Clinics in Human Lactation - Breast Pumps and Pumping Protocols

By Marsha Walker, RN, IBCLC

Breast Pumps and Pumping Protocolscovers everything from the history of breast pumps to pumping plans.  Below is an excerpt from the book, followed by the table of contents.


Breast pumps have been used for hundreds of years to assist mothers in removing milk from their breasts, providing breastmilk during separations, treating engorgement, or everting flat nipples.Pumping milk is a very personal behavior for most women and often quite subjective. Maternal preferences for manual or powered, double or single pumps reflect the interdependent needs of mother and child, the circumstances that suggest or require pumping, and the affordability of the pump. An employed mother may decide a double electric breast pump is the best option, while a stay-at-home mom may have enough spare moments for a slower single, manual breast pump.  Mothers describe their ideal breast pump as one that is inexpensive and works efficiently and comfortably. They want a pump that is easy to assemble, easy to use, and easy to keep clean. Two of the most important features of a breast pump are how much milk can be expressed and how much time it will take to do so.

Walker (1992) conducted an informal survey with more than 200 mothers regarding breast pump usage and opinions. A breast pump was rated highly if it:

·      Worked quickly––(less than 20 minutes total)

·      Obtained two or more ounces of milk from each breast

·      Did not cause pain.

The mothers in this survey utilized several techniques to reduce pumping times and to increase the volume of milk per pumping session. In other words, they added interventions to make the pumps work better. Many mothers expressed the most milk before or after the first morning feeding, when the breasts were reported to be fullest (and intramammary pressure was the highest). The pumped milk volume decreased steadily throughout the day. Many mothers mentioned that if they were not relaxed or if they were uncomfortable or felt rushed, their output dropped by one-third to one-half the usual amount. The majority of mothers used one or more techniques to increase pumping efficiency. The two most frequently mentioned techniques were eliciting the milk-ejection reflex before starting to pump and massaging the breast while pumping. Both techniques reduced the time needed to pump and increased milk output. Some mothers were able to double the amount pumped by using both of these techniques at each pumping session. When looking at breast pump reviews on the Internet, the powered or electric models seemed to receive far more favorable reviews than did the manual models. This was often due to their ease of use and greater efficiency. A few manual breast pumps were given good reviews. The performance features mothers mention in on-line reviews include comfort, ease of milk expression, and pumps that can be easily and quickly cleaned.

The use of breast pumps is becoming more and more common. Data from the Infant Feeding Practices Study II in the United States showed that 85% of breastfeeding mothers in a sample of 1,564 had successfully expressed milk since their infant was born (Labiner-Wolfe, Fein, Shealy, Wang, 2008). Reasons for milk expression that mothers described were to allow someone else to feed the infant and to have an emergency supply on hand for situations such as unplanned separations. Maternal employment was the characteristic that was most strongly associated with expressing milk. Mothers of older infants also expressed to have milk to mix with cereal or other foods. Electric pumps were most frequently used, followed by manual pumps, hand expression, and a combination of electric and battery pump. Less than 2% of mothers used only a battery-powered pump. Similar results were seen in an Australian study of 587 mothers (Perth Infant Feeding Study II - 2002-2004). By six months postpartum, 83.8% of mothers had expressed milk. Mothers who expressed breastmilk in this study were less likely to stop breastfeeding before six months compared with mothers who had never expressed milk (Win, Binns, Zhao, Scott & Oddy, 2006). The authors speculated that the appropriate use of expressed breastmilk could be a means to help mothers achieve six months of exclusive breastfeeding, while giving them more lifestyle options. A survey of breastfeeding women done after the first three weeks of breastfeeding found that mothers who reported expressing milk were 75% less likely to discontinue breastfeeding within the first 12 weeks postpartum than women who did not express breast milk (Schwartz et al., 2002). Binns and colleagues (2006) found that the proportion of mothers who expressed breastmilk had almost doubled between the first Perth Infant Feeding Study conducted in 1992-1993 and the second Perth Infant Feeding Study done a decade later (Binns, Win, Zhao, & Scott, 2006). The majority of mothers in this study expressed breastmilk to manage breastfeeding problems. The authors account for the increase in pump usage through several factors:

·      An increase in employed mothers.

·      Improved breast pump technology.

·      An increased emphasis on exclusive breastfeeding.

·      A possible shift in how breastfeeding difficulties are being managed by healthcare providers.

Geraghty and colleagues (2005) looked at the pumping rates of 346 mothers of singleton infants, multiple infants, and preterm infants. Seventy-seven percent of these mothers pumped milk at some point in time during the first six months postpartum. Feeding only at the breast during early postpartum time points was associated with a longer duration of human milk feeding. This most likely emphasizes the importance of getting preterm and multiple infants to the breast as early and as often as possible during the first weeks after birth.

Pumping for some mothers can be an integral part of being able to extend the length of time that an infant is breastfed or receives human milk. In a study of 903 mothers, nearly all had expressed milk (98%), with the most frequent reason being insufficient milk or to make more milk (Clemons & Amir, 2010). Mothers also described pumping to relieve engorgement and to store extra milk. The second most frequent reason for pumping was the return to work. Most women used electric breast pumps and preferred this method to the use of hand pumps or hand expressing. However, only 21% used a double pumping system, despite the fact that pumping both breasts simultaneously is more efficient by more than three hours per week in exclusively pumping mothers (Groh-Wargo et al., 1995; Zinaman, Hughes, Queenan, Labbok, & Albertson, 1992). Although a high use of hand expression was found in this study, very few women preferred this method.

Table of Contents:

Part 1.  Background


Chapter 1. History of Breast Pumps

Chapter 2.  Regulation of Breast Pumps

Safety Issues

Open & Closed Systems

Sharing A Pump Or Buying A Used Pump

Cost of Breast Pumps

Insurance Coverage for Breast Pumps

Part 2.  The World of Breast Pumps

Chapter 3.  Mechanics


Cycles Per Minute

Suction Curves


Hormonal Issues


Clinical Implications


Chapter 4.  Review of the Literature

Chapter 5.  The Pumps

Hand or Manual Pumps

Bicycle Horn and Rubber Bulb Breast Pumps

Battery-Operated Pumps

Electric Pumps

Chapter 6.  Simultaneous or Sequential Pumping

Chapter 7.  Flanges

Chapter 8.  Parameters for Choosing a Breast Pump

Chapter 9.  Compliance with the International Code of Marketing of Breastmilk Substitutes

Part 3.  Pumping Protocols and Problems

Chapter 10.  Pumping Protocols

Chapter 11.  Facilitating More Effective Pumping

Chapter 12.  Scenarios and Pumping Plans

Employed Mothers

Mothers of Preterm, Late Preterm, Ill Infants, or Infants With Conditions That Preclude Feeding at the Breast Who Will Be Pump Dependent                                      

Mothers of Late Preterm Infants (34-37 Weeks) Who Are Not Completely Pump Dependent

Chapter 13.  Problems With Pumps and Pumping

Diminished Milk Production

Pumping Schedule

Pumping More Effectively

Pump Mechanics

Maternal Health Issues

Overfeeding By Childcare Providers

Sore Nipples

Chapter 14.  Galactogogues



Pump Manufacturers 

Resources For Use Of Herbals And Botanicals for Insufficient Milk Production





Marsha Walker is the Executive Director of National Alliance for Breastfeeding Advocacy, Research, Education, and Legal Branch (NABA REAL).  She is on the board of directors of the Massachusetts Breastfeeding Coalition, Baby Friendly USA, the US Lactation Consultant Association, and Best for Babes.  She is ILCA’s representative to the US Department of Agriculture’s Breastfeeding Promotion Consortium and NABA’s representative to the US Breastfeeding Committee.  Marsha has written many books on breastfeeding, including several reports on Code monitoring activities in the U.S.