Pumping breast milk for your baby: Dr Pamela Douglas in conversation with New York City breastfeeding counsellor Emma McCabe 2021 (transcript)

In this transcript taken from the 2020 Baby Podcast recorded 25 April 2021, Dr Pamela Douglas and Emma McCabe explore the role of pumping breast milk, including for increasing supply and returning to work. Access the full podcast here.

When you might use a breast pump

Pam:

Most women use a breast pump at some stage during their breastfeeding experience, or many find themselves pumping all the way through. Pumping is demanding work. It's more important than ever that women are able to get breastfeeding working for them and here we'll consider the role of the breast pump. Let's start by looking at when the pump can actually help us, when it becomes a tool that has used for getting breastfeeding on track.

Emma:

I think that part of the reason for that is the set of circumstances that surround birth. I see a lot of families where the mother's milk may be delayed coming in, might not come in until day five, day six, and whose babies have been getting supplementation. Often necessarily, if your milk hasn't come in by day five, day six, you really do need to start supplementing, otherwise, your baby is not going to thrive and might lose a dangerous amount of weight. We all want to avoid any sort of worst case scenario. When I see a baby who has been getting two ounce or a 60 milliliter bottles of formula from day two and mom's milk hasn't come in until day five, she's probably not going to be able to immediately produce the amount that the baby is used to getting. So that can create a lot of frustration and challenges.

Pam:

Also you'd have to make sure that the fit and hold was optimal, that the baby really was acting to transfer milk or the supply is still not going to respond, even with very frequent access to the breast and switch feeding.

Emma:

It's just not manageable to have the baby at the breast all day and night, especially if your milk hasn't even come in yet. So in a situation like that, then I do often recommend pumping, but it's not something that we ever want to do for a really prolonged period of time. Because it's also very challenging, it's incredibly a difficult thing to do.

Pam:

Pumping is typically advised every three hours, both breasts. In a situation where we've got complex obstacles from birth, for sure there's a role for pumping because when we remove the milk from the breast, we're stimulating the supply. But of course, as quickly as possible, we want that baby to become the woman's best pump.

Emma:

If your baby isn't adequately removing milk from your breasts when they feed, then that means that there's milk sitting in your breasts, and that tells your body to slow down on how much milk it's making. Those frequent feeds that we keep talking about send a really strong signal to your body to make the milk, it's symbiosis. Your baby's communicating how much milk it needs to your body, and then your body can respond. But if your baby's not effectively communicating that need, then pumping can be a really useful tool until we're able to resolve these underlying issues of why your baby's not transferring well, so that your body is able to maintain the whole supply.

Pam:

That's right. We know that very frequent access to the breasts, achieved through lots and lots of skin to skin opportunities in the very first 12 hours, 24 hours after birth is very important in 'priming' the breasts, if you like. Setting you on a trajectory of good milk supply. Through that first week, again, very frequent, flexible access to the breast is so important for setting a woman on a trajectory of good supply. In that first week, if there are problems then yes, pumping has a very important role. The fact is, that if women are feeling really well-educated about all of this they can make their own decisions.

Once the baby is a little older, and a woman knows that the baby's stacking on the weight, 200 grams a week, 250 grams a week or more, things are going well, we've got a contented baby, then she can feel confident in her supply. Then she may have a situation where her partner or another loving adult is giving a bottle of express breast milk. But then we also have the situation where breast pumps are being used because the families aren't able to get the support that they need around getting that fit and hold right. So these will be situations where the baby's not efficiently transferring milk, either the baby's causing the woman nipple pain as she feeds, or the little one's very fussy at the breast. Many women find themselves pumping in this situation in order to maintain supply. But generally once we've moved through actual medical situations, babies can transfer milk beautifully, as long as the fit and hold is optimal. Babies who have trouble transferring milk are given all sorts of labels that are very unhelpful. ... That the baby's got a weak suck or the baby's got a recessed chin, or baby's got a high palate. That tongue's restricted in the absence of a classic tongue tie.

Women are still often be told the tongue's restricted, but in fact, it's really a matter of fitting that baby into the woman's body. The strategies that we work through need to be applied very carefully and surprisingly subtly, but are very empowering for women when actually they see that they're not experiencing pain. The baby's not fussing at the breast. The baby is transferring milk efficiently and gaining weight well. And in fact, once we've really got the biomechanics working well, and again there's a whole set of strategies that we can put in place to optimise the biomechanics, then the babies should really be the best pump.

If a woman says she has full breasts after a feed and has to pump to get the milk out, I check firstly to see how often she's offering to breast. Even when all is going wonderfully well, some breastfeeds will be very short, in some breastfeeds babies don't necessarily transfer a lot of milk at all. They don't necessarily swallow a lot. What we want is a pattern over time, over a 24 hour period, of enough feeds where there's enough milk transfer. We can't tell whether our breasts are full with milk in them just by the feel. A woman whose baby is frequently at the breast may never feel full in her breast, particularly after the first weeks, because her supply calibrates to meet that baby's needs - the breast is never empty. And another woman might have a very generous supply and her breasts still feel rather full even after breastfeed sometimes. Having a full breast like that will help dial down her supply. When the breasts are running full, then the supply is dialing down.

So what matters is offering each breast at least 12 times in a 24 hour period without counting, often it'll be for short periods of time, not always with a lot of milk transfer happening. Other times for longer, and you'll hear the milk being swallowed down by the baby. But we have to do this in a way that's positionally stable. It's misleading to think that a single feed tells us a lot about milk transfer. This is why, for instance, I don't use pre and post feed test weighing, even though I know that's commonly used in the U.S. What matters is patterns of milk transfer over a 24 hour period and the baby's throughput and then of course, weight gain over time. We're certainly worried if the baby's not doing much swallowing over the day and the night. But typically with frequent flexible, erratic offering of the breast, babies meet their needs, as long as their position is stable at the breast. When we have the idea that each feed is a discreet event that needs to fill up the baby's tummy, we run into all sorts of problems. Firstly, it's tempting to use a little bit of pressure or coercion to keep the baby on the breast to make sure that the baby's filling up his or her tummy, and that can result in a condition dialing up. It also gives us the idea that if the baby is fussy after feeds, then the baby must be hungry. When in fact the baby may have had enough time at the breast, but is ready for a much richer sensory experience, wants to see the world. You can see that if we immediately come in then with expressed breast milk or indeed formula, we undermine the baby's appetite drive to the breast, and can in fact undermine supply.

We don't need to focus on the baby's jaw-dropping at all. The jaw will drop reflexively if the baby's on the breast and the mouth's filling up nicely with breast tissue, because we've eliminated any breast tissue drag and the vacuum is drawning breast tissue in. So the jaw drop actually depends on the absence of breast tissue drag, not on temporomandibular muscle tightness or the presence or absence of oral connective tissue restrictions. The problem for women is getting that positional stability, getting that fit and hold right, getting the biomechanics right. This is where the strategies of the gestalt approach can really make a big difference.

We were talking about the delay in women's milk coming in, often not till day five or day six. We've got to think through what that means, and sometimes there appears to be a delay because the breasts are not being adequately stimulated. The more often the breasts have milk removed from them, the better the stimulation of supply. There was a study that showed that if each breast is offered up to 12 times in the first 24 hours, milk supply will be significantly better at day five. We never want to force the baby of course, we'll never use any pressure. But there does need to be a lot of opportunity often best achieved in that first 24 hours, and indeed as the days passed beyond that by skin to skin contact.

Finding the right pump settings

Emma:

Make sure that you're using the right flange size, that you're using the right settings on your pump. If you're in pain pumping, then that's definitely something you want to troubleshoot. So you don't want there to be more than three to five millimeters between your nipple and the side of the flange. We don't want too much areola being drawn into the flange, but we also don't want your nipples to be touching the sides of the flange before pumping begins.

Pam:

Can I jump in there and say how I usually describe it, because I tend not to talk in terms of millimeters or measurements. Because the truth is women's nipples will expand and expand variably during both feeds in a baby's mouth, but also with pumping. Rather than try to give measurements, I just say we don't want the nipple ever rubbing against the flange, but we also don't want much of the areola being drawn up into the flange.

Emma:

When I give that measurement it's before the pump starts. So it's when the flange is actually around the tip of your nipple but before you're pumping.

Pam: For sure. And so often I say to women, you really need a couple of sizes of flanges to experiment with, to make sure that we're getting that nice drawing up of the nipple without rubbing, but not a lot of the areola coming in. And trying to fit with just one size I find is a bit hit and miss, but if women again know what they're looking for, then they can experiment between different sizes.

Emma: I would say generally, I think I see more women pumping with a flange size that's too big than too small and it can cause discomfort. So it can cause a lot of discomfort if you're pumping with the wrong flange size, it can feel painful and pinchy. It can also mean that you're not optimising the milk flow while you're pumping if the flange is too small. So getting that right flange size so that you feel comfortable particularly is really important.

How long should you pump for?

Pam: There's a tendency to recommend that women engage in power pumping, long sessions of pumping. What are your thoughts there?

Emma:

I think that it's really hard. I think it's a lot to ask of women. The idea behind it is that you're simulating a cluster feed. So you're stimulating what your baby would do at the breasts often in those early evening hours, when they will feed on and off very frequently. I don't find a lot of space for power pumping in my practice, because generally I'm only recommending pumping if there's some serious underlying milk transfer issue, or mom's milk is delayed coming in, or we're talking about going back to work. Generally those are the only situations that I'm recommending frequent pumping. I would rather the baby do that frequent feeding than a woman be on a pump.

Pam:

Exactly. I really never recommend 'power pumping'. I explained to women that they're better having short, perhaps more frequent, but short times of pumping. Of course, if a woman's doing this much pumping, she really needs to have a double pump.

Emma: Yes, an electric pump, yes. Because doing it with a manual pump it's much more time consuming.

Pam:

That's right. Also to make this as least burdensome as possible. So just to do a quick little pump, whenever she's got the strength for it really, some days she might be able to do more other days less, and it may not last for long at all. I certainly don't recommend power pumping or pumping for long periods. So, I would consider 10 minutes, five to 10 minutes, but doing that whenever possible, much more effective than a couple of bursts of the very long half an hour pumping.

When can a bottle be introduced to allow another parent to do the feed?

Emma:

Often women want to know when they should stop pumping. And I'd be interested to get your thoughts on this too, actually. Because a lot of families that I see wanting to maybe supplement a bottle at night, so maybe Dad gives the little one a bottle at night and mom can rest a little bit longer. So I'd be interested to hear your thoughts on that, because that's also a common question I get. Can I pump to do one bottle feed a day?

Pam:

Well, that can work for some families, but for others not necessarily, because the evenings can be a time of heightened need for rich sensory motor experience for our babies, but also a time when the little ones can be on and off the breast very regularly and frequently. And so if we have a situation where the dad has offered the little one a bottle and is attempting to let the breastfeeding woman sleep, but the little ones nevertheless, screaming and dialing up and the mother is unable to sleep, we've not really achieved anything.

Emma:

Are you talking about in the evening or the early morning hours in the night?

Pam:

Well, I'm thinking the scenario of milk being expressed so that the other partner can offer a bottle late evening in the hope that the breastfeeding woman is actually already asleep and catching up on rest.

Emma:

I also see families wanting to do have the partner do one of the night feeds instead of mom getting up in the night.

Pam:

I would argue that there can be a place for that in a crisis situation. So where there's excessively frequent night waking, parents are just not getting much sleep throughout the night. We'd be wanting to look at the underlying causes of that and what we might need to be doing to work with the circadian clock, which can take one to two weeks. But as crisis management, the other partner might use the bottle in the night and the breastfeeding woman has her ear plugs in, door closed in another quiet room in the house. If we have a situation though, where the breastfeeding woman is still waking at the same time as the other partner is intending to go out and get the bottle of milk, you could argue that it's just as quick to breastfeed that baby back to sleep and get everyone to sleep.

Emma:

All right, back to what you're saying is that if it does work for a family, then there's nothing wrong with that.

Pam:

That's it. It's all about workability, isn't it, and families finding their own way through.

Emma:

I'm thinking that if say a mom is out of the house or dad is doing one of the night feeds, then they'll want to know if it's ok to introduce a bottle? And that would go hand in hand obviously with pumping.

Pam:

Well, I don't think there's a right or wrong about this. Again, families just find their own way through and sort out what's workable in their unique situation. We use breast pumps to remove milk from the breast either to be stored and used at a later date or to stimulate supply. So families find their way through, pragmatically, when they're looking at building up a store of breast milk. It's wise not to overdo it if you've got a generous supply because pumping can actually drive your supply up even greater.

Emma:

That was one of the things that I had problems with when I was breastfeeding. And pumping looks different for every woman in the same way that breastfeeding does as well, I tend to find. So women respond to pumps differently. For a lot of women, pumps are never going to transfer milk or be as effective at draining the breast as their baby will. But then there are also some women who, like me - I had a very large supply, and when I pumped, it put my body into oversupply, into feeling really uncomfortable, I would end up quite engorged for a couple of days after even just one pump in those early weeks.

Pam:

So that's a woman who may be best not trying to put up milk for storage.

Emma: I tried to avoid pumping for a number of weeks because it really would cause me pain every time after I pumped. But everybody's body responds differently to a pump, it's what I tend to find. Sometimes I see situations where a mother has been breastfeeding with very, very sore and damaged nipples for a while before she was able to find support. And I often see women being advised to pump for 24 hours to let their nipples heal a little bit before continuing to breastfeed. And so I wonder what your thoughts are on that.

Pam:

Severe nipple damage can be a very good indication for the need to stop putting the baby to the breast for a time, let those nipples heal. She might either pump the breast milk very carefully so that we're not perpetuating nipple damage or indeed as a short term solution the parents may also supplement with formula, just to get us through the next four to seven days while the nipples heal. We also need to be dealing with the underlying breast tissue drag that caused that nipple damage, and showing the woman, helping her start to lay down new neural pathways around how to fit the baby into her body so that there is no breast tissue drag. So that damage isn't going to be perpetuated when she next puts the baby back on the breast.

Emma:

So you're saying that a woman could pump for four to seven days while their nipples heal without breastfeeding?

Pam:

Well, it's true, Emma, that I'll often see such excruciatingly damaged nipples or even nipple areola complexes, often at the end of a long road of trying to make breastfeeding work before they present to me. We may actually elect to let those nipples heal or let that particular damaged nipple heal. And that can actually take a week depending on the extent of the injury and ulceration.

Emma:

Do you ever see babies who then struggled to get back to the breast after a week if they're not breastfeeding at all?

Pam:

Actually I would say that that's not typically a problem, as long as we know how to manage the transition back from bottles to the breasts. So firstly, as we've been emphasising, we need to get that fit and hold right, so that damage is not going to be perpetuated. But then it is quite common for anyone who is pumping and using expressed breast milk to find themselves caught in a cycle of let's say three hourly pumping routines. The woman pumps, the baby is offered a bottle of express breast milk. This triple feeding - and sometimes good heavens it's then quadruple feeding because there's another top up with formula - these feeds can go on for well over an hour, an hour and a half, by the time they move through all those steps. It's quite unmanageable but if you look at it. The baby is being offered the breast, whether it's one, whether it's both breasts, perhaps no more than eight times in a 24 hour period. And of course we know that most babies, most women will really need to offer the breast or to take the breast or to offer the breast 12 times in a 24 hour period, frequently and flexibly without watching the clock in order to maintain baby's weight gain and her supply. So you can see how pumping can actually reach a point where it's undermining a woman's capacity to breastfeed her baby. So let's look at a situation where her baby is being exclusively fed breast milk, but a lot of that's happening with the bottle. So the baby's gaining weight well, but much of it's happening through expressed breast milk rather than direct from the breast into the baby's mouth and gut. Women often find in this situation that their confidence in their capacity to get milk from the breast directly into the baby is undermined.

And this is where it becomes really important to know that when breastfeeding is going really well, you can't overfeed, you can't offer too often. With the very frequent, flexible, erratic offering of the breast, never think: oh, she just fed 10 minutes ago, I can't put her on. You just put it back on if you think she needs it. Encouraging women to normalise this, and also to know that it tends to make the days much easier rather than harder, is important. So I think traditionally over the past decades, health professionals have been very anxious that frequent flexible access to the breast is burdensome for women. And we don't want to be seeing marathon feeds and truly excessive burdens and breastfeeding, because that's a sign that something's not going right, that the baby's not transferring milk efficiently. Typically of course what's happening with marathon feeds is that there's breast tissue drag and underlying positional instability that hasn't been identified. But when things are going well, very frequent, flexible offers of the breast at least 12 times in a 24 hour period with no one counting actually makes the days easier. It keeps the baby dialed down, it really supports supply, it makes sure that the baby's gaining weight well. But the three hourly pumping, offering the breast than pumping then offering the expressed breast milk, actually means that the baby's not getting the access to the breast that they perhaps need to be really dialed down and doesn't stimulate supply in the same way.

Emma:

Most woman I see have started to pump when milk was delayed coming in and the baby was in the NICU, or bilirubin levels were really high in the first couple of days, or maybe the baby lost a really large amount of weight. And I would tend to find that most women who I suggest start triple feeding are not necessarily able to fully supplement with breast milk afterwards, but are having to use formula. Because it's not as if they're pumping a huge amount of milk after they feed the baby.

Pam:

Sure. Just to flag there, that some women may have perfectly ample supplies, but never really pump very much, never really managed to get a lot of milk out of their breasts with the pump. It's really important to communicate to women that the amount that they can pump is not really a measure of their supply.

Emma:

It's not an indication of how much milk you have. Some women will really struggle to pump anything, even though their baby's totally efficient at feeding and able to get everything they need from them. Some women just really don't respond to a pump. So when you breastfeed your baby, the suckling stimulates oxytocin, oxytocin triggers a letdown, which is like all the little muscles around your mammary glands contracting and squeezing and then the milk flows. And some women will not respond to a pump that way simply because you're not looking at your beautiful, lovely little one and experiencing the same oxytocin boost that you would with your little one when you're at a pump. Pumping feels very different. Pumping is, I think for a lot of women, it's a little bit of an uncomfortable feeling, really.

Transitioning off the use of expressed breast milk or formula to exclusive use of breast

Pam:

So I thought it would also be useful to dive a little bit deeper into this idea of transitioning off the use of express breast milk back to exclusive or predominant use of the breast alone, rather than bottles of express breast milk. Often women will say, "I've fed my baby, but he or she's clearly still hungry. And that's when I come in with the bottle of express breast milk." And this is where we want to move into the concept of frequent and flexible offers of the breast. If the little one seems to dial up at the end of a breastfeed, and we've dealt with the underlying clinical problems that have got us into this situation anyway, then think sensory-motor nourishment.

Now, this is a complex topic in times of social isolation, but I discussed that in another podcast. We won't attempt to open that up here at the moment. But often the little one is dialing up, not because they need more milk in the tummy, but because they're needing a change of sensory-motor experience. So try thinking, okay, I've offered the breasts, the little ones dialing up, instead of thinking hunger, I've absolutely got to use the bottle of express breast milk. Try moving into the next activity, moving into the day, and then you can offer the breast again in a short period of time anyway, if you want to keep that little one dialed down. So you can see how the idea of the little ones come off the breast and dial up so I've got to fill up him or her up with express breast milk can actually undermine breastfeeding and keep us trapped in this cycle of feeling as though we've got to keep using the expressed breast milk, or the formula. If we've got a situation wherethe baby is only receiving expressed breast milk or the breast and the baby is doing well, gaining well, then we know it's just a matter of getting that fit and hold right. There needs to be no pressure on any particular feed. We're not thinking of any particular feed as a time when that baby is got to get milk in. We're looking at patterns over time, frequent flexible, irregular offering of the breast, and over a 24 hour period, that little one will take the breast milk they need. You're not able to measure quantities of breast milk with direct breastfeeding, because you're not giving bottles, then you can be comforted by the five heavy wet nappies in a 24 hour period, a contented alert baby, regular throughput of stool. If we've got a situation where we've got formula supplementation in the mix, the baby is obviously at this point needing that formula to maintain weight gain. So at that point, having some monitoring, if we are easing back from the formula, doing it in a way that's careful watching babies throughput, but also having weight being monitored each week by your health professional. Sometimes depending on the particular transition we're trying to do, you might even watch it a little bit more closely than that.

So transitioning from formula to just the breast needs to be done with a bit of care. But the real trap that so many families fall into is the thought that 'I've just put the baby on the breast, the baby's now dialing up, that must mean that I've got to come in with formula to dial down my baby'. When in fact you could get on with the day, change the baby's sensory experience, and then offer that breast within a fairly short period of time, again, just to dial the baby down. So easing back from the use of that formula and thinking sensory nourishment, sensory nourishment, frequent flexible offerings of the breast.

Emma:

It's very hard to not feel like that your baby is constantly hungry when you have been supplementing for a long period of time.

Pam:

.... When the baby may in fact just be dialing up because of low sensory interior environment. Remember too it will be important to do the switch feeding between breasts, offering one breast, then the other, then the other. But in doing switch breastfeeding, we don't want to cause a condition dialing up, so just read your baby. If the baby is not tolerating going from side to side to side, then don't try to do it so often. But to the extent that you can, that's going to build supply.

Emma:

I'll often recommend trying to offer each breast a couple of times if you're building supply, as long as your baby is happy.

Pumping for return to work

Emma:

I never really thought about pumping in terms of structure, but I also didn't have a very structured life. And I was very frequently and flexibly feeding and I didn't have a nine to five job at the time. So when I was away from my son and sometimes for a number of days in a row, I would pump when I felt I needed to, and just sort of trust my body in that way. But when supply is still growing and prolactin receptors is still being laid down and for whatever reason, if the baby is not transferring well, we want to pump and protect mom's supply.

When a pump is useful, well, obviously a lot of women will be pumping when they go back to work. So for women here in the United States, that's usually pretty early. Most women are going back to work at about three months, some less than three months. Some will very fortunately get more than three months. But it's a conversation that I have with most clients in the first consult I have with them, because it really isn't that far away. And obviously when you're going back to work, it looks different for different women. You have different rooms available to pump in, maybe you can pump in your office because you have a private office. Maybe you have to a lactation room. Maybe your lactation room is on a different floor on the other side of the building. Maybe you are able to pump at lunch. Maybe you have meetings all through lunch. So, work is different for every woman, but I'm often saying I would rather that you were able to pump more frequently for less time. If you're just fitting in a five minute pump here, there, and you're able to do that more frequently than waiting and holding off for a really big, long block of time where you can pump for half an hour.

Pam: That's right, because if her breasts are running full, then in fact her supply is being dialed down.

Also, what I'm always saying to working parents, the women who are returning to work, is that we don't need to worry about teaching the baby to take a bottle before we return to work. Because the fact of it is that, our little ones are flexible and adaptive. If you go off to work and that baby is in the care of another adult, when he or she is thirsty enough, they'll take the bottle. Or depending on the age of the baby, they'll take sips from a cup.