We discuss the use of breast pumps, including their purpose, usage, and storage of expressed breast milk. We are joined by Linda Catterton, IBCLC at the University of Texas Southwestern Clements University Hospital.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. In the last episode, you heard our lactation consultant Linda Catterton explain the ins and outs of breastfeeding. Today, she's back and we'll be talking about pumping. Linda, thanks for joining us again today.
Linda Catterton:
I am so happy to be here.
Dr. Neeta Goli:
So let's get started talking about pumping. So what are some reasons that moms might need to pump for their babies?
Linda Catterton:
Well, if a baby is born preterm, then that really is one of the main reasons when they have to pump to establish that milk supply. When mothers are returning to work, oftentimes they'll pump when they've returned to work. If mothers choose to provide expressed breast milk via bottle, then that's how they choose to provide that source of nutrition for their baby. And then oftentimes early on, when the milk supply starts increasing, then they have fullness where a pump may help to relieve that fullness to prevent engorgement from happening.
Dr. Neeta Goli:
So if mom, for whatever reason, needs to pump, how often does she need to pump?
Linda Catterton:
Well for preterm baby the recommendation, and even looking at the research that's involved in pumping to establish a milk supply, the recommendation is to use a hospital grade double electric breast pump to pump at least every three hours, but pumping every two to three hours for 15 minutes. Now, if they have multiples then that pumping time would actually be a double amount of time to place more of an order for more babies. And then when it starts out where it's more hormonal in those first few days, so they're placing the order, I will even tell them, "Let the pump be your friend. The pump is placing the order." We try to take measures to make it as easy as possible, allowing them to pump hands-free, and then when the milk begins to increase, then they'll pump a little sooner because they feel more fullness, and pump a little longer. The recommendation is not to pump longer than 30 minutes. Now they can pump at more frequent intervals, but just not for longer than 30 minutes.
Dr. Neeta Goli:
So say mom has a preterm infant who isn't able to nurse directly, so she's pumping for that baby. How much volume might moms expect to see in the first couple of days after a baby's born?
Linda Catterton:
Right. So in the first few days, even in the literature that we have, we encourage mothers to keep a log of the volume. So in that first 24 hours, they may not express anything, but using their hands and hand expression they may see a few milliliters or 1/10th of a milliliter, it really is a very small amount, especially the first 24 hours. The second day, they may start to see a few more drops, but again, using the hands and hand expression is going to increase what they get. It's usually around that third, fourth, and fifth day when the volume begins to slightly increase, so they may see 10 to 15 milliliters with each expression. And the goal is by the end of the second week to have at least 750 milliliters for a total volume in 24 hours, and that's a good indicator that they are establishing a good milk supply. So there are apps that they can keep up with the pumping, with the amount that they're pumping, or a log, we just use a paper log at work, but usually the moms choose to have the app.
Dr. Neeta Goli:
And then sometimes I get moms who ask me if they need to pump to build a freezer stash before they go back to work. What are your thoughts on this?
Linda Catterton:
Well, actually the literature will say if you're planning to go back to work, then a couple of days before to add some pumping sessions in. So that that first day maybe eight to 12 ounces of milk is available for the baby, and then you're pumping at work to provide what the baby needs the next day. Now, when you hear mothers saying, "I want a freezer stash," that is very common, and mothers choose to pump early on so that they can have more milk. I think sometimes when they see more milk that is in the freezer available for their baby, it can cause less stress, and that stress can have an effect on decreasing the milk supply, even being separated from the baby oftentimes decreases that milk supply for a bit, so I can certainly understand why mothers want to have milk available, plenty of milk available.
Linda Catterton:
Now, a lot of times when they say, "I'm returning to work, how can I achieve this so I make sure I have enough milk?", we don't tell them to start pumping early and pump often because they're returning to work. Oftentimes it's eight to 12 weeks before they're going to go back to work, so of course that time of healing, that special time with their baby, that special time establishing breastfeeding with their baby is important.
Linda Catterton:
Now, after a few weeks, if they want to introduce a bottle, then they could pump after the first feeding of the day. Generally what we'll see is more milk in the mornings, and as the day progresses, the milk is not quite as full as in the mornings. But the interesting thing about the volume is it has been shown in the composition of that milk as it changes throughout the day, the end of the day may not be higher in volume, but it's higher in the fat content. So even what that's leading to is babies tend to cluster feed in the evening, and they build up that fat so that they can sleep longer. So sometimes pumping at the end of the day can be discouraging to moms because they don't see as much milk, but the composition of the milk is of value to the baby at the time of day that it's pumped.
Dr. Neeta Goli:
Very interesting. So you mentioned earlier that moms only truly need as much saved up as baby will need for the first day that moms go back to work. For our listeners, that typically comes out to about an ounce to an ounce and a quarter per hour. So moms don't necessarily need more of a "freezer stash" than that, but every baby is different. Can you tell us a little bit more about that?
Linda Catterton:
Right. Some babies will take four ounces from a bottle. Some babies will take six to eight ounces from a bottle. Some babies feed it more frequent intervals. Breast milk is easily digested, so even the composition of the milk impacts the volume that they take. And of course, what they're looking at from that growth and development is weight gain, making sure that babies do have what they need nutritionally for their growth and development.
Dr. Neeta Goli:
And I think sometimes it's so hard as a mom, because you focus so much on how much is my baby getting, is my baby getting enough? Sometimes I'll have moms who say that they want to pump or bottle feed versus breastfeed, because they want to make sure that baby's getting enough. One thing I like to tell these moms is that the amount of milk that you get from pumping is not necessarily an accurate reflection of the amount of milk baby is getting through a nursing session, so if you truly want to know how much baby is getting through an individual nursing session, you can always, in conjunction with a pediatrician and lactation consultant if the facilities are available, do a weighted feed as a more accurate way of assessing how much baby's getting through breastfeeding. But that's not necessarily something that needs to be done if baby is having appropriate number of wet and dirty diapers, and has an acceptable amount of weight loss. So we like to provide reassurance when we can and if we hear those concerns from mom.
Linda Catterton:
Right. And oftentimes we do hear those concerns from mom. When babies are first learning to feed at the breast, it does take time for them to become more efficient at removing the milk. The same thing's going to be true with pumping, and your body responds hormonally to the pump. Sometimes I'll even say, especially if they start with one pump and then they're changing pumps when they return to work, or they go from a hospital grade pump to a personal pump, sometimes I'll say, "Give your pump a name, let the pump be your friend," because you are responding hormonally to how your body is giving the pump the milk.
Linda Catterton:
So yes, you're going to see different amounts when babies take it from the breasts than when a pump takes it from the breast. But for some mothers who choose exclusively to pump, it is the pump that gives them the most. So it really goes in line with how different it is for every mother, all breasts, and then certainly babies, how different and individualized it is in each setting.
Dr. Neeta Goli:
And what other tips do you have for moms, in terms of maximizing milk production when they're pumping?
Linda Catterton:
Right. So I think if we can give them tips, in fact, I'll even say, "Here are measures that can maximize the milk your body can make." So early on we're going to use hands, let hands help to maximize that milk. Massaging the breast before pumping, using breast compressions while they're pumping, hand expression after pumping. So the hands make a difference, it has been shown in the research that hands-on pumping makes more milk. So we always use hands when we're pumping.
Linda Catterton:
And then not getting engorged. Pump sooner if the breasts are filling, so if mothers feel that fullness we'll have them pump sooner, pump longer to maximize that milk. Even in the first few days, we don't expect to see a lot, and sometimes when mothers first start pumping, especially for the preterm babies, they don't see anything. The only time they see something may be with hand expression after pumping, but I remind them, the pump is your friend and you're placing the order for the milk that's going to come. And then around three to five days, that's when we see a change in the volume, that's when lactogenesis II begins, so there is a more abundant milk supply as the milk begins to increase.
Dr. Neeta Goli:
And for our listeners, that's often referred to as the milk coming in, when the milk supply increases like Linda mentioned. So once we do have that increased milk supply, how do we appropriately store all that milk if it's pumped?
Linda Catterton:
So expressed breast milk, when it is first pumped it can stay at room temperature for four hours. There's even some literature that says four to six hours. It can stay in the refrigerator for four days, some of the literature will say five to seven days, and then in the freezer, it can stay for six to 12 months. Now, if it's a refrigerator freezer, we'll tell the moms to put the milk at the back or the bottom of the freezer so that it does have a longer life.
Dr. Neeta Goli:
And side note, so the CDC does recommend that breast milk, if stored in the freezer, can be stored for 12 months. That doesn't necessarily mean that once the milk is 12 months old, that it has gone bad, what it means is that the nutrition might not be the same as the nutrition when it was first pumped. So take it on a case by case basis, but the milk does not need to be thrown away, per se, after 12 months in a freezer.
Linda Catterton:
And if mothers have an abundant milk supply and they have a lot of milk that they've stored up that they're not using, if their baby is over six months of age and they're a healthy individual, they have the option of donating that extra milk to the milk bank. In Texas we actually have two milk banks, which is the only state that has that. But there's one in Fort Worth, the Mother's Milk Bank, and there's also one in Austin, so that's even an option for a surplus of milk.
Dr. Neeta Goli:
And that would be a great resource, because again, all of our babies who are born premature or babies who are in the NICU who benefit so much from breast milk, if their moms aren't able to produce the breast milk themselves, they rely on donor milk, so it's a great resource to know about.
Linda Catterton:
Absolutely.
Dr. Neeta Goli:
And then if we have the bottle of pumped breast milk and we offer it to baby, baby starts drinking it, but then doesn't finish the bottle, what do we do with the rest of that bottle?
Linda Catterton:
Yeah, I'll always even remind the mom, you may not know in the very beginning how much your baby's going to take, it's always better to start off with a little less, because you can always add more. But once you've given that bottle for that feeding, after an hour or two you have to throw out the milk. Breast milk is so precious, mothers work so hard to remove it, that we want to make sure that it's within that time limit.
Dr. Neeta Goli:
And now what about all those pump parts? How do moms need to clean them or store them?
Linda Catterton:
So before a mother even starts using the pump parts, if it's her own personal pump, then she would sterilize those pump parts prior to using. If she's using a hospital grade pump and the pump is set up in the hospital, then we have a sterilized kit that is used for those mothers. But after they have pumped, then those first few days there may not be milk that's even touching the pump parts, so they may only have to clean the flange size. But the recommendation is to have clean hands, to rinse in cool water, wash in hot, soapy water, and then allow the pump parts to air dry away from a dirty sink.
Linda Catterton:
So when mothers are collecting milk, they want to make sure that where the milk is being collected into those pump parts, that it is a clean area. It doesn't have to be sterile every time, although for preterm babies the recommendation is to sterilize daily. For mothers who have full term healthy babies at home, then they can sterilize their pump parts every few days. So even on the clean pump parts, the reason it's recommended to air dry, it's because we don't want a dirty cloth to be taken to dry out the bottles by bringing in possible bacteria into that milk, but keeping those pump parts clean, and that's why air drying is recommended.
Dr. Neeta Goli:
Okay. So what about when moms go back to work and they're pumping at work, how should they clean and store the pump parts?
Linda Catterton:
So, there's different information that mothers may hear. And if they're in a work setting where they do have a refrigerator, it's possible that they can have a clean Ziploc bag where they refrigerate those pump parts and then clean the pump parts when they get home. Now, the recommendation would be the same: rinse in cool water, wash in hot, soapy water, allow to air dry. But refrigerating those pump parts at work may be an option for them.
Dr. Neeta Goli:
So if you're a mom who's looking at pumps, there's lots of different kinds of pumps. There's hand pumps, there's electric pumps, and then there are things that are marketed as pumps, but are really more just kind of for passive collection of breast milk. Can you talk about the different kinds of pumps that are available? And actually, I do want to just make the statement, we don't have any financial interest in any of these, we don't have any conflicts of interest to report, we're just kind of discussing for our listeners and knowledge about what's available.
Linda Catterton:
So for preterm babies the recommendation is to use a hospital grade, double electric breast pump. And the reason the hospital grade is recommended is it has a motor that has more horsepower, it just has a little more efficiency to the motor. It's made for multi-users, so it works more effectively to get the milk supply established when you don't have a baby that's doing it. Now, the personal pumps, a lot of insurance companies provide breast pumps for mothers, there are so many to choose from. I couldn't even start with the list on, "Oh, this is the one you should use."
Linda Catterton:
So the recommendation would be look at the reviews, look at what the literature says about using breast pumps, making sure that you have one that has the cycles that begin with the let-down mode, and those are faster cycles in the beginning, and then it switches after a couple of minutes, or manually you switch it to the expression mode. Making sure that there is that pump and release, the cycles do have a release. Now some breast pumps are used for batteries, sometimes batteries aren't always the best resource, an outlet might be better, or there may be a battery pack that does provide that motor to work effectively.
Linda Catterton:
The recommendation is a pump has a life for about a year. So even with other babies, to go ahead and get another pump and not just use the same pump for multiple babies. It may be that that motor, which is no longer guaranteed, isn't working as effectively, so you don't want to risk jeopardizing the milk supply because the motor is not working as effectively on the personal pumps.
Linda Catterton:
Now, when you're using a pump that's more passive, it's not recommended for milk removal during separation from a baby, but it's a great thing to have for just passively collecting milk with a strong let down, or when feeding on one side and the baby's not going to feed on the other side, then there are pumps that attach to the breast with very gentle vacuum. Now it's not recommended to use it all the time, because that vacuum can actually cause the nipples to become quite sore, if it's continuously used. And even on those particular pumps it sometimes doesn't stay attached, so you always want to pay attention to how it is attached, and if you move around a lot oftentimes it falls off, and then you lose all of that milk that you're passively collecting.
Dr. Neeta Goli:
And then there are lots of newer technologies that are available as well. So there are the typical pumps that you think of that are electric, that plug into the wall, there's also some new wearable pumps, so that moms, especially if they're going back to work or if they're moving around a lot, have a lot of activities to do, they can pump while they're on the go or at work. So lots of exciting things to learn about.
Linda Catterton:
Yes, and mothers learn all of these things. They try, they share the information, so they are even a good resource amongst themselves. And sometimes one pump does work more effectively for one mother than another, and sometimes it has to do with milk volume. So early on, establishing the milk supply is really a key component to having options with pumping and continuing to provide the breast milk.
Dr. Neeta Goli:
So Linda, thanks again for joining us today. It's been wonderful to talk to you. To end the episode today, what is your favorite part of your workday?
Linda Catterton:
You know, I think one thing I say to my moms on a daily basis when I'm there is, "This is why I get to be here. I get to come help you." I love my job. I love what I get to do. I see the value and the importance of breastfeeding, but I also see the value and the importance of every mother, whether they choose to breastfeed or not. So it's just a great place to get to be, I'm glad I've had the opportunity to do it. Thank you so much for asking me to come.
Dr. Neeta Goli:
We're so happy to have you here.
Linda Catterton:
Thanks.
Dr. Neeta Goli:
Thanks for listening to Newborn News, we hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests, and do not necessarily reflect the views of the university.