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Exploring the World of Breast Pumps

Sharon Knorr, BS, IBCLC
Newark NY USA
From: LEAVEN, Vol. 40 No. 3, June-July 2004, pp. 51-55.

Bring up the topic of breast pumps and an interesting discussion is sure to follow. Are they a blessing or a curse? Mothers in many parts of the world breastfeed quite nicely without any breast pumps at all; they even hand-express milk for their premature babies. Those of us who were breastfeeding 20 years ago or more did not have a wide range of choices for pumps, but we were still able to help mothers find a way to provide their milk for their babies. Regardless of how we may feel sometimes about the presence of breast pumps and other gadgets in the world of breastfeeding, the fact is that mothers are very interested in them and we sell a variety through our LLLI Catalogue and Web site. Many mothers have found these tools to be an integral part of their ability to provide human milk for their babies. Therefore, even Leaders who may not have used pumps themselves need to be able to give mothers accurate and usable information when they ask about these products.

Breast pumps can be categorized and analyzed in many different ways, some of which are overlapping. They include:

a. Comfort and fit
b. Efficiency
c. Manual or electric
d. Automatic or manual cycling
e. Hygiene
f. Intended use
g. Availability and Support
h. Cost

Let’s talk about comfort. We tell mothers that pumping is not supposed to hurt. What does that really mean? The most important factors influencing comfort are the amount of suction applied, the length of time that maximum suction is applied before it is released, and how well the mother’s breast fits into the pump flange and tunnel. These factors are measured using: mmHg (millimeters of mercury), cycles per minute, and tunnel size in mm.

Studies by Einar Egnell and others have established that a total negative (vacuum) pressure of about 220 to 230 mmHg is produced when a baby is breastfeeding and the maximum pressure is usually held for less than one second. This information about maximum pressures and cycling times has subsequently been used by breast pump companies to calibrate their pump settings in order to minimize the possibility of pain and/or breast damage during pumping. Most good quality pumps cannot exceed approximately 250 mmHg of maximum pressure. Nipple damage is most likely to occur when the initial phase of creating suction lasts longer than one to two seconds. Thus, breast pumps with automatic cycling will usually do so at a rate of 40 to 60 cycles per minute. With pumps, the phase including the creation and release of pressure is relatively short and then accompanied by a longer relax phase where no pressure or slightly positive pressure is being applied to the nipple. Many of the battery-operated breast pumps have small motors which can take from 10 to 50 seconds to reach maximum vacuum, and thus may cycle fewer than 10 times per minute–this exposes nipple and areolar tissue to increased trauma from prolonged unrelieved suction. Some mothers can tolerate higher pressures more than other mothers.

Another aspect of comfort is how the pump works. Generally speaking, automatic cycling electric pumps are considered easier to use because the mother only has to hold the flanges in place on the breast (or use a hands-free option such as tucking them inside of a modified bra or using special accessories for that purpose). Those with arm or hand problems, such as carpal tunnel syndrome, may find some manual pumps uncomfortable to use. The pedal-operated pump from Medela can be a good option for those mothers. Some mothers find the gentle pulsing of the Whittlestone to be extremely comfortable, likewise the Whisper Wear.

Fit is another big factor in pumping comfort. Ideally, when the pump is operating, the nipple is drawn into the tunnel and the areola is gently squeezed against the flange. In a good fit, the nipple moves freely within the tunnel. If the nipple is too large for the tunnel, it will be dragged along the sides of the tunnel, causing friction, damage, and pain. If the nipple is small and the tunnel too large, a portion of areola tissue may be drawn into the tunnel and there is often a ring shape imbedded into the breast when it is removed from the pump flange. Breast pump companies are looking for solutions to the fit problem (See sidebar: “Nipple Tunnel Diameter”):

  • Both Ameda and Medela offer a variety of different sized flange/tunnels and inserts, which can further change the interior diameter. However, not all flanges are available with all breast pumps.
  • Many breast pumps include an optional soft silicone insert or soft flange, which can give a better and/or more comfortable fit; the Avent Isis has a particularly comfortable and effective insert.
  • Medela has a template, which can be used to estimate the probable best flange size based on nipple size (remember that nipples often increase in size during pumping).
  • Whisper Wear reports good results with a wide variety of breast sizes as long as the pump maintains good contact with the breast tissue. Some women find that a sports bra keeps these pumps in place better than a regular bra.

Efficiency is another way of rating breast pumps, and this can also go hand in hand with comfort. An efficient pump will stimulate a milk-ejection reflex (MER) or let-down and remove milk thoroughly and quickly, an especially important consideration for employed mothers with time constraints or those pumping frequently to maintain a milk supply for a baby who is sick, was born prematurely, or is not sucking properly. The biggest step forward in this area was the development of breast pumps that can drain both breasts at one time, better known as double-pumping. A mother who lets down easily with a good pump can be finished in as little as 10 minutes rather than at least twice that time for pumping one breast at a time. Double-pumping has also been shown to stimulate a greater release of prolactin than single pumping. Some mothers will respond better to pumps that can simply achieve the most suction. Other mothers do better with pumps offering a wider range of pressure and cycling options. The “Natural Expression Pumping” now available on some Medela pumps is an attempt to more closely simulate what a baby does during a nursing session. The Whisper Wear also includes an option for more rapid cycling to stimulate the milk ejection reflex.

Hygiene and possible contamination can also be an important consideration. Breast pumps with special traps built in, such as the Ameda and the Nurture III, prevent pumped milk from entering the tubing and then getting into the pump motor itself. The Medela pumps do not have such a system and milk can go into the tubing and even get into the motor, which is very difficult to clean. The diaphragm of the Pump in Style often becomes contaminated. This is one reason why buying a used Pump in Style may not be a good idea (see sidebar). Mothers need to be careful while pumping in order to prevent this from happening; keeping the pump at chest level helps protect against contamination.

Intended use of the breast pump is another important way of determining what might be the best choice for any particular mother. The chart below gives an idea of the most commonly accepted ways of categorizing pumps according to use. Be aware, however, that every mother is different. In general, full-size automatic cycling pumps are recommended for use by mothers whose babies are not yet nursing well and who are trying to use the pump to establish and maintain a full milk supply. However, some mothers have accomplished this using manual or inexpensive electric pumps or even hand expression. This is most likely to be an option if the mother is able to pump easily and quickly using the lowest setting on the hospital grade pump. A mother already using high settings on a big pump will most likely see a drop in production when switching to a smaller model. The Whisper Wear is proving to be very useful to mothers who are busy with other children or work and are trying to provide for a premie or sick baby. Because they can pump while driving to or from the hospital or while doing things around the house or with other children, they may be pumping with the Whisper Wear significantly more times each day than was possible with a full-sized hospital grade breast pump. This increased frequency is important, as long as the breast pump is doing a good job of emptying the breasts. In general, for frequent use, double-pumping is very desirable and the better the pump the more likely that the milk supply will remain robust. However, good manual pumps may suffice for some women. (See sidebar: “Types of Pumps”)

Even with a good breast pump, mothers will find that their milk supply will stay robust longer if they nurse the baby frequently when they are together, especially at night. No pump can empty a breast as well as a healthy baby can.

Availability and support as well as cost are other considerations. Medela probably has the most extensive sales and support staff throughout the country, as well as a very useful Web site. Ameda, now owned by Hollister, is the original hospital grade pump, the manufacturer operates a customer service department, and these pumps are carried by many retailers. Some of the other pumps mentioned in this article, are available through the LLLI’s print and online Catalogue. If a pump is not available from LLLI, you can locate a distributor at each company’s own Web site. Remind mothers to check for warranties and return policies. When considering cost, the amount of money spent on any pump will almost never exceed the amount of money that would have been spent on buying formula if that baby were not receiving human milk instead. It is all relative and most mothers report that it is money well spent. Some companies, including Ameda and Medela, have grant programs for supplying pumps to low-income mothers.

Helping a mother to choose the best breast pump for her situation is only the first step. No matter what pump she chooses, the mother will need to work on a plan for a pumping routine which will take into consideration her unique circumstances. It does little good to jump from breast pump to breast pump when things aren’t going well if the mother hasn’t already tried the usual methods for stimulating her milk ejection reflex so she can pump milk effectively and efficiently. It may be a little different for each mother and baby you are trying to help. Use your Leader resources, including your Professional Liaison Department, to help you find the kind of information that the mother needs. You might want to review the sections on pumping in THE BREASTFEEDING ANSWER BOOK (pp. 212-215 and 641-650, 2003 edition) and THE WOMANLY ART OF BREASTFEEDING (pp. 117-122, 2004 edition), and the LLLI publications Choosing a Breast Pump and A Mother’s Guide to Pumping Milk. For more information on individual pumps, you can visit company Web sites or speak with local sales representatives who can provide you with technical information as well as suggestions for best use of each product. Talk with other Leaders or lactation consultants in your area who are active in pump rentals and/or sales. Use the Leader Speciality File, looking under the category “Pumps, Breast” for Leaders who specialize in pump questions. (This section of the the LLLI Web site is password protected; see box on page 55 for more information.) The bad news is that as the market expands, you may need to spend more time keeping up with the latest and greatest in the breast pump world. The good news is that mothers and babies will benefit from the increasing diversity in the products that they may need in order to maintain their breastfeeding relationship.

Web Editor's Note:

For more information, see the sidebars from pages 52 and 53 of the original article and the companion article from the same issue, Are Used Breast Pumps a Good Option? Issues to Consider.

References

Riordan, J. Breastfeeding and Human Lactation. Boston: Jones and Bartlett Publishers, 2004.
Egnell, E. The mechanics of different methods of emptying the female breast. J Swed Med Assoc 1956; 40:1-8.
Frantz, K. Breastfeeding Product Guide/Supplement. Sunland, CA: Geddes Productions, 1994/1999.
Hill P.D. et al. The effect of sequential or simultaneous breast pumping on milk volume and prolactin levels: A pilot study. J Hum Lact 1996; 12:193-9.
Lawrence, R. and Lawrence, R. Breastfeeding: A Guide for the Medical Profession. St. Louis, MO: Mosby, 1999.
Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: LLLI, 2003.
Walker, M. Solving breastfeeding problems: useful techniques and gadgets. ILCA Regional Conference, Tarrytown, NY, 2002.

Useful Web Sites

www.lalecheleague.org
www.artofbreastfeeding.com
www.pumpingmothers.org
www.medela.com
www.ameda.com
www.whisperwear.com
www.avent.com

Sharon Knorr is an LLL Leader and Area Professional Liaison in New York State West, USA. She works full-time as a medical technologist and is also a lactation consultant in private practice and in a local hospital. She presently serves as president of the Rochester Regional Breastfeeding Network. Sharon has two children (Joshua, 25; and Rachel, 22) and lives with her husband, Butch, in Newark, New York, USA. Special thanks to Norma Ritter, Contributing Editor, who initially developed this article for the Leaven column, “Keeping Up-to-Date.”

Understanding the Complexities of Breast Pumps

Carole Wrede
Managing Editor

I certainly do not consider myself knowledgeable about breast pumps, and I learned just how little I do know from Sharon Knorr’s article "The World of Breast Pumps." As the article developed, I realized pump evaluation is subjective and things such as pump pressures can vary even from pump to pump among the same exact model. In writing her article, Sharon sought information from varied sources: direct discussions with company representatives; information from Web sites and other official literature; previously published literature or studies; and personal observation and study. The author tried hard to be fair in her evaluations and not to overstate or understate anything to the extent that it could be considered inaccurate or misleading, and Leaders who are familiar with pumps further reviewed the article. Still, I imagine someone will read the article and think, "Why didn’t she mention this?" or "That was not my experience with that pump."

Sharon says it well: "I think that everyone is still looking for the pump that will solve everyone’s problems, and it just doesn’t exist. One woman’s preference can be another woman’s disappointment. My hope is that the article will help Leaders to think about all the different aspects involved in determining the possible appropriateness of a pump for any particular mother and/or situation so that she can help mothers understand the complexities as well."

Our purpose as Leaders is to help mothers breastfeed, and Leaven exists to support Leaders in that role. Special thanks to Sharon Knorr for this article, and to Norma Ritter, Contributing Editor, for identifying the topic and collaborating with Sharon to develop this article originally for the "Keeping up to Date" column.

Thank you for all you each do to help mothers and babies. You are making a difference.


Last updated 12/29/06 by jlm.
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