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Co-worker consulted me for extreme issues removing milk with a breast pump.  32 year old, healthy except PCOS, no hx infertility, experienced NICU nurse.  Throughout duration of lactation she took lecithin 1200 mg 4 times a day (see below for description of plugs), and “Motherlove with goat’s rue”.  No history breast/ chest trauma or surgery.  During pregnancy described hyperemesis needing zofran, “double dose” of Prilosec, and occasional IV fluids.

1st child (boy) born in 2018, 37+3, normal vaginal birth, spontaneous labor.  Described as having a weak shallow latch, choking with feeds, poor milk transfer and not gaining weight.  Lip tie and tongue tie released at 1 week of age; also had a high arched palate.  Used nipple shield throughout nursing duration and needed constant breast compressions to transfer milk.  Started bottle-feeding early on for poor weight gain.  Stopped latching at 3 months.  Mom describes overall “eating issues” and he stopped taking her breast milk at 10 months.  It took her 2 months to then wean from pumping (extreme discomfort if she tried to go faster). 

2nd child (girl), born in 2020 (currently 7 months old), 40 weeks, normal vaginal birth, spontaneous labor.  Again described shallow latch and only being able to nurse baby in football hold.  Nursed exclusively for 3 months, no nipple shield, but needing constant breast compressions to keep babe eating at breast.  Weight gain also poor and needed a supplement once a day of pumped milk.  At around 3 months babe frustrated at breast with slow flow.  Stopped latching daytime at 5 months and would only latch at night.  Stopped completely at 6 months.  Evaluated for lip and tongue tie at 6 months; was found to have a high arched palate.  

Mom pumped for a total of 12 months with 1st child and still trying to pump for 2nd child, mostly using a Symphony.  Has tried a variety of flanges, flange shapes, and silicone inserts.  Also tried a wearable pump.

With her 1st she described her supply as averaging 32 oz/day, pumping every 3 hours with hands-on technique.  With pumping she needed to lean forward, and what she described as “moving the flange around a lot and having to pull the breast tissue taut”.  She also describes feeling full all the time and persistent tiny little plugs everywhere, “the few times I would get a good latch at night the plugs would go pop-pop-pop, like a pimple, then finally I would get a good stream of milk”.  Denies sx mastitis.  Stopped responding to the pump around 8 months (about 1 oz would come out, but she still felt very full afterward).  She responded initially to hand expression and being able to hand express another 3-4 oz over 10-15".  Over time she needed 45-60” to empty a similar amount.  

I watched her pump with a Symphony breast pump.  Excellent technique, breast massage, hands-on pumping, etc.  She does not use a hands-free pumping bra so she can get her hands on her breast tissue to massage.  Using techniques as described above (needing to manipulate the flange and her breast tissue a lot, constant hands on her breasts).  I observed a few letdowns with the pump, and after about 20” she was unable to get any more and moved onto hand expression.  Superb technique, doing both breasts at the same time, with copious robust sprays coming from multiple nipple pores.  To truly get herself empty she stated her routine would take an hour, and when trying to wean from 7x/day to 6x/day she felt her plugs got worse.  She had zero letdowns with the wearable pump.

This is obviously a very motivated mom, but she is at her wit’s end with this unsustainable routine (plus she developed flexor tendinitis in her pointer fingers severe enough to need prednisone).  She is unable to multitask while pumping as her hands are in constant use, making it difficult to eat at work, as most pumping moms are eating and pumping at the same time due to time constraints.  She is distraught that her daughter stopped latching about a month ago and doubts she could tempt her back to breast (even when she did nurse it did not sound like a stress-free experience).  She asked “Is there something wrong with me?  Why can’t I get milk out with a pump?  Is it something with hormones, or structural?  No one else has to manipulate their breasts the way I do”.  She has tried relaxation, imagery, etc, all the things to try to relax and help oxytocin flow but nothing works.  She has observed many NICU mothers pumping and knows what most women’s pumping routine looks like, and how unusual hers is.

Any and all ideas and suggestions welcome.

Christina Zimpfer, RNC, IBCLC

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