The Three Phases of NICU Lactation Support
Breastfeeding Literacy Project Module 7.3
Redefine lactation success in the NICU:
- Early initiation of expression
- Sustainable expression routine
- Mother-baby connection - not necessarily direct breastfeeding
In the healthy newborn setting, success in the first 100 hours often means a baby who’s latching well and transferring milk. That’s not realistic for most NICU families. So we need to clearly redefine what we’re aiming for: getting milk removal started early, building a milk expression routine the parent can actually sustain, and fostering connection even when the baby is being cared for by others.
If NICU moms are trying to meet the standards set for moms of healthy, term babies, it makes sense that they’re going to feel like they are not doing enough for their babies.
Phase 1: Initiate
- Skin to skin after birth whenever possible and for as long as possible
- Begin expression as soon as mother is stable (ideally within 1–3 hours of birth; within 6 hours per Baby-Friendly NICU standards)
- Orient the family to what’s happening and why it matters
- Begin relationship-building despite separation
- Show moms how to hand express their colostrum and treat drops as meaningful therapy for the baby
The first 24 hours are about two things: getting the signals to the breast started and helping parents feel like participants instead of spectators. Ideally, hand expression or pumping begins within one to three hours of birth—or as soon as the parent is medically stable. The Baby-Friendly NICU standards say within six hours for preterm births.
This is also when we start building trust. We explain why this matters, we show them their colostrum, we help them to see that even a few drops are meaningful. Orientation to lactation support isn’t just logistics—it’s where we support parents to feel emotionally connected to their baby and build their relationship.
Phase 2: Build
- Ramp up frequency to 7–8 expressions per 24 hours
- Optimize technique: comfort, hands-on pumping, positioning
- Skin-to-skin whenever possible
- Normalize NICU pumping life: alarms, interruptions, the chair next to the isolette, who’s around to help them, how to take breaks for eating , drinking, and personal needs
By day two and three, we’re shifting from “get started” to “build the routine.” This is where technique matters—comfort, hand expression with pumping, positioning. It’s also where we continue to advocate for skin-to-skin whenever possible.
And critically, this is when we normalize what NICU pumping actually looks like: alarms, interruptions, pumping in a chair next to an isolette, thinking about asking to use the curtains or barriers for privacy if they want. We’re not pretending it’s easy. We’re helping them build a life around it- a temporary life.
Phase 3: Assess and Plan
- Assess Day-4 volume (first checkpoint)
- Triage support based on volume category
- Plan for Day-14 goal
- Discuss the possible pathways to first breastfeeding and how we will know baby is ready
Day four is our first real checkpoint. Not a pass/fail—a signpost. We look at 24-hour volume, we watch for risk factors, and we help mothers adjust their plan. When things are on track, we reinforce what’s working.
For those who are at risk of stopping or struggling, we escalate support before they leave the birth hospital, before they’re pumping alone at home without a lactation consultant down the hall.
We also start talking about what’s next: Day-14 goals, and working with the baby’s whole care team to plan for when direct breastfeeding might enter the picture.
About The Breastfeeding Literacy Project
Breastfeeding Literacy is a free, evidence-based curriculum for anyone who supports breastfeeding families.
Built on the First 100 Hours framework, this curriculum covers the physiology of lactation, clinical assessment and intervention, ethics and industry influence, and support for special populations including late preterm infants and NICU families.
It’s designed for lactation professionals, nurses, midwives, doulas, medical students, peer counselors — and parents who want to understand how breastfeeding actually works.
Why free? Because access to accurate lactation education shouldn’t depend on what you can pay. No paywall. No sponsors. No industry influence.
About Christine Staricka
Christine Staricka is an IBCLC with 25 years of experience, an international speaker, and founder of Evolve Lactation Media. She is the author of Evolving the Modern Breastfeeding Experience: Holistic Lactation Care in the First 100 Hours.