Carol writes: "I have located much of the literature by Peter Hartmann et al.... [In it]
the
expression phase is defined as the first 5 minutes of a feeding/pumping session. Despite
the
fact that milk yields differ drastically between women, the mean percentage of available
milk
expressed by a breast pump during a 5 minute session is 99.4%. Furthermore, at 5 minutes,
the
rate of milk expression decreases. These findings support the suggestion to mothers who are
pumping and only get 5 minutes worth of pumping into their tight schedules of baby care,
self-care, and supplements to take the short 5-min. pumpings as having great significance
on
potential higher milk yields."
I found your post interesting. My understanding of this research (Mitoulas, L. et. al.
Efficacy of breast milk expression using an electric breast pump. J Hum Lact
2001;18(4):344-352), however, is different from yours, as is my interpretation of how it
applies to clinical practice.
According to my reading of this study, the expressed milk was not measured until the
mothers had a let-down, which occurred on average after about two minutes of pumping. (Six
of the 30 mothers took longer than two minutes to let-down--between 2 and 7 minutes.) The
amount of milk expressed during the five minutes after the let-down was called the
"expression phase," but the term "expression phase" simply referred to the change in the
pump's sucking pattern. This five-minute period was the time limit imposed by the
researchers and did not correspond to any naturally occurring event. So I think it is
incorrect to say that after this five minutes that "rate of milk expression decreases." I
don't see anything in the study that indicates this. They did not measure the rate of milk
expression for longer than five minutes.
The researchers' definition of "available milk expressed" corresponded to the amount of
milk a baby would take from the breast within the same period of time. (They had each
mother do 24 hours of test-weighing with the BabyWeigh to determine this amount for each
baby.) So to say that the pump expressed 99.4% of the "available milk" simply means that a
breastfeeding baby would consume about the same amount of milk during the five minutes
after the first milk let-down.
This "99.4%" has no bearing on the degree of breast drainage, which is one critical factor
in the rate of milk production. If a baby was a slow breastfeeder and normally breastfed
for a long time, this amount of milk could potentially be a fairly small percentage of the
total amount of milk the baby normally taken during a feeding (i.e., for the baby who feeds
lets say 40 minutes, this would only be 12.5% of the milk he would normally take at a
feeding) and result in a small degree of breast drainage.
This makes it a stretch to conclude "These findings support the suggestion to mothers who
are pumping and only get 5 minutes worth of pumping into their tight schedules of baby
care, self-care, and upplements... [can] take the short 5-min. pumpings as having great
significance on potential higher milk yields."
That certainly would not be true for the mothers who took 3 to 7 minutes to let-down their
milk.
It is these individual differences that make me very uncomfortable recommending a pumping
protocol for mothers of non-nursing babies based on total number of minutes pumped per
day. I like the approach Paula Meier takes in her 2001 article, (Meier, P. Breastfeeding
in the special care nursery: prematures and infants with medical problems. Ped Clinics N
Amer 2001; 48(2):425-42), in which mothers of non-nursing premies start ASAP after birth
pumping 8-10 times per day. Until the milk increases, pump 10-15 min. per pumping.
Thereafter, until they have a full milk supply (defined as >750 ml per 24 hours) as many
times a day as practical pump for 2 minutes after the last drop of milk, up to a maximimum
of 20-30 min.
I found in my practice that once these mothers are up to a full supply, most can reduce
their pumping to 6-7 times per day and reduce their pumping time to 10-15 min. But they
need to continue to monitor their milk production, because those with small breast storage
capacities may find that their milk supplies go down when they reduce the number and length
of pumpings and these mothers may need to keep their pumpings up to 8 or more times per day
(and/or pump longer) to maintain. A "one-size-fits-all" approach will not work well for
many mothers.
For the mother attempting to increase a low milk supply, as Linda Pohl astutely observes,
our suggestions are currently based on our best guess. In my private practice, I gave these
mothers two options and suggested they do whichever works best for them within their daily
routines (highly motivated mothers could do both). One option: pump right after feedings to
increase the degree of breast drainage, which research has found increases the rate of milk
production. Unless a baby is a very ineffective breastfeeder, this often yields very little
milk. Second option: wait to pump for 30-60 minutes after a feeding. This is usually long
enough to allow more milk to accumulate (so she'll have more milk to use as a supplement or
for storage) but not too close to the next feeding.
Regarding number of times a day to pump, I put this in the mother's court. I tell her that
more pumpings will increase her supply faster. Fewer will produce slower (or even
negligible) results. At one extreme, one mother I worked with, who came to me with her baby
well below birth weight at one month, asked her mother to move in with her to help care for
her three older children (all of whom had been exclusively breastfed) and pumped 14 times a
day until her supply was sufficient (she set my record for number of pumpings per day).
All the other mothers I worked with chose fewer daily pumpings, which varied from mother
to mother. Giving the mother this choice freed me from the possibility of giving the mother
more (or less) than she could handle and put the ball firmly in the mother's court, where I
think it belongs.
I consider my job to be to share what I know (which is often far less than what I *wish* I
knew) so that the mother can choose among the possible options for the best ways to meet
her goals. I give her the big picture (i.e., what is a full milk supply and an adequate
weight gain, how to increase milk supply, etc.); she helps sort out the details.
In my private practice, I usually spoke with each mother daily until the crisis was
resolved in order to help her figure out what was working and what wasn't, so that we could
come up with a "Plan B" together if needed. I learned the hard way that this consistent
follow-up was critical, as most mothers do not have the lactation perspective needed to
determine whether their own "Plan B" was going to move them in the right direction or
undermine their efforts.
Hope this helps,
Nancy Mohrbacher, IBCLC
Lactation Education Specialist, Hollister Inc.
Chicago suburbs, Illinois USA
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