Patient education: Pumping breast milk (Beyond the Basics)

OVERVIEW — To maintain a plentiful milk supply, the two most important factors are breast stimulation and removing milk from the breasts. A breast pump is a device that allows a person to express (remove) milk from the breasts when it is not possible to breastfeed. Many people choose to use a breast pump so that they can continue to provide breast milk while away from their baby (for example, when returning to work or school) or if their baby is hospitalized. Breast milk has many benefits for your baby whether you breastfeed or use a pump. (See "Patient education: Deciding to breastfeed (Beyond the Basics)", section on 'Benefits for the baby'.)

This article discusses the use of breast pumps and breast milk storage and preparation. If a breast pump is not available, hand expression may be used; this will be discussed briefly as well.

Additional information about breastfeeding is available separately. (See "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)" and "Patient education: Common breastfeeding problems (Beyond the Basics)".)

CHOOSING A BREAST PUMP — Not everyone who breastfeeds chooses to buy or use a breast pump. However, you might want to pump for any of the following reasons (or others):

●To signal your breasts to make milk if you are unable to breastfeed after birth (eg, if your baby is sick or separated from you)

●To signal your breasts to make more milk if your milk supply is low (eg, by pumping your breasts after or between breastfeeding sessions)

●To maintain your milk supply when you are away from your baby (eg, after returning to work or school)

●To provide breast milk if you choose to feed your baby from a bottle rather than directly from the breast or so your partner (or another support person) can feed the baby

If you do choose to pump, there are many different breast pumps available; these vary in cost, quality, and efficiency. The best pump for you depends upon your situation and how frequently you plan to pump. You may want to wait to buy a pump until after your baby is born and you have a better idea of your needs.

The different types of pumps are discussed more below.

Hospital-grade electric breast pump — A hospital-grade electric breast pump is recommended if you must establish and maintain your milk production for extended periods of time, for example, if your baby is born premature or hospitalized and cannot breastfeed immediately after birth. This is the most efficient type of pump and is the most effective way to maintain an adequate milk supply for a baby's full nutritional needs. Although most people prefer to pump both breasts at the same time (sometimes called "double pumping"), a hospital-grade pump can also be used on one breast at a time.

The amount of time it takes to empty both breasts can vary but is generally approximately 10 to 15 minutes after "let-down" (see 'Let-down' below). A hospital-grade pump can be safely used by more than one person in a hospital and may be rented for home use. Some health insurance plans cover the cost of renting a hospital-grade breast pump.

Personal electric pump — A smaller personal electric breast pump might be a good choice if you are doing some direct breastfeeding or need to pump sometimes, such as when you are at work or traveling. This type of pump is more portable than a hospital-grade pump and can be used up to several times per day, but it is not as effective as a hospital-grade pump in establishing and maintaining milk supply. Most models allow you to pump one or both breasts at a time. The life expectancy of these pumps is generally approximately one to two years, depending upon how frequently the pump is used.

Some of the high-quality personal pumps are self-contained in a carrying case (as a backpack or shoulder bag) that includes the motor, supplies, and, in some cases, a cooler for storing milk. The pump and related equipment are small and light enough to carry on a daily basis. These pumps are intended for use by only one person; sharing or reselling of a personal pump is not recommended. More information about choosing a personal electric breast pump is available from the US Food and Drug Administration website.

Personal single-sided pump — If you want to pump occasionally (for example, so another caregiver can give your baby breast milk from a bottle), you might choose to use a single-sided breast pump. Single pumps are powered by hand, batteries, or electricity. Single breast pumps are not recommended if you need to maintain your milk supply while working or for a premature baby but are adequate for occasional use. Pumping both breasts with a single-sided pump takes approximately 20 to 30 minutes.

HOW TO PUMP — Each of the different types of pumps has specific instructions for use. The following are general recommendations for use of a breast pump.

●Wash your hands for at least 20 seconds with soap and water before pumping. If you are not near a sink, you can use hand sanitizer with at least 60% alcohol content. It is not necessary to wash your breasts or nipples.

●Clean the controls on your pump and any nearby surfaces.

●Ensure that the pump pieces and milk collection containers are clean. Washing with hot soapy water is sufficient; it is not necessary to sterilize the pump or bottles when pumping for a healthy baby. Do not let the pump parts soak in water between use; instead, rinse and allow them to dry. Do not wash the pump tubing, because it cannot be dried easily. If you see moisture or milk in the tubing, contact the manufacturer. It may be necessary to purchase new tubing. For extra germ removal, pump parts (except for the tubing) may be sanitized once a day using steam, boiling water, or a dishwasher with a sanitize setting. A fact sheet outlining how to keep your breast pump parts clean is available online.

●Most people prefer to sit while pumping. For electric pumps, set the pump's suction strength to a comfortable level. Pumping should not hurt. On some pump models, the cycling speed (the number of suction cycles per minute) can be set based on personal preference; some people start with a rapid cycle speed then slow the speed after their milk begins to flow in a steady stream. (See 'Let-down' below.)

●Be sure that the flanges (the cone-shaped pieces that fit over the breasts and nipples) are the appropriate size (figure 1). When pumping, the nipples should not rub against the tunnels of the flanges. It may be necessary to purchase larger flanges to pump comfortably and signal the breasts to produce more milk. If your breast size changes as your milk production increases or decreases, you might need to change the flange size. If you experience discomfort, ask a lactation specialist to observe a pumping session to ensure that the flange is a good fit. Be sure to purchase pump parts that are the same brand as that of the pump. Parts should not be interchanged from different manufacturers.

●Some people choose to buy a special bra or garment with holes or flaps that hold the flanges securely in place. This allows for hands-free pumping, which may be more convenient.

Let-down — "Let-down," also called the milk-ejection reflex, is the term used to describe what happens in the breasts when milk is released from the milk glands into the milk ducts (figure 2).

The let-down reflex is usually triggered by the baby sucking at the breast and stimulating the release of a hormone called oxytocin in the mother's brain. This causes cells in the breast to eject the milk. Some people experience let-down at other times, for example, by just thinking about their baby or hearing their baby cry. For people who use a pump exclusively for breast stimulation, just seeing or hearing the breast pump may cause let-down.

Let-down usually occurs within the first minute or two of nursing or pumping. Some people feel a sense of heaviness or tingling in the breasts during let-down, while others cannot feel let-down at all.

Some people have difficulty with let-down while pumping. When this happens, only drops of milk are seen rather than streams of milk flowing from the nipples. If this happens to you, you can try the following things to help promote let-down:

●Gently massage your breasts before pumping

●Apply a clean, warm, wet cloth to your breasts before pumping

●Pump in a quiet, darkened room to avoid distractions

●Look at a picture of your baby or smell the baby's blanket

●Warm the flange of the breast pump with water or wrap a warming pack around the flange

Pumping for a premature or hospitalized baby — If your baby is hospitalized due to prematurity or illness following birth, you may need to use a breast pump to increase your milk production. By emptying your breasts frequently and completely, pumping signals your body to produce more milk. The first few weeks following delivery are critical in establishing a milk supply that meets the needs of your baby.

The amount of breast pumping during this time is critical to this process. If you are separated from your baby after birth, you should start pumping early (ideally within six hours after delivery). Then, continue to pump frequently (every three hours, including overnight, for a total of 8 to 10 times per 24-hour period) for approximately 15 minutes each time. Continue to do this until your milk volume increases, usually around the third or fourth day after delivery. Following this, you should pump at least eight times daily and express milk for approximately two minutes after milk flow stops to maintain an adequate supply. By two weeks after the birth, if you have established a good milk supply, you may be able to pump less frequently during some parts of the day (for example, pumping only once overnight). (See 'Tracking daily milk volumes' below.)

One way you can help increase your milk supply further is through "hands-on pumping." To do this, massage both of your breasts prior to the start of pumping. Then pump both breasts at the same time, while continuing to massage and compress the breasts during pumping as much as possible. Wearing a special bra or other hands-free device will make this easier. Once the milk flow slows to drops, stop the pump and further massage your breasts, then finish the session by using your hands to express milk into the container or using the electric pump with massage to fully empty the breasts. The following is a link to a video demonstrating ways to increase milk production for mothers who are pumping: Stanford Medicine: Maximizing Milk Production with Hands-On Pumping.

Tracking daily milk volumes — If you choose to pump either exclusively or partially, it's important to make sure that you continue to produce enough milk for your baby over time. To track your progress, it is useful to keep a pumping log to track the number of times and volume of milk expressed. Pumping logs are available in written form or smartphone apps.

For people who are pumping to exclusively provide breast milk for their baby, the goal should be a target milk volume of 20 to 24 ounces per day by the end of the second week. A premature baby needs somewhat less than this daily milk volume at first but will need more milk as they grow. Ways of estimating the milk needs of an older baby are discussed below. (See 'Usual needs' below.)

Pumping at work — If you are feeding your baby at the breast and plan to return to work, begin pumping two to four weeks prior to your return. While you are separated from your baby, you will need to express your milk several times during your working hours. Pumping will allow you to maintain your milk production and provide your expressed breast milk to your baby while you are apart. Pumping on a schedule similar to your baby's usual feeding pattern is usually sufficient; for most people, this means pumping two to three times over eight hours. If possible, returning to work in the middle of the work week will help to ease the transition.

It can be challenging to find the time and space to pump, especially for people who do not have a private office. You should discuss your need for a private space with your employer prior to returning to work. It may be helpful to speak with coworkers who have returned to work and pumped to determine if a private space is available. Some employers offer a "pump room" or other private area.

Since 2010, the United States has had a law requiring employers to provide time and a private space for breastfeeding employees to pump for up to a year after giving birth. Additional details are available here. Other countries may have different laws around employer requirements. Advice for pumping milk at work is provided by the Office on Women's Health.

Expressing milk without a pump — You can also express milk without a pump ("hand expression") if a pump is not available. Hand expression is also an easy way to collect colostrum if you are separated from your baby during the first few days after birth. Hand expression is sometimes done in combination with pumping to help signal your breasts to make more milk.

Follow these steps to hand express your milk:

●Make sure you have a clean container to collect the milk. You can use a spoon or small tube for colostrum or a wide-mouth container for larger volumes of milk.

●Gently massage your breasts with your hands and fingers to start the milk ejection reflex ("let-down").

●Hold your breast with your fingers and thumb in a "C" shape positioned behind the areola.

●Express the milk with these motions (figure 3):

•Press your fingers and thumb back toward your chest

•Compress your breast between your fingers and thumb, moving toward your nipple without lifting your fingers off of the breast

•Release without moving your hand

●Repeat this compress-and-release process while moving your hand around your entire breast.

At first, you will express only a few drops of milk. After a few minutes, the flow will increase. If you are expressing colostrum, the volume will always be small.

Hand expressing milk may take 20 to 30 minutes on each breast.

STORING BREAST MILK

Storage temperature — The temperature at which milk is stored depends on whether you plan to feed it to the baby right away or later, as well as whether the baby is healthy.

●Healthy babies – For babies who are healthy and at home, breast milk may be safely stored as follows:

•At room temperature (approximately 77 to 79ºF [25 to 27ºC]) – Up to four hours.

•In an insulated cooler with ice packs – Up to 24 hours if necessary.

•In the refrigerator – Ideally three to five days (although storage for up to eight days has been shown to be safe if collected under very clean conditions).

•In the freezer – Up to 12 months. Thawed breast milk can be safely stored in a standard refrigerator for up to 24 hours. Milk that was frozen and then thawed should not be refrozen.

●Hospitalized babies – Storage guidelines are stricter for babies who are hospitalized because of prematurity or other conditions. Most neonatal intensive care units (NICUs) permit storage of milk in the refrigerator for up to 96 hours (four days), but check with the staff for the storage guidelines in your NICU or hospital.

Storage containers and labeling — Breast milk should be placed in a sealed, clean, glass or rigid-plastic bottle designed for storing food products. Plastic breast milk storage bags are not recommended for hospitalized babies, due to the loss of some nutrients. However, plastic bags can be used to store breast milk for healthy babies.

Milk should be stored in small amounts (1 to 4 ounces) and labeled using permanent ink and a waterproof label. The label should indicate the date that the milk was pumped. Milk from different pumping sessions within the same day may be combined; the milk should be cooled in the refrigerator before it is combined. Often referred to as the Pitcher method, this way of combining milk over a 24-hour period can be considered depending on the situation. A fact sheet with additional details is available online. Do not combine milk that was pumped on different days.

Milk that is warm or refrigerated should not be added to frozen milk. The oldest milk should be used first. NICUs may have stricter guidelines about milk storage and handling.

PREPARING PUMPED BREAST MILK FOR FEEDING

Thawing and warming breast milk — Milk can be warmed gradually by placing the storage container (bottle or bag) in warm water for up to 20 to 30 minutes (for example, in a bowl or mug). Avoid submerging the milk container under the water when using this method since this could cause water to get into the container. After warming the milk, be sure to test the temperature before giving it to a baby; the milk should feel lukewarm or at room temperature but never hot. Milk should be gently swirled to redistribute the cream that often rises to the top during refrigeration. Waterless milk warmers (ie, bottle warmers) are available to warm breast milk prior to feeding. If you use one of these, be sure to follow the manufacturer's guidelines.

Do not heat breast milk in a microwave. Rapid heating or microwaving adversely affects the breast milk's immunologic and nutritional properties; in addition, microwaving heats milk unevenly, which could burn a baby's mouth.

HOW MUCH MILK SHOULD I OFFER? — The most important sign that a baby is getting enough milk is that they seem satisfied after feeding and are gaining weight well. Your baby's health care provider will help you monitor the baby's weight gain and let you know if they are on track. Remember that the two most important factors to maintain your milk production are breast stimulation and removal of milk from the breasts. So, if you need to increase your milk volume, breastfeed and/or pump more frequently. (See "Patient education: Breastfeeding guide (Beyond the Basics)".)

Usual needs — By one month of age, most babies are satisfied with approximately 24 ounces of milk a day (3 to 4 ounces per feeding). Then, they take approximately 24 to 30 ounces a day (4 to 8 ounces per feeding) until solid foods are introduced, at approximately four to six months of age. As they increase their intake of solid foods, their milk intake will gradually decrease to approximately 20 ounces a day.

Feeding breast milk with a bottle — Babies feed very differently from a bottle compared with the breast. When you are breastfeeding, milk only flows when the baby sucks and the baby stops feeding when they are satisfied. When you are feeding with a bottle, the milk flows faster and continues to flow even when the baby isn't actively sucking, which may lead to overfeeding.

To avoid having the milk flow too quickly while bottle-feeding, it may help to follow these steps for "paced bottle-feeding":

●Begin with your baby in an upright position

●Brush the baby's lips with the bottle nipple and insert the nipple when the baby opens their mouth

●Tilt the bottle up so that the nipple is partially full of milk, and let the baby suck for a few minutes; when the baby pauses, tilt the bottle down to empty the nipple

●Repeat this process until the baby shows signs of fullness

A bottle feeding should typically take at least 10 to 15 minutes, just like at the breast. If there is milk left in the bottle after a feeding, it can be used for up to two hours.

WHAT IF I HAVE QUESTIONS? — Your health care provider or your child's health care provider is the best source of information for questions and concerns related to breastfeeding, pumping, storage of milk, or bottle-feeding your baby. Some additional resources are listed below.

Finding help with breastfeeding — Resources for finding a lactation specialist, peer support (online or in-person), and other types of support are listed in the table (table 1).

Finding a breast pump — Quality breast pumps, both hospital-grade and for personal use, are available at various sites (retail stores, pharmacies, and hospitals) for rent and purchase. Speak with someone knowledgeable about breast pumps and their capabilities before making your decision. The website listed below provides information about various types of breast pumps, and the manufacturer's websites provide information about models and pricing. Talk to your insurance provider regarding coverage.

●US Food and Drug Administration

(www.fda.gov/consumers/consumer-updates/what-know-when-buying-or-using-breast-pump)

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Pumping and storing breast milk (The Basics)
Patient education: Breastfeeding (The Basics)
Patient education: Mastitis (The Basics)
Patient education: Weaning from breastfeeding (The Basics)
Patient education: What to expect in the NICU (The Basics)
Patient education: When a baby is born premature (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Breastfeeding guide (Beyond the Basics)
Patient education: Health and nutrition during breastfeeding (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Breastfeeding: Parental education and support
Common problems of breastfeeding and weaning
Infant benefits of breastfeeding
Maternal nutrition during lactation
Nutrition in pregnancy: Dietary requirements and supplements
Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding
Breast milk expression for the preterm infant
Prevention of HIV transmission during breastfeeding in resource-limited settings

Websites

Resources for pumping breast milk:

●Stanford Medicine: Maximizing milk production with hands-on pumping

(https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html)

●Texas Health and Human Services Commission WIC Program: Pumping at Work

(www.breastmilkcounts.com/working-moms/pumping-at-work)

●Academy of Breastfeeding Medicine: Human milk storage for home use for full-term infants

(https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf)

General resources for reliable information on breastfeeding:

●United States National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●Centers for Disease Control and Prevention

(www.cdc.gov/breastfeeding)

●American Academy of Pediatrics

(www.healthychildren.org/english/ages-stages/baby/breastfeeding)

●Academy of Breastfeeding Medicine

(www.bfmed.org)

●La Leche League International

(www.llli.org)

●Office on Women's Health

(www.womenshealth.gov/patient-materials/health-topic/breastfeeding)