Early establishment of breast milk supply in mothers of preterm infants; comparing hand expressing and massage within the first hour of birth to expressing in the first 6 hours.

INTERVENTION: Intervention is hand expressing and massage within one hour of birth. The education session will take approximately 30mins including education and demonstration and handing out the education materials. Massage will be taught by a lactation consultant at recruitment and undertaken by the mother within the first hour following preterm birth with the supervision of a midwife. Massage duration is 1‐3 minutes prior to hand expressing. Massage steps include lifting the breast up and holding, while holding with one hand use the pads of the middle three fingers and rub in a circular motion around the entire breast so it shakes. Using same motion rub the pectoral muscle (at the top of the chest) to loosen and either side of your sternum (breast bone). Instruction for the massage and hand expression will be provided on a palm sized card for reference during massage Hand expression will be demonstrated at recruitment and the participant will demonstrate this back to the lactation consultant. The partner if available will also be educated to assist the participant. Hand expression education is as follows; Position your thumb and first two fingers about 2.5–4 cm behind the nipple. Place your thumb pad above the nipple and the finger pads below the nipple forming the letter "C". Push straight back into the chest wall. Press thumb and fingers together gently behind the nipple and then release. Repeat step two and three to establish milk flow. Rotate your thumb and finger position to milk the other ducts. Any handling of your breast should be gentle and non‐painful. If discomfort occurs, move your fingers further behind the areola which should increase comfort as well as milk flow. Information handout will be given to the mothers as a reference guide. Participants will be asked to document the date and time of their first expression on an expressing log provided at recruitment, this will include an area for the participant to tick that massage was undertaken. Participants can use these techniques following the initial expression within the first hour and will document on their expressing log if they used massage or hand expression to express. CONDITION: Breast milk supply Breastfeeding Engorgement Mastitis Premature infants PRIMARY OUTCOME: Number of preterm births (28‐34 weeks) each week will be documented during the 6 months trial period by reviewing the admissions to the neonatal nursery and confirming with the patient bed lists for the hospital. Number of women recruited Proportion of potentially eligible women not recruited and reasons. This will be measured by auditing the consent process and and reason for not consenting as well as reviewing admissions to the neonatal nursery and patient bed lists. ; Total volume of milk expressed from birth to end of day 7. All mothers will be educated on measuring with a syringe and provided with 1ml, 3ml, 5ml and 10ml syringes to document amount of breast milk following each expression session. When milk is flowing into a bottle mothers will be asked to extract the milk into a syringe to accurately measure the amount and document. Large quantities of milk will be transferred back into the bottle for storage. This will be reported on the expressing log given to mothers at time of consent. Were participants prescribed antibiotics for mastitis in the first 3 months. Mothers will be asked whether they were prescribed and took antibiotics in the first 3 months post‐partum. INCLUSION CRITERIA: 1. 16 years of age or older 2. Preterm birth 28 to 34 completed weeks gestation 3. Maternal intention to breast‐feed 4. Able to provide informed consent SECONDARY OUTCOME: Experience of engorgement in first 2 weeks. Participants will be asked if they experienced engorgement in the first 2 weeks including signs of redness, swelling and pain, a yes or no answer will be recorded. Experience of mastitis in the first 3 months. Participants will be asked if they experienced mastitis symptoms in the first 3 months, including signs of redness, swelling, pain or temperatures above 38.5, a yes or no answer will be recorded. Time to establish milk supply, this will be measured by the mothers symptoms and a time frame given. Data on signs of lactogenesis stage II or ‘milk coming in’ will be collected from the expressing log as charted by the participant reporting the following signs: Maternal perception of the onset of lactation, swelling, fullness, engorgement and leaking of the breast as reported by the participant each day to determine time of milk coming in. Milk volume will be correlated with the mothers’ signs of milk coming in and time will be recorded in 12‐hour increments as either occurring 0800–2000h or 2000–0800h. This is a traditional method of determining timing of milk coming in and has been shown to correlate with actual timing of this stage.