Pumping Basics

It is recommended that a mother begin expressing breast milk after the baby is about 6 weeks old, since by then, a mother's milk production is usually well established. It is also best to delay returning to work until at least the milk supply is well established and longer if possible.

The reason for starting to express at about 6 weeks, is for practice and building a freezer stash. Providing baby with fresh breast milk should be the ultimate goal. Fresh breast milk maintains nutrients at optimal level. Cooling milk will reduce those and freezing will further reduce them. Regardless of the manner in which breast milk will be stored, it is definitely a far superior choice over artificial baby milk. A freezer stash is an “insurance” and a bit of a stress reducer for a mother in knowing that there is an “extra” stash in case it is needed.

An Australian study of 28 breastfeeding mothers with established and ample milk production found 11% were unable to express much milk using any of the seven pump cycling patterns tested. For many women, milk expressing is a learned skill that takes time and practice to master (it is not the same relationship than with a baby). Even when the most effective types of pumps (hospital grade rental pump) are used, factors unrelated to milk production (such as fit and responsiveness) can affect the volume a mother is able to pump.

When a mother first starts pumping at 6 weeks or so, she may get very little milk. This is normal. After all, she has just spent the first weeks of baby's life getting her milk supply into an exact balance with baby's needs. There is not supposed to be any extra. She may also need some time to get the hang of pumping, and may be worried about whether she will be able to pump enough. This is why she is practicing! Time pumping at home teaches her how to set up the pump, how to set it so that she gets the most milk in the least time, and most importantly, how to relax when pumping, so the milk will let down.

How often to pump: Once back to work, the common guideline is pumping for each missed feeding, roughly for every 3 hours a mother is away from her baby. In general, this works out to about three times in a standard eight-hour workday. However, she will have to adjust it according to her baby's needs, her schedule and her “magic number” (see article on Maintaining Milk Production).

She can pump on one side during that first morning while breastfeeding the baby on the other side. This takes advantage of the baby getting the let-down and is a good way to get the maximum millilitres in a brief period of time.

If baby feeds every two hours, a mother may need to spread out the pumping sessions a little more, but make them a bit longer than baby typically feeds. If she does not have time for enough pumping sessions during the day, she can pump when she gets up, before work, after baby goes to bed at night or during the night ― it can be done!

Some babies start sleeping more while they are away from mom and breastfeed more when they are together (usually at night). Gale Pryor, author of Nursing Mother, Working Mother, calls this "reverse cycle breastfeeding". If baby adopts this pattern, mom might be able to eventually pump less when she is away from baby. Keeping baby close at night allows baby unrestricted access to the breasts while mom gets as much sleep as possible. When babies and moms sleep near each other, their sleep cycles start to synchronize. That means that when mom is in a deep sleep, so is baby, and when mom is in lighter sleep, her baby will be more likely to wake up. Mom wakes up easier and falls back to sleep faster. If baby is right near her, she will wake up at the first little noises, instead of waking because baby is crying.

During a growth spurt, baby drinks more expressed milk than usual, making it harder for a mom to provide enough expressed milk. Growth spurts are temporary; one can try adding a feeding session or two at home until the growth spurt is over.

How long to pump: It is recommended that a mother who is working full time, express 2‒3 times for approximately 15‒30 minutes per session. But because 76% of the total milk expressed occurs during the first two milk ejections (during a typical breastfeed milk lets down between 0‒9 times), if under time restrictions, expression for as little as 8 minutes with a good quality pump may be sufficient.

Relaxation skills: Most mothers who struggle to pump milk are under the impression that stronger suction means they will get out more milk. BUT the pump does not get the milk out of the breasts by brute force. Breasts are factories NOT containers. One has to knock at the door; ask milk to come out, etc. Stronger suction might result in excruciating pain, or damage the breasts. An important factor in being able to express breast milk is the let-down reflex or MER (Milk Ejection Reflex). This causes the milk to release from the alveoli (where milk is made AND held). When baby sucks at the breast, nerves send a message to the brain, which causes the hormone oxytocin to be released, coming back to the breast in the bloodstream and contracting the muscle cells around the alveoli squeezing out the milk = milk has let-down.

It is possible to start this MER without a baby sucking, because the brain is wired in such a way that the nerve pathways for milk ejection run through the emotion-processing area of the brain, it is thus also possible that the MER can be slowed by things like pain, tension or stress.

When expressing, a mother can help the let-down reflex work by: relaxing (her shoulders and chest muscles) and taking deep breaths; involving as many of her senses as possible, like listening to music, thinking about baby, a photo sometimes helps, or some mothers record baby’s gurgles and play it during the pump-break. Some mothers respond very strongly to the smell of baby, and bring the clothes to work that baby wore the previous day. Placing a warm (not too hot) face cloth over the breast; massaging the breast with smooth strokes from the chest towards the nipple and drawing the nipple out gently between the fingers; and sitting in a comfortable position, will also help.

What the pump needs to do to get the most milk out is imitate baby. One can pay attention to baby’s sucks and the strength of that suckling at the beginning of a feed and a few moments later (when the milk has let down). One should then try to adjust the pump to match baby. From there, one can experiment to see if slightly more, less, faster or slower suction feels better and produces more milk. What is the best setting? The one that works for that particular mother, so she should rather not pay attention to how other people’s pumps are set, it is a personal thing.

Warning: sometimes the best way to stop a let-down in its tracks is to watch the bottles. The stress of watching the millilitres is enough to severely limit anyone’s ability to pump. Look at something else – anything! Chant: “any breast milk at all is a precious gift to my baby” and visualize waterfalls, baby’s contented face after a feeding – whatever helps one to relax. Menstruation or ovulation could result in a temporary drop in milk supply. One should remember that the amount of milk that a mother pumps is not a measure of her milk supply and it is normal for pumping output to vary from session to session and day to day. Having an occasional low volume day is not unusual. Many times a decrease in pumping output is because pump parts need to be replaced.

Breast Compressions: Doing breast compressions while pumping can help stimulate additional let-downs, and help to thoroughly drain all of the milk ducts; it also increases the amount of milk and fat content expressed. Studies have found that mothers combining manual techniques with pumping express higher levels of fat-rich calorie-dense milk. While pumping, a mother can use one hand to massage her breast from the armpits towards the nipple (or as close as she can get without dislodging the pump flange). She can gradually increase the pressure, and finish with a few firm but gentle squeezes of the breast, like when she is hand expressing. Remove the pump once the milk stops flowing and massage each breast from the armpit to the nipple, then again from the centre of the chest towards each nipple - stroking each breast gently towards the nipple a few times. She can then bend over and cup her breast in her hands. Giving each a good relaxing/gentle shake, not a painful jiggling-shake! Then put the pump back on – she should see more milk begin to flow.

A study (that tried to determine the effect of the strength of applied vacuum on the flow rate and yield of breast milk using an electric breast pump); found at the maximum comfortable vacuum (190.7 ± 8.8 mmHg) 4.3 ± 0.4 milk ejections occurred during 15 minutes of expression and yielded 118.5 ± 11.4 ml of milk (65.5 ± 4.1% of the available milk). Cream content of the milk was highest after expressing for 15 minutes using the mother’s maximum comfortable vacuum. CONCLUSIONS: Use of the mother’s maximum comfortable vacuum enhances milk-flow rate and increased volume of milk expressed. The cream content of the milk at the end of the expression period was an indicator of how effectively the breast had been drained. Thus a mother should pump at a level that is comfortable for her and not a too high setting.

In summary: If a mother is using a hand pump, it is a bit more work than using an electric pump, but the plan is still the same (although the timing varies slightly) roughly 10 to 20 minutes. It is not necessary to sit and pump until the last little drop is forced out. A mother needs to simulate a typical feed.
  • Wash hands before using the pump;

  • A mother should clean and assemble a breast pump using the manufacturer’s written instructions that come with the pump;

  • Before starting to pump, she should try to stimulate a let-down;

  • When applying the pump, she needs to make sure the nipple is in the centre and that the funnel has good skin contact all around to stop air leaking in. If the nipple hurts when she starts expressing with the pump, she needs to stop and check to make sure the nipple is centred in the pump tunnel;

  • Start the suction on the lowest suction setting. Remember the baby’s suck starts off slow and low, not fast and high;

  • After a minute she can move the suction to a higher, comfortable setting’

  • If she is not using a double-pump she can consider switch pumping, 5 minutes on breast A, 5 minutes on breast B, again 5 minutes on breast A and lastly 5 minutes on breast B, starting on the minimum setting every time she switches;

  • When pumping for the first time some mothers may only express small amounts, but they will be able to express more milk as the body gets used to expressing;

  • It can be helpful to finish off each session with a few minutes of hand expressing. This will help to drain the breasts and help increase volumes pumped.

Cleaning information

Mothers should generally follow the cleaning instructions provided with the pump. If she is expressing several times a day and if baby is healthy, breast pump parts (which comes in contact with the milk) could be cleaned well once a day when in frequent use, or if used only occasionally, after each use.

How to clean well (this might be at the end of a working day)
  1. First wash hands well with soap, and dry them on new paper towel or a clean, unused cloth towel.

  2. Take the breast pump kit apart, and separate all pieces. Rinse in cold water all the parts that have been in contact with milk.

  3. Take care to remove all traces of grease, milk and dirt with a small amount of dishwashing liquid and hot water. Use a brush kept only for this purpose. Harsh chemicals and abrasive scrubbing should not be used so that small scratches are not created that could harbor bacteria or mold.

  4. Rinse all parts in hot water, at least twice.

  5. Drain pump parts upside-down on a new paper towel and cover with more paper towel while they air-dry. Finish drying all containers with a new paper towel before putting it away. Store the dry kit in a new plastic bag, plastic wrap, more paper towel or clean, covered container until next use.

- Am Fam Physician. 2003 Dec 1;68(11):2201-8. Returning to work while breastfeeding. Biagioli F.

- Kent J.C., Ramsay D.T., Doherty D., Larsson M., Hartmann P.E. Response of breasts to different stimulation patterns of an electric breast pump. J. Hum. Lact. 2002;19(2):179–187.

- Breastfeeding Mothers Returning to Work: Possibilities for Information, Anticipatory Guidance and Support from US Health Care Professionals, Michelle A. Angeletti, MSW, PhD, J Hum Lact May 2009 vol. 25 no. 2226-232.

- The Breastfeeding Mother’s Guide to Making More Milk by Diana West, Lisa Marasco, 2009.

- J Perinatol. 2009 Nov;29(11):757-64. Epub 2009 Jul 2. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Morton J., Hall J.Y., Wong R.J., Thairu L., Benitz W.E., Rhine W.D.

- Journal of Perinatology , (5 January 2012) | doi:10.1038/jp.2011.195 Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants J. Morton, R.J. Wong, J.Y. Hall, W.W. Pang, C.T. Lai, J. Lui, P.E. Hartmann and W.D. Rhine.

- Importance of vacuum for breastmilk expression. Kent J.C., et al. Breastfeed Med. 2008 Mar;3(1):11-9.[NL1]

#pumping #express #pump #breastmilk

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