J Perinat Educ. 2015;24(3):145-53. doi: 10.1891/1058-1243.24.3.145. PMID: 26834435; PMCID: PMC4720867.
Tara Piccininni
I am a Lactation Consultant in an NICU . I always start my moms with hand expression, to capture the colostrum for our little ones. This was a very helpful study. Thanks for sharing it.