To promote breastfeeding after a mother returns to work, clinicians need to make knowledgeable recommendations about which breast pump to use and provide guidelines to ensure proper milk storage.
To promote breastfeeding after a mother returns to work, clinicians need to make knowledgeable recommendations about which breast pump to use and provide guidelines to ensure proper milk storage.
The American Academy of Pediatrics, citing breast milk as the "optimal form of nutrition for infants," recommends exclusive breastfeeding for approximately the first 6 months of life.1 Similarly, ACOG's bulletin on breastfeeding states that "human milk provides developmental, nutritional, and immunologic benefits to the infant that cannot be duplicated by formula feeding."2 Complementary foods should be added at about 6 months of age and breastfeeding should continue for at least the first year.1 In line with these recommendations, the national goals of Healthy People 2010 are that 75% of mothers will initiate breastfeeding, 50% will still be breastfeeding 6 months later, and 25% will be breastfeeding at 1 year.3 Regrettably, breastfeeding rates in the United States don't come close to these goals. As of 1998, only 64% of new mothers in the US initiated breastfeeding and only 29% were breastfeeding at 6 months.4 In light of such statistics, Former Surgeon General David Satcher, MD, called the need to increase breastfeeding rates "a public health challenge."5
In the US, 60% of employed mothers rejoin the workforce before their infant is 2 months old. Studies suggest that returning to work within 1 year of the baby's birth is associated with a shorter duration of breastfeeding.6 Going back to work, however, need not be a reason for stopping breastfeeding. Breast pumps offer the means by which a mother can express her milk so that it can be stored and fed to the baby later and so that she can maintain her milk supply.
While pediatricians are ideally positioned to encourage continued breastfeeding, ob/gyns can also play an important role in this area.7 Anticipatory guidance on a variety of topics is a keystone of the physician's role, and breastfeeding is no different. Advice to help ensure "back-to-work" breastfeeding success is listed in Table 1.
Obtain a high-quality breast pump
Begin pumping at least once a day to build up a supply of frozen milk for later use
Introduce a bottle of expressed milk once a day
Make plans for a manageable back-to-work transition, such as working only two days the first week
Establish a space at work where pumping will be done
Confirm cooperation of the supervisor or manager in regard to taking pumping breaks
Plan refrigeration to be used at work and for transporting expressed milk home. Many "personal use" pumps come with a tote bag that has a cooler section for milk storage. A small cooler and a few blue ice refreezable ice packs work fine.
Find a photo of the baby or an item of clothing to take to work
Plan to breastfeed before leaving for work and as soon as returning home
Be aware that the first week back to work is the most difficult
Source: Meek J. Breastfeeding in the workplace. In Schanler RJ, ed. Pediatr Clin North Am. Breastfeeding, 2001; Part II: The Management of Breastfeeding. Philadelphia, Pa: WB Saunders; 2001.
When clinicians want in-depth information about breast pumps, they often seek out an experienced lactation consultant whose knowledge on the subject is up to date. With that in mind, I (Dr. Philipp) decided to pick the brain of an expert colleague, Anne Merewood, IBCLC, the lactation consultant and source of breast pump information at Boston Medical Center.
How does a breast pump work?
All breast pump manufacturers try to replicate the best "pump" aroundthe baby who sucks at a rate of 60 "suck and pause" cycles per minute. The infant's sucking capacity reaches a maximum negative pressure of about 220 mm Hg.8-10 A breast pump works by reducing resistance to the outflow of milk from the alveoli by exerting negative pressure on the breast. The pressure generated within the breast by the milk-ejection reflex and pulsatile oxytocin levels pushes the milk out.9
Interestingly, much of what we know about the ideal design for a breast pump for humans comes from the dairy industry. Einar Egnell, a Swedish scientist who pioneered the human electric breast pump in the 1950s, based his early designs on cattle milking pumps.
Where do you start when a mother asks for help selecting a breast pump?
With a careful assessment of the mother's needs.11 Breast pumps come in a variety of models, sizes, and capabilities. Factors to consider before recommending one to a mother include: the baby's age; the mother's work status (full-time or part-time); any support that the mother's work environment offers, such as designated private space and pumping breaks; the mother's finances as they relate to buying or renting a pump; and the family's health insurance. Most insurance companies don't pay for pumps unless the baby is ill (see "Coverage for breast pumps: far from universal").
Be aware that mothers often say they have a breast pump, but it may not be a very good one or it may not be strong enough to do the job. So it's important to find out more about what they mean.
Let's say the infant is 3 months old, the mother is returning to work full-time, the only place to pump is the women's rest room, and the family's health insurance does not cover breast pumps. What would you recommend?
Ideally, this mother should obtain a high-quality, double set-up electric breast pump. These pumps have adjustable speed and suction levels, pump both breasts simultaneously, and, like the infant, "suck" then pause in an automatic cycle. These features make them a good choice for a breastfeeding mother who is returning to work; studies show these women are most concerned about how much milk they can express (which depends on many variables, such as the baby's age and the time of day pumping occurs) and how long it will take.9
In my experience, many women in the Boston area choose breast pumps made by Hollister (formerly Ameda Egnell) or Medela. The quality and reliability of both brands are comparable. Hollister's Elite and Medela's Lactina are the pumps commonly purchased by employers to put in their expressing rooms or rented by mothers of infants in the neonatal intensive care unit (Table 2). Rental fees vary with length of time: A prepaid 6-month rental, for example, may work out to around $30 a month, whereas a 1-month rental may cost about $75. The mother will also need to buy the milk collection kit, which includes collection bottles, tubing, and breast flanges, for about $50.12
For mothers who can afford to buy a pump, some manufacturers have developed a relatively new "personal use pump" line. Hollister's Purely Yours retails for about $200 to $225. Medela's Pump in Style sells for about $275. No research exists to demonstrate whether the Elite or Lactina are any more effective in establishing a milk supply than the Purely Yours or Pump in Style. Apart from the minimal difference in pressure levels, the differences seem to be in the durability of the motor, length of the manufacturer's warranty, personal amenities, and style of packaging.11
You mentioned two pump manufacturers, and there are many others. Is any one pump better than the rest?
Very few studies have compared the efficacy of different breast pumps.13 Information becomes outdated quickly because new pumps continually appear on the market. The research is rather predictable, too: Bilateral pumping takes less time than pumping each breast individually, and large, efficient, double-setup electric breast pumps, with adequate pressure and cycles per minute, express a greater amount of milk14 than less powerful, slower pumps.15 Bilateral pumping produces higher prolactin levels than single-sided pumping.16
One study compared the four major types of milk expressionelectric, battery, mechanical, and manualto the baby's natural suck in terms of their effect on maternal prolactin and oxytocin levels and amount of breast milk produced. Prolactin levels were highestcomparable to those produced by the baby's suckwhen an electric pulsatile pump was used bilaterally for as long as 15 minutes. The mechanical pump and the battery- operated pump were less successful in elevating prolactin levels. Maternal oxytocin levels did not differ significantly among any of the methods studied. The electric pump produced the most milk, followed by manual pumps, battery-operated pumps, and hand expression. The results of this study suggest that the most efficient pump is the double-setup, electric pulsatile breast pump.13
What would you recommend for a new mother who is not planning to be separated from her baby for long periods and wants a pump for occasional use only?
A small battery-operated or hand pump is best for a mother who does not need the "industrial" model. Hand pumps made by Medela and Hollister usually work well. Women seem to like Medela's Mini Electric, which is one of the better battery-operated small pumps. I have also heard good things about the new Avent ISIS hand pump.17
A good hand pump does not cause pain, is easy to operate and clean, and is durable. Unfortunately, it is usually impossible to assess this critical information until you actually use the pump. Some women spend $50 or more on a battery-operated pump only to find that it hurts and doesn't work properly. It's interesting, thoughwomen rarely blame the pump. They assume it's their fault they are not making enough milk or think they are doing something wrong.
The breast pump industry is a sizeable one. Is it regulated in any way?
In the US, no legislation sets minimum quality standards that breast pump manufacturers must meet. The Breast Pump Safety Act (H.R. 3372) was introduced recently in Congress by Congresswoman Carolyn B. Maloney (D-N.Y.) and would require the Food and Drug Administration to develop minimum quality standards for breast pumps to ensure that products on the market are safe and effective. At the moment, though, there is no regulationso buyer, beware.
Often, doctors write a vague, generic prescription like, "Disp: #1. Sig: Breast Pump," thinking the mother will automatically get an electric pump of adequate quality. I have seen pharmacists fill such scripts with a small, poor-quality hand pump, like the infamous, painful "bicycle horn" pump. This type of pump is almost impossible to clean. It also can generate extremely high levels of negative pressure, causing sore nipples and leaving a mother with little enthusiasm for breastfeeding.
I suggest clinicians find a breast pump they can recommend by talking with mothers in their practice and then developing a relationship with a rental station or dealer. They should then provide women with the name of a specific breast pumpjust as they write prescriptions for a specific drugas well as exact information about where to obtain the pump.
Take me through a pumping break, start to finish.
Hopefully, the mother can retreat to a quiet, private area in her workplace that is designated as the expressing or breastfeeding room and is equipped with a comfortable chair. If possible, she should wash her hands and then set up the pump and collecting system.
To produce the most milk possible, it helps to elicit the milk-ejection reflex before pumping. To achieve this, a mother may find it helpful to look at a picture of her baby, smell an article of the baby's clothing, listen to soothing music, or spend several moments with her eyes shut taking slow, deep breaths. It is also helpful to manually massage the breasts while pumping. When time is short, relaxingso important to eliciting the milk-ejection reflexcan be the most difficult part of the session.
The mother should pump for every missed feeding and then store the expressed milk in a cool place (see Patient Information). When she is finished pumping, she should carefully rinse the breastfeeding kit.
What do you recommend if the baby refuses a bottle?
This is a common and extremely frustrating problem because exclusively breastfed infants may develop a strong preference for the breast. Refusal of the bottle makes the parents feel even more dubious about leaving their infant to return to work. Solutions for one infant may not work for another, so offer several ideas. For example: Someone other than the mother can attempt to feed the infant breast milk from the bottle. This may work best when the baby is sleepy and the mother is out of sight. Or, offer the baby breast milk in a container other than a bottle. An infant 4 months of age or older can be offered breast milk in a cup with a lid. For a younger infant, try a small, clear, flexible medicine cup, a syringe, or a spoon. Introducing a bottle at around 1 month of age rather than later sometimes helps to avoid refusal of the bottle.
What are common pumping problems?
One problem I see all the time at this inner city hospital is that women can't afford to rent a breast pump in the first place. Beyond that, by far the most common problem I see is dwindling milk supply over time. Maybe the woman is not pumping frequently enough at her job. At work, the mother should double pump about every 3 hours for 10 to 15 minutes, or for every missed feeding (for example, if the baby is 9 months old and only breastfeeding twice during the day, the mother should pump twice daily at work). Or, maybe the mother is using an inefficient pumpone that has neither adequate levels of consistent pressure nor enough cycles per minute. Sometimes the family gets into the habit of bottle-feeding and the baby is given bottles on the weekends, even when Mom is home. It is important to breastfeed the baby at home as much as possible to make sure the breasts are adequately stimulated to continue to produce enough milk.
Another frequent problem is sore nipples. This is usually the result of a bad pump, of turning the pump up too high, or of pumping for too long at once. (When a woman misses a pumping session, she may try to compensate by pumping longer the next time.) Fatigue is another issue, especially at the beginning, when returning to work, leaving the baby in child care, and pumping can all be overwhelming. Most women find things settle down a little after the first 2 or 3 weeks, and they get into a pumping routine.
What pumping guidelines should a mother of a sick or premature infant follow?
The mother of a sick baby is often separated from the infant for long periods. A premature baby or a baby with a significant chronic disease may require lengthy hospitalization. In such a case, the mother needs to initiate pumping as soon as possible after the separation. Because regular pumping stimulates and maintains the milk supply, she should try to pump every 3 hours around the clock, each time for approximately 10 to 15 minutes, using a double milk collection kit. Any mother who is not nursing her baby at the breast because of a medical reason should pump with a double electric breast pump at least five times in 24 hours, for a total pumping time of approximately 100 minutes a day.18 Even if the infant is not eating, the mother should pump and freeze her milk for future use. Human milk can be given by nasogastric tube until the infant is able to start oral feedings at the breast.
If the baby has hyperbilirubinemia, every attempt should be made to continue breastfeeding. The laxative property of colostrum stimulates the gut to expel meconium, decreasing the enterohepatic circulation of bilirubin. If the baby is not feeding well at the breast, the mother may need to use a breast pump to stimulate her milk supply. Any extra milk she pumps can be fed to the baby using a cup, syringe, spoon, dropper, or other alternative feeding method.
1. Breastfeeding and the use of human milk. Pediatrics. 1997;100:1035-1039
2. ACOG Educational Bulletin, # 258, July 2000 "Breastfeeding: Maternal and Infant Aspects."
3. US Department of Health and Human Services. Healthy People 2010: Conference Edition, Volumes I and II, January, 2000; Washington, D.C., Department of Health and Human Services.
4. Ross Products Division, Abbott Laboratories: Mothers' Survey, Columbus, Ohio, 1999.
5. US Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, D.C., Department of Health and Human Services, Office on Women's Health, 2000.
6. Visness C, Kennedy K. Maternal employment and breastfeeding: findings from the 1988 National Maternal and Infant Health Survey. Am J Public Health. 1997;87:945-950.
7. Philipp BL, Merewood A, O'Brien S. Physicians and breastfeeding promotion in the United States: a call for action. Pediatrics. 2001;107:584-587.
8. Zoppou C, Barry SI, Mercer GN. Comparing breastfeeding and breast pumps using a computer model. J Hum Lact. 1997;13:195-202.
9. Riordan J, Auerbach KG. Breastfeeding and Human Lactation. 2nd ed. Sudbury: Jones and Bartlett; 1999.
10. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 5th ed. St. Louis: Mosby; 1999.
11. Zinaman MJ. Breast pumps: ensuring mothers' success. Contemporary OB/GYN . 1988(Oct. 15);30:55.
12. Merewood A, Philipp BL. Breastfeeding: Conditions and Diseases. Amarillo, Tex: Pharmasoft Publishers; 2001.
13. Zinaman MJ, Hughes V, Queenan JT, et al. Acute prolactin, oxytocin responses and milk yield to infant suckling and artificial methods of expression in lactating women. Pediatrics. 1992;89:437-440.
14. Groh-Wargo S, Toth A, Mahoney K, et al. The utility of a bilateral breast pumping system for mothers of premature infants. Neonatal Netw. 1995;14:31-36.
15. Green D, Moye L, Schreiner RL, et al. The relative efficacy of four methods of human milk expression. Early Hum Dev. 1982;6:153-159.
16. Neifert M, Seacat JM. Milk yield and prolactin rise with simultaneous pumping (abstract). Ambulatory Pediatric Association Meeting, May 7-10 1985, Washington, D.C.
17. Fewtrell MS, Lucas P, Collier S, et al. Randomized trial comparing the efficacy of a novel manual breast pump with a standard electric breast pump in mothers who delivered preterm infants. Pediatrics. 2001;107:1291-1297.
18. Hopkinson JM, Schanler RJ, Garza C. Milk production by mothers of premature infants. Pediatrics. 1988;81:815-820.
Most large health insurance companies, as well as Medicaid, pay for a breast pump only if the infant is ill and the mother and baby are separatedthat is, if the infant has been admitted to the neonatal intensive care unit. In Massachusetts, however, several insurers are now covering pumps for all babies. They include Healthy Start (a state initiative for women who are not covered by Medicaid or other health insurance) and three insurance companiesthe Boston Medical Center (BMC) HealthNet Plan, Blue Cross Blue Shield, and Neighborhood Health Plan (NHP).
The BMC HealthNet Plan, initiated in 1997, decided to pay for a breast pump for any breastfeeding member after the hospital's breastfeeding team provided the HMO with information about how much money is saved when a baby is breastfed instead of being fed formula.1 As word of this benefit spread, physicians began steering families to the BMC HealthNet Plan. Blue Cross Blue Shield then decided to pay for breast pumps for any member, with the funds coming from the mother's durable medical equipment budget; the mother can choose a breast pump instead of, say, a wheelchair.
Then NHP, an HMO covering the greater Boston area, followed suit. James Glauber, MD, medical director of pediatric populations at NHP, said in a letter to community physicians: "We must collectively overcome the numerous barriers to achieving . . . important [breastfeeding] goals. Inability to afford a quality breast pump should not be one."
At BMC, many women switch their health-care coverage to get a breast pump. The fact that so few insurers pay for a pump makes a case for having corporations provide one for mothers who are returning to work. More and more, workplaces are providing well-equipped pumping rooms. In fact, there is even a lactation room at the Pentagon!
1. Ball TM, Wright AL. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103:870-876.
The patient handout may be photocopied and distributed to patients in your practice without permission of the publisher.
If you are pumping your breasts and feeding your baby breast milk at a later time, you must follow certain guidelines on storing the milk. Here are the answers to some commonly asked questions.
What type of bag or container should I use to freeze breast milk?
Many women use disposable bottle bags (made of polyethylene). Cheaper, generic bottle bags are fine to use, too. They come in a tear-off roll and can be purchased at your local pharmacy. Brand name bags (such as Medela and Playtex), sold specifically for breast milk storage, work well but are more expensive and sometimes harder to find.
When using disposable bags, double-bag the milk to eliminate the risk of contamination from nicks: Fill the bag with breast milk, tie off the top with a freezer tie, and then place that bag in a larger storage bag (like a zipper-lock bag) along with other bags of frozen milk.
A hard-sided storage container is best for storing breast milk. Options include glass (clear or brown), clear hard plastic (polycarbonate), and frosted hard plastic (polypropylene). These containers are more expensive than disposable bags and take up more room in the freezer.
How much should I freeze?
Freeze breast milk in small amounts2 to 4 oz. These small volumes thaw faster than large amounts, and less is wasted if your baby is unable to finish all the milk.
When filling any container with the breast milk that is to be frozen, leave a little space at the top. Breast milk, like most other liquids, expands when it freezes.
Do not add fresh, warm milk to already frozen milk. This defrosts the previously frozen milk.
How will I know if the freezer is cold enough?
If the temperature is cold enough to freeze ice cream then it is cold enough to freeze breast milk. Choose the coldest location in the freezer to store breast milk; the back of the freezer is colder than space near the front or in the door.
Label the bag or container with the collection date and the volume. Also, write your baby's name if a day-care provider or other caregiver will be preparing feedings for the baby. Place the newest milk in the back of the pile in the freezer and move older milk to the front.
How long can I store the milk?
That depends on where the milk is stored. The table below lists the different times by storage location. These guidelines apply to milk for healthy infants only.1-5
How should I defrost frozen milk?
You can move it from the freezer to the refrigerator, in which case it will thaw in 12 hours. Or, you can place it on the counter at room temperature. Placing it in a container of tepid water or running it under warm tap water will speed up the thawing process and also warm it up. Do not microwave the milk!
The fat in breast milk rises to the top so it may appear layered after it defrosts. Swirl the milk to mix it before feeding. Breast milk may acquire a tinge of color depending on the mother's diet, but it remains perfectly good to use. Some mothers complain that defrosted milk smells sour, soapy, or fishy. It is not clear why this occurs, but general agreement in the lactation community is that the milk can still be used as long as the baby does not reject it.
1. Williams-Arnold LD: Human Milk Storage for Healthy Infants and Children. Andover, Mass., Health Education Associates, 2000.
2. Slusser W, Franz K. High-technology breastfeeding, in Schanler R, ed. The Pediatric Clinics of North America. Breastfeeding 2001, Part II. The Management of Breastfeeding. Philadelphia, Pa; WB Saunders: 2001:505-516.
3. Ogundele MO. Techniques for the storage of human breast milk: implications for antimicrobial functions and safety of stored milk. Eur J Pediatr. 2000;159:793-797.
4. Quan R, Yang C, Rubinstein S. Effects of microwave radiation on anti-infective factors in human milk. Pediatrics. 1992;89:677-669.
5. Hamosh M, Ellis LA, Pollock DR. Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk. Pediatrics. 1996;97:492-498.
Barbara Philipp. Encouraging patients to use a breast pump. Contemporary Ob/Gyn 2003;1:88-100.