Early Breast Milk Improvement Project Toolkit

Part 1: Background and research evidence

Background

Funded by NHS England South West (NHSE SW), Health Innovation Wessex (HIW) is supporting the spread of a quality improvement project initiated in University Hospital Southampton (UHS). The project focuses on equity of access to appropriate equipment for expressing maternal breastmilk.

Research shows correctly measured and fitted flanges on breast pumps increase yield of breastmilk, reduce mother’s discomfort, and can reduce the incidence of developing mastitis.

Currently, there is a low level of knowledge and nipple measurement is not standard practice. Trusts only stock a standard size which is far too large for the majority. Mothers are required to buy the correct fitting flange, which disadvantages those from low income families.

This project is working across Wessex to support staff training, develop education resources for parents, and improve access to the correct equipment through NHS procurement. At time of writing, this project is currently being evaluated, however, early data shows the percentage of pre-term infants receiving breast milk in the neonatal unit has increased by 11%. By receiving breastmilk, children benefit from improved long-term health. Maternal breastmilk has been shown to reduce the incidence of premature babies developing necrotising enterocolitis (source). 

This toolkit should help you to implement a similar project in your own healthcare setting.

Above: Example of nipple sizing tool and different sizes of flanges. 

Research evidence

This project is informed by scientific evidence of the impact of flange sizing on the expression of breastmilk. Of particular influence is the article 'Flange Size Matters: A Comparative Pilot Study of the Flange FITS™ Guide Versus Traditional Sizing Methods.' This was published in the Journal of Human Lactation by Lisa A. Anders, Jeanette Mesite Frem, and Thomas P. McCoy. 

Research found that the standard fit flanges had significantly less milk output and less comfort when compared to the newer small-size fitting.

The paper concluded that:

"Flange fitting is a process that should be individualized to the patient and may require a trial of one or more sizes during a pumping session. Smaller sizes determined using this individualized process and starting with nipple tip measurement may be used without compromising milk output or comfort."

You can read the article in full here or access it as a PDF in the resources tab to the right of this page.

Project goal and measurement

Impact statement

Through training staff, educating women, and supporting trust procurement, more women will have free access to appropriately fitted equipment to support expression of breastmilk, thus contributing to patient experience.

Measured by...

• Number of staff trained using training resources developed.
• Number of women accessing an educational video resource developed to support expression of breastmilk.
• Number of stock items issued outside of 24mm standard stock item.
• Qualitative feedback from staff trained.
• Qualitative feedback from women supported to express.
• Increase in breastfeeding data captured in Thames Valley and Wessex Neonatal Operational Delivery Network dashboard on preterm optimisation elements.

Colostrum is "liquid gold" - real-world application

Colostrum is the first milk your body produces following birth. It is thick, nutrient-rich, and high in antibodies. Colostrum helps to protect babies from infection and supports their immune system. It helps their digestive system to develop and helps prevent jaundice. It is particularly beneficial for premature babies, helping reduce the risk of necrotising enterocolitis, and is a recommended element of preterm optimisation (Saving Babies Lives V3).

These photos were taken at University Hospital Southampton, and both pots were filled after 15 minutes of pumping just 48hours after giving birth. Prior to swapping to the correct flange size, the colostrum gathered barely covered the bottom of a single pot. 

Initial project feedback

“I love the patient education video - the information is so clearly explained and visual. I am really excited to use this within our Trust and I think it will hugely improve the outcomes for our families who use breast pumps.” 
- Infant Feeding Lead.

“I have never had my nipples measured for flange size or had any idea that adjusting part sizes and fits could have such an impact. The video highlights all the key information that I was missing from my pumping journey. It is so friendly and easy to understand, Amber is clear and the information is detailed and relevant. Having the measuring tools on the pumps and on the wards would be so helpful, even if a baby appears to be breastfeeding well, I feel it would be helpful for women to know what size their nipples measure at! Just in case they need to start pumping. I went through 4 flange sizes and am sure none of them were right! Seeing an actual lactating women use the sizer and pump is really helpful and the video is a good length for a very tired new Mum to process. Thank you for this, I feel it will make such a difference to people in a similar position to me. Had my 3rd baby had been my 1st, there is no way I would have breastfed, it was so painful and challenging. Having more information about how to pump pain free will help more women to extend the time the breastfeed. Thank you 😊” 
- Maternity and Neonatal Voices Partnership, Hampshire and Isle of Wight.

“I’m really excited about the flange sizing project and the resources available within the toolbox to better support staff and the parents of babies in our NICU. This is already helping more families to meet their goals and more babies to receive milk made just for them.” 
- Neonatal Infant Feeding Lead Nurse.

Part 2: Tools, resources, and materials to help you implement

Optimising the Expression of Breastmilk and the Importance of Flange Sizing - NHS Learning Hub webinar

Flange FITS™ Guide

The infographic below provides a quick overview to flange fitting. This is taken from the Flange FITS™ Guide developed by Babies in Common (full version available here or in resources tab on the right of this page). 

©Copyright Babies in Common 2023 Jeanette Mesite Frem, IBCLC. Reproduction permitted with attribution. April 2023.

Expressing breastmilk patient information video

This patient information video was produced to support women to measure themselves for the correct flange size and offer advice on good expressing technique. 

Nipple sizing tools

For this project, we commissioned engraved laser cut nipple sizing tools, which can be sanitised with antibacterial wipes after use in the same way as other breastfeeding equipment. 

These tools which were given to trained staff and attached to breast pumps at secondary care locations to allow women to measure themselves. The breast pumps also feature stickers with QR codes on which takes patients to the Wessex Healthier Together website and a video on how to find their size and express breastmilk. 

The size guides provided on the tools are: 10mm, 13mm, 15mm, 17mm, 18mm, 19mm, 21mm, 22mm, 24mm. 

For this project, the supplier was YEAH laser, however, other suppliers are available. They have since made these nipple sizing tools available on their website for ease of ordering.

Above: Examples of nipple sizing tool.

For this project, the supplier was Ana Wiz, however, other suppliers are available. The flanges can be bought in smaller quantities from their website. For orders of 24 units or more, please email sales@anawiz.com and use the product codes below:

*correct at time of writing.

The above flanges are compatible with pumps other than Medela, however, additional connectors may need to be purchased. 

For use with Ardo Pumps, silicone flange inserts are available, such as the below examples from Amazon: 

• Nuliie (£9.99 for a pack of 10 at time of writing).
• Luxemum (£8.99 for a pack of 10 at time of writing).

Patient information on breast pumps

Stickers with QR codes were produced and attached to breast pumps. These direct patients to the Wessex Healthier Together website, which features a patient information video with advice on expressing milk for the individuals using the pump. The stickers used in this project were printed by Inkdrop Signs and Graphics in Southampton, however, other providers are available. 

The QR code on the sticker goes to the Wessex Healthier Together website. For people outside of Wessex, we have produced generic stickers - an example is below and is also available as a PNG and a sticker sheet template under the resources tab on the right hand side of this page. These stickers will take you to a patient information video, which is featured on the Healthier Together website and is also embedded below or available on Vimeo. 

We'd love to hear what you think about our toolkit!

Please take a moment to fill out our feedback survey here: https://forms.office.com/e/49hDAekkfj. 

This would help us improve our provision in future and provide better experiences to mothers and babies.

If you have any questions regarding the toolkit or the project, please contact Holly Green by emailing holly.green@hiwessex.net. 

We also invite you to get in touch and share any additional resources or experiences related to this project to improve the toolkit for everyone.