Ouch! What If Pumping Hurts?

Some moms assume pumping should be painful.  Not so!  “No pain, no gain” does not apply here.  Painful pumping means something needs to be adjusted. 

Pump Suction Set Too High.  The highest suction setting does not always pump the most milk. In fact, too-high suction can actually slow your milk flow.  Set your pump at the highest suction that feels comfortable during and after pumping…and no higher. (If you’re gritting your teeth, it’s too high!)

Pumping milk is not like sucking a drink through a straw. With a straw, the stronger you suck, the more liquid you get. When pumping, most milk comes only when a let-down, or milk release, happens. Without a milk release, most milk stays in the breast.

What is a milk release?  Hormones cause muscles in the breast to squeeze and milk ducts to widen, pushing the milk out. When this happens, some mothers feel tingling. Others feel nothing.  A milk release can happen with a touch at the breast, hearing a baby cry, or even by thinking about your baby. Feelings of anger or upset can block milk release.

While breastfeeding, most mothers have three or four milk releases, often without knowing it. To get more milk with your pump, you need more milk releases, not stronger suction.  To see my tearsheet on how to trigger more milk releases, click here.

Flange Fit Issues.  Many mothers pump comfortably with the standard flange that comes with their pump. But if pumping hurts even on low suction, you most likely need another size. If the standard flange is too small or too large, a better-fitting flange will feel more comfortable and may also pump more milk.

To check your flange fit, watch your nipple during pumping. If you see a little space all around your nipple as it’s drawn into the flange’s nipple tunnel, you have a good fit. If your nipple rubs against its sides, the flange is too small (click here to see fit photos).  If too much of the dark area around the nipple is pulled in or the nipple bounces in and out of the tunnel, it is too large. 

Two pump companies, Ameda and Medela, offer many flange sizes with their pumps, so you can go larger or smaller as needed.  Other companies may not.  Nipple size changes with birth, breastfeeding, and pumping, so the pump flange that fit you well when you started pumping may not as you pump more.  For that reason, it’s a good idea to recheck your flange fit from time to time.

Breast or Nipple Issues can also cause pain during pumping.  If your pain is not due to too-high suction or too-small or too-large flanges, it is time to consider these questions.  Do you have nipple trauma?  If you had nipple trauma in the past, could you have a bacterial infection of the nipple?  Do you have an overgrowth of yeast (also known as thrush or candida)?  Is mastitis a possibility?  Does your nipple turn white, red, or blue after pumping?  If so, see your lactation consultant or other health-care provider to rule out Raynaud’s Phenomenon and other causes related to breast and nipple health.   Thankfully, in nearly all cases, pain during pumping is a solvable problem. 



More on the 'Magic Number' (Part 2)

In response to the previous post, "The 'Magic Number' and Long-Term Milk Production," a reader of this blog wrote: “I have a 6-week-old and just returned to work. I pump once every 3 hours and am pumping more than enough milk for my baby. But I am fearful of pumping less. Given my son’s eating routine is still getting established and will likely change still, how do I determine my ‘magic number?’”

I suggest you begin by thinking back to your maternity leave, assuming you were breastfeeding exclusively and your baby was thriving.  On average, how many times every 24 hours did your baby breastfeed?  As a starting point, consider this your “magic number.”  For example, if the answer is 8 (which seems to be average), assume that to keep your milk production steady long-term you will need to continue to drain your breasts well at least 8 times each day.  If you’re pumping 3 times each workday, this means you’ll need to breastfeed 5 times when you and your baby are together.  (This will be much easier if 2 of these breastfeedings include one just before leaving your baby for work and another as soon as you and your baby are reunited again.)

Another factor that can affect milk production is the longest stretch between breast drainings (breastfeedings or pumpings).  Ideally, to keep milk production stable, do not regularly allow your breasts to become uncomfortably full, as that gives your body the signal to slow milk production.  If your baby sleeps for long stretches at night, I usually suggest going no longer than about 8 hours between breast drainings.  Despite the social pressure for your baby to sleep through the night as young as possible, for most mothers it is easier to keep long-term milk production stable if they continue to breastfeed at night. 

So don’t just focus on your pumpings at work.  Also keep your eye on the number of breastfeedings outside your work hours.  As I mentioned in a previous post, many of the employed breastfeeding mothers I talk to pump often enough at work, but as the months pass, the number of breastfeedings outside of work gradually decreases.  It’s not just how many times you pump at work that determines your milk production.  More important is the number of breast drainings every 24 hours and how this total compares to your “magic number.” 

The 'Magic Number' and Long-Term Milk Production (Part 1)

In my last blog post, I told a military mother who had returned to work at six weeks postpartum that she was making as much milk as her thriving baby would ever need.  To meet her breastfeeding goal of one year, I told her, “all she had to do was maintain her milk production.”  But maintaining milk production is not always easy for employed mothers, especially when they don’t know the basic dynamics affecting how much milk they make.  I shared some of these with this mother, and my explanation set her mind at ease.

Breast storage capacity.  This is the amount of milk in a woman’s breasts when they are at their fullest each day and this amount can vary greatly among mothers.  Breast storage capacity affects how many times every 24 hours a woman’s breasts need to be drained well of milk—either by breastfeeding or expression—to maintain her milk production.  When her breasts become full, this sends her body the signal to make milk slower.  In other words, “drained breasts make milk faster” and “full breasts make milk slower.”  The amount of milk needed to slow milk production will be much greater in a woman with a large breast storage capacity, so she can remove her milk fewer times a day without her milk production decreasing

The “magic number.”  This refers to the number of times each day a mother’s breasts need to be well drained of milk to keep her milk production stable.  Due to differences in breast storage capacity, some mothers’ “magic number” may be as few as 4-5 or as many as 9-10.  But when a mother’s total number of breast drainings (breastfeedings plus milk expressions) dips below her “magic number,” her milk production slows.

Daily totals.  Many of the employed breastfeeding mothers I help by phone are diligent about maintaining their number of milk expressions at work, but often, as the months pass, they breastfeed less and less at home.  With this change in routine, they may drop below their “magic number,” which causes a dip in milk production. 

Recently, as I asked one employed mother with decreasing milk production about her daily routine, she told me that her baby was sleeping in a swing all night.  She discovered that in the swing he did not wake at night to feed, so she was sleeping on the couch in her living room next to the swing and waking every hour to check on him.  I told her that eliminating those nighttime breastfeedings was the likely cause of her decreased milk production and I asked if she thought returning to breastfeeding at night might mean more sleep for her as well as more milk for her baby.

More Breastfeeding When Together Means Less Expressed Milk Needed.  The amount of milk per day babies need between 1 and 6 months stays remarkably stable, on average between 25 and 35 oz. (750-1050 mL) per day.  By thinking of the 24-hour-day as a whole, it becomes obvious that the more times each day the baby breastfeeds directly, the less expressed milk will be needed while mother and baby are apart.  But many mothers don’t realize that dropping breastfeedings at home and encouraging baby to sleep more at night adds to the amount of expressed milk their baby needs during the day.  Understanding these basic dynamics can go a long way in helping mothers meet their long-term breastfeeding goals.

Facts Every Employed Breastfeeding Mother Needs to Know

Today I spoke by phone with an employed breastfeeding mother in the military who had recently returned to work.  She told me she was worried she would not be able to keep up her milk production over the long term.  I shared with her some facts that could smooth the way for any employed breastfeeding mother but are not widely known.

From 1 to 6 months of age the breastfed baby’s daily milk intake stays relatively stable.  This mother assumed—like most—that as her baby grew bigger and heavier, he would need more milk.  In fact, that’s not what the research shows. Because babies’ rate of growth slows between 1 and 6 months, daily milk intake remains remarkably consistent during this time.¹ I told this mother that since her baby had been thriving on exclusive breastfeeding for his first six weeks that she was golden.  She was already producing as much milk as her baby would ever need.  All she needed to do was maintain it.  (Note: This is not the case for the formula-fed baby, as explained in my blog post “Breast Versus Bottle: How Much Milk Should Baby Take?” which leads to many mistaken assumptions.) 

After solid foods are started, the breastfed baby needs less milk.  This mother also expressed concern about meeting her one-year breastfeeding goal because her husband was scheduled to deploy in January, when her baby would be 7 months old.  She was worried that as an employed mother alone with a 7-month-old baby and a 2-year-old toddler, she would not be able to keep up with her baby’s need for milk.  I told her that once her baby started on solids, which is recommended at six months, the baby would actually need less and less milk, as he ate more and more solids.^2,3  

She told me that this information was a huge morale booster and that it made meeting her breastfeeding goals seem much more feasible.  This is information every employed breastfeeding mother needs to know.

References

¹Kent, J. C., et al. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-395.

²Islam, M. M., et al. (2006). Effects of varied energy density of complementary foods on breast-milk intakes and total energy consumption by healthy, breastfed Bangladeshi children. American Journal of Clinical Nutrition, 83(4), 851-858.

³Cohen, R. J., et al. (1994). Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomised intervention study in Honduras. Lancet, 344(8918), 288-293.

Breast Versus Bottle: How Much Milk Should Baby Take?

Q:  Why does my breastfed baby take at most 4 ounces (120 mL) from the bottle when my neighbor’s formula-fed baby takes 7 or 8 ounces (210-240 mL)?  Am I doing something wrong?

A: You are not doing anything wrong.  And in this case, more is not necessarily better.  Formula-fed babies typically consume much more milk at each feeding than breastfed babies, but they are also more likely to grow into overweight children and adults.^1,2  One large study (16,755 babies in Belarus) compared feeding volumes in formula-fed and breastfed babies and found that the formula-fed babies consumed 49% more milk at 1 month, 57% at 3 months, and 71% at 5 months.³  Australian research found that between 1 and 6 months of age breastfed babies consistently take on average around 3 ounces (90mL) at a feeding. (Younger babies with smaller tummies take less milk.) 

Breastfed babies’ milk intake doesn’t increase from months 1 to 6 because their growth rate slows.⁴  As growth slows, breastfed babies continue to get bigger and heavier on about the same daily milk intake, averaging about 25 ounces (750 mL) per 24 hours.

Why do formula-fed babies drink so much more milk?  There are several reasons: 

• The bottle flows more consistently.  During the first 3 to 4 months of life, after swallowing, an inborn reflex automatically triggers suckling.⁵  Milk flows more consistently from the bottle than the breast (which has a natural ebb and flow due to milk ejections, or let-downs), so babies tend to consume more milk from the bottle at a feeding.  Before this reflexive suckling is outgrown, babies fed by bottle are at greater risk of overfeeding.  
• Breastfeeding gives babies more control over milk intake.  Not seeing how much milk is in the breast makes a breastfeeding mother less likely to coax her baby to continue after he’s full.^3,6  As the breastfed baby grows and thrives, his mother learns to trust her baby to take what he needs from both breast and bottle and also solid foods when they are introduced later.  One U.K. study found that between 6 and 12 months of age breastfeeding mothers put less pressure on their babies to eat solid foods and were more sensitive to their babies’ cues.⁷ 
• More milk in the bottle means more milk consumed.  In the Belarus study mentioned before, babies took more formula at feedings when their mothers offered bottles containing more than 6 ounces (180 mL).³
• Mother’s milk and formula are metabolized differently.  Formula-fed babies use the nutrients in formula less efficiently,⁸ so they may need more milk to meet their nutritional needs.  Formula is also missing hormones, such as leptin and adiponectin, which help babies regulate appetite and energy metabolism.^9,10  Even babies’ sleep metabolism is affected, with formula-fed babies burning more calories during sleep than breastfed babies.¹¹

Q:  If my baby takes more milk from the bottle than I can express at one sitting, does that mean my milk production is low?

A:  See the previous answer.  Babies commonly take more milk from the bottle than they do from the breast.  The fast, consistent milk flow of the bottle makes overfeeding more likely.  So if your baby takes more milk from the bottle than you express, by itself this is not an indicator of low milk production.

To reduce the amount of expressed milk needed and to decrease the risk of overfeeding, take steps to slow milk flow during bottle-feeding: 

• Use the slowest flow nipple/teat the baby will accept.
• Suggest the feeder try holding the baby in a more upright position with the bottle horizontal to slow flow and help the baby feel full on less milk.
• Short breaks during bottle-feeding can also help baby “realize” he’s full before he takes more milk than needed.

References