While sales of breast pumps for expressing mother’s milk soar, Alice Allan asks do so many mothers need to use them?

Worldwide, sales of breast pumps are estimated to have reached 8.4 million units by 2022. The United States represents the largest market worldwide with Asia-Pacific ranking as the fastest growing market. While some of these pumps may be purchased by mothers who have breastfeeding difficulties, or mothers who are returning to work after maternity leave, increasingly new mothers, or even pregnant women, are buying a pump as part of their baby ‘kit.’

In the first days and weeks of their new, untroubled breastfeeding relationship, mothers are pumping their milk. Why?

Many mothers buy a pump when they are pregnant. Research by Helene Johns (2013) in Australia found that nearly 50% of the first time mothers in her test group already owned a pump at the time of the birth. Should we be surprised? Mother and baby websites sell pumps as basic equipment. Of course, first time mothers want to cover every eventuality.

I was living in Japan when I was pregnant with my first child and I knew few other mothers. Although I had a normal pregnancy, an extremely medicalized antenatal system meant I had lots of scans and a vaginal examination at every check-up. Pregnancy was treated like a dangerous condition. No wonder then that I developed a level of distrust about my own body. “I’d like to breastfeed, if I can,” I thought, but as a first time mother, I felt untested. Would my breasts work or would they need a bit of help? I got a hand pump “just in case.”

At 37 weeks pregnant my breasts had grown, but this wasn’t enough to convince me. What if I didn’t have enough milk? What if it dried up? The pump was an insurance policy, a talisman, and it helped me to feel safer about my voyage into the unknown. It would have been better to have the wise words of a group of experienced mothers telling me that everything was going to be fine, that my body would know what to do.

maternal-oxytocin-its-role-in-milk-ejection-and-warmth-provisionWhen my daughter was born she latched on straightaway and I consigned the useless hand pump to the cupboard. Not to the dustbin, because despite her avid feeding, her weight gain, and the fact that from far across the room I could shoot my husband in the eye with a jet of milk, I still wasn’t that confident. That confidence didn’t come until my second baby.

One mother in the mothers’ group I ran in Addis Ababa shared the following words with me:

“When my baby was born, I was breastfeeding well but the pediatrician insisted I pump, just so he could check that the baby was getting enough. He told me to pump 30 ml. I didn’t want to. I could tell my baby was getting enough. But my husband got nervous. He wanted to check too. So I pumped 30 ml of milk, absolutely fine, no problem. I said to the doctor, ‘What should I do with the milk?’ He said, ‘Ah well, now your husband can give it to the baby in a bottle so you can rest.’ I said, ‘No way! Why should I introduce a bottle?’ So I threw the milk down the sink. What a waste. I still tease my husband, ‘You still owe me 30 ml of milk you know. You haven’t paid me back for that!’”

Not only are mothers exhorted to show proof of their milk, but it is assumed they need to share the ‘burden’ of breastfeeding.

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Ken Tackett

The fact that breasts are not calibrated can be a source of great anxiety to new mothers and fathers, and, unfortunately, to some health professionals. However, for mothers for whom breastfeeding is progressing well there are problems associated with unnecessary test pumping or even feeding of the baby with expressed breast milk (EBM) in the first days of life. Helene Johns and her colleagues’ 2013 review showed that the use of formula and EBM in hospital after birth in healthy term infants was associated with decreased breastmilk feeding at three and six months.

We know why formula supplementation can be harmful, but why would giving EBM have this effect? Perhaps the answer is related to maternal confidence, the infant relationship with the breast in a very key period of cognitive development, plus a cascade effect from poor pumping results. After all, some mothers cannot let down for a pump and will produce only a measly few drops, when in reality they have a good milk supply. It’s not surprising that they can’t though—a breast pump is not a baby. It is a piece of plastic, sometimes with a motor attached. It does not smell like new-mown hay and make lovely squeaky noises. It does not set off a gorgeous flood of oxytocin (the hormone of love). And besides, oxytocin is known as the “shy hormone.” With everybody looking and judging, how is it meant to do its thing?

Other mothers might respond to a pump and do well against that particular motherly ‘exam.’ For them, it is reassuring to see the milk with their own eyes. However, though test pumping is tempting, it is often ineffective as a measure of breastmilk production. Health workers may recommend it if they don’t have the skills and questions to evaluate a successful breastfeeding relationship. UNICEF’s assessment tools for observing a breast feed can help, by asking questions about the baby’s pees and poops, about any pain during a feed, and whether the baby spontaneously lets go of the breast. When women and health workers are taught how to look for these signs, intrusive pumping checks can be avoided.

Here’s another mother in the Addis Ababa group talking about why she pumped her milk in the first few days after birth:

“My husband really wanted to feed the baby. He couldn’t see how he was going to bond with her unless he could feed her. I felt guilty that I wasn’t sharing this joy. I pumped a bottle in the morning for him to give that evening. I fed her at 7pm and went to bed. At about 9 pm I woke up with milk leaking from my breasts, to hear my daughter screaming. My husband was jiggling her and walking up and down the kitchen. ‘I gave her the milk but she won’t sleep,’ he told me. He now sees just how useful breastfeeding is, not just nutrition but for soothing her. They have found lots of other ways to bond.”

Mothers often do not anticipate how intense their need to be with their new baby will be. How even giving up one feed feels like torture. Maternal instincts often underpin biological imperatives, which are usually pretty wise, if we learn how to listen to them.

Other relations, sometimes well meaning, other times greedy for a bond with a baby when they feel they are missing out, may push for the mother to pump. But pumping often leads to breasts being stimulated at one point of the day, with milk production getting a boost, then a long, possibly uncomfortable, period of not feeding from the breast later on, with the potential for mastitis in a worst case scenario. Some mothers find that pumping causes over supply. Some mothers who don’t feed from the breast at night risk losing their milk supply early as prolactin, the milk-stimulating hormone, is at its highest level at night. A Spanish study (2009) suggested that milk pumped during the day may not help babies to sleep in the same way as nighttime milk.

Mothers often mistakenly think they need to wait until their breasts feel full before they pump. Professor Peter Hartman’s research on milk synthesis shows that this kind of scheduled pumping leads to a build-up of feedback inhibitor of lactation (FIL) and a reduction in milk supply. The rate of milk synthesis, how fast the secretory cells make milk, is related to the degree of emptiness (or fullness) of the breast. As the breast fills, compounds in the retained milk (FIL, peptides, fatty acids, and other components) signal the secretory cells to slow down milk synthesis.

Another common reason for early pumping is that mothers have to return to work in the coming months and fear that their baby will struggle to take a bottle. They believe that early introduction of bottles of EBM will give their baby the flexibility to deal with their absence in the future. However, introducing bottles of EBM in the first days and weeks has not been proven to make the transition easier, indeed it can have negative effects for the regulation of milk supply and for a baby’s ability to suckle. It’s appalling that in some countries maternity leave is not even long enough to establish breastfeeding adequately.

do-i-need-a-breast-pump
Ken Tackett

I have always liked the idea of breastfeeding being conversational. A description that moves breastfeeding away from mere physical nourishment to embrace its being a communicative act as well. Demand feeding means the baby’s call and response—or ‘serve and return’—needs are met. The child gets the idea that he has agency in the world, that someone is listening to him at exactly the moment he chooses to express his need.  

All those breast feeds have the effect of priming the mother’s milk supply and keeping it up to date with the baby’s current need. The feeds may respond to a growth period, a spell of hot weather, or a time of stress. And the antibodies that a direct breastfeed provides give protection against germs in the current environment, germs that might not have been present when the milk was pumped a few hours ago.

If you have ever fed an older baby you’ll remember the passionate ‘conversations’ that they can have with the breast. I remember my daughter, with a mouth full of breast, shouting joyfully, clearly conversing with it. Sometimes she’d give it a bang with her fists to get the milk flowing. At other times, she’d break into chuckles while feeding, as if the breast had made a joke. I don’t know if babies communicate in the same way with their bottles but I suspect not.

Research (2013) tells us that demand feeding, rather than the scheduled feeding that often comes with expressing, results in increased cognitive development among children. The reasons are as yet unknown but the authors of the study point out:

“It is possible that babies fed to a routine become relatively more passive participants in the world: feeding (arguably the most important event in their lives) is something which is done to them, rather than something which their own desires and actions play a part in bringing about. This may translate, in later life, into a less active degree of engagement with learning.”

As breastfeeding mothers and their supporters, it’s important to be aware of the disruptive potential of early pumping to the body’s natural balancing systems. Isn’t it time to stop unnecessarily interrupting those first breastfeeding conversations?

References

Daly, S. & Hartmann, P. (1995). Infant demand and milk supply. Part 1: Infant demand and milk production in lactating women. Journal of Human Lactation 11(1), 2126.

Daly, S. & Hartmann, P. (1995). Infant demand and milk supply. Part 2: The short-term control of milk synthesis in lactating women. Journal of Human Lactation 11(1), 2737.

Johns, H., Forster, D, Amir, L., & McLachlan, H. (2013). Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic review. BMC Pregnancy and Childbirth, 13, 212. http://doi.org/10.1186/1471-2393-13-212

Iacovou, M., & Sevilla, A. (2013). Infant feeding: the effects of scheduled vs. on-demand feeding on mothers’ wellbeing and children’s cognitive development. The European Journal of Public Health, 23(1), 13–19. http://doi.org/10.1093/eurpub/cks012

Sánchez, C., Cubero, J., Sánchez J, Chanclón, B., Rivero, M., Rodríguez, A., & Barriga, C. (2009). The possible role of human milk nucleotides as sleep inducers. Nutritional Neuroscience. 12, 28. http://dx.doi.org/10.1179/147683009X388922

Alice Allan grew up in rural Devon then studied English at Cambridge University. She worked as an actress and a corporate trainer in London and Tokyo, then as a lactation consultant in public hospitals in Addis Ababa, Ethiopia, where she taught about breastfeeding, skin-to-skin and kangaroo care for premature babies. She has written for a number of publications including The Telegraph, The Sunday Express, the Ethiopian Herald, The Green Parent and The Mother Magazine. She currently lives in Tashkent, Uzbekistan with her diplomat husband, two daughters and a large Ethiopian street dog called Frank.

What-big-teeth-you-have-grandmotherHer novel, Open My Eyes That I May See Marvellous Things is published by Pinter and Martin. Set in Ethiopia, it tells the story of an adopted midwife who falls in love with an abandoned baby, and asks, “How can you hold a baby next to your skin without it touching your heart?” It is available from Amazon, pinterandmartin.com and good bookshops. www.aliceallan.co.uk Twitter: @alicemeallan and find her on Facebook.

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