Hello Amy,

In response to your post ["I’m wondering if a physician’s order is required when an inpatient mother uses a breast pump in your facility?  It seems that everything requires an order but for some reason a breast pump does not, at least in our area.  I have seen significant nipple damage caused by improper use and feel that pumping should be more closely monitored.  Any feedback is appreciated!"]:

I do share your concern in regard to unfortunate and unnecessary nipple and/or nipple-areolar damage caused by a poorly placed, off-centered flange and/or a poorly fitting flange.  Rather than requiring a physician's order for a breastpump, I feel that the best approach is ongoing staff education and patient education (which is always needed), since a physician's order for a pump will not ensure correct placement and otherwise correct use of the pump.  In my opinion, requiring a physician's order for a breastpump would very much impede the ability to assist one or both members of the dyad in a timely manner.  When an infant is not yet effectively feeding at the breast, lactation consultants and other clinicians often recommend and provide a medical-grade electric breastpump in various situations, such as:

- to improve breast comfort during severe breast engorgement, with or without mastitis present 

- to assist in addressing task constraints for the infant re: protracting the nipple during latch difficulties (when there is minimal nipple protractility; see also breast engorgement above)

- to assist in the need to build and sustain the milk supply when separated from a preterm and/or ill infant 

Over the course of a career in human lactation and infant feeding, there are many instances of latch difficulties due to truly flat nipple anatomy or nipple anatomy with only minimal protractility via gentle manual stimulation.  In such instances, a medical-grade electric breastpump is an excellent choice to help stimulate nipple protractility in order to support the baby's sensory-perceptual-motor learning for the oral grasp.  Babies are often displaying advancing hunger cues at the beginning of a consult, and it would be a profound stressor for all concerned to wait for a physician to write an order for a breastpump while a baby's hunger is increasing, or to proceed with the consult and then request the physician's order for the pump after the fact.  

Here in the U.S., breastpumps are also available in various retail settings as well as through the federally-supported WIC Nutrition program in all 50 states.  Confusion would ensue if breastpumps would require a physician's order during a hospital stay, without such an order being required before and/or after the hospital stay.   Due to often inadequate breastfeeding education for the public and much of the staff (see the many myths about breastfeeding), there is already a certain amount of cognitive dissonance in the field without adding one more barrier to lactation management, i.e., if breastpumps were to require a physician's order.  Prior to (and following) the implementation of the Affordable Care Act in the U.S. in 2009, an insurance company may well have requested a physician's order for a breastpump in a NICU population, to facilitate insurance coverage or reimbursement for the pump.  But for decades here in the U.S., medical-grade breastpumps have been otherwise available for inpatient use without requiring a physician's order for such use.  

Your concern is valid re: "I have seen significant nipple damage caused by improper use and feel that pumping should be more closely monitored."   I very much agree, and staff and patient education should be ongoing in this regard.  

I am thinking of three particular cases of nipple damage with partial thickness wounds during the early postpartum hospital stay.  In 2000, the hospital where I was then working (a very supportive environment for lactation and infant feeding) was transitioning their inpatient breastpump account from one major medical-grade EBP manufacturer to their primary competitor (I am certain of the year 2000 due to having just begun my employment there).   There were still some pumping kits left on the unit from the previous manufacturer, and although I had been educated and trained NOT to interchange pump kits from one manufacturer to the other, another LC the previous day had opted to provide two mothers with pump kits still on the unit but from the other (departing) manufacturer.  I rounded with these two mothers the next day, both of whom were pumping for NICU babies.  Both mothers were reporting nipple pain when pumping, both mothers had visible nipple-areolar wounds with bleeding, and one of these two mothers firmly stated that she would no longer use the pump if something didn't change to stop her nipple pain while pumping, in spite of her wish to provide her milk to her baby in NICU.  Management included treatment for these nipple-areolar wounds, as well as replacement of the pumping kits with a kit from the same manufacturer, and I stayed with both mothers as they used the new & appropriate pump kits with their pumps to ensure their comfort.  A progress note was entered into the chart, and a collegial verbal report was given to the patients' nurses, the nurse manager, and the lactation manager.    

Those two cases of partial thickness nipple-areolar wounds occurred many years ago (21+ years ago).  In more recent years, I very well recall a P2 mother who had brought in her high-end "professional" double electric breastpump during her hospital stay.  She reported pumping for a short period of time with her first baby due to that 1st baby being unable to latch re: flat nipple anatomy.   The nurse who had provided lactation care to this mother on the previous day had encouraged the mother to use the high-end pump that she had brought to the hospital with her, although we had ample medical-grade pumps available on the floor.  I first met this P2 mother when I rounded with her on Day 2, and she had partial thickness nipple-areolar wounds, even though the flange was centered on her nipple anatomy.  But the issue was that the flange was much too small for the diameter of her large-in-diameter nipple anatomy, and by providing her with a medical-grade pump and appropriately-sized flanges, the mother was then able to comfortably pump for nipple stimulation.  However, her nipples were minimally protractile even with the medical-grade pump, and her baby was unable to latch and sustain the latch until provided with a nipple shield correctly sized for the mother's nipple anatomy.   The mother also expressed her wish to continue using the nipple shield due to the amount of nipple-areolar damage from the previously used too-small flanges, and she was delighted to be able to comfortably nurse her baby with the nipple shield in place.  At discharge, management of this dyad included a referral to a private practice IBCLC to further manage the mother's nipple-areolar wounds as needed, and to assist the baby in learning how to latch without the support of the nipple shield (a "transfer of learning" in the language of kinesiology).  

I've been an IBCLC since 1998, and these three above instances of pronounced nipple damage come quickly to mind, although they are not the only instances of severe nipple damage I've seen during my career.  There are very unfortunate situations where there is such extensive nipple damage that a particular amount of healing is necessary before the feeding can be comfortably tolerated at all, even with a nipple shield in place - - I've worked with mothers who have reported 2 to 4 weeks of no breastfeeding at all during the healing process of full-thickness nipple-areolar wounds.  There is a perpetual myth that breastfeeding is supposed to hurt for the first two weeks until the nipples "toughen up", and many mothers stop nursing in the first two weeks or very soon thereafter due to the pain associated with the infant's shallow latch, which may be associated with ankyloglossia, for example.   There is so much work to be done to move beyond the many breastfeeding myths with correct information.    

When setting up a breastpump and providing patient teaching, the clinician should stay throughout the pumping session whenever possible for these reasons:  

- To ensure that the flange stays well-centered during the pumping and that the entire pumping session is well-tolerated (new mothers are typically exhausted and may relax their hand position while holding the breastpump's flange against the breast, and the flange may then slide off-center from the nipple-areolar complex at some point during the pumping, causing pain and visible damage if not quickly corrected)

- To provide instruction about the normal range and average timeframe for the onset of the initial milk release (Milk Ejection Reflex or MER), as well as the range and average duration of the initial MER and subsequent MERs in one pumping session.  Such clinical support is critical in normalizing the pumping experience in regard to milk release and how to build a full milk supply (using the pump not just for one MER and then turning off the pump when the first MER slows down and stops, but continuing to stimulate at least 1 to 2 more MERs as needed in one pumping session).  Providing a pumping log is important in normalizing the initial small volumes of colostrum, as well as the expected and gradual increase in volume as L2 begins.  

Over the years, many of us have heard new mothers state that "the nurse brought in this breastpump and then she just left" in regard to a manual pump or a medical-grade pump and the attachment kit.  A nurse who needs to instruct a patient in how to self-administer insulin will surely not drop off the syringe and medication to the patient and then expect the patient to read the instructions or otherwise attempt to figure out the correct administration technique on their own.   

Given that labor and birth are often followed by a period of exhaustion and sleep deprivation (which compounds the common sleep deprivation of late pregnancy), giving patients access to a medical-grade breast pump (as opposed to a manual pump) is the logical and humane response, unless the patient request is specifically for a manual pump.   Many pump kits include a manual attachment, and patient teaching can include that option, in addition to double-pumping with the medical-grade pump to make pumping more efficient by dropping the pumping time by half (versus pumping each breast separately, which takes twice as long as pumping both breasts at the same time).  

If medical-grade electric breastpumps are in short supply in an inpatient setting, the sales representative for that pump manufacturer can be contacted with a request for more pumps (this will seem routine for many readers, but may be new information for others).  For decades, at least in regard to the two major breastpump manufacturers of hospital-grade pumps, it has been a common practice to provide -- upon request -- a specific number of additional medical-grade/hospital-grade pumps each year to inpatient facilities that contract with the manufacturer, based upon the number of pump kits purchased by the inpatient facility over the previous year.   By making such a request, small hospitals, as well as large teaching hospitals, can increase their pump inventory from a handful of pumps to significantly more pumps, improving patient care in dramatic ways.  Additional medical-grade pumps can also be used for staff pumping rooms.  It's also important to monitor pump inventory on a regular basis.  
  
As with the initial pumping session (in regard to staying for the duration of the first pumping session), staying with the nursing dyad throughout a feeding whenever possible -- and throughout a cluster-feeding whenever possible -- is so very important in teaching and normalizing infant feeding behaviors.    

Please accept my apologies for the long reply.  

With kind regards,

Debbie

Debra Swank, RN BSN IBCLC
Program Director
More Than Reflexes Education
Elkins, West Virginia USA
http://www.MoreThanReflexes.org 

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