Low Milk Supply -- How to Pump

How to Pump

Before your first pumping session, take some time to read and understand the instruction manual that comes with your pump, or ask for a demonstration at the pump rental station. Look at all the accessories and learn how the parts fit together. Some parts may need to be sterilized or washed before you use them for the first time; other parts may be damaged or destroyed by washing or boiling. The pump manual or the rental station should give clear instructions on the best way to prepare your kit for use. How often or whether you will need to sterilize the parts varies according to your unique situation and the age of your baby. The Human Milk Banking Association of America does not consider regular sterilization necessary when pump parts are cleaned well and regularly; this position was based on a study that found no difference in bacterial contamination of milk when collection by sterile kits and a mother’s own kit were compared.(1) Your health care provider will be able to give you advice appropriate to your circumstances. If sterilization is recommended, one product that is particularly convenient for sterilizing pump and bottle parts if desired is a microwave steam sterilization bag, which uses your microwave to create sterilizing steam.

Before turning the pump on, you may wish to moisten your breasts slightly to improve the fit and suction of the flange on your breasts. Be sure to center the flange over your nipple so that your nipple can move into the tube without rubbing against the sides, and be aware that sometimes a nipple that looks centered can pull out at an odd angle once the pump is turned on.

Some mothers find that the best way to help their milk ejection is to first start the pump at a rapid cycling speed with suction set at a low level. Then, once the milk ejection reflex has been triggered, the cycle can be slowed down and the vacuum level gradually increased to the maximum level that is comfortable. Do not increase it to the point of discomfort, since that can damage your nipple and areolar tissue and impact on your milk production.

When you are finished pumping, all the parts that come in contact with milk can be washed in warm, soapy water.(2) Once washed and rinsed, allowing the parts to air dry on a clean towel is more sanitary than hand-drying them.

Ordinarily, there is no need to clean the plastic tubing. However, systems that are open between the flange and the tubing (such as Medela) do have the potential for accidental contamination. If milk should back up into the tubing, it must be cleaned. First, run cold water through the tubing to flush out the milk. When clear, take the tubing by one end and begin “whipping” it in a circle (typically over your head) to use centrifugal force to push the water out. This is often best done outdoors and away from children. When most of the water is gone, hook the tubing up to the pump without the flange and run it for several minutes or until dry. An optional additional step that can be done after the water rinse and whip dry is to pour a small amount of rubbing alcohol through the tubing to help “sterilize” the inside and speed evaporation; whip again until most of the alcohol is gone, then hook up to pump to finish drying. If sterilizing Medela tubing in a Micro-Steam bag, be sure to use four ounces of water (or it can melt), and then use the same drying technique.

Sometimes tubing can become contaminated with dried milk or mold that cannot be cleaned out. If this happens, purchase new tubing.

Single vs. Double Pumping

Most of the automatic electric piston pumps allow either single or double pumping, allowing either one breast or both breasts to be pumped at a time. There are advantages to each method.

Single pumping may be a more comfortable choice for mothers who have a much greater yield in one breast than the other since the lower yield breast can hurt when it is producing little milk; using a bit of breastfeeding-grade lanolin on the low-yield nipple may help. Some mothers find that alternating breasts while single pumping results in a higher volume of milk. Single pumping also allows a mother to use her free hand to do breast compressions on the breast that is being pumped.

Double pumping has been found to be the most effective in removing milk as well as stimulating higher levels of prolactin.(3), (4) It is also much faster because you can pump both breasts at once. Working out the logistics of pumping both breasts at once can take some practice, but most mothers find that they can develop a technique fairly easily. Some hold each bottle or flange with a separate hand, while others may use one arm to reach around to the opposite breast while “tucking” the first bottle to the breast with the inside of the same arm, leaving one hand free. There are also special bras that hold the pump flanges to allow hands-free pumping.(5)

Pumping Tips

The key to pumping is to trigger as many milk releases as possible–unlike sucking through a straw where the more you suck the more you get, the breast depends on milk release to allow milk to flow freely. Depending on the cause of your low milk production, you may find that certain techniques to increase milk ejections, including massage, breast compression, visualization, relaxation, warm compresses, conditioning, and reminding yourself of your baby through pictures, sounds, and smells, can be very effective in increasing your milk ejections and pumping yield. You may also find that gentle nipple stimulation before and during pumping will also help milk ejection. Holding your baby while you pump may be the best stimulus of all.

Pumping without your baby present can sometimes make it difficult to experience milk ejection. Mothers often find that, in order to pump well, they need to make pumping as much like nursing as possible. They make sure that they are comfortable and have all their needs within easy reach. You may find that it helps to make and listen to a recording of your baby’s gurgling, coos, or gentle cries. If you have a special song that you often sing to your baby, try humming it to yourself as you pump. The sense of smell is also very powerful–try holding your baby’s unwashed blanket or piece of clothing next to your face as you pump.

For many mothers, one of the most difficult aspects of pumping is wondering what to do when your baby cries or fusses in the middle of a pumping session. It can seem very important to finish the pumping session, but doing so while listening to your baby cry can be agonizing. If this should happen to you, remember that your baby’s emotional needs come first and that nothing is as important as comforting a miserable child. You can always resume pumping later. Pumping should never cause you or your baby emotional stress.

Susan Burger, MHS, PhD, IBCLC, developed the following five tips and techniques to help mothers maximize their milk output through pumping:

Pumping Tip #1: Use Oil

Pumping with low production is often a “dry” experience that can be uncomfortable. For many mothers, a touch of olive oil rubbed inside the flange or a bit of breastfeeding-grade lanolin on the nipples can make an enormous difference in comfort.

Pumping Tip #2: Be Comfortable

Just as it is important for the mother to be comfortable while nursing, it is also important for her to be comfortable while pumping. In contrast, many mothers jam the pump flanges deep into their breasts, elbows sticking out like chicken wings, with their backs curled over so they can look at their breast while pumping (or because they have been told they have to lean over to pump). Is it any wonder that they complain of a miserable experience? Instead, try to find a comfortable spot with adequate pillows where you can lean back. The amount of milk pumped does not increase with leaning forward, so you may as well be comfortable! One caveat: The milk may stay in the flange tunnel because of the angle and can leak back onto the breast if you don’t rock forward periodically and allow it to empty into the bottle.

Pumping Tip #3: Use a Hands-Free Bra

A hands-free bra allows for multi-tasking while pumping. You can either buy one of these specialty bras, or you can try making a homemade version with a stretch sports bra or yoga top with an internal shelf bra and holes cut to fit. This can be great for hands-free pumping and allows you to eat, drink, scratch your nose, comfort your baby, or click on the TV remote while pumping. It also prevents you from curling up in an uncomfortable ball to watch what is coming out.

Pumping Tip #4: Flexible Nighttime Pumping

Nighttime pumping sessions are often the most dreaded part of pumping. Susan believes that a reasonable and practical approach is to pump when you wake up on your own, rather than pumping by the clock. This works with your body rather than against it as you are waking during light sleep (the state we usually wake from) rather than having your deep sleep interrupted. Coordinating with your sleep cycle can make a big difference in how you feel in the morning. Pumping is also a safe “sleep drug” ―the oxytocin release will put you back into a deep sleep, which for exhausted mothers is a good thing. This approach has been used with mothers of hospitalized premature infants and has been found to work better than the standard strict schedule for pumping at night. (If your baby is still in the hospital and you worry that you might not waken, try this simple alarm clock: Drink a large glass of water before bed. We guarantee that you’ll wake up before morning!)

Pumping Tip #5: Have Patience

Finally, some mothers take a while for their milk to increase for no clear reason. Sometimes it just takes time and patience, otherwise known as “tincture of time.”

Pumping Yield Amounts and Expectations

The amount of milk you are able to express with a breast pump is <I>not<I>always an accurate gauge of your milk production, because a pump extracts milk by a different mechanism than a baby does. Pumps can only create a rhythmic vacuum to withdraw milk that is easily available in the ducts and encourage milk ejection. A baby, on the other hand, is warm and cuddly and also adds tongue and jaw movements, which act to induce effective milk ejection and efficiently draw out the milk. Ideally, pumping to increase milk production frequently happens after full feedings. Collection of only a quarter of an ounce (7.5 ml) after fifteen minutes of pumping does not mean that is all you are capable of producing. Rather, that is part of the residual amount that baby left in the breast after nursing (remember, you can never really empty your breast completely; it is always in the process of refilling).

It is also important to remember that the human breasts are not designed to provide eight ounces of milk from the moment a mother’s milk comes in. Normally functioning breasts produce, on average, up to two ounces (60 ml) per feeding at the end of the first week. This is exactly what the baby needs at this stage, so don’t be disappointed if you’re unable to pump more at first.(6), (7), (8)

Pumping Problems

Pumping is not always easy and it does not always go smoothly. Most difficulties, though, can be resolved with some perseverance and appropriate assistance.

If you feel that your pump is not doing a good job of removing all of your milk, it is important to rule out a problem with the pump. Linda Smith, IBCLC, recommends the following steps to rule out a weak, damaged, or ineffective pump:

First, try putting the flange against your cheek and using the pump. You should feel a very strong, almost painful pinch. If your face is small or thin, you may need to puff your cheek out first in order to create a seal. You may also be able to seal the flange against your stomach.
Next, test it using a vacuum gauge fitted to the flange. (Your lactation consultant or rental station may have one.) Your pump should get to at least 100 mm of pressure in 1 to 2 seconds.
If the tests show that the suction is weak, check all of your kit pieces first to make sure that they are assembled properly and tightly, and that there are no cracks in hard pieces or rips in soft pieces. Hairline cracks will affect suction. If you are using the Medela Classic, the white filter between the tubing and motor must be bone-dry and CLEAN. Double-check pressure settings.(9)
If your pump is properly assembled and your kit is not damaged in any way, the pump motor may be the culprit. Does it sound strange, has it slowed down, or do moving parts hesitate? Return the rental pump to your depot and get a more effective one. Purchased pumps can sometimes be returned to the retailer, but more often consumers are required to contact the manufacturer directly.
Clean all parts that touch the milk with warm soapy water. If a part is gummy with dried milk, soak it in vinegar for several hours, then wash and rinse well.

If you have completely ruled out a problem with the pump, have a lactation specialist evaluate your pumping technique.

References

(1) Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book, 3rd Rev Ed. Schaumburg, IL: LLLI, 2003; 648.

(2) Human Milk Banking Association of America: Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings. (2005)

(3) Arnold, L. Recommendations for Collection, Storage, and Handling of a Mother’s Milk for Her Own Infant in the Hospital Setting. Sandwich, MA: The Human Milk Banking Association of America, 1999.

(4) Auerbach, K. Sequential and simultaneous breast pumping: a comparison. Int J Nurs Stud 1990; 27(3):257-65.

(5) Jones, E., Dimmock, P., Spencer, S. A randomized controlled trial to compare methods of milk expression after preterm delivery. Arch Dis Child Fetal Neonatal Ed 2001; 85:F91-F95.

(6) Hoover, K. and Wilson-Clay, B. Pumping for your premature baby (handout, 2004).

(7) Hartmann, P. Lactation and reproduction in Western Australian women. J Reprod Med 1987 Jul; 32(7):543-7.

(8) Daly, S., Owens, R., Hartmann, P. The short-term synthesis and infant-regulated removal of milk in lactating women. Exp Physiol 1993 Mar; 78(2):209-20.

(9) Smith, L. My Pump Isn’t Working!! Troubleshooting for Breastpump Users. Bright Future Lactation Resource Centre website. http://www.bflrc.com/ljs/breastfeeding/pumpwork.htm. Accessed Sep 5, 2004.