The Knack of Hand Expression

Coach Smith

2008 Update

Donna Ramsey Geddes's Ultrasound studies have profoundly changed our understanding of breast anatomy. There are no visible "sinuses" in the lactating breast. Instead, the entire duct opens during the milk -ejection reflex, which lasts about 1-2 minutes. The "knack" of milk expression now focuses on (1) triggering a milk let-down reflex, then (2) expressing a substantial amount during the moments of peak flow.

Nevertheless, there seems to be a "sweet spot" or area where milk is more easily and comfortably expressed than elsewhere. When reading the following (1996) description of hand expressing, keep in mind that although our understanding of the breast ANATOMY has changed, the techniques for hand expression are still approximately the same! Deep latch has been found to be even MORE important, and getting a "deep mouthful of breast" is still vital!

Here's what I wrote in 1996:

The knack in hand expression is finding exactly where the lactiferous sinuses are, and how deep. Imagine a pea inside a thin straw, and each breast having a cluster of 10-20 straws, each with a pea inside. The sinuses are softer than peas, more like little milk-filled pillows or tiny cylindrical squirt guns. When you've located the pillow, press the milk out with your thumb on top and forefinger or middle finger underneath, starting the movement on the chest-side of the bulge and rolling across the pillow toward the nipple side. The pillows don't move inside the straw. Another way of imagining the sinuses is weak spots in a garden hose that bulge out with collected water - if you step on the bulge, it squirts. The trick is to find the bulges - they're only about 1/4" long.

Start your search with your fingers around the edge of the areola, about 1.5 inches back from the nipple tip. Go closer to the nipple or back away from it till you find them. They may be on the surface or deep in the breast, like the core of an apple. Use enough pressure to squirt out milk if it's there. Once you've found them, you'll be amazed how easy it is to press out milk. It usually sprays across the room if your fingers are in the right place.

THIS is what "proper positioning" during breastfeeding is all about - getting the lactiferous sinuses inside the baby's mouth, over the tongue. (Or, conversely, getting the baby's mouth around enough of the breast to include the lactiferous sinuses.) The baby should be positioned with her upper gum ridge at or on the chest side of the milk sinuses; her tongue can press/strip the milk out of the pillows if her chin is up against the breast. Assuming the tongue is working well, of course. But that's another discussion. This fixes at least 80% of the BF problems I see.

Linda Smith, BSE, FACCE, IBCLC in Dayton, Ohio