08 Nov Breast pumps: An introduction for moms
By Anthea Taylor – SACLC – SA certified lactation consultant
The first safe and effective modern breast pump was invented by Einar Egnell in the 1940s. Since then many different types have been developed, manufactured by dozens of companies. With so many different types of pumps on the market it can be a daunting task to decide which pump to recommend to a mother in a given situation.
This article aims to guide you on the basics of breast pump selection and use.
There are various reasons that a mother may need or choose to express or pump her breastmilk. These include having a preterm infant unable to feed from the breast, to feed breastmilk when an infant has latching or sucking difficulties, to increase or maintain milk supply, feeding when returning to work or when separated from her infant, to relieve engorgement, and to donate to a human milk bank. In most of these situations pumping can be crucial to preserving the breastfeeding relationship, however, the time and effort that pumping may take has also been cited as a reason for early cessation of breastfeeding. If we consider the implications of that statement it cannot be denied that it is vital we ensure mothers have the right pumping equipment and know how to use it effectively. In this way we can ensure optimal pumping results which may play a role in lengthening the duration of exclusive breastfeeding.
Types of pumps
There are a variety of pumps with distinguishing characteristics that make them appropriate in different situations. Manual pumps are operated by hand and do not require batteries or electricity. Because of this design they do necessitate some effort from mothers to pump by hand usually resulting in a lengthier period of time to pump the desired amount of milk when compared with automatic varieties. They are the most affordable models with prices ranging from R250* to around R800* and can easily be found in stores. One would usually recommend these pumps to mothers who have already established breastfeeding and who only intend on pumping breastmilk occasionally. They are not suitable for women who have conditions like carpal tunnel syndrome or arthritis that will make using a manual pump difficult.
Other types of pumps recommended for occasional use are battery-operated pumps and single electric pumps. Battery-operated pumps usually come with adapters so they can also be powered by electricity. These pumps are advantageous as they can be used during power-outages and because they require much less effort than manual pumps. However, some of these pumps are reported to be very noisy and they can be pricey to operate when running on batteries since they drain batteries rather quickly. They are priced from R1300* to R1700*.
Single electric pumps can only be powered by electricity. They are also more effective than manual pumps, but have the added benefit that they are often more powerful and quieter than their battery-operated counterparts. The costs involved range from approximately R1000* to R4800*.
For the mothers who will be pumping when they return to work full-time or who need to pump more than a few times a week, it is recommended that they purchase a double electric pump (i.e. both breasts are pumped at the same time) to maximise the pump yield and minimise the time spent pumping. They are more expensive, pricing between R2600* and R8600* depending on the brand.
Multi-user pumps, sometimes colloquially called “hospital grade pumps”, are usually used for initiating and maintaining breastmilk supply. Mothers in hospital with premature or critically ill infants use these pumps to establish their supply and provide breastmilk to these infants who are unable to breastfeed effectively. Typically, they are double pumps, although they can also be used as single pumps depending on the collection kit used. Double pumping, otherwise known as simultaneous pumping, has been shown to produce greater prolactin levels than if two breasts were pumped one after the other (sequential pumping). It also delivers a higher milk yield in a shorter length of time which makes it the logical choice for a mother who needs to pump several times a day over a long period of time. A mother who requires a multi-user pump once she is at home can rent one from a representative in her area. Pump hire ranges from approximately R650* to R1200* per month depending on brand and type. The mother will also have to buy the collection kit which usually costs about R800* to R1000* once off.
Multi-user pumps are named as such because they are the only pumps that can be used by more than one person. They are closed system pumps; in other words the breastmilk cannot come into contact with the motor and other working parts of the pump. Each mother who uses such a pump purchases her own collection kit (flange, tubing and milk container) that she connects to the pump. Only these parts come into contact with the milk and are replaced easily for the next user. All other pumps are seen as single-user pumps and are usually open system pumps which means small amounts of breastmilk can pass into motors and other parts of the pump that are unable to be cleaned. Over time mould and bacteria can grow in these components and so these pumps do have a limited lifespan. Mothers should be discouraged from sharing pumps or buying used pumps because it could expose their infant to dangerous pathogens. It is important to note that not all closed system pumps are multi-user pumps. Some closed system pumps are only meant to be used by one person and the motors usually don’t last long enough to be passed from one user to the next. The warranty on all single-user pumps, whether open or closed system, is also deemed null and void if the pump is used by someone other than the original owner.
Other factors also play a role in choosing a specific breast pump and brand. For example, a more compact pump will be useful for a mother who travels a lot. It is also wise to consider if spare parts are available and if universal milk containers will fit the pump. Availability of different sized flanges (the part that fits over the breast) is also very important. Most breast pumps have a standard flange size that will fit the average woman but not fit someone with very small or very large nipples. Consider choosing a pump that has flanges of different sizes available if the need arises.
Pump vacuum and cycling can be another deciding factor in choosing a pump. When infants suckle on the breast they remove milk by creating negative pressure. This pressure ranges from -50 to -150 mmHg going to a maximum of -220 mmHg. The infant will usually only hold this pressure for less than a second. Multi-user pumps mimic this pressure and sucks per minute (or cycling), making them the most effective of all the pumps. They usually apply a minimum of 50 mmHg and a maximum 250 mmHg of pressure and have 40 to 60 cycles per minute. This means each cycle lasts 1 to 1.5 seconds. Applying pressure for 2 seconds or longer can result in damage to the nipple and areola. Less sophisticated pumps like battery-operated pumps have weaker motors and so they take much longer to build up to the maximum pressure. As a result they cycle much slower and so expose the breast to the vacuum for much longer than 2 seconds. Though some mothers will be able to tolerate this, other mothers could require a more sophisticated pump to prevent nipple and areolar damage.
As mentioned above, the standard size flange may not be the right size for every mother. Flanges that fit poorly can result in painful pumping, low pumped milk yield and not emptying the breast, and decrease in milk supply. A lactation consultant should assist her clients to find the right flange size. Most breast pump manufacturers have sizing guides on their websites based on the diameter of a woman’s nipple (at the base of the nipple). A proper fitting flange will support the areola without pulling it into the shaft of the flange and ensure that the nipple does not fit too tightly. Bear in mind that a woman’s nipples will swell slightly during pumping which may affect the size of the flange needed. A lactation consultant could get different flanges for different pump brands and use those to help a mom select the right size (providing she can sterilise them) before she spends a lot buying a pump with a flange that does not fit.
For many mothers cost will be the deciding factor in choosing a breast pump. If it is necessary for a mother to pump a great deal and she cannot afford to buy an expensive pump, perhaps buy the best one you can afford for your needs.
Frequency of pumping
When breastmilk supply is being initiated with pumping, for example when infants are premature or sick, pumping/ expressing should start within 6 hours after birth. Hand expression can be more effective at removing colostrum in the first few days and should not be underestimated. For the first two weeks the mother should pump 8 to 10 times per day. This helps to develop prolactin receptors and frequently empty the breasts which is essential to initiating and increasing milk supply. Mothers who express at work should express as often as they would have fed if at home.
Though it will differ from one mother to the next mothers who pump with a manual pump need to pump 10 to 20 minutes per session; with a single-sided pump they can pump 10 to 15 minutes per session; and with a double electric pump they can pump for an optimal duration of 7 to 10 minutes. They should stop pumping if the milk flow stops or is very little.
Mothers will need guidance on how to get the best use out of their pumps and how to get the maximum pumped milk yield. It is essential that she reads the instructions for her particular pump before she starts using it. She should always wash her hands before pumping and ensure that she is using clean equipment. Stimulating a milk ejection reflex before starting to pump will help to increase the amount she expresses. If she is with her infant, she could stimulate it by letting the infant suck on the breast and then pumping, or by breastfeeding on one breast while pumping on the other. Encourage her to do skin-to-skin whenever she has the chance because this will also help to release hormones which will assist milk production and ejection. If she is at work or otherwise separated from the infant, it may help to look at photos of the baby, smell a clothing item of the baby, listen to calming music or by doing slow chest breathing. Applying a warm compress to the breasts before pumping can also assist in getting the milk flowing. It is important that she finds a way to relax when pumping and gives herself enough time to pump because anxiety can inhibit her milk ejection reflex. When she pumps she should set the vacuum to the highest comfortable level that maintains milk flow. If the vacuum is set too high it may result in pain or nipple damage which, like the anxiety, can inhibit the release of oxytocin and so hinder the let-down. Suggest setting aside time in the morning to pump as pumping yields are higher in the morning.
Hands-on pumping (HOP) is a technique that has been proven to get the most milk out of the breasts and increase milk production. The technique is done as follows:
- Before pumping, massage both breasts. This can be done by massaging finger tips in circles over the breasts; by using the palm of the hand to massage from the outer part of the breast towards centre of the breast; or by using the side of the thumb from the outer part of the breast towards the centre.
- The mother should then preferably double pump while using a pumping bra to keep the flanges in place, freeing up her hands. She can even cut holes in a normal sports bra to support the flanges if she doesn’t have a special pumping bra. She then uses her hands to do breast compressions while she pumps. To do compressions, place the fingers and thumb around the breast near the chest wall and squeeze. Keep pumping and doing compressions all around the breast until the milk flow slows to only a few drops.
- Remove the pump and massage the breasts again focusing on any areas that still feel hard or full.
- Finally, use hand expression to empty the breast of the milk that was not removed during pumping.
This technique can be viewed online at: http://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
If milk supply is low, another technique called power pumping can be used to increase production. This method replaces one normal pumping session with an hour-long intense pumping regime. It is done like this:
- Pumping for 20 minutes (or until the milk stops flowing) and then resting for 10 minutes
- Followed by another 10 minutes of pumping and 10 minutes resting
- And lastly by pumping again for 10 minutes
The first milk ejection reflex of any pumping session releases the most amount of milk that will be pumped in a given session. By having three pumping sessions so close together one benefits from having three big milk ejection reflexes which will release a lot of milk. The frequent stimulation of the breast increases prolactin levels and the frequent emptying will remove the compound FIL (Feedback Inhibitor of Lactation) from the breasts which will assist in increasing supply. Supply may start to increase within two to three days of power pumping but for some mothers they may need to power pump for seven days before they see an increase.
Cleaning of pumps
It is essential that each mother knows how to clean her breast pump. She can read the instruction manual for her specific pump but the basics of cleaning stay the same for most pumps. Before and after using a multi-user pump, the pump switches, dials and casing around the motor should be wiped with a disinfectant. After each pumping session, the pump parts that come into contact with the milk should be taken apart, this includes flanges, collection bottles, valves, tubing etc. All these parts should be rinsed under running water. Then the parts may be washed in the top drawer of the dishwasher if the manufacturer states it or they can be washed by hand. If the parts are washed by hand it is suggested that a dedicated wash basin and bottle brush are used, to avoid contamination from the rest of the kitchen. The parts are washed in hot soapy water and then rinsed in fresh water. Following that, the parts should be air dried on a paper towel or unused dish towel in an area where they cannot be contaminated or become dusty. The paper towel or dish towel should not be used to dry the parts. The bottle brush and wash basin should also be washed and allowed to air dry. If using the dishwasher, all the parts should be in the top drawer and the small parts need to be placed in a mesh laundry bag or a cutlery basket that can close to prevent small parts getting lost or getting stuck in the dishwasher filter. The dishwasher should run with hot water and a heat drying cycle can be used if it has such a setting. Remove the parts from the dishwasher with clean hands and allow any wet parts to air dry as explained above.
The CDC suggests sanitising the pump parts at least once a day. This can either be done by using a microwave sanitising apparatus or by boiling the parts. It is not necessary to sanitise the parts if a dishwasher was used with a heat drying / sanitising cycle. To sanitise using a microwave, follow the instructions on the sanitising apparatus that was purchased. To sanitise by boiling, submerge the clean parts in a pot with water and boil for 5 minutes. Then remove using clean tongs and allow to air dry. The wash basin and cleaning brush should also be sanitised.
Though many microwave sanitisers are labelled ‘sterilisers’ it is important to note that neither boiling nor using the microwaving apparatus actually sterilises the pumping equipment according to the FDA. Fortunately sanitisation is all that is needed to keep the parts safe for a single user.
Once clean and dry, the pump parts can be reassembled and stored in a clean area until the next use. Mothers should inspect their equipment regularly to ensure that there is no damage or mould growing.
Pumping can play a huge role in preserving the breastfeeding relationship and providing infants with precious breastmilk.