10/24/2019
Breastfeeding without Nursing Exclusive Pumping
Marsha Walker, RN, IBCLC [email protected]
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Breastfeeding but not at the breast Why exclusive pumping?
85% of breastfeeding • Latch difficulty mothers expressed milk • Pain sometime since their infant was born • Oral anomaly/cleft/ Labiner-Wolfe et al. Pediatr 2008;122(suppl 2):S63-S68 tongue-tie 5.6% of these mothers • Congenital condition exclusively expressed • Infant illness Pumping without feeding at Adoption the breast is associated • with shorter breastfeeding • Preterm infant durations and earlier introduction of infant • Multiples formula • Maternal choice Keim et al. Breastfeed Med 2017;12:422-429 • Breast anomalies/surgery Also associated with • Employment development of high efficiency commercial • Weight loss strategy pumps • Sexual abuse history
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Much information on exclusive A few things we don’t know expressing comes from the lay literature
Does exclusive Internet and social pumping result in: media represent the Reducing or increasing the bulk of advice sources risk of maternal on exclusive pumping reproductive cancers, Type Are some of these 2 diabetes, myocardial infarction, metabolic sources promulgating syndrome for the mother advice that is harmful, anecdotal, or Altered nutritional and ineffective immunological benefits compared to milk directly A whole industry has from the breast resulting in sprung up related to different infant health pumping outcomes Does this introduce The erosion of societal commercial bias rather support for direct than expert breastfeeding interventions
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Alteration and contamination of Many mothers think pumped milk pumped breastmilk is equivalent to milk directly from Milk expressed by pumps can have higher levels of bacteria, the breast including pathologic bacteria, than direct breastfeeding or hand expressing Pumped milk may be Boo et al. J Hosp Infect 2001;49:274-281 stored between minutes and months Bifidobacterium spp. exist in breastmilk at high levels but are Pumped milk can significantly depleted in pumped breastmilk experience 5 or more A family of bacteria that includes E. coli and salmonella are temperature changes more abundant in pumped milk than direct breastmilk Pumped milk may come in contact with 2-6 Pumped milk lacks inoculation by the infant’s oral microbiota containers before being through retrograde or backwash movement of the milk fed to the infant Moossavi et al. Cell Host & Microbe 2019;25:324-335 Different bottle systems may contribute to Enterobacteria and other potential pathogens are enriched nutrient degradation with indirect breastfeeding. Pump expression increases the Infant formula may be abundance of this and other gram-negative bacteria in milk added to human milk in such as Pseudomonas and Stenotrophomonas the same container Felice et al. Matern Child Nutr 2017;13:e12425 Jimenez et al. PLoS One 2017;12:e0181071
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Infant gut microbiome is altered Altered infant health outcomes when using pumped breastmilk
Increased risk for otitis media Gut microbiota is crucial Boone et al. J Pediatr 2016;174:118-125 in the development and risk for pediatric respiratory infection and asthma education of the infant immune system Klopp et al. J Pediatr 2017;190:192-199 Increased risk of coughing and wheezing Lower milk bacterial Soto-Ramirez et al. J Hum Lact 2013;29:71-80 richness was found in pumped milk Increased risk of jaundice with Bifidobacteria depletion Pumped milk is enriched with environmental and involved in metabolism of bilirubin through galactose metabolic pathway pump-associated bacteria Paul Rogers, NY Times and lack bacteria from Pumped breastmilk fed by bottle increased infants infant oral cavity risk of becoming overweight or obese Azad et al. Pediatrics 2018;142(4):e20181092
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Effects of handling, storage, & Storage containers and nutrient transport of expressed breastmilk integrity
Riboflavin (vitamin B2) and Vitamin C (ascorbic acid) levels can decrease by vitamin C can be degraded when exposed to light 1/3 after 24 hours of refrigeration When placed in clear Buss et al. Acta Paediatr 2001; 90:813-815 containers, mean levels of breastmilk vitamin C and B2 Calorie and fat content decrease with increasing dropped rapidly freezing time Riboflavin dropped below 75% by 30 minutes and over 6 Maximum decrease was seen between 0-7 days hours to <35% of baseline in a clear container Garcia-Lara et al. Breastfeed Med 2012;7:295-301 Ascorbic acid level decreased antioxidant capacity with lowest seen at freezing to <68% of baseline by 30 minutes in a clear container for 7 days Best container is amber colored as compared to clear, green, blue, opaque Francis & Dickton. J Nutr Health Food Eng 2015;2(6):00083
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Reducing photodegradation Where mothers pump and store milk Geraghty SR. Breastfeeding Medicine 2011;6:433-435
Feeding bottle covers and sleeves are typically used for insulation or on glass bottles to protect from breakage Perhaps the use of a sleeve or cover would help reduce vitamin C loss when feeding expressed breastmilk
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Feeding bottles and nutrient integrity Ascorbic acid
Milk-to-air interface (diameter of the Bottle systems bottle) had the greatest impact on studied decrease in ascorbic acid Avent Natural The larger the surface of milk Born Free (glass) contacting air, the greater the vitamin Dr. Brown’s Natural reduction Flow Vitamin C levels decreased up to 76% Evenflo Elan Bubbles rapidly formed in all bottles Gerber Classic except for Dr. Brown’s Playtex Drop-Ins (plastic liner) Air moving through milk and formation of bubbles on the milk surface Playtex Ventaire impacted levels of ascorbic acid depletion Venting of the bottle (no air moving through the milk and no bubbles) should be considered in bottle choice Francis et al. Intl Breastfeed J 2008;3:19
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Feeding bottles and nutrient integrity Retinol and alpha-tocopherol Marketing to meet a need!! In a 20-minute simulated feeding, retinol (Vitamin A) and alpha-tocopherol (Vitamin E) displayed decreases over time significantly different than that of the Control, which was milk not exposed to bottle feeding. The correlation between degradation and bottle feeding systems was dependent upon Nursh silicone bottles the formation of bubbles in the with collapsible liner milk as the milk was removed 8oz pack of 3 from the bottle $24.99 on Amazon A decrease of up to 12%, in retinol and 35% alpha- 9 pack of silicone tocopherol was seen pouches $16.99 on Amazon Francis et al. Matern Child Nutr $24.99 on Amazon 2012;8:215-224
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“Off” or rancid flavors and odors of Rancid flavors and odors
stored breastmilk Even though rancid-flavor of frozen breastmilk may be Milk lipolysis is the process of milk lipids (fat) being hydrolyzed by described as objectionable (at lipase into free fatty acids (FFAs) and glycerol 7 days) and intolerable (at 30 days) by adults, it may be Large accumulated amounts of FFAs, especially short and acceptable by many infants intermediate fatty acids, cause a rancid flavor in the milk As evidenced by some infants Milk lipolysis is inhibited when pasteurized or frozen at accepting the flavor of -70C (-94F) but home freezer temps are ~ -20C (-4F) Nutramigen Rancid flavor compounds, FFAs caproic acid and lauric acid, were Extreme lipolysis may increase found to increase with frozen storage time, with highest levels at the probability of infant refusal 30 days compared with 7 days, gradually increasing over storage time If infants refuse thawed milk, mothers could try providing The flavor of frozen milk may exceed the unacceptable rancid freshly expressed milk or milk flavor threshold, especially for adults frozen for <7 days Lauric acid has an unclean and soapy flavor and may be the main Hung et al. BMC Pediatrics 2018;18:94 contributor to rancid flavor of frozen breastmilk Try flavoring the milk with vanilla
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Rancid flavors and odors Chrononutrition Hahn-Holbrook et al. Pediatr Research 2019;85:936-942 Survey of 84 mothers who stored their milk Breastmilk is formulated to communicate time of day to 73% froze milk infants 27% stored milk in refrigerator Day milk has cortisol & 24.6% had at least 1 episode of activity-promoting amino acids infant refusal Promote alertness Abnormal odor was noted by 25% Feeding behavior of mothers Catabolic processes 95% of those infants refused the Night milk has increased milk with the off smell melatonin & tryptophan Mothers discarded the milk with Foster sleep the off smell Relax digestion Francis & Dickton. J Nutr Health Food Eng 2018;8:391-392 Support cell restoration Scalded milk = 180F Feeding from the breast Boiled milk = 212F matches maternal and other circadian rhythms Holder pasteurization = 145F (for 30 Inactivates lipase and decreases vitamin C minutes) Pumped milk may not be circadian-matched
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Chrononutrition Chrononutrition
Circadian-matched milk may improve infant health Cortisol levels are 330% higher in morning milk Time spent in active feeding during the day Cortisol acts as a modulator of infant circadian clock Growth rate Melatonin levels not detectable during the day but rise in Sleep consolidation the evening and peak in the early morning hours Neurocognitive development Leptin regulates energy balance by inhibiting hunger, with Infants who are at high risk of infection or currently experiencing levels higher in milk collected between 10:00pm and infection might benefit from milk collected during the day when 4:00am immune factors are highest (such as IgA) Daytime milk has higher levels of immune factors Daytime colostrum and mature milk contain higher levels of phagocytes that engulf and destroy harmful microorganisms Circadian clock controls rhythms in sleep-wake cycles, respiratory rate, body temperature, digestion, metabolism Mothers may wish to label expressed milk with time of day when it was expressed Infants with colic have blunted cortisol rhythms with lower morning cortisol and higher evening cortisol Feed the infant with the stored milk that best corresponds with the current time the infant is being fed
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Which pumps are best?
Formula companies understand Best pump depends on the Avoid previously used situation and the mother (could chrononutrition! breast pumps unless they even be hand expression!) are designated as multi- High efficiency double electric user Thickened with rice starch and pump for preterm and exclusive re-labeled from Enfamil AR Insurance-provided pump pumping from the start (Ameda, may or may not be Medela, Spectra) Taken quickly off the market suitable for all mothers due to complaints Closed system May want a hands-free bra Formula companies adding May want or need to rent a Extra sets of pump parts alpha-lactalbumin to formulas pump to decrease protein content All kinds of gadgets and May be able to use a personal accessories for exclusive Alpha-lactalbumin is a source use pump if mother has started pumping of tryptophan breastfeeding but switched to exclusive pumping Lactalite Tryptophan is a precursor of serotonin, a neurotransmitter May want to use a hands-free that may regulate sleep-wake pump (Elvie, Willow, Baby rhythm and the response to Buddha) stress May want a manual pump for backup 25 26
Gadgets-www.lacteck.com Flange size Nipple diameters range from <12 mm at their base to >23 mm at the base Nipples swell during pumping Mothers with large nipples may find that a standard size flange is too small to accommodate both the large nipple and subsequent swelling Wilson-Clay and Hoover (2005) speculate that if a mother has a nipple size of approximately 20.5 mm (or the size of a US nickel) or larger she may benefit from using a larger than standard size pump flange
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Proper flange fit Flange size • The nipple should be able to elongate without rubbing against the sides of the nipple tunnel • Too small: areola cannot move into tunnel – nipple is sore, tender – nipple blanched white on removal of flange – skin flakes visible on the nipple tunnel • Tight fit compresses milk ducts and does not allow for effective milk removal • Incomplete drainage can lead to low milk Too Tight Just Right! supply, plugged ducts and mastitis
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Pumpin’ Pal Flange cushions and inserts
Different sizes of angled flange may Beaugen Mom help if mothers cannot find a good flange cushions fit Marketed to Some mothers customize fit, rotate flange sizes reduce friction, and during pumping sessions to account replace need for for nipple swelling lubrication Can apply olive oil https://www.beaug for better seal and en.com/ to prevent abrasion
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Maymom shield sizing Open system
Inner diameter of Multiple use of flange should be single-user devices 1-2mm larger than typically invalidates diameter of nipple the manufacturer’s after pumping, or warranty 3-5mm larger Many single user before a pumping pumps are open session systems and may not have any 15, 17, 19,, 21, Downloadable caliper for measuring nipples protective barrier 24, 25, 26, 27, 29, www.maymom.com to prevent cross 30, 34, 36mm and contamination from 22 and 28mm multiple users inserts
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Closed system Used pumps
Physical separation A borrowed pump can be ineffective or between air intake break, necessitating the purchase of a and milk replacement pump May be a barrier Because pumps have a limited lifetime, inside the pump some mothers who borrow or purchase Reduces the previously used pumps may put their chance of internal milk supply at risk because the device pump cannot operate at its optimum contamination and The motor may be worn down so much milk contamination from use that it cannot generate from ambient air enough vacuum to be effective
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Cleaning pumps S marcescens Makes bacterial contamination obvious First Years pump with Produces a pink pigment to the naked eye Serratia marcescens called prodigiosin Cleaning instructions should include taking apart all of the pieces for washing Moisture in Medela tubing should be removed by swinging tubing or leaving just the tubing attached while running the pump for several minutes 37 38
Mold in pumps and pump parts Pumping more effectively
• Increasing the frequency of pumping beyond a certain number of times or lengthening the duration of pumping sessions may be less effective than increasing the degree of emptying of the breast
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Pumping more effectively Pumping more effectively
Amount and rate of milk a mother expresses Combining milk expression techniques may result each time she pumps is highly variable in greater milk output (Morton et al. 2009). individual rate of milk production Found that in pump-dependent preterm mothers, those that used hand expression greater than 5 vacuum pattern generated by the pump times/day and an electric pump 5 times/day the amount of milk stored in the breast when the during the first 3 days postpartum produced mother begins a pumping session significantly larger volumes of milk than mothers time since she last pumped or breastfed who only used an electric pump. Massaging each breast while using an electric Rate of milk expression changes over the first breast pump significantly increased the amount 5 minute expression period of milk pumped at each session. Rate of milk removal remains constant over Over the 8 week study, mothers who combined the first 2.5 minutes, but decreases by 5 early hand expression of colostrum in the first 3 minutes days following birth and who used breast First 2 milk ejections make the most amount massage and compression while pumping and hand expression if needed, produced more milk of milk available for removal than term mothers (average 955 mL per day). 41 42
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Pumping more effectively
Pumping more effectively Timing of when breastmilk expression is begun relative to delivery can have an important influence Once mature milk came in, mothers who used on pumped milk volume. Parker et al (2012) studied effects of early initiation of breast massage/compression/hand milk expression on the onset of lactogenesis stage II expression in addition to pumping were most and milk volume in mothers of very low birthweight likely removing a greater percentage of milk infants. per expression, which allowed greater milk 20 women randomized to initiate milk expression production with less frequent expression. within 60 min of birth (group 1) or 1 to 6 h after birth (group 2). The authors found that the use of high Milk volume and timing of lactogenesis stage II was frequency pumping (> 7 times/day) was compared between the two groups. more important for the establishment of Group 1 produced significantly more milk than group lactation than its maintenance. two during the first 7 days and at week 3. Group one also demonstrated a significantly earlier Some mothers in the study who used the lactogenesis stage II. hand techniques concurrently with the breast Clinicians may wish to recommend that mothers of pump were able to maintain and increase preterm or ill infants start milk expression within an milk volume despite less frequent pumping. hour of birth
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Pumping more effectively Warmth Ohyama et al. (2010) found that manual expression yielded twice as much colostrum as did electric The warming of tissues is a known pumping during the first 48 hours therapeutic intervention that has the following delivery in mothers who effect of increasing local blood flow delivered between 29 and 39 weeks. and metabolism in tissues, Net milk yield was 2 mL (range 0 to facilitating excretion of tissue waste 12.6 mL) in the hand expression materials and phagocytosis, and group and 0.6 mL (range 0 to 7.2 enhancing tissue nutrition mL) in the pump group. Warm compresses placed on the Mothers in this study alternated breasts have long been between manual expression and recommended to aid the let down using a double electric pump every reflex. three hours, such that every other Kent et al(2011) found that warmed expression session was done by pump flanges resulted in a larger hand. amount of available milk removal.
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Warmth Yigit et al (2012) studied if warming the Music breast prior to pumping would increase the volume of milk expressed from a warmed breast compared with the other breast which was not warmed. Keith et al (2012) found that pump Mothers placed a warm compress (40.5C/104.9F) on one breast prior to dependent mothers pumping with an electric breast pump. who listened to The amount of milk obtained from the music while warmed breasts was significantly higher than pumping produced that obtained from the non-warmed breasts. significantly more Warming probably has an enhancing effect on the milk ducts or milk flow, allowing more milk with a higher milk to be pumped, rather than increasing fat content actual breastmilk production.
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Acupressure http://www.newbornconcepts.co Esfahani et al. 2015. Iran J Nurs Midwifery Res, 20:7-11. m/products#pumping_cd Acupressure for enhanced milk production Can be applied by the mother GB20 (in a depression between the upper portion of the sternocleidomastoid muscle and the trapezius on the same level with GV16), acupoint LI4 (on the dorsum of the hand, between 1st and 2nd metacarpal bones), and acupoint SI1 (1 cun posterior to the corner of the nail on the upper side of the little finger)
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Pump mechanics Have the mother try a Acupuncture for insufficient milk different pump. A different suction curve may provide a boost to Clavey (1996) Wei et al (2008) milk output. reported 90% described electro- Check the mother’s expectations of the effectiveness for acupuncture at pump. insufficient milk Shaoze (SI 1) as The mother may think a when started effective for small electric pump within 20 days of should behave in the insufficient milk same manner as a delivery Wei, et al. (2008). hospital-grade pump. American Journal Journal of Traditional The small pump may be working correctly based of Acupuncture Chinese Medicine on its capabilities, but 1996; 24:35-46 28:168-172 not in an effective enough manner to support an abundant milk supply
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Sore nipples Sore nipples
Pumping has an impact on nipple and areolar tissue Avoid using a pump that cycles less than 40 times/min. Such a pump holds vacuum on the nipple Structural difference between for prolonged periods of time during each suction left and right breast phase. The nipple/areola stretched to twice its resting length with Use a properly fitting flange. direct breastfeeding and quickly Some mothers start out a pumping session with a returns once infant is unlatched standard size flange and switch to a larger one Pumping can cause swelling, midway through as the nipples swell. Mothers may erythema, pain need to change flange sizes during the pumping experience if the nipples become sore from pumping. Abnormal enlargement of nipple diameter and length can persist Use a larger flange or a different pump if the nipple after pumping sessions turns purple while pumping. This may indicate that Francis & Dickton. Breastfeed Med 2019; the vacuum curve is not allowing venous blood to https://doi.org/10.1089/bfm.2019.0008 leave the nipple and is blocking oxygen rich blood These symptoms may indicate from entering. Mothers may need a larger flange or a soft tissue injury different pump, with a suction curve better suited to May need different flanges and https://pumpinpal.com/milk-duct-dysmorphia/ the mother. or different pump
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Sore nipples Hang in there Mama-- Elicit milk ejection prior to the start of you got this! pumping to decrease the time vacuum is applied to the breast when milk is not flowing. Pump for shorter periods of time, but more frequently. May need different size flange for each breast Lubricate the flange with a little olive oil. Temporarily reduce the amount of vacuum until the nipples feel better. Consider hand expression
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