As healthcare providers and advocates, it’s important that we inform families and colleagues about the latest legal protections for lactating individuals at work. This year, I’m urging each of you to join me in a crucial community-wide effort. Let’s make it our mission to educate and inform everyone, from healthcare providers to the families that we serve, about these important changes.
In this article, I delve into the essentials of pumping, including understanding different pump types and features, and the importance of using an appropriate flange size. We’ll also discuss how to recognize and try to avoid potential pumping complications, and we acknowledge some of the emotional aspects of pumping. I’ve also included crucial advice on milk storage and handling. While the article covers a lot of material, don’t be overwhelmed. Convenient jump links are provided so you can easily navigate to the topics most relevant to you. I have also included some links where you can go to learn more.
Your engagement in this conversation is key to spreading awareness and support. Let’s work together to ensure that everyone in our community, especially those who are lactating, feels informed, supported, and empowered.
–Elaina Lee, MD, NABBLM-C
The Pump Act
As discussed in Breastfeed Durham’s January, 2023 article (link here), many parents who provide human milk for their babies incorporate pumping. The PUMP Act, passed in Dec., 2022, states that employers are required to provide designated space and time for employees who are pumping milk. This law, in combination with the expanding variety and accessibility of breast pumps in recent years, should increase the numbers of parents who will continue pumping at work, resulting in more babies receiving human milk for longer periods of time.
Many health insurance plans provide electric breast pumps to new parents. The insurance company might designate a specific pump, or they may give parents several options to choose from. However, the pumps arrive without specific guidance about how to use them. Sure, there is an instruction manual, but there’s no lactation support provider in the box!
People are told to pump their milk, but often without specific instructions about why, how, when, and how much. Parents are frequently encouraged, by healthcare providers, peers, and/or social media, to try to express as much milk as possible. On social media, we see photos of freezers full of pumped milk, and we are led to believe that this is the definition of successful pumping and “normal” milk production, something to aspire to. Parents are often not educated about the problems that can sometimes occur with pumping. This article will touch on some of these issues. The intention is not to scare people away from pumping, but rather to help people improve their pumping experience by knowing what to look out for and how to get help if problems do arise.
Why choose to pump?
Each family has unique circumstances that factor into the decision about how to feed their baby. Every family deserves to receive appropriate, non-judgmental education and support, regardless of their chosen feeding method.
The reasons for pumping are numerous and may include physical or mental health concerns, difficulty with direct feeding, societal pressure, past trauma, or family circumstances. Pumping (exclusive or partial) may be the best solution for many people who want to feed human milk to their babies. Some parents exclusively pump and bottle feed, and some transition from nursing at the breast/chest to exclusively bottle feeding. Some feed directly at the breast/chest when they are with the baby, and they provide pumped milk or formula for caregivers to bottle feed. Some parents induce lactation and pump milk for an adopted baby. If a lactating parent is hospitalized and unable to feed directly, they may need to pump during the hospitalization to maintain their milk supply.
How do I know which pump to use?
There are several categories of breast pumps. People can base their choice of pump on multiple factors, including cost, size, portability, wearability, power source, sound, and suction features.
Your lactation support provider can help you decide which pump(s) may be best for you. Many people use a combination of pumping methods in different circumstances.
Manual pumps are operated by hand. The user squeezes the pump’s handle to create a vacuum that extracts milk from the breast.
Electric breast pumps are usually able to pump both breasts simultaneously or one breast at a time. Some can also be used with batteries or a car charger. There are many brands of pumps available, and they vary in price and features. They typically have adjustable speed and suction power so that the user can experiment to find the best settings that work for them. Some pumps have pre-set modes for stimulation and expression. Personal use pumps are meant to be used by a single user. Hospital-grade pumps are designed to be used by multiple users, and they are usually rented out or provided in some workplace lactation spaces. These pumps are often very effective in people who are working hard to build their milk supply.
Many wearable breast pumps, which are worn inside the bra, have come to the market in the past few years. They can be very convenient for people who have difficulty finding the time and/or space to use an electric pump. Typically, they are not as powerful as electric pumps, but the convenience makes them a great option for people who need to pump while continuing their activities at home, work, or on-the-go.
Passive collection devices are generally made of silicone and can be applied to the breast to collect milk passively—that is, to collect milk that flows out when nursing a baby on the other breast, or even when doing routine activities.
Some people prefer to hand express milk; this works better than a pump for some people.
How do I know which size flange to use?
The flange is the part of the breast pump that fits the breast to create suction for milk extraction. Finding the right flange size/fit is an important part of using a pump properly. If the flange is too large or too small, there is a risk of difficulty with milk expression and injury to the nipple and breast tissue.
There are many video resources available about flange fitting, including: https://www.babylist.com/hello-baby/breast-pump-flange-fit
When should I pump, and for how long?
Just as the type of pump is individualized, the frequency and duration of pumping also need to be tailored to each situation. Lactation works on a supply/demand system: the more breast stimulation and milk removal (via nursing and/or pumping/hand expression), the more milk will be produced.
A parent with a baby in the NICU may need to pump every 2-3 hours to optimize milk supply. This milk can be fed to a baby via feeding tube until the baby is able to nurse or take milk from a bottle. Extra milk can be frozen for later use. Some parents with babies at home also pump every 2-3 hours at first to optimize milk supply. They pump less as their supply increases and baby feeds more effectively at the breast/chest. Some people pump for a few minutes after feeding the baby at breast/chest, in order to build more supply. Parents who induce lactation need to pump frequently to increase milk supply. Some people may not be able to, or choose not to, pump a full supply of milk (they supplement with donor milk or formula), so they might only pump 1-3 times a day. Some parents only pump when they’re away from their babies (e.g., at work or while traveling). Parents may not need to pump at all if they are home with their nursing baby and produce enough milk to meet the baby’s needs. After an infant loss, some parents will lactate/pump to honor their baby by donating milk to other babies in need.
The duration of pumping sessions can vary, depending on goals and needs, but it is generally best not to exceed 15-20 minutes per session to reduce the chance of developing the adverse effects of pumping too much.
What kinds of physical problems can happen with pumping?
Overproduction of milk (hyperlactation) can occur because of too much pumping. What’s the harm in that? While it’s fine to have some extra milk frozen for future use, over-pumping can be problematic for some people. It increases the risk of swelling and pain, blocked ducts, nipple blebs, and infection.
Pumping with a flange that is too large or too small, or pumping too often or for too long at each session can cause pain, swelling, and damage to the delicate glandular tissue in the breast. This makes it more difficult for milk to flow through the network of tiny ducts. If milk doesn’t flow well, nipple blebs or breast infection (like mastitis and abscesses) can develop, and feeding difficulties can occur. Sometimes people are told to feed or pump MORE in these cases, or to massage their breasts to work out the “plug.” However, massage and extra pumping can lead to more injury, so it is best to feed or pump on a normal/physiologic schedule and avoid massaging the breast. An exception would be lymphatic massage, which can help reduce tissue swelling and promote drainage of milk: https://eadn-wc01-5994650.nxedge.io/wp-content/uploads/2021/08/Lymphaticmassagehandout2.pptx.pdf
For people with oversupply, a knowledgeable lactation support person can help develop safe strategies for gradually reducing milk production and managing complications that may arise.
Is pumping stressful?
Even if there are no apparent physical complications from pumping, some people feel stressed, depressed, or anxious about how much milk they’re pumping, storing, and feeding. While wanting to do the best for their babies, parents’ feelings of self-worth or parental adequacy can become linked, in their minds, to the amount of milk they express and store. With social media photos and blogs about maximizing milk production, and numerous apps to track feeding/pumping, diaper counts, etc., it’s easy to get caught up in the numbers. People can quickly develop a sense of pride over their huge milk stash, and they may want to share their story to help other people. Conversely, some parents may feel inadequate if they are struggling to produce milk, especially when they see the overproducers on the internet, or when a healthcare provider has told them that their baby is not gaining enough weight and needs to be supplemented.
Difficult feelings around milk production are very common. Anyone (even partners and other support people) can experience stress and mood changes during this time. These feelings may be more likely to occur in people who already have mental health challenges or past trauma, or in parents who are grieving because their pregnancy/birth and/or lactation journey did not go as planned. Good support from medical and mental health providers, lactation professionals, and support groups can help families process these emotions. Here’s a great resource for finding postpartum mental health help:
Home
How much extra milk should I have in the freezer?
Many people like to save enough frozen milk to last for a day or two in case of emergency, while others like to freeze more. Some people don’t produce enough milk to be able to store any extra, or they choose not to.
Pumping small amounts, like 1 to 2 ounces a day, can quickly build up an adequate freezer stash. Someone who is overproducing might pump many extra ounces of milk each day. As noted above, overproduction can sometimes cause physical complications, so it is important to be on the lookout for signs of problems.
Frozen milk, stored and handled properly, is safe and healthy for babies. However, freezing gradually decreases some of the nutrient and antibody content of the milk, so it is best to feed fresh milk to babies whenever possible. In addition to providing the perfect nutrition for babies, fresh breast milk contains active antibodies to help babies fight bacterial and viral illnesses that the lactating parent and baby have been exposed to.
Some people who produce a lot of extra milk choose to donate it to a milk bank, or they donate directly to someone who needs it. Learn more about milk banking here:
- https://www.wakemed.org/care-and-services/womens/support-for-baby/mothers-milk-bank/
- https://www.hmbana.org/
Learn more about safe milk sharing here:
How do I store expressed milk?
Milk storage and handling recommendations vary a bit, depending on the source.
A good general guideline is 6-6-6: Under optimal conditions, breast milk may be stored for:
- 6 hours for fresh milk at room temperature,
- 6 days for refrigerated milk,
- 6 months for frozen milk (12 months if stored in a deep freezer)
More detailed guidelines for milk storage can be found in the Academy of Breastfeeding Medicine’s protocol #8:
Other resources include:
What if I’m not making/pumping enough milk to meet my baby’s needs?
Working with healthcare professionals like lactation consultants and physicians can help determine if a baby is getting enough milk at the breast/chest and/or a bottle. If the baby isn’t gaining enough weight, the baby may need to be supplemented with donor milk or formula. Depending on the parent’s goal (e.g., do they plan to try to produce a full supply, or are they happy with their current supply?), the providers can work with the parents to make a plan to ensure that the baby is eating enough to grow and develop at a healthy rate. Peer support groups like La Leche League and Nursing Mothers of Raleigh can also provide valuable advice and support during this time.
What if I have leftover milk after my baby is no longer taking milk in a bottle or supplementer?
If a baby has weaned off of human milk, any extra milk (as long as it meets safe storage guidelines) can be given to the baby in a cup or mixed in with other foods. Some parents may donate extra milk to a milk bank or an individual who needs it. If the milk has expired, it might still be used for other purposes. Milk can be added to bathwater or applied to baby’s skin. Some people make soap, lotion, or jewelry using breast milk!
Where do I go for help?
While pumping milk is very important for lactation in many people, parents often don’t learn that pumping can sometimes lead to complications. Knowledgeable healthcare providers and peer counselors can provide excellent education and support. They can help parents choose pump features and appropriate flange sizes, avoid over-pumping, and recognize signs of potential problems. This support can reduce risk of complications, increase the numbers of babies receiving human milk for longer periods of time, and improve the pumping experience.
- Breastfeed Durham’s website has many helpful resources
- https://breastfeednc.com/
- Lactation consultants, other healthcare providers, and support groups in NC:
- Lactation consultants:
- Breastfeeding and Lactation Medicine physicians:
IABLE has an interactive, though incomplete, map for searching for lactation support and BF/Lact Med physicians:
LactMap
Community-based peer support groups:
Find Breastfeeding Support
www.nursingmothersofraleigh.org/
-More detailed medical info about pumping considerations and many other topics:
Pumping