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Pumping Breast Milk? Troubleshooting Tips to Maximize Production and Save Time

Robyn Roche-Paull, BSN, RNC-MNN, IBCLC

Tips and tricks to make pumping as stress free and effective as possible.

Expressing your breast milk is one way of connecting with your baby when you must be separated. It provides him with your precious milk, along with all the antibodies and nutrition that are so important for his growth and development; but more than that, it also keeps your milk supply up, so you can breastfeed and remain close when you are together. However, pumping is not a natural process. We are not meant to be hooked up to a machine. It can take time and a bit of a learning curve to get the hang of it and do it well.

Getting started

Depending on when you need to return to work, you may want to start pumping about four to six weeks before your maternity leave ends. Begin by pumping in the mornings, when your supply is at its highest. Center your nipple in the breast flange (some mothers find that lubricating the flange with water or olive oil helps to create a stronger seal and reduces friction). Then start the pump. When using an automatic pump, turn it to its lowest setting and gradually increase the speed and suction. With a manual pump, start with a gentle, slow rhythm. Set the pump to the maximum comfortable setting for you. Pumping should not be painful. If it hurts, something is wrong. Continue pumping for about 15 minutes or around two minutes past the last drops. With pumping, frequency is more important than duration for building and maintaining a good milk supply.

frequency is more important than duration for building and maintaining a good milk supply.

Pumping is a skill that you learn and it takes time to master it. Do NOT be alarmed if you get only drops or even nothing at all the first few times. Expressing your breast milk with a pump is as much a psychological process as it is a physical one. Your body is used to letting-down to a warm, cuddly baby and is trying to get used to letting-down to a cold, hard plastic pump instead. With time and practice, it will become second nature and you’ll be pumping like a pro!

Pumping Breast Milk? Troubleshooting Tips to Maximize Production and Save Time
Ken Tackett

Maximize your production

After pumping regularly for a while you may find that your milk supply is dwindling. A low supply of breast milk can be caused by numerous factors, but is most often from a lack of time to pump during the work day. Keep in mind that even the best breast pump on the market can never remove milk as effectively as your baby, and milk supply varies throughout the day and from day to day, so dips in supply are more noticeable when pumping than when breastfeeding.

Follow these tips to maximize your production when expressing your breast milk.

  • Don’t skip pumping sessions! Aim for 8–10 breastfeeding/pumping sessions in 24 hours and double pump (that’s both breasts) for 15–20 minutes or about two minutes past the last drops. Pump at least every 3–4 hours while at work. Full breasts signal your body to slow/stop milk production. With pumping, frequency is more important than duration.
  • Breastfeed or pump at least once at night. Prolactin, a milk-making hormone, peaks during the nighttime hours, increasing your overall milk supply. Try to breastfeed or pump at least once between midnight and 5 am.
  • Power pumping. Power pumping is very effective at boosting production. Try pumping for the length of each commercial break during your favorite TV show. Pump for just 5 minutes with many sessions sprinkled throughout the day. Take a “pumping vacation”: for 2–3 days pump after every breastfeeding session.
  • Establish a routine. Pumping is as much about your brain as it is your breasts. Try to pump in the same place and at the same time every day to condition your let-down reflex.
  • Stimulate a let-down. Along with establishing a routine, you might try the following when you pump:
    • Relax shoulders
    • Deep breathing
    • Apply warmth to breasts (hot packs)
    • Massage breasts before pumping
    • Visualize “rivers of milk”
    • Smell a piece of your baby’s clothing or blanket
    • Listen to a recording of your baby’s sounds (crying, laughing, babbling)
    • Watch a video of your baby breastfeeding (taken over your shoulder)
  • Pump with a buddy. Don’t be shy, pumping with a friend or co-worker increases oxytocin, resulting in higher milk yield during your pumping session for both of you!
How to Choose a Breast Pump
  • Pump during your commute. If you have a long commute, consider using a hands-free bra so you can pump during your drive. This can add two more pumping sessions to your day and can really boost your supply.
  • Breastfeed at drop-off and pick-up from day care. Breastfeed your baby at day care to add more sessions at the breast for increased stimulation. This is really important if you have a long commute or can’t pump often at work. Ask your day care provider to hold off feeding your baby an hour before pick-up so you can feed before heading home.
  • Hands-On Pumping (HOP). HOP is a well-researched way to increase your production and is very simple to do. Massage breasts before pumping, and do breast compressions during pumping. Finish by hand expressing for a minute or two after pumping. HOP empties the breasts better and has been shown to increase milk yield by up to 48%, as well as doubling the fat of expressed milk. View these videos on HOP.
  • Tandem pump while breastfeeding. By putting your baby on one breast and pumping the other breast at the same time, you can double your stimulation and capture more milk for later use.
  • Adjust settings on pump. Change things up a bit: consider pressing the let-down button or changing the suction and frequency settings on your pump throughout your pumping session. Babies usually trigger 2–3 let-downs when they breastfeed, you should mimic the same when pumping. Make sure to set suction to your maximum comfort level for best output.
  • Rent a hospital-grade pump. If you’ve hit a rut, you might consider renting a hospital-grade pump for a few weeks to increase your milk supply. The change in motor strength and cycling frequency can be enough to jump-start your supply again.
  • Alternate flange sizes. Are your flanges (shields/horns) the correct size? Switching to a smaller or larger pump flange can make a big difference in pumping comfort and/or output. You may also want to look into angled Pumpin’ Pals Super Shield flanges or soft-inserts that “massage” the breast if you find your flanges don’t fit properly. See an IBCLC to be fitted correctly.
  • Galactagogues. Your body may need a boost that can only be created by herbs or medications. Speak with an IBCLC about which ones are best in your situation before running out to the store. Herbs are a medication and should not be taken without proper precautions and supervision, especially if you or your baby have any underlying medical conditions.
  • Do NOT watch the collection bottles. Watching the bottles while you pump can be a self-fulfilling prophecy, as you worry about your output and then don’t see any milk. Cover your flanges and bottles with a blanket when pumping and concentrate on a video of your baby or playing a mindless game on your phone while pumping. Before you know it the bottles will be full of milk!

Pumping Breast Milk? Troubleshooting Tips to Maximize Production and Save Time


Sometimes just shaving a few minutes off your pumping routine is what you need to do to make it through the work day, or keep your boss off your back about pumping. Try adding some of the following to your routine:

  • Invest in a hands-free bra. A hands-free bra, either store bought or home made, offers you the ability to complete tasks while at work (such as charting on a computer) but also allows you to do hands-on pumping which increases milk yield. There are two ways to make your own hands-free bra:
    • Cut slits in a criss-cross pattern over the nipple area in a sports bra
    • Use rubber bands to make a hands-free bra (for instructions and photos click here)
  • Extra flanges. Have 2–3 sets of flanges and tubing at work. Use a new set with each pumping session. Wash all of them at night when you get home.
  • Refrigerate your parts. Another option is to refrigerate your flanges between pumping sessions, and wash them all when you get home. The cold reduces bacterial growth and the milk expressed is considered safe for a full-term healthy infant.
  • Partner help. Your partner can wash your pump parts and get your pump ready for the next day, so you can sit on the couch and breastfeed. The extra time your baby is at the breast will boost your production.

Troubleshooting tips

There may be times when you are doing everything right to increase and maximize your milk production, but it’s just not working. You might have started a new medication or the membranes on your pump need replacing. Take a glance through the following checklist to determine if the decrease in your pumping output is due to you or your pump.

Is it you?

Sometimes a dip in supply when pumping is due to personal factors:

  • Hormonal birth control methods can cause lowered milk supply, especially those with estrogen in them, as can Depo-Provera. Some mothers are even sensitive to the hormones in the mini-pill or Mirena IUD. Check with your doctor for options if you feel this is impacting your milk supply.
  • Medications, such as decongestants used for the common cold, can cause lowered milk supply in up to 20% of women who take them.
  • Growth spurts. Is your baby asking to breastfeed a whole lot more than usual? If so, he may be having a growth spurt and is building up your supply. Growth spurts are normal at around 2 weeks, 6 weeks, 3 months, and 6 months. Be prepared and breastfeed as much as possible when you are together. Consider adding in a few extra pumping sessions as well.
  • Illness. If you have you been sick lately with a cold or the flu, you may find that your milk supply is down a bit. Increased breastfeeding, lots of fluids, and rest should bring it right back up.
  • Overfeeding is a common culprit, especially at day care. Bring your milk in small quantities (2–4 ounces), and teach your provider “Paced-bottle feeding,” which means holding the baby, giving small, frequent feeds, and watching the baby for feeding cues. Give your provider this information about how to bottle-feed the breastfed baby.
  • Pacifiers. If you use a pacifier a lot when you are together, you may be sabotaging your milk supply inadvertently. Every time you use a pacifier instead of breastfeeding, that is one less time your breasts are stimulated to make milk. Only use pacifiers when you are apart. When you are together, breastfeed!
Pumping Breast Milk? Troubleshooting Tips to Maximize Production and Save Time
Ken Tackett
  • Period or pregnancy. Has your period returned? Could you be pregnant? Hormones can cause a lowered milk supply in the week leading up to your period or during pregnancy.
  • Sleeping through the night. If your baby has started sleeping through the night, you may find your milk supply has taken a nosedive. The hormones responsible for making milk are at their highest during the nighttime hours and breastfeeding at night boosts those hormones, which in turn boosts your supply. If your baby is sleeping through the night, you are missing out on that boost. Consider pumping at least once at night, or look into “reverse-cycle feeding” (i.e. breastfeeding your baby through the nighttime hours, which is easier while co-sleeping or bedsharing).
  • Stress. If you are stressed, it can affect your milk supply—who isn’t stressed when working and pumping? Breastfeeding produces a naturally occurring relaxing hormone. After work, sit on the couch to enjoy that down-time with your baby. Let the hormones do the trick to relax you both after a long day.

Is it your pump?

Trouble with your pump can also cause milk supply issues:

  • Proper pump. Is your pump appropriate for the amount of pumping that you do? An occasional-use pump is not meant for hardcore use, 3–5 times a day, by a working mother. Invest in the proper pump for your needs. Check out How to Choose a Breast Pump for more information on what to look for in a breast pump.
  • Age. How old is your pump? Breast pump motors are generally under warranty for one year. The motors in pumps older than a year often start to wear out, especially if you are pumping more often than the pump was designed for. This can lead to ineffective pumping and a lowered milk supply. Have your pump’s suction tested by an IBCLC.
  • Maintenance. Do your pump parts need to be replaced? Check your pump and replace any parts that are worn or that haven’t been replaced in the last 3–6 months. Check tubing for leaks or holes, and membranes for tears. A little preventive maintenance often fixes pump problems ASAP.
  • Used pump. Are you using a used pump? A used pump’s motor may be dying, leading to lowered milk output. If your pump is not a closed system pump, designed for multiple users, it may be harboring mold, bacteria, or viruses on the parts that cannot be sterilized. Buy a new pump, not just new flanges and tubing. The cost of a good pump is about the same as two months of formula, but will provide your baby with your breast milk for a year or more. In the United States, insurance companies are required to provide you with a breast pump free of charge.

Pumping for your baby takes a huge commitment. You should feel very proud of your accomplishment, no matter how much or how little milk you can express to provide for your baby. Remember, that while providing your milk is important, your breastfeeding relationship is more important. Pumping while you are separated allows you to be able to breastfeed when you are together to keep that connection between you strong.

health-implications for breastfeeding mothers
For all your breastfeeding needs
Robyn Roche-Paull

Robyn Roche-Paull, BSN, RNC-MNN, IBCLC, is the award-winning author of the book, Breastfeeding in Combat Boots: A Survival Guide to Successful Breastfeeding While Serving in the Military and the Executive Director of the non-profit, Breastfeeding in Combat Boots.

pumps and pumping protocols

How to Choose a Breast Pump

Robyn Roche-Paull, BSN, RNC-MNN, IBCLC

Which breast pump? Robyn aims to clear up some of the confusion that exists to help you choose the best pump for your particular situation.

There are so many different breast pumps available on the market today. Making a choice can be mind-boggling, not to mention time-consuming, as you try to figure out which pump is best for your situation. There are many factors to consider, such as how and where you will use it, what options you will have available for expressing your milk at your workplace, and whether it is within your budget. With so many pumps available, each with numerous features, including a range of cycle and suction settings, sizes, power sources, and prices, how do you begin to choose?

Breast pumps: the lowdown 

Many pumps claim to be the “next best thing to having your baby at the breast,” and it can be hard to cut through the hype to determine which is the best pump for your particular needs. There are four main categories of breast pumps—from hand-operated to hospital-grade. Here is a rundown of what they offer, the workplace situation they are best suited for, and their advantages and disadvantages.

how-to-choose-a-breast-pumpHand-operated pumps. These pumps come in two basic types: cylinder and handle squeeze. Cylinder pumps have two cylinders, one inside the other, with a rubber gasket between them. You create suction by pushing and pulling the cylinder in and out. Handle squeeze pumps create and release suction when the handle is squeezed and released. Both types are very portable, as they are lightweight, small, and quiet. These usually do not come with a cooler or storage case (the Ameda One-Hand and the Avent Isis are the exceptions), and they are easy to clean. Some mothers buy two hand-operated pumps in order to pump both breasts simultaneously.

Hand pumps are best suited for women who need to pump to relieve fullness or work in an area with no access to electricity. Very few women can maintain a full milk supply using a hand pump full-time due to the pump’s inability to cycle at the same speed a baby sucks. It can be useful to keep a spare hand pump with you, in case you are without your regular pump or there is an electricity shutdown.

how-to-choose-a-breast-pumpOccasional-use, single, or double pumps. Occasional-use pumps, whether single or double, are generally “semi-automatic,” meaning they require that you manually cycle the pump. Even if the pump is labeled as a double pump, most cycle too slowly to drain the breast effectively or provide the proper stimulation to increase your prolactin levels enough to maintain a milk supply. These pumps can be battery operated or use an electrical adapter. However, the cost of batteries adds to the overall expense of the pump (and they go through batteries quickly). The pump may need to be replaced if used frequently over a long time period because the motor is small and not meant for heavy-duty use. Most of the newer models now come with a cooler or storage case. They are lightweight, small, and often noisy. These pumps are meant for occasional use only, no more than a few times a week, and are best suited for those women who want to pump for a date night out or who work part-time.

how-to-choose-a-breast-pumpPersonal-use, electric, double pump. For employed mothers who will be separated from their babies for 40 hours a week or more, these lightweight, portable, highly effective, and fully automatic pumps are the best choice. Personal-use pumps are excellent at maintaining a milk supply. All of these pumps double pump (and can convert to single pumping if need be) and cycle 40–60 times a minute automatically. These pumps have dual-control mechanisms, allowing you to regulate the speed and suction to suit your comfort. And some models have a two-phase pumping action, a fast “let-down” phase and a slower milk-expression phase. Most come in an attractive briefcase or backpack, with chill packs, and a compartment for storing milk. They can be used with multiple power sources: electricity, AC adapters for use in a car/12v, and batteries, or a rechargeable battery pack. These pumps are best suited for use by working mothers with a regular pumping schedule and some place to pump.

how-to-choose-a-breast-pumpHospital-grade, rental, double pumps. These are the most efficient, effective, and comfortable pumps available. Hospital-grade rental pumps automatically cycle 40–60 times a minute with a very smooth action, can double or single pump, and are the most effective at mimicking a baby’s sucking pattern. Hospital-grade pumps are excellent at initiating and maintaining a milk supply. Like personal-use pumps, most hospital-grade pumps have dual controls for setting the speed and suction to your preference, and some also offer the two-phase pumping technology. These pumps are large and heavy, due to the industrial-size motor, and are not very portable, as most do not have a carrying case or a compartment to store expressed milk. They run on electricity, although a few offer battery packs for use when electricity is unavailable. Hospital-grade pumps are multi-user pumps, meaning you must supply your own collection kit (which must match the pump brand and is not interchangeable). These pumps are best suited for pumping within a workplace lactation center.

Ken Tackett

Which features to consider

All breast pumps need to do one thing: remove the milk from your breasts. How that is accomplished and what makes one pump better than the next depends on its features. The problem is every manufacturer claims to have the breast pump that has the best features and most closely mimics a baby at the breast (and the U.S. Food and Drug Administration (the FDA) does not regulate these claims). Here are some of the features YOU need to look at when buying a breast pump. Keep in mind what makes a breast pump effective for one mother may not work for you.     

how-to-choose-a-breast-pumpCycles and suction settings. Breast pumps are designed to empty the breast by mimicking both the suction pressure and frequency of a baby’s suckling. A pump that cycles automatically between 40–60 times a minute will be the most effective at removing milk, keeping your prolactin levels high and your milk production up. Suction pressure affects your comfort, the efficiency of milk expression, and the production of milk. Suction levels that are less than 150 mmHg are ineffective at emptying the breast, and those that are more than 220 mmHg can cause nipple pain. Most quality pumps will have either adjustable levels of suction and cycles (within the above specified ranges) that allow you to alter them to suit your needs, or pre-set controls that automatically create and release the suction. With many of the low-end pumps, you must regulate the suction and cycles manually, by pressing a lever or placing and removing your fingers over a port.

how-to-choose-a-breast-pumpDouble vs. single pumping. A good pump will allow you to pump both breasts simultaneously, which is faster and increases the amount of prolactin released, leading to higher milk production. Once you become proficient at pumping, using a double pump can take as little as 10–15 minutes. Single pumping shouldn’t take longer than about 20–30 minutes.

how-to-choose-a-breast-pumpOpen vs. closed system. Breast pumps are based on either an open or closed system. In an open system, the pump motor is exposed to your milk as there is no barrier between the collection kit and motor. This can lead to the unintentional “drawing-in” of your milk into the motor and the eventual growth of mold (the inside of a breast pump is warm, dark, and damp—ideal conditions for mold growth), or the harboring of bacteria and viruses, which can then be passed back into your milk at a later date. There is no way to completely clean and disinfect this type of pump. The FDA recommends that open-system pumps be used by a single user because infectious particles remaining in the pump may potentially cause disease. In a closed system, the collection kit and pump motor are completely separated via a barrier (filters or membranes) so that your milk cannot reach the motor. This decreases the possibility of mold growth and infectious particles contamination.

If your pump is not listed here, check with the manufacturer or an International Board Certified Lactation Consultant (IBCLC) to determine if it is an open or closed system

  • Open: All Medela pumps except hospital-grade (Lactina, Symphony)
  • Closed: Ameda (Elite, Platinum, Purely Yours), Bailey (Nurture III), Freemie (Freedom, Equality), Hygiea (EnDeare, EnJoye), Lansinoh (Signature Pro, Affinity Pro), Lucina (Melodi One), PJ’s (Comfort, Bliss), Spectra (M1, S1, S2, Dew)

Adapters and batteries. What kind of power will you have available? Some pumps require access to electricity, while others come with 12v car adapters. Some can run on rechargeable internal batteries; others require replacement AA batteries. If you are traveling overseas, make sure that you have the proper adapters for the outlet or you risk blowing the motor.

Carrying case. Is the pump portable and easy to transport? Does it come with a carry bag and have a compartment to keep your milk cool (especially important if you won’t have access to a refrigerator)? Many of the better pumps come with gel/ice packs that fit the compartment, and some have removable cooling compartments that allow you to leave sections you don’t need at work. Some pumps are very large, bulky, and heavy, while others are small enough to fit in the pocket of a backpack or purse. Many of the personal-use pumps come in a black, microfiber case with a shoulder strap.

Other features. There are a number of other features available on breast pumps that you may want to consider. One of the most important is whether the flanges or shields are interchangeable. You want flanges that fit you correctly, as this can impact your milk supply. Some pumps have a “let-down” feature that automatically sets the cycles fast and suction light to mimic the quick sucking your baby does to help the milk flow. Other pumps offer a “cry” feature that allows you to record your baby crying (laughing or cooing), as that has been shown to help the milk-ejection reflex in breastfeeding mothers. Many newer pumps offer LCD displays that show the speed and suction, as well as time and length of your last pumping session. Other extras may include soft “petal” inserts that massage the breast, timers, and nightlights.

Spare parts. How easy is it to obtain spare parts for your pump, especially if you are overseas? Does the manufacturer ship overseas? Do they have a worldwide presence with parts that are carried by local drugstores and/or lactation consultants? This can save you a lot of heartache if pieces go missing or become damaged while traveling for business or pleasure.

Don’t choose a used breast pump

Some mothers consider sharing a pump or buying a used pump as a means to save money. This is not a good idea for a variety of reasons. Personal-use pumps are considered “single-user” equipment by the FDA and are not to be shared or resold. Breast pumps of this type cannot be properly sterilized between users due to the way they are built (open versus closed systems). Even with new tubing and flanges, airborne pathogens in milk particles may have entered the motor from the previous user and then are blown towards the bottles, where they can possibly be passed on to the next user. This can present a small, but nevertheless very real risk of transmitting certain bacteria and viruses from mother to mother (a mother can be a carrier and not know it or show symptoms). Also, in some pumps the milk goes towards a sealed chamber, while in other pumps the milk can go back up the tubing and get sucked into the motor, where mold can grow and then be blown back towards the bottles.

Breastfeeding Without Birthing: Tips for Pumping Success
Ken Tackett

Many personal-use pumps are only made to last about a year with full-time use (about 2–3 pumping sessions per day during a work week) and most warranties are often only for a year. Buying a used pump runs the risk that the motor may be wearing out and no longer functioning at peak performance, which can negatively affect your milk supply. You can change all the membranes, tubings, and valves you want, but if the suction seems to be decreasing then it probably is because the motor is dying. Warranties are also voided when pumps are shared or used by more than one user. With the passage of the Affordable Care Act, breast pumps in the United States are a covered item by insurance companies. There is little reason to buy a used breast pump.

The type of pump you choose is as individual as you are, and what worked for your friend or co-worker may not be the best choice for you. Take your time and research all your options when choosing your breast pump. Your breast pump is the link between you and your baby when you are separated. It allows you to produce your baby’s milk and remain a committed breastfeeding mother. This is an important decision to make. For a downloadable handout with this information check out Choosing A Pump on the Breastfeeding in Combat Boots website.

Robyn Roche-Paull

Robyn Roche-Paull, BSN, RNC-MNN, IBCLC, is the award-winning author of the book, Breastfeeding in Combat Boots: A Survival Guide to Successful Breastfeeding While Serving in the Military and the Executive Director of the non-profit, Breastfeeding in Combat Boots.


Breastfeeding Without Birthing: Tips for Pumping Success

Pumping milk. Help for the mother who does not give birth to her baby but wants to breastfeed.

Alyssa Schnell, MS, IBCLC

This third post concludes our mini series about what to expect when breastfeeding a baby you did not give birth to, adapted from Breastfeeding Without Birthing, an essential guide to breastfeeding for mothers through adoption, surrogacy, and other special circumstances.

Using a breast pump is a learned skill. Unlike breastfeeding, it is not natural or instinctual. Responding to your precious baby suckling at your breast, the feel of his downy hair, that new baby smell, his gurgles and coos, and his hands kneading your breasts trigger your milk to flow. Understandably, you may not respond as well to a cold, hard machine. Fortunately, there are tricks to help. No mother finds all of these tips helpful, but I hope that you will find a few that make your pumping experience as successful and positive as possible.

Breastfeeding Without Birthing: Tips for Pumping Success
Ken Tackett

The basics

TIP 1. Rent your pump from a reliable source. Multi-user breast pumps are available for purchase or rental. Due to their expense most mothers choose to rent. These pumps may be available through a variety of sources: lactation consultants, hospital pharmacies, baby boutiques, and drug stores. Your local lactation consultant or breastfeeding counselor can help direct you. Once you’ve got a list of breast-pump rental stations in your area, here are questions you may want to ask before renting:

  • Which breast pumps do you rent out? In general, multi-user breast pumps are quality pumps, but it may be helpful to educate yourself about which are available in your area.
  • What rental terms are available? The rental terms may be monthly, weekly, or daily.
  • What is the rental fee?
  • What is the cost of a personal kit? “Multi-user” refers to the motor of the breast pump only; you will still need to purchase your own personal kit to use with the pump.
  • How do you test your pumps between renters to ensure they are working properly? Between each user, the rental station should test each breast pump with a suction gauge to ensure that the pump is reaching a suction level of at least -200 mm/Hg, and that the motor is running smoothly and consistently at various settings.
  • How do you clean your pumps between users? I have heard stories of mothers renting a pump that came with another mother’s milk splashed all over it—yuck! The pump rental station should wipe down each pump with a disinfectant wipe or cleanser between users.
  • Will you show me how to use the pump? You should have access to an instructional manual for your pump, either with your pump or online. Even so, it can be very helpful to have someone experienced with the breast pump show you how to use it the first time. Many of the mothers I work with who are inducing lactation will pick up a breast pump from me on the day they are ready to begin pumping so that the first time they pump, I am there to help.
  • Do you carry various sizes and styles of flanges, and can you help fit me with the appropriate flanges? (See tip 2 for more information.)
  • What happens if I have any problems with or questions about the pump? If you are having difficulties with your pump, the rental station should offer you prompt and reliable assistance.

TIP 2. Use properly fitting flanges. Flanges, also called breast shields or cups, are the part of the breast pump kit that comes in contact with your breasts. Although your breast pump kit comes with one (or possibly two) flange sizes, several sizes and styles of flanges are available for your multi-user breast pump. (The exception is PJ’s Comfort breast pump by Limerick. This breast pump uses a flexible silicone flange made to accommodate all mothers.) Using a properly fitting flange will maximize your output and comfort from the pump (Kassing, 2002). Many lactation consultants are trained to fit you with flanges.

TIP 3. Optimize pump settings. Even for mothers who have breastfed or pumped for previous babies, inducing lactation with a breast pump can be rough on nipples. Start slowly and gently with short pumping sessions: only about 5 minutes or so. It may also help to use a lower suction level at first. If your breast pump has a separate cycle speed setting, you may find it more comfortable at first to set the cycle speed on your breast pump for faster cycles so that the suction on your nipple is held for just a short time each cycle. Over time, your nipples will be acclimated to the stimulation of the breast pump and you will be able to increase your pumping time to 15 to 20 minutes, raise the suction level, and increase the length of the cycles if that makes the pump more effective for you.

The lack of milk flow can also cause discomfort at first. Some mothers choose to hand express for a couple of weeks in order to initiate milk production and then switch to the breast pump. In addition to being an effective way to jump start milk production, hand expressing for a couple of weeks before pumping is a gentler way to introduce regular nipple stimulation.

Once your nipples are acclimated to the breast pump, find the settings that offer you the most comfort and the most output in the shortest amount of time. Because mothers respond to different stimuli, the pump settings can be different from mother to mother. If the highest comfortable suction level is quite a bit less than the maximum suction level on your pump, this may be an indication that your flanges do not fit properly. Finding the optimal settings for you is a little trickier than it sounds because at first there will be little to no milk. Over time, the amount of milk you produce will increase, and you can make adjustments to the settings if necessary.

breast pump do I need one
Ken Tackett

TIP 4. Use lubrication as needed. If you have the properly fitted flanges and have found your best settings on the pump but still feel some discomfort, use lubrication. Apply 100% extra virgin olive oil or a commercial nipple cream as a lubricant as needed. Lansinoh brand lanolin is not recommended for this purpose because it is tacky rather than slippery.

TIP 5. Express your milk frequently. For mothers who are exclusively pumping, the key is to simulate the nursing patterns of a baby who is establishing his mother’s milk production. A newborn baby nurses at least 8 to 12 times per day, so it is essential to pump at least 8 times per day on a regular basis. It is important that one of the pumping sessions happens during the middle of the night. Although it is ideal to empty the breast each time you pump, pumping for 5 to 10 minutes is more beneficial than not pumping at all.

Some situations in which you might pump even more often are a “Pumping Holiday” and “Power Pumping,” for no more than a few days at a time. These are both excellent strategies for using pumping frequency to give your milk production a boost. (See Chapter 11, Physical Techniques for Inducing Lactation, for details.)

TIP 6. Pump with one or both hands free. Because you may be pumping very frequently, it can be convenient to have one or both of your hands free while you are pumping. When you first start to pump, you may need to hold the flanges to each breast with one hand each. When you become more comfortable, you may be able to free up one hand by holding the flange on the right breast with your left hand while the left flange is held on with left forearm, leaving your right hand free (or vice-versa if you are left-handed). It is also possible to pump completely hands-free using a hands-free bustier or attachment.

Breastfeeding Without Birthing: Tips for Pumping Success
Ken Tackett

TIP 7. Keep cleaning of collection kit and milk storage simple. For mothers who are pumping many times throughout the day, cleaning the pump collection kit and storing pumped milk after each pumping session is unnecessary. For mothers who are pumping very frequently, or are power pumping, the kit and bottles can sit at a typical room temperature for up to 4 to 6 hours. Aim for 4 hours in warmer temperatures. While the pump kit sits out, cover the kit and bottles with a clean cloth diaper, receiving blanket, or towel. Then, after 4 to 6 hours, the milk can be stored in the refrigerator, the pump collection kit parts are washed, and you are ready to go for the next 4 to 6 hours (Genna, 2009).

Another approach is to detach the pump collection kit and attached bottles from the tubing. Place the pair of kits/bottles in a zippered plastic storage bag in the refrigerator between pumping sessions for up to 12 hours at a time before cleaning the collection kit and storing the expressed milk. Before pumping with refrigerated kit, detach flanges and run under warm water before pumping; applying chilled flanges to the breast can decrease the effectiveness and efficiency of the breast pump (Kent, Geddes, Hepworth, & Hartmann, 2011).

Some mothers find having a second pump-collection kit is worthwhile. One kit is air-drying while the second is in use.

Additional tips

For many mothers, the basic pumping techniques above will give the results you are looking for. If you are one of those lucky mothers, feel free to skip right over this section. However, if you are finding pumping challenging or you are not getting the output you are looking for, listed below are some additional tips.

TIP 8. Use hands-on pumping. Hands-on pumping simply refers to using breast massage during pumping and/or hand expression after pumping. If you are not getting the output you’d like from your pump, hands-on pumping is a very effective method for increasing the amount of milk you express. In one study of mothers of preterm babies, 86% of the mothers found that breast massage during pumping, and hand expression after pumping, increased the amount of milk they were able to express by 93% (Morton et al., 2012). Another study found breast massage (without hand expression) during pumping increased the amount of milk they expressed by 42% (Jones, Dimmock, & Spencer, 2001). Hands-on pumping is described in detail in Chapter 11, Physical Techniques for Inducing Lactation.

TIP 9. Distract yourself. While pumping, do not watch the bottles. Sometimes it helps to throw a receiving blanket over the kit and bottles. An enjoyable activity while pumping (watching a movie, reading, talking on the phone, listening to music or nature sounds) can distract you and take off some of the pressure.

TIP 10. Increase relaxation. You know what helps you to relax. It might be deep breaths, an enjoyable activity, or a scented candle, a hypnosis CD or App that helps you increase your milk production, and pumping output.

TIP 11. Use visualization. It can help to visualize your milk flowing, or a waterfall flowing freely, or whatever image helps you.

Read more here

TIP 12. Use sensory input. When the baby nurses, a mother receives a lot of sensory input from the baby that helps trigger the milk to flow. For many mothers, using sensory stimuli that remind her of her baby can help while pumping: a picture of her baby, a recording of her baby’s sounds, or the scent of an unwashed baby blanket or piece of clothing.

If your baby hasn’t arrived yet, consider sensory input that makes you think of your baby-to-be. You could pump in your nursery, if you have one. You may have a picture of your baby—even an ultrasound. You could listen to lullabies, or whatever connects you with your baby-to-be.

TIP 13. Boost your oxytocin. Oxytocin is the hormone that causes the milk to eject, also known as let-down. Letting down for a breast pump can be much more difficult than letting down for your baby. In addition to sensory input, try things that boost your oxytocin. Having your partner massage you while you are pumping—between the shoulder blades works especially well—will release oxytocin. Laughter and feelings of romance boost oxytocin. Consider reading books or watching movies that are funny or romantic while you pump. One mother found that simply pumping with her husband in the room increased her milk output!

TIP 14. Apply a warm compress to your breasts before pumping. A warm compress, such as a warm, moist washcloth can help the milk to flow. Or, make a warm compress by filling a tube sock with rice, knotting the open end, and warming in the microwave. Apply to the breasts just before pumping.

My story of pumping to induce lactation

For the 6 weeks before Rosa was due, I pumped 8 times per day, each day producing more milk than the one before. By the time she arrived, I was pumping 15 ounces per day! I believe that my pumping success was due to a combination of factors. First, I rented a breast pump from a local IBCLC in private practice. She showed me how to use the pump and she fit me with the proper flanges. Then, because I knew that we would have a long and intimate relationship, I named my breast pump. (Lucy, if you must know!) I set up my pumping station in the future nursery. It was comfortable and cozy, with a place for a glass of water and a book. Everything about that room connected me with my baby-to-be. My intention was that being in the nursery would also offer privacy. However, by the second day of pumping, my 3rd grader came in to ask for help with his homework. Pumping isn’t very discreet, so I was uncomfortable about an older child witnessing it. But he wasn’t uncomfortable, and in the end I think that it helped that I could make pumping flexible around the other needs of the family.

In addition to all of the ways the nursery connected my senses with my baby, I was surprised to find how strongly I responded to the smell of my own milk. That smell was what I associated with baby smell. At each pumping session, I double pumped for about 15 minutes. Then I stopped pumping to “massage, stroke, shake” to elicit another letdown. I pumped again for another 5 minutes or so. I wanted pumping to be as relaxing and enjoyable as possible, and for me that meant fun books to read while pumping. Reading also distracted me from watching the bottles. Prior to inducing lactation, I was always a mystery reader. Yet, while I was pumping, I preferred funny romantic novels. Hmm … laughter and feelings of romance boost oxytocin, the hormone responsible for milk release. I didn’t use all of the techniques suggested in the chapter, but I found just the right ones for me.

Why We Learn How to Form Relationships
Ken Tackett

Part 1: Breastfeeding Without Birthing: Making Milk

Part 2: Breastfeeding Without Birthing: Hormones

I hope you have enjoyed this 3-part mini series and found it a useful starting point.

You can read in more detail my book, Breastfeeding Without Birthing. Good luck!

Buy it here

Genna, C. W. (2016). Selecting and using breastfeeding tools: Improving care and outcomes.Amarillo, TX: Praeclarus Press.

Jones, E., Dimmock, P. W., & Spencer, S. A. (2001). A randomised controlled trial to compare methods of milk expression after preterm delivery. Archives of Disease in Childhood – Fetal and Neonatal Edition, 85(2), 91F–95. doi:10.1136/fn.85.2.f91

Kassing, D. (2002). Bottle-feeding as a tool to reinforce breastfeeding. Journal of Human Lactation, 18(1), 56–60. doi:10.1177/089033440201800110

Kent, J.C., Geddes, D.T., Hepworth, A.R., & Hartmann, P.E. (2011). Effect of warm breastshields on breast milk pumping. Journal of Human Lactation, 27(4), 331–338. doi:10.1177/0890334411418628

Morton, J., Wong, R. J., Hall, J. Y., Pang, W. W., Lai, C. T., Lui, J., … Rhine, W. D. (2012). Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. Journal of Perinatology, 32(10), 791–796. doi:10.1038/jp.2011.195

pumps and pumping protocols

Breast Pumps: Do You Need One?

While sales of breast pumps for expressing mother’s milk soar, Alice Allan asks do you need one?

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.

breast pump do I need oneI 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.

When 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.

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 breast milk 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?

Ken Tackett

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 breast milk 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.

Promoting Breastfeeding as an experience
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?


monograph_cover_nipple_pain_tn__74237.1436816456.1280.1280 copyDaly, 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. doi:10.1177/089033449501100119

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.  doi:10.1177/089033449501100120

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. doi: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. doi: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. doi:10.1179/147683009×388922

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, and good bookshops. Twitter: @alicemeallan and find her on Facebook.

June 2018. VOTE for Alice Allan’s Open My Eyes in The People’s Book Prize!

Also by Alice Allan:

Let’s Get Political: Breastfeeding and The Law

The Comfort of Childhood Toys and Attachment

What Big Teeth You Have, Grandmother

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Another Five Myths About Breastfeeding

In our culture, breastfeeding is no longer the usual way to feed a baby and this position helps many myths surrounding breastfeeding to persist. Here are another five of them.

1. It’s a myth that if a mother has an infection she must stop breastfeeding.

If a breastfeeding mother has a head cold, the flu, or even pneumonia, it will not adversely affect her milk, nor will she transmit the illness to her baby by continuing to breastfeed. In fact, it is important she does continue to breastfeed because she will start to produce antibodies to the illness, which will quickly pass in her milk to her baby to partially or even completely protect her child from developing the illness.

2. It’s a myth that something the mother has eaten which has given her gas may also make her baby gassy too.

Certain foods, beans for instance, can give the eater gas when particular carbohydrates they contain pass whole into the large intestine where bacteria ferment them, which leads to the production of gas. Anything that travels from the digestive tract into a mother’s milk goes via her blood stream and bubbles of gas do not get into her blood or her milk. Pediatrician Carlos Gonzalez, writes:

“you can eat as many beans as you want. But perhaps you prefer not to debunk the myth. This way, if during a gathering there is an embarrassing explosion, you can always say nonchalantly: ‘That was my baby, I’m breastfeeding him…'”

Radically restricting your diet has an impact on your nutrient intake, so don’t avoid too wide a range of foods, even in the early months when ‘colic’ is more common.

Esther Edith Photography

3. It’s a myth that breastfeeding mothers should not engage in intense physical exercise.

Some babies may not like the salty taste of sweat, so a quick clean up before nursing may be necessary. In the unlikely event that you have the time as a breastfeeding mother to do really hardcore physical exercise, it is possible that a build up of lactic acid in your milk could alter its taste and lead to your baby refusing a feed. Lactic acid is what’s there when your muscles feel stiff. It is harmless, will not hurt your baby, and it won’t be in your milk for more than a few hours at most. Exercise is really good for both a mother’s physical and mental well-being and there is no need to cut down on your level of activity in order to breastfeed. Check out this story. From a practical perspective, you will be holding your baby a lot of the time so taking exercise that does not separate you from your little one can be great for both of you. Hiking, strolling, mother and baby yoga, and swimming are all possibilities.

4. It is a myth that you need a breast pump if you are going to express milk for your baby.

Your two hands can do the job just as well. In fact, research has shown that in the early days following your baby’s birth, hand expression is a more effective way of removing colostrum when your breasts may be swollen. Colostrum is produced in small amounts and if you use a pump this leaves only sprays on the side of the bottle that are hard to give to the baby, but hand expression into a spoon can catch every drop. Hand expression can also be used as a technique during and after pumping to increase caloric content and remove more milk.

Breastfeeding After Breast Reduction Surgery
Ken Tackett

5. It is a myth that breastfeeding makes your breasts sag.

Breast shape, size, and appearance are altered by pregnancy and age, not by breastfeeding.

An entertaining book dispelling this myth is Saggy Boobs by Valerie Finigan, Pinter & Martin 2009. Talking to mothers who have breastfed their children might help new mothers who fret unduly about this happening. Mothers come in all different shapes and sizes and we all age at different rates too, just as we don’t all grow up at the same speed. 

These are just five myths.

Watch here

There are some more in this entertaining and engaging video from the charming Nurse Stefan.

Here are some more.

We’d love to hear any you might like to share.
Understanding Breastfeeding and how to succeed



How to Prepare for Breastfeeding While Pregnant.

Emma Smith

How to prepare for breastfeeding while pregnant

Breastfeeding is a gift from nature and whilst it can be challenging for most women initially, it is definitely worth persevering.  With time and practice breastfeeding becomes much easier and the benefits that both you and your baby receive from this wonderful gift, outweigh the potential hardship experienced to begin with.


How do I prepare for breastfeeding talk?

Talk to friends and family members who have breastfed!  They will give you valuable advice and real experiences.  Remember that everybody’s experience can be slightly different, so do not hang on her every word.  Take all advice with a pinch of salt and store away in your memory bank for later.


The Internet is a plethora of knowledge! Read articles written by professionals and, for contrast, read blog posts written by real women who are experiencing breastfeeding for the first time.  This way you get a real balance and understanding of how diverse each woman’s experiences can be.


Some trusted resources you might like to check out are:

Ilca Org


Pregnant Chicken

BF support group

Research and make contact with your local breastfeeding support group.  Understand how they may be able to help you, should help be needed later on.


Attend breastfeeding classes before you have your baby.  Classes will help to give you some insight, techniques, and you’ll get to meet other like-minded women.

What will I need?

Technically all you really need is your breast.  This is the way nature intended it.

However, in the modern world we have been blessed with a number of accessories, which do help to aid in our breastfeeding journey.

Breast pump

Breast pumps are extremely handy.  You may choose to invest in one or hire one, the choice is yours to make, but go for a double electric one.

A breast pump is a wonderful tool for mothers who return to work, but want to continue to breastfeed.  The milk can be pumped at work and stored in the fridge or freezer for use later.  This way your baby can continue to receive the great benefits of breast milk.


Bottles and sterilizer

Bottles and a sterilizer go hand in hand with a breast pump.  Invest in no less than 4 bottles to ensure you always have clean bottles on hand when needed.

Nursing bra

Nursing bras are extremely important.  They are functional, providing easy discrete feeding.  And they also help to support and nurture your tender, heavy breasts.

Wearing a quality supportive bra will help to reduce the risk of ligament damage, which can cause continued discomfort.

Purchase no less than 3 nursing bras.  One for wear, one for the drawer and one in the wash.

Learn more about the best nursing bras and what type you should be wearing.

Nursing pads

Nursing pads are not always necessary as every woman’s body is different. Initially when your milk comes in most women will experience some leakage as your milk may let down easily.

Nursing pads can be used inside your nursing bra to help keep you dry and secure.

TIP:  Avoid disposable nursing pads.  Most of them are made from processed fibers that can be hot, uncomfortable and because they are not breathable they can aid in breeding thrush and other bacterial infections.

Good washable nursing pads are best.  They are generally made from cotton or other breathable fibers.  They will keep you dry, cool and comfortable, allowing your skin to breath.

Nursing pillow

Nursing pillows have been specifically designed to help aid in nursing.  They can be expensive and whilst very handy for new mums a regular bed pillow can be just as effective.


Comfortable chair

Nursing initially can take long periods of time.  Finding a comfortable chair is worthwhile.  It may be your couch or a favorite existing chair you have at home.  You don’t have to invest in a specialty nursing chair or nursing station.  The choice is yours.

Cover up

Cover-ups are great for new mums who want to feed discretely in public.  They fold up small and are easily stored for use in your baby bag.

Choose a cover up that is made from cotton or some other lightweight breathable fabric.  This will help to keep the baby cool whilst feeding.

Are you prepared?

Being prepared with all of the wonderful products is only a small part of preparation.  Being mentally prepared is just as important.

Remember to be kind to yourself and understand that everybody’s journey is different.  Try not to compare yourself to others and ask for help should you need it.

About the Author

tracey-montfordLike many women out there, Tracey Montford is an exceptional multi-tasker! Apart from steering a global business, managing 2 young boys and keeping the clan clean and fed, Tracey still finds time to provide creative inspiration and direction to the exceptional designs of Cake Maternity. From the branding, presentation and delivery, creativity is a big part of what Tracey does so naturally and effectively. Find out more at or catch up with her on social @cakematernity.

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Featured post

Promoting Breastfeeding as An Experience

Ted Greiner, PhD gave the following presentation on Promoting Breastfeeding as An Experience at The Australian Breastfeeding Association HOTMILK meeting, 2007. Fast forward more than a decade and some of his colleagues want him to share this talk once again. The original text is reproduced here with the author’s gracious permission.

I work with nutrition in developing countries, and breastfeeding has always been a major component of my work. I lived in Sweden for 20 years. My sons were exclusively breastfed for close to 6 months and continued breastfeeding until they were 3.5 years old. We practiced attachment parenting, including a family bed for many years.

While many mothers in Sweden may start breastfeeding because they know it is better for the baby’s health, sustained breastfeeding is not promoted in Sweden as particularly important for infant health. About 40% breastfeed for longer than 9 months and about 20% for longer than one year. Some women ARE breastfeeding for a longer period of time; it is now accepted as something that is all right to do if you want to. Probably most women who do it simply do not want to force the infant to stop when they see how important it is for the child.

In my family research project with a sample size of two, the children have always been healthy, their teeth remained strong and free of caries, they were, if anything, very independent young children and now young men, and they have had relationships with girls and women that fit well within the Swedish norm. As to the impact of the family bed approach we followed, this sample of 2 were never afraid of the dark, never were interested in teddy bears and never sucked their thumbs much. But they did breast feed a lot!

When breastfeeding is exclusive, it is quite a challenge, both for the mother and for us who try to support and promote it. It is something new, at least in the minds of most scientists, health workers, and social engineers—if there is such a thing. It’s strange that it did not occur to hardly anyone before the 1970s—as far as I know—since it would seem to be the “natural” thing that presumably was done by our most ancient ancestors. Exclusive breastfeeding does not seem to have been understood or respected in recorded history, however—which goes back only for a few hundred years in most cases and for a few thousand years in a few. Thus, people have come to assume it was not possible or desirable, since it did not seem to be traditional.

Since we did not know exclusive breastfeeding was possible, let alone desirable, we have not created a society which provides women the support they need to practice it. Thus the challenge is broad, far beyond the usual approach of educating health workers, however important that may be.

I imagine that the Australian Breastfeeding Association asked me to give this talk because they share my concern about promoting breastfeeding as breastfeeding, not as the provision of breast milk. Swedish people might have trouble understanding what that meant, but I imagine all of you do. About 14 years ago I gave a talk in New York on the concepts of “protecting, supporting and promoting” breastfeeding. An old American friend was in the audience and we discussed my talk afterwards. I gradually realized we were not communicating. Finally we realized that this was because to her “exclusive breastfeeding” meant basically providing breast milk exclusively to the child, which in turn nearly always meant doing a lot of pumping. So the idea that the mother and child had to be together during this period had never occurred to her—while the idea that they could be apart regularly had never occurred to me.

It had simply never occurred to me that in countries without the long paid maternity leaves common in Europe, pumping is the norm for those who want their babies to get a lot of breast milk—let alone to get exclusively breast milk. In Sweden women do pump in rare circumstances, but most do so for a short time if at all. Why and what are the implications?

For Swedish women, I would say that breastfeeding is now seen as part of the experience of having a family. Nearly all women work before and after each baby they have, but they breastfeed exclusively during the first 4–6 months. (In Norway the pediatric community is more strongly behind exclusive breastfeeding until 6 months, so it is more common there. In Sweden confusion abounds, especially regarding the need to introduce gluten early to prevent celiac disease, but for the past 13 years 60–70% of babies have been exclusively breastfed through at least 4 months.) As is similar in most European countries, Swedish women have about a year of maternity and parental leave at about 75% pay, and the right to gradually go back to work, starting at even an hour a day if they want.

All of this I see as an expression by women that they and their children enjoy the breastfeeding experience, not that women are doing it out of a sense of duty or a sense that they provide certain biochemically-mediated advantages to their babies. At the very least, pumping is taking away something pleasurable from both mother and baby. Being a man I cannot comment on this from personal experience, but I have certainly seen how breastfeeding (not the consumption of breast milk) seemed to transport my sons to realms of bliss, even when they were three years of age.

I recognize that pumping is for many the best solution. But I wonder if many mothers assume that pumping will be a relatively painless way to “have your cake and eat it too,” only to find out that it is more difficult than they expected. Or that it is fraught with unexpected risks, even leading at times to premature cessation of breastfeeding. The more time a mother spends away from her infant, the higher the risk.

Promoting Breastfeeding as An Experience
Ken Tackett

Breast milk is not magic. It’s as normal and ordinary as sex and pregnancy; like masturbation and caesarean section, artificial feeding has its place, but is inherently inferior and should only be used when the natural alternative is not available. Similarly, the expression and pumping of breast milk should be recognized as something inherently inferior and used only when required. Pumping should be seen as a short-term approach to cope with a situation where mothers’ and infants’ rights are not being respected.

Thus perhaps one should counsel pregnant primiperas or those with newborns to (if at all possible) plan their lives in such a way as to delay, reduce, or even avoid getting into pumping or expression. It may at times be the best solution but should not be viewed as a relatively unimportant decision. But we should not be negative about pumping—that would be blaming the victim!

In my nutrition work, I find it very useful to divide up plans for program and policy work into two categories—long term and short term. But when I talk about breastfeeding outside of Europe, I like to focus on the long-term goals. I think that in focusing on short-term solutions like breast milk pumping, we all too often lose sight of the long-term goal.

Why do we form civilized societies if not to meet the needs of the people? A large proportion of them are mothers and babies. Not meeting the psychological needs of babies is surely dangerous, even if they cannot report the effects to us. I wonder if this may be part of the explanation for the more serious social and psychological problems of various kinds the modern world seems to be saddled with.

No doubt in Australia, like America, there is less trust of government than in “old world” Europe where most believe that government has an obligation, to the extent it can be afforded, not only to respect but to fulfill its citizens’ economic, social and cultural rights. This may explain why Australia and the U.S. are the only developed countries with no mandated period of paid maternity leave. (But some Australian states do mandate a short period of paid leave; and when it comes to unpaid leave, Australians have 46 weeks more than Americans!)

No doubt many of you in the audience who work do have access to paid leave, but certainly the lower socio-economic groups never will as long as access to such an entitlement is decided on by the employer rather than mandated by the government.

Does it feel to you like mothers and infants have a RIGHT to spend the first months together? That, as the Innocenti Declaration said, working women have a right to breastfeed? When Sweden was debating nearly a century ago whether women should get the vote, one argument against it was that elections would cost twice as much! We smile at that today only because human rights thinking has come a long way since then. Voting was actually not a right in Sweden or the U.S. in 1910, it was a privilege that those who had the most power in society kept for themselves. Now we do not see personal power or wealth as being a criterion for who should get to vote—-it is a right. That does not mean you HAVE to vote, just that no one has the right to stop you from doing it if you want to.

Two hundred years ago there was a debate about the economic consequences of doing away with slavery. Now, even though it still would benefit everyone who was not a slave, we do not entertain even the thought of it. We only got an International Labor Organization Convention against the worst forms of child labor only a few years ago. But already no one would argue that it is too expensive to implement. The money will simply have to be found to allow all children to attend school and not work under the slave-like conditions that many live under today. Carpets will have to cost more.

Promoting Breastfeeding as an experience
Ken Tackett

Babies have not only a need but a right to be with their mothers during the first months of life. This is not just a breastfeeding issue. Babies get confused by having too many caregivers too soon before they have had a chance to bond with one person. The great expert on infant development, Uri Bronfenbrenner, once said that a child can do well without even having a mother, but EVERY child needs someone who is crazy about them, who delights and shows that delight at every little developmental step they take.

My first born was born in 1979 while I was a PhD student at what I do think was an enlightened department of nutrition at Cornell University. The same day, a secretary there gave birth. Two weeks later, after taking her annual leave, she was back at work full time. That would not happen to the infant of a university employee in hardly any other country in the world, industrialized or developing. Even the poorest countries are not so stingy to their mothers and babies.

You’ve all seen bumper stickers about the meaning of life with texts like, “the one who dies with the most toys wins.” Maybe we should print up ones that say, “the one who dies with the most toys and the most miserable children wins.”

We know the benefits of breast milk. What we desperately need is more research on the importance of the mother and infant being together during the early months—and widespread dissemination of the results. The giant multinational companies of the world are being completely honest when they tell us they are just giving us what we want. If all you want is the biochemical benefits of breast milk, the brave new future is already here. Infant formula continues to evolve and there are patents already for implanting genes for making human milk in mice. I have no doubt that the baby milk companies are patiently laying up long-term plans for how to get the mothers of the world to accept milk made in such mice, or other gene-manipulated animals. Then, unless we have a lot more research on mother-infant proximity, there will eventually no longer be any need to breastfeed at all.

If children raised on perfect food without their mother’s presence is not your idea of a utopia, I suggest we all stop focusing so much on the biochemical wonders of breast milk and look more closely at the issues involved in exclusive breastfeeding and in mother-infant proximity.

A society where pumping is the norm has serious problems, and breastfeeding advocates should seek allies in making broader social change. Short-term measures to deal with this situation include: crèches at the work place, time and space for pumping at the work place, etc. But such short-term approaches should not take resources or attention away from the long-term work needed to create a society that recognizes and facilitates the mother being with her infant for at least the first six months of life.

I am sometimes confronted by women who find this provocative. They point out that many women have to pump and many want and need to be away from their babies. Let me deal with this kind of statement now.

I am not saying pumping is bad. Unlike many in the breastfeeding community, I also do not think infant formula is bad. It can be life-saving, just like caesarean section can. Hurray for us human beings who can in that sense play God and save babies who otherwise might die! All I’m saying is that these things are for emergency use and where they become the norm something is awry in society as a whole. In saying they are inferior to nature, I am stating a fact, not trying to hurt anyone’s feelings.

Women do not have to go back to work soon after giving birth in a society that respects their and their babies’ rights. Only a few women actually want to go back to work when their baby is less than six months of age if they are receiving something close to the same pay to be at home with the baby and ensured of returning to the same or an equivalent job without losing seniority. In Sweden, your pension is not even reduced much if you take off work for less than four years to be with each child.

Breastfeeding provides a convenient “excuse” for the men, so we do need to deal with the gender inequality inherent in women having to do more of the child care. Some countries are moving in the same direction as Sweden, where parents receive 14 weeks of maternity leave and 10 days of paternity leave at about 80–90% pay. Then the couple is offered another year or so of paid parental leave and another several months with only token payment. Each parent must take two months of parental leave or those months are lost. Sweden is considering increasing that. Thus the ideal might be for the mother to take the first six months full-time, then the father to take over ¼ time and the mother ¾ for another six months, then equal for six months, and so on until the careers of both are equally affected by the birth of each child. Even in Sweden this is a long-term ideal—now men take only about 20% of the parental leave (but this has doubled in the past 7 years or so). Spending equal time with the baby should be optional of course, since not all mothers or infants would want it this way, even if the father did. But it illustrates how there need not be inherent gender unfairness in creating societies in which six months of exclusive breastfeeding was enabled and eventually taken for granted.

Promoting Breastfeeding as An Experience
Ken Tackett

About 25 years ago, the “breastfeeding promotion community” decided that health worker training was the most important intervention. I agree that reducing the harm untrained health workers tend to do is useful; that trained lactation management experts can play one important role; and that lay counselors can play an even larger one. But as its foundation, breastfeeding promotion does not need doctors. It needs empowered women. When they need it, such women will get help from health professionals, and where possible reject or educate those they encounter that say and do breastfeeding unfriendly things. Even if basic research DID convince all the health professionals about breastfeeding, they are going to need a complete sea change in their mentality before they are the right people to depend on to empower anyone about anything. More importantly, it’s only parents who can create a society that fosters mothers and babies being together—getting back to breastfeeding as an experience!

Australian babies are worth as much as babies everywhere else: don’t give up the fight!

Ted GreinerTed Greiner PhD has advanced degrees in education, communication, and international nutrition. His first research, done in 1975, was on the impact of advertising of commercial infant foods on infant feeding practices in the West Indian country of St. Vincent. He has been involved in numerous research projects, policy initiatives, speaking and writing about various aspects of breastfeeding ever since. Among other jobs, he was the nutrition advisor to the Swedish government’s development assistance organ, Sida for 19 years, and was their representative during the 3-year process leading up the only global breastfeeding policymakers meeting ever held, the Innocenti Meeting, in 1990. He was later professor of nutrition in South Korea for 7 years, and is now retired, living in NE Brazil.


Regulating Infant Formula

A Sad Reason for 10 Minutes of Fame

Since 1976, Chris Auer has assisted mother-baby pairs, particularly those within a high risk demographic. Here she recounts a sad reason for 10 minutes of fame and implicates the health care system and its complex relationship with the insurance industry for failing these families.

What precipitated my brief minutes of fame was a cluster of tragedies. Once these cases were reported, the Prime Time Live crew, two camera men and a journalist taking Diane Sawyer’s place, arrived at our hospital in 1998. The camera crew rounded with me in patient rooms, as I talked to mothers all afternoon. As we walked down the hall, I recall the men admiringly commenting to each other when they saw a framed certificate signed by Hugh Downs, on behalf of the U.S. committee for UNICEF, where he served as Chairman of the Board. (Ironically, Mr. Downs was from my hometown of Akron, Ohio.) The certificate he had signed affirmed our hospital’s intent to seek the designation of a Baby-Friendly Hospital. The requirements for the designation assured that a hospital is complying with best-known practices to support breastfeeding. One of those practices includes assuring that breastfed babies have early, appropriate follow-up care. Dr. Ballard ordered two visits by home care nurses prior to the pediatrician visit. I attribute this decision to assuring our breastfed babies were protected.

Mothers held their babies close as we discussed how their breastfeeding experience was going and what to expect in the early days at home. Following this, the crew recorded an interview between the journalist and me.

Five babies, 5 to 14 days old (average 10 days old), had been admitted to the local Children’s Hospital over a 5-month period for treatment for dehydration and other sequela. Ten percent is usually the upper acceptable limit of weight loss in the first days of life. The average weight loss for these babies upon readmission was 23 percent. It was frightening to hear each of their stories from their neonatal nutritionist. At that time, their hospital had no lactation department. The nutritionist and several of the doctors turned to me for insight into how these tragedies could have happened. With each call, the stories began to unfold with eerie similarity: older (age 28 to 38), first-time mothers, relatively short hospital stays (average for the four vaginal deliveries, 33 hours, for the one cesarean-section, 48 hours), no pediatric visit after discharge, infrequent breastfeeding, weak suck, and each mother, college-educated.

Without conducting in-depth, interviews myself, it was impossible to understand exactly what had gone wrong with each particular case. We agreed that the mothers had been through too much already to be interviewed. What I did know was that upon admission, no mother produced milk when she first pumped at the hospital. Was this because her mature milk, which normally arrives by day 3, had never come in? They each had reported some leaking. Or was it that the stress of her baby’s readmission inhibited the release of the milk, or worse, had dried it up altogether? I’d had a mother once tell me that she only breastfed for 5 months because, upon seeing the baby’s daddy shot dead, she subsequently never made a drop of milk. Stress is powerful.

A Sad Reason for 10 Minutes of Fame
Ken Tackett

As I watched the Prime Time segment a few weeks later, I wasn’t surprised that only two of the five mothers consented to be interviewed. As one described watching her newborn wither away on the ambulance drive to the hospital, I thought of how unfair it is to expect a first-time parent to distinguish between a baby who sleeps because he has a full tummy, and one who sleeps because he’s getting inadequate calories and milk. I thought of how tired moms are after delivery and how difficult it is to recall the myriad instructions they are given during their postpartum stay. The interviewer didn’t mention that each new mother had had a short hospital stay. At the time of these births, a new dictate from health insurance companies mandated shorter stays, 24 hours for vaginal births. Many neonatologists felt this was a strong contributing factor to the tragedies. I had done my best to navigate the interview without in any way sounding like I blamed the parents. I did not. Four of the five had taken a prenatal breastfeeding class, mind you. They’d tried their best to prepare. In my estimation, it was a sad systems failure—short hospital stays coupled with delayed follow-up.

I was invited to meetings that senior Children’s Hospital physicians and administrators had with insurance officials from several companies. I was able to provide input on what would best serve the mothers of breastfed babies, both during their hospital stay and after discharge. It took nearly a year, but the meetings led to states requiring that insurance companies cover a hospital stay of up to 48 hours for a routine birth and 96 hours for a cesarean birth. This remains the law of the land. The Academy of Pediatrics (AAP) then revised its guideline for how soon a breastfed infant should be seen by a health care provider. When I had my children 40 years ago, babies were not seen until they were 2-weeks-old. Now, the AAP recommends that babies have a physician or nurse practitioner follow-up visit between day 3 and 5 of life.

None of these five women delivered at our hospital. Fortunately, we had a policy in place that made these types of tragedies less likely. The timing of the two home visits that were ordered contributed to this: one visit at 24 hours post-discharge, the other, 48 hours later. Additionally, in 1995, cut-backs had not yet occurred within the health department, and public health nurses were available to make many of these home visits.

After the Prime Time coverage, positive strides were made along the care-continuum, from prenatal to post-discharge, all over the U.S. One month later I received a letter from Dr. Ted Greiner, a Swedish professor of International Child Health, with his own speculations of why the U.S. health care system was failing to be a safety net for babies. He had great insight into best breastfeeding practices around the world, had studied at New York’s Cornell University, and had conducted some of the most detailed studies of breastfeeding practices in West Africa. His PhD work in nutrition focused on breastfeeding in Yemen. Dr. Greiner’s curriculum vitae also includes work with the World Alliance for Breastfeeding Action, whose focus is to protect, promote, and support breastfeeding. I was hearing from an expert. He insisted that women should be better educated during their pregnancy and be allowed longer hospital stays. He was certain that if more U.S. hospitals followed the Ten Steps to Successful Breastfeeding, as outlined by the World Health Organization, then babies would be discharged with breastfeeding better established.

In the end, one baby’s jaundice was so severe that it crossed into the brain, causing permanent neurologic damage. Two babies had grade III brain bleeds. The consequences of this, only time would tell. One of the babies suffered a stroke. The parents of the fourth baby, born in February, called on a snowy day to cancel a follow-up appointment at the delivering hospital. The father mentioned that his son’s leg seemed a little blue. Days later, this infant’s leg was amputated secondary to an iliac artery thrombosis. The final baby, despite severe weight loss and dehydration, had no apparent other maladies. There was no getting around the fact that this Prime Time segment created so much fear about breastfeeding that the breastfeeding initiation rates in the country dipped for several months. How could it not?

Twenty years later, though infrequent, there are still feeding tragedies. Babies need very close follow-up after discharge and parents need to know when to supplement breastfeeding without any overlay of external or internal pressure, save keeping their little one safe. We’re allies to this end: all parents, all health care providers, the insurance industry, and all lactation consultants. 

A Mother and Her Newborn’s Drug Withdrawal

A Mother and Her Newborn’s Drug WithdrawalChris Auer is a registered nurse and lactation consultant who has worked at the University of Cincinnati Medical Center for 42 years caring for mother-baby pairs from all walks of life and from as many as 77 countries, particularly those within a high risk demographic and in a Level III NICU setting. For over 20 years, Chris has provided pediatric resident lactation education and internship training and has published articles in seven peer-reviewed journals. Under One Sky is available here.

Read a review of Under One Sky by Doraine Bailey.

The Mother in the Tilt-a-Whirl Bed

Since 1976, Chris Auer has assisted mother-baby pairs, particularly those within a high risk demographic. The tale of the mother in the tilt-a-whirl bed is from Under One Sky.

You don’t utilize that bed unless a person is knocking on death’s door. —Annie,
Critical Care Nurse.

She is prone, belly down, unconscious, facing the floor, facing off death just after the birth of her daughter. When I am called to the adult ICU, I rarely know ahead of time what I may come upon. Stroke victim? Boating accident victim? Burn victim? Regardless, they’re always critical. Today, it is an upside-down mother. It’s obvious, logistically speaking that I won’t be setting her up to pump for now.

When I ask to speak to her nurse, I’m approached by a bustling RN, who immediately asks why I am there. My badge does not signal my occupation, as it says only “nurse clinician.” I preface by saying I work in the newborn ICU and have just come from the baby’s bedside. I’m hoping this will ease what I say next. “I’m the breastfeeding consultant.”

I understand ICU nurses. They are territorial and fiercely protective of their patients, a quality I admire. I underestimate how she will react. Nearly jumping back a huge step, she looks at me quizzically as if to say, “You’ve got to be kidding me!” As she shifts her eyes toward the patient strapped to the tilt-a-whirl bed, I give the nurse a short minute to process the fact that I indeed want to assist with breast pumping—at least, eventually, when the roto-prone bed shifts the mother upright and she’s deemed stable enough. But for now, she’s in acute respiratory distress, from pulmonary hypertension. The mother is carefully strapped in, while the bed rotates a complete 360-degree circle, shifting fluids away from her lungs where they’ve been building up. Despite the high maternal mortality rate after births in the U.S., I’ve seen so few mothers die after birth, I’m probably overly optimistic that this mother will survive. Clearly, the nurse doesn’t share my optimism because she’s been caring for the mother since the delivery.

The Mother in the Tilt-a-Whirl Bed
Ken Tackett

I tell the nurse that the doctors have asked me to assess the feasibility of expressing the mother’s milk. She explains that the mother is critical, that over half of women who deliver with a diagnosis of pulmonary hypertension don’t make it. I assure her that I understand and let her know I’ll report back to the physician caring for the mother’s extremely low birthweight infant.

Two more days go by and Chris, our attending neonatologist, aware the mother is still alive, asks me to go with her to pay the patient and ICU staff a visit. When a mother is critically ill, her milk doesn’t always come in, or often comes in late or in small quantities. At times, this is secondary to medicines she’s received while in a critical state. I’ve also seen milk come in as late as 11 days after a birth instead of the usual 72 hours. I’ve no idea what this mom’s lactation potential is.

Coming into the unit, Chris sees her counterpart in the adult world. The ICU attending doc has just finished rounds and is giving her residents the day’s parting instructions. Chris approaches the group and introduces herself with the confidence of a seasoned physician. The team perks up, interested to learn the status of the premature infant. Then she comes around to the question of pumping the mother, but before anyone can object, she builds a case for how removing milk, could actually help the mother’s condition, alleviating the strain of added fluid (milk) and the swelling associated with severe engorgement from around the mother’s lungs. The physician is cautiously entertaining this as an added therapeutic approach to the mother’s care. In the end, the mother’s doctor agrees, but asks our neonatologist to sign a legal document stating that expressing milk is in the mother’s (and obviously the baby’s) best interest. Once she does this, I introduce myself to the new nurse caring for the mother. She’s upright now, but I have no supplies with me. This nurse has breastfed her own children and is receptive to the education and reassurances she is receiving from Chris. We agree that I’ll return within the hour to initiate pumping while the mom is still in an upright position.

Milk pours out like a crack in a child’s plastic swimming pool, steadily draining. We have collected over three ounces, as the mother lies motionless on the bed. I speak to her as though she were wide awake, telling her how cute her baby is, and letting her know we look forward to her first visit to the NICU. It’s days before I meet a quasi-alert mother, who, though not yet speaking, seems happy that I’m pumping her, half-smiling as she watches the milk empty into the bottles, once I’ve moved her oily, long brown hair off her chest so she can see.

The father of the baby tells us she’d wanted to breastfeed all along. She can’t speak for herself yet, so his rather talkative and assertive demeanor doesn’t surprise me. Over time, the ICU staff tells me he hardly lets her speak, even when she can. Still, I don’t know if this results from a sense of overprotection. Over the coming days, I can see that her family is reserved in his presence. He looks about 15 years her senior, which may play a factor.

Remarkably, as mom becomes more stable, she continues to make ever-increasing volumes of milk. Dad is vigilant in insisting the ICU staff help with pumping every three hours around the clock, until the two of them can manage it on their own. His forcefulness doesn’t endear him, but I have to admit that she probably pumps twice as often with his advocating. When she is considered fully out of the woods, she makes a wheelchair visit to the NICU, several bottles of milk in hand. We switch her from the two-ounce bottles to larger four-ounce bottles, to make pumping easier and to get a nice mix of calories in all bottles. Dad has been holding their daughter in mother’s absence, but she now sheds her gown and blissfully holds her daughter skin to skin.

Dad continues speaking for mom throughout the baby’s hospitalization, only relenting when the nurses say, “We’d like mom to answer this question, if that’s OK with you.” Over time, they learn the art of breastfeeding together and the baby is discharged home partially breastfeeding and partially receiving her mother’s expressed milk that is fortified with added protein, minerals, and calories.

Eight months after discharge, two lactation consultants drive 45 minutes to a neighboring county to participate in a fair sponsored by the county’s WIC department. This family strolls up to the booth, mother holding her baby in a sling and breastfeeding as she walks. Dad begins his own PR blurb, attributing the survival of the mother and baby to the staff of UCMC. It’s rewarding to overhear these stories, and today we’re glad he’s such an extrovert!

Several months after this, we receive an email from the WIC nutritionist assigned to their county. She tells us that dad is singing the praises of the lactation staff who came to their rescue when she couldn’t speak for herself, and when he didn’t know there was a way to preserve breastfeeding. She reiterates that they are grateful for the LCs who started mom on the path of nursing. The parents had been in for a well-baby check, she was still breastfeeding, still quiet in the dad’s presence, but healthy–and alive. Alive!

A Mother and Her Newborn’s Drug Withdrawal


A Mother and Her Newborn’s Drug Withdrawal

Chris Auer is a registered nurse and lactation consultant who has worked at the University of Cincinnati Medical Center for 42 years caring for mother-baby pairs from all walks of life and from as many as 77 countries, particularly those within a high risk demographic and in a Level III NICU setting. For over 20 years, Chris has provided pediatric resident lactation education and internship training and has published articles in seven peer-reviewed journals. Under One Sky is available here.

Hear the Chris here.

Read a review of Under One Sky by Doraine Bailey.

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Breastfeeding Mother Runs Ultramarathons

Helen Fong tells how she ran an ultramarathon just months after giving birth and while still breastfeeding her daughter.

Before my pregnancy, I ran many ultramarathons. You not only have to qualify but have also to be selected by lottery to take part in the Western States 100 Mile Endurance Run. After three years of trying, I was finally selected for the race. However, my baby was due to be born the month the race would take place! So I signed up to try again in future.

Breastfeeding Mother Runs UltramarathonsBeing an ultra runner has given me the ability to believe in the impossible. Reading about how other élite runners had managed to get back into running after having a baby gave me confidence and I became a member of a wondeful support group called “Running Pregnant/While-Nursing – Moms Run This Town.”

Preparing for the Rio Del Lago 100-Mile Endurance Run (RDL) scheduled for just five months after the birth of my baby turned out to be even harder than I’d anticipated.

In June my labor and delivery were difficult. I had complications before, during, and after the birth. While my baby was healthy, motherhood was (and is) hard. I knew it would be, but you don’t know just how hard until it’s you who is doing it. Breastfeeding was a learning curve and a lot of work. I had a lot of feeding challenges during the first month or so.

I wanted to be sure my body had recovered from the birth so I didn’t start running again until my baby was about a month old. My first run amounted to walking and short one-minute runs. From there, I worked on increasing my running time and distance. Balancing training and being the mother of an infant was challenging. Trying to work out while taking care of my baby was too difficult, so I started a routine on the treadmill at night after I had put her down to sleep. I came to really enjoy those nighttime runs as “me” time. On the weekends, my very supportive husband helped care for our baby so that I could do my longer training runs.

By August, I had worked up to a 20-mile run. That was the first time I’d stopped to pump my breast milk in the car, half way round. Pumping was an interesting element to add to my training! I couldn’t just go out and run whenever or wherever I wanted. I had to think about how long I would be running and plan ahead when and where to pump. I also had to re-figure fueling my long runs to make sure I was drinking and eating enough for training and for making milk. I struggled a lot on my long runs with cramping and ‘bonking’ as I re-trained my body for distance running.

In September, I went back to work. Balancing work, training, and motherhood became another new challenge. Some weeks, I’d run less than others. I tried to make sure I got quality over quantity in my training. In October, I ran the Folsom Lake Ultra Trail. I had a friend set up my electric pump at certain aid stations on a little table. I would run in, take off my pack and shirt, pop the freemie cups in my bra and begin pumping away. That worked well. I did, however, make the mistake of worrying too much about how pumping would add extra time to my run so that I tried running faster to make up for it, which backfired as my legs gave way from going out too fast. After starting off well, I fell apart with the heat, lack of water, under training, and cramping. I quit just shy of 50 miles. I wasn’t too disappointed because it was a good training race for me and showed me the adjustments that were necessary in preparation for the RDL.

Breastfeeding Ultramarathon Mother
Helen Fong

On November 7, I toed the start line to the RDL. I made sure I didn’t start off too fast this time and moved steadily through the race. At mile 19, I pumped following the same plan as my training race. At mile 35, I arrived at the aid station and the pump was there ready for me. My husband and baby were there too to cheer me on. At the sight of my baby, I decided it was easier simply to breastfeed her. I enjoyed the snuggle with her. At mile 51, I arrived at the aid station just after it got dark. There again, I breastfed rather than pumping. It was getting near dinner time and I needed to get more calories inside me, so while I fed my baby, I fed myself as well.

After that, it got pretty cold at night. Time was getting to be a factor, so I just kept moving along. It would be a long night and I did my best to keep ahead of the cut-off times which kept getting closer.

Breastfeeding Mother Runs UltramarathonsIn the late morning, I finally made it. About half a mile from the finish, I saw my family waiting for me to come in. My baby was in a stroller and I took it and ran with her towards the finish line. Before going into the finish chute, I took her out of the stroller and carried her across the finish line while my many friends cheered. I’d completed 100 miles in 29:41:28.

The feeling of finishing an endurance race is pretty amazing but this time it was extra special being able to share that special moment with my baby!

You can read more about my crazy running adventures and subsequent pregnancy on my blog.

Breastfeeding mother runs ultramarathons


Should HIV+ Mothers Breastfeed?

Pamela Morrison, IBCLC, explores the research that has helped form policy and answers the questions surrounding whether HIV+ mothers should breastfeed.

Global recommendations endorse exclusive breastfeeding for all babies for the first six months of life and continued partial breastfeeding for up to two years or beyond. Yet it is commonly believed that one exception is the baby of a mother who has been diagnosed as HIV-infected, due to the fear that she may pass the virus to her baby in her milk (Horvath, Madi, Iuppa, Kennedy, Rutherford, & Read, 2009).   

Most HIV-exposed babies are born in places where breastfeeding is the cultural norm and where formula-feeding is particularly unwelcome, unnatural and stigmatizing (see the UNAIDS (2013) report on the global AIDS epidemic).

Current World Health Organization guidance on HIV and infant feeding is clear that for most mothers in most countries, exclusive breastfeeding for the first 6 months, followed by continued partial breastfeeding for at least the first year of life will enhance HIV-free child survival. In other words, research suggests that formula-feeding is more risky than breastfeeding with HIV. As more knowledge is gathered, increasing numbers of HIV-positive (HIV+) mothers in industrialized countries are questioning whether the risk of HIV transmission through breastfeeding is as high as they have been led to believe and, if not, whether they too can breastfeed?   (NEW: July 2018. WABA. Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource.)

What information will help these mothers to make an informed decision on whether breastfeeding will be safe for their babies?

What research can they discuss with their doctors and HIV clinicians as they express their ambitions and ask for support? How is the risk of breastfeeding-associated HIV transmission measured?

Since 1985, breastfeeding in the context of HIV has received very bad press. Fear about early high risk estimates persists. But there is a great difference in transmission risk between a mother receiving effective antiretroviral therapy (ART) and the unfortunate mother of several decades ago for whom no drug therapy was available and the risk of postnatal transmission through any breastfeeding vs no breastfeeding was estimated to be 15–30% (Dunn, Newell, Ades, & Peckham, 1992).

The transforming effect of effective antiretroviral therapy (ART)

A growing body of research shows that effective ART can not only improve the health of an infected individual so that he or she can enjoy a normal life-span (Samji, Cescon, Hogg, Modur, Althoff, Buchacz, et al., 2013) but that treatment also constitutes an effective form of prevention between infected and uninfected members of a couple, and between an infected mother and her infant during pregnancy, birth or breastfeeding.   

No cases of transmission of HIV were found during two years of follow-up of sero-discordant couples when the HIV-infected partner received and took antiretroviral medications (Rodger, et al., 2014). Up-to-date World Health Organization guidance recommends that all women diagnosed as HIV-infected should receive immediate ART which should be continued for life. HIV-infected expectant mothers who are diagnosed as HIV+ during early pregnancy can receive a long enough course of ART to ensure that the number of viral copies in their blood becomes undetectable by their due date, posing a negligible risk of transmission of the virus during labor and delivery, and allowing them to have a normal vaginal birth. The duration of treatment is important: a study published in 2011 showed that ART needs to be taken for approximately 13 weeks to reduce the number of viral copies to levels that are no longer detectable on a standard HIV test; mothers who received ART for less than 4 weeks had a 5-fold increased risk of HIV transmission to their babies (Chibwesha et al., 2011).

Should HIV+Mothers Breastfeed?
Courtesy Lena Ostroff

Exclusive breastfeeding

The importance of exclusive breastfeeding in reducing the risk of postnatal HIV transmission was first established in a South African study (Coutsoudis, Pillay, Spooner, Kuhn, & Coovadia, 1999) and subsequently confirmed amongst Zimbabwean infants in 2005 (Iliff et al., 2005). In the latter study, compared with early mixed feeding (breast milk and other foods and liquids), exclusive breastfeeding (feeding only breast milk) reduced transmission by 75% in babies tested at 6 months. It was hypothesized that too-early feeding with other foods and liquids besides breast milk may disturb the normal infant gastrointestinal flora (Smith & Kuhn, 2009). When babies are mixed fed, pathogens and dietary antigens in formula can cause small sites of damage and inflammation to the baby’s intestinal mucosa. Once the integrity of of the baby’s gut has been compromised, it is easier for HIV in breast milk to cross the mucous membranes and to make contact with the baby’s bloodstream. On the other hand, protective components in mother’s milk, e.g. epidermal growth factor, can help the intestinal epithelial barrier to mature, thus helping to protect against infection with HIV.

HIV and Breastfeeding
Morrison, P. (2010). How to support first world HIV+ mothers who want to breastfeed. Fourth International Breastfeeding Symposium: Breastfeeding in Special Circumstances. Bilbão.

Normal mixed feeding after 6 months

As a result of the findings about the protective effects of exclusive breastfeeding during the first 6 months, concern was initially expressed about the possible dangers of HIV-transmission during normal mixed feeding after 6 months. As a result, HIV+ mothers who elected to breastfeed were advised to practice what was called “early cessation of breastfeeding,” or premature weaning, as soon as practicable (Ekpini et al.,1997; WHO, 2005).

Subsequent studies have confirmed that after the recommended period of 6 months’ exclusive breastfeeding, continued partial breastfeeding with the addition of other foods and liquids, as recommended for babies outside the context of HIV, resulted in an extremely low risk of transmission in the 6–12 month period (Kuhn et al., 2007; Ngoma et al., 2011). Further studies from Zambia, where maternal ART was initiated in early pregnancy and continued to 12 months postpartum, while infants were exclusively breastfed to 6 months and continued breastfeeding with complementary feeding from 6–12 months resulted in postpartum HIV transmission rates of 1–2% at 12 months (Ngoma et al., 2011; Gartland et al., 2013)Confirmatory results showed that the only postnatal transmissions occurred in one infant at 2 weeks postpartum, which most likely occurred in utero (Gartland et al., 2013) or after 6 months in women who were non-adherent to their medications (Silverman, 2011; Ngoma et al., 2015). The multicenter PROMISE study results released in 2016 involving nearly 2500 babies showed that estimates of mother-to-child transmission through breastfeeding at ages 6, 9 and 12 months were 0.3%, 0.5% and 0.6% (Taha, T. et al., 2016). Consequently, current WHO guidance was updated in 2016 to recommend continued breastfeeding to 24 months.

What is the risk of not breastfeeding?

In spite of these excellent results, there remains a common assumption that because mothers living with HIV in industrialized countries such as Europe, North America and Australia have access to clean water and safe infant-feeding alternatives breastfeeding avoidance is free from risk. This may in part stem from misleading reporting of research results (Smith, Dunstone, & Elliott-Rudder, 2009) but in fact, formula-fed babies experience higher rates of morbidity and mortality than their breastfed counterparts, even in industrialized countries (Bachrach, Schwarz, & Bachrach, 2003; Bartick, & Reinhold, 2010; Chen, & Rogan, 2004; Duijts, Jaddoe, Hofman, & Moll, 2010; Glass, Lew, Gangarosa, LeBaron, & Ho, 1991; Ip, Mei Chung, Gowri Raman, Trikalinos, & Lau, 2009; Quigley, Kelly, & Sacker, 2007).

Breastfeeding and HIV+
Maria Griner Photography

Current guidance in developed countries

In the industrialized countries of the UK, Europe, Australia and Canada, a high percentage of mothers diagnosed as HIV+ are immigrants from countries of high HIV-prevalence, particularly those in Eastern and Southern Africa. In recognition that their guidance needed to fit the population it was designed to assist and following extensive consultation, the British HIV Association (BHIVA) published a revised position paper in 2011 stating that although formula-feeding remains the first recommendation for infant feeding in the context of HIV, when an HIV+ mother with an undetectable viral load wishes to breastfeed, then she should be supported to do so (Taylor et al., 2011). BHIVA recommend that mothers who choose this option should practise exclusive breastfeeding for the first six months of life while receiving regular monitoring of maternal viral load and infant HIV status.  BHIVA is currently working on a revision of its 2011 guidance.

A similar relaxation of a former absolute prohibition of breastfeeding and accompanying threats of imposition of child safe-guarding measures against mothers who did not comply has also occurred in the USA. In early 2013, the American Academy of Pediatrics published revised recommendations to support breastfeeding by HIV+ mothers as long as mothers are adherent to ART, achieve an undetectable viral load, when breastfeeding is exclusive for the first six months and when the health of mother and baby are closely monitored and optimized.

Breastfeeding support in the context of HIV

Breastfeeding in the context of HIV is best planned meticulously. Prenatally, HIV+ mothers need to be in touch with their physicians and HIV clinicians. They should discuss with them what they know of up-to-date research findings, including the risks and benefits of different feeding methods, the importance of ART, the duration of therapy, undetectable viral load and on-going adherence to their medications. They would also be well advised to inform themselves about local and/or national HIV and infant feeding policy and to query any misinterpretation of current national policy where it occurs, e.g. a recently published booklet translated in Swahili for HIV+ mothers living in the UK erroneously suggests the only recommendation is for formula-feeding and to seek legal representation if there are likely to be any safe-guarding concerns or any threat of coercion to bottle-feed as is occasionally reported.

If the decision is made to breastfeed, HIV+ mothers should receive competent and well-informed breastfeeding assistance from a recognized health provider or an International Board Certified Lactation Consultant (IBCLC) before and after birth. Mothers will need practical assistance with latching their baby comfortably to the breast, and ensuring effective breastfeeding without the need for invasive oral surgery such as tongue or buccal tie revision which would allow contact between the virus in breast milk and the infant’s bloodstream. Mothers may also need advice and on-going follow-up to  avoid, minimize and quickly resolve any postpartum breast or nipple problems, e.g. sore nipples, breast engorgement, or symptoms of mastitis. It is important to prevent or treat these kinds of difficulties promptly should they occur, not only to avoid increasing the risk of transmission of postpartum HIV but also so that exclusive breastfeeding can easily be initiated and maintained for the full first six months of their infant’s life. The baby’s HIV status should be tested at birth, and at monthly intervals until 3 months after breastfeeding ends (Taylor et al., 2011; AAP, 2013).

Finally, it is not possible to overstate the need for lactation consultants to liaise with and be guided by the mother’s and baby’s primary healthcare providers so that all parties can work together as a team for the best health outcomes for both mother and baby.   

Hope for the future

When the risk of mother to child transmission of HIV in utero, during birth or during breastfeeding can be reduced to almost nil, as it can today, it is no longer necessary for HIV+ women to give up all hope of breastfeeding. Up-to-date evidence-based research suggests that when HIV+ women receive adequate ART, they can safely embark upon a pregnancy and deliver their children vaginally. Research also shows that improved health outcomes can be achieved with breastfeeding compared to not breastfeeding. There are only two provisos:

  1. Mothers must be meticulously adherent to their medication.
  2. Breastfeeding should be practised exclusively during the first six months of life.

When these two pre-conditions are met, the risk of mother-to-child transmission of HIV through breastfeeding can be reduced to negligible levels. The World Health Organization describes these findings as “transforming” and it follows that there should thus be no need to discourage breastfeeding, both within and outside the context of HIV.

July 2018. WABA. Understanding International Policy on HIV and Breastfeeding: A Comprehensive Resource.


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Bachrach, V. R. G., Schwarz, E., & Bachrach, L. R. (2003). Breastfeeding and the risk of hospitalization for respiratory disease in infancy. Archives of Pediatrics & Adolescent Medicine, 157(3), 237. doi:10.1001/archpedi.157.3.237

Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. PEDIATRICS, 125(5), e1048–e1056. doi:10.1542/peds.2009-1616

Chen, A., & Rogan, W. J. (2004). Breastfeeding and the risk of postneonatal death in the United States. PEDIATRICS, 113(5), e435–e439. doi:10.1542/peds.113.5.e435

Chibwesha, C. J., Giganti, M. J., Putta, N., Chintu, N., Mulindwa, J., Dorton, B. J., … Stringer, E. M. (2011). Optimal time on HAART for prevention of mother-to-child transmission of HIV. JAIDS Journal of Acquired Immune Deficiency Syndromes, 58(2), 224–228. doi:10.1097/qai.0b013e318229147e

A Mother and Her Newborn’s Drug WithdrawalCoutsoudis, A., Pillay, K., Spooner, E., Kuhn, L., & Coovadia, H. M. (1999). Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. The Lancet, 354(9177), 471–476. doi:10.1016/s0140-6736(99)01101-0

Duijts, L., Jaddoe, V. W. V., Hofman, A., & Moll, H. A. (2010). Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy. PEDIATRICS, 126(1), e18–e25. doi:10.1542/peds.2008-3256

Dunn, D., Newell, M., Ades, A., & Peckham, C. (1992). Risk of human immunodeficiency virus type 1 transmission through breastfeeding. The Lancet, 340(8819),585–588. doi:10.1016/0140-6736(92)92115-v

Ekpini, E.R., Wiktor, S.Z., Satten, G.A., Adjorlolo-Johnson, G.T., Sibailly, T.S., Ou, C.,Y., Karon, J.M., Brattegaard, K., Whitaker, J.P., Gnaore, E., K., De Cock, K.M., Greenberg, A.E. (1997). Late postnatal mother-to-child transmission of HIV-1 in Abidjan, Côte d’Ivoire. The Lancet, 349(9058): 1054–1059.

Gartland, M. G., Chintu, N. T., Li, M. S., Lembalemba, M. K., Mulenga, S. N., Bweupe, M., … Chi, B. H. (2013). Field effectiveness of combination antiretroviral prophylaxis for the prevention of mother-to-child HIV transmission in rural Zambia. AIDS, 27(8), 1253–1262. doi:10.1097/qad.0b013e32835e3937

Glass, R. I., Lew, J. F., Gangarosa, R. E., LeBaron, C. W., & Ho, M.-S. (1991). Estimates of morbidity and mortality rates for diarrheal diseases in American children. The Journal of Pediatrics, 118(4), S27–S33. doi:10.1016/s0022-3476(05)81422-2

Morrison, P. (2014). HIV and breastfeeding: The findings that transformed policy.

Horvath, T., Madi, B. C., Iuppa, I. M., Kennedy, G. E., Rutherford, G. W., & Read, J. S. (2009). Interventions for preventing late postnatal mother-to-child transmission of HIV. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd006734.pub2

I-Base. (December 2017). Pocket ART. Virusi Vya Ukimwi (VVU) na ujauzito.

Iliff, P. J., Piwoz, E. G., Tavengwa, N. V., Zunguza, C. D., Marinda, E. T., Nathoo, K. J., … Humphrey, J. H. (2005). Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS, 19(7), 699–708. doi:10.1097/01.aids.0000166093.16446.c9

Ip, S., Mei Chung, Gowri Raman, Trikalinos, T. A., & Lau, J. (2009). Breastfeeding Medicine 4(s1): S-17-S-30.

Kuhn, L., Sinkala, M., Kankasa, C., Semrau, K., Kasonde, P., Scott, N., … Thea, D. M. (2007). High uptake of exclusive breastfeeding and reduced early post-natal HIV transmission. PLoS ONE, 2(12), e1363. doi:10.1371/journal.pone.0001363

Ngoma, M. S., Misir, A., Mutale, W., Rampakakis, E., Sampalis, J. S., Elong, A., … Silverman, M. S. (2015). Efficacy of WHO recommendation for continued breastfeeding and maternal cART for prevention of perinatal and postnatal HIV transmission in Zambia. Journal of the International AIDS Society, 18(1). doi:10.7448/ias.18.1.19352

Ngoma, M., Raha, A., Elong, A., Pilon, R., Mwansa, J., Mutale, W., Yee, K., Chisele, S., Wu, S., Chandawe, M., Mumba, S, Silverman, M.S. (Sept.19, 2011). Interim Results of HIV transmission rates using a lopinavir/ritonavir based regimen and the new WHO breast feeding guidelines for PMTCT of HIV International Congress of Antimicrobial Agents and Chemotherapy (ICAAC), Chicago Il.

Quigley, M. A., Kelly, Y. J., & Sacker, A. (2007). Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom millennium cohort study. PEDIATRICS, 119(4), e837–e842. doi:10.1542/peds.2006-2256

Rodger, A., Bruun, T., Cambiano, V., Vernazza, P., Estrada, V., Van Lunzen, J. PARTNER Study Group. (2014). HIV transmission risk through condomless sex if HIV+ partner on suppressive ART: 21st Conference on retroviruses and opportunistic infections, Boston.  

pumps and pumping protocolsSamji, H., Cescon, A., Hogg, R. S., Modur, S. P., Althoff, K. N., … Buchacz, K. (2013). Closing the gap: Increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS ONE, 8(12), e81355. doi:10.1371/journal.pone.0081355

Silverman, M.S. (October, 2,  2011). A personal communication with the author.

Smith, J., Dunstone, M., & Elliott-Rudder, M. (2009). Health professional knowledge of breastfeeding: Are the health risks of infant formula feeding accurately conveyed by the titles and abstracts of journal articles? Journal of Human Lactation, 25(3), 350–358. doi:10.1177/0890334409331506

Smith, M. M., & Kuhn, L. (2009). Exclusive breast-feeding: Does it have the potential to reduce breast-feeding Transmission of HIV-1? Nutrition Reviews, 58(11), 333–340. doi:10.1111/j.1753-4887.2000.tb01830.x

Taha, T., et al., (2016). The multicentre PROMISE study. Comparing
maternal triple antiretrovirals (mART) and infant nevirapine (iNVP) prophylaxis for the prevention of mother to child transmission (MTCT) of HIV during breastfeeding (BF). AIDS 2016. Poster abstract LBPE013.

Taylor, G.P., Anderson, J., Clayden, P., Gazzard, B.F., Fortin, J., Kennedy, J., Lazarus, L., Newell, M-L., Osoro,B., Sellers, S., Tookey, P.A,, Tudor-Williams, G., Williams, A. & De Ruiter, A. BHIVA/CHIVA. British HIV Association and Children’s HIV. (2011). Association position statement on infant feeding in the UK. HIV Medicine. 12(7), 389393. doi:10.1111/j.1468-1293.2011.00918.x

Quigley, M. A., Kelly, Y. J., & Sacker, A. (2007). Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom millennium cohort study. PEDIATRICS, 119(4), e837–e842. doi:10.1542/peds.2006-2256

UNAIDS. (2013). Report on the global AIDS epidemic.

World Health Organization. (2016). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. Second edition. Geneva. ISBN: 978 92 4 154968 4.

World Health Organization. Global Strategy for Infant and Young Child Feeding

World Health Organization. (2010). Guidelines on HIV and infant feeding. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. ISBN 978 92 4 159953 5.

World Health Organization. (2005). HIV and infant feeding counselling tools, reference guide, ISBN 92 4 159301 6

World Health Organization, United Nations Children’s Fund. (2016). Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva.

Pamela Morrison lived the first 45 years of her life in East and Southern Africa. She has worked with breastfeeding mothers since 1987 and became the first IBCLC in Zimbabwe in 1990. She has also lived in Australia and is now living in England. She has been a long-term member of the Zimbabwean National Breastfeeding Committee, the BFHI Task Force and Co-coordinator of the WABA Task Forces on Infant Nutrition Rights, Breastfeeding and HIV. Pamela  supports mothers to breastfeed and specialises in helping with latching difficulties, babies with low weight gain and faltering growth and mothers who are struggling to make enough milk. Pamela speaks passionately on breastfeeding and is a well-loved mentor and friend to many in the lactation field.

The Dance of Teaching Childbirth Education


Placenta Encapsulation: An IBCLC’s Perspective

By Sarah Hollister, RN, PHN, IBCLC

sarahAs a nurse and an International Board Certified Lactation Consultant (IBCLC), I have the opportunity to work with nearly every pregnant woman and new mom and baby at a group of four primary care health centers in Northern California. I would like to share my experience, concerns and request for collaboration to closely examine the new practice of placenta encapsulation, as it has grown to become a component of the postpartum experience for the new moms whom I work with and throughout the United States. I have encountered assumptions that placenta consumption increases milk production, is a prevention for postpartum depression, and has existed in history as an ancient human practice. I will provide a summary here of the work I do and what I have found with my clients involving this practice.

In my role providing perinatal services, I work both within the community clinics offering prenatal education, and in the mom’s home doing the initial exams for the newborns and breastfeeding assessments for moms after every birth as the standard of care, whether things are going well with breastfeeding or not. When there are challenges with breastfeeding, I am able to offer unlimited lactation consultations. All of my services are free of charge to the moms, as they are provided through our clinics’ primary care services. I also hold a weekly drop-in lactation clinic and postpartum support group. In addition, I have one-on-one assessments scheduled with all moms at four weeks postpartum as a routine visit. My visit notes are immediately available to their primary care physicians. I have access to the babies’ growth charts as well. I work closely with the family practice doctors, who are very supportive of breastfeeding and are trained to do interventions for breastfeeding challenges such as frenotomies for tongue-ties and osteopathic craniosacral therapy to help with latching issues related to the birth. With all of this, I have full access to our community of moms and babies over the long term of their care, and great resources to support breastfeeding success. Our patient population is quite varied, with women giving birth in hospitals, birth centers, and at home.

Over the past five years, I have noticed an alarming trend of moms with low milk supply and failure-to-thrive babies. It was initially a puzzle to me, as the majority of these cases were with healthy moms who had given birth at home or at a birth center, or at least had a doula supporting them in the hospital, all factors that should set a mom up for an optimal start to breastfeeding. They usually had no explainable reason why their milk supply was so low, as I worked diligently with them on resolving any factors that could be contributing.

breast pump do I need one
Illustration by Ken Tackett

It was another lactation consultant who was consulting with me on one of these cases who brought up the fact that the mom was consuming her encapsulated placenta. I had assumed that this was a healthy and even traditional practice of which I was supportive, and brushed it off as having nothing to do with her low milk supply. However, in discussing it more deeply, and looking into the physiological connection between pregnancy hormones and lactation hormones, my colleague’s concern began to make sense to me. We know very well that the dominant pregnancy hormone, progesterone, inhibits the dominant lactation hormone, prolactin, from binding to the prolactin receptor sites, thereby inhibiting milk production during pregnancy.

A woman’s milk comes in at approximately three days after the birth because of the rapid drop in progesterone due to the expulsion of the placenta from the body. This is the hormonal trigger that allows prolactin levels to rise and milk production to begin. If there are retained placental fragments in the uterus after the birth, a woman’s milk is likely to be delayed coming in because of the inhibitory effect of the progesterone on prolactin, thereby halting Lactogenesis II (i.e., the onset of copious milk production on day 3 after the birth). Estrogen is the other dominant hormone of pregnancy, and it is also a potent suppressor of prolactin during lactation.

When a nursing mom gets pregnant with a new baby, her milk is at risk of drying up due to the hormones of the new placenta growing. We know of the detrimental effects hormonal birth control can have on milk supply. This is a very basic fact of lactation physiology: progesterone and estrogen are inhibitors of prolactin (Academy of Breastfeeding Medicine, Protocol #13, 2015; Neville et al., 2001; Riordin, 2005; Walker 2017).

I went back to the previous cases I had encountered of moms who never established a full milk supply or whose babies took 4–6 weeks to regain their birthweight despite immediate and extensive lactation support, and interviewed them about this piece of information. I found that nearly all had consumed their encapsulated placenta. I started paying attention to this possible correlation, and asking all the new moms I worked with whether they were consuming their placenta.  Over the past four years that I have been aware of this issue, I have noted many cases with a clear negative effect of placenta pill consumption on milk supply. I find that the sooner a woman stops taking her placenta capsules, the sooner her milk supply will begin to increase. However, if I don’t find out about this fact until after she has consumed the entire 4-6 week course of them, the milk supply often cannot be fully established. Based on my personal experience, placenta pills are likely to suppress a woman’s milk supply by approximately 50%. In addition, I have been hearing increasing reports from other lactation consultants, both locally and nationally, that confirm these same findings of low milk supply associated with placenta consumption.

I now discuss this information with all women whom I see in their pregnancy, and advise them against consuming their placenta. I point out to them that there are no valid research studies that prove that placenta consumption either improves or suppresses lactation, but that risking milk supply is not a decision to be taken lightly and that my colleagues and I are seeing a concerning trend. I share with them the recent research papers on this topic, including literature reviews that show that postpartum placenta consumption is actually a new trend and has not been a human tradition found in any culture (Young et al.,2010; Cole, 2014; Coyle et al., 2015; and Hayes et al., 2016).

I show them a recent study that offers data on the hormonal content retained in placenta pills after the processing and encapsulation (Young et al., 2016). The authors of this study found that there are only estrogens and progesterone remaining in the pills and that these reach physiological effect thresholds. This fact helps us understand the hormonal picture we are seeing with the suppression of milk supply. Another recent study shows that there is no iron benefit to consuming placenta vs a placebo, which debunks one of the claimed benefits of consuming placenta that is promoted by encapsulators (Gryder et al., 2016). The doctors at our clinics are giving the same message to all pregnant women to not consume their placenta, based on these cases we have seen. With this prenatal education, the cases I now see of low milk supply have markedly decreased. I still get women coming into my lactation clinic who are new to our health center, referred to me for low milk supply and failure-to-thrive babies and again, placenta encapsulation is the most common reason that I find for this problem.


Sarah’s now 18-year-old son at 4 months

I had my own two babies with midwives, the first at a Birth Center and the second as a home birth. I have experience both personally and professionally with the high quality of midwifery care, and I remain very supportive of the traditional work that midwives and doulas do. A large percentage of my clients give birth with our local midwives and doulas, so I have many opportunities to share the care with them postpartum. Yet I have encountered resistance from some doulas and midwives upon hearing my concerns about placenta encapsulation.

The response I often get is that placenta pills are “medicine” for postpartum depression and boost milk supply, and that they have never seen women who had negative experiences. Yet, these moms who I have worked with and whose problems I have documented are often also the clients of those midwives and doulas. As such, I am concerned that the doulas and midwives are in fact not accurately assessing milk supply and infant weight gain and therefore do not see the picture I am seeing. In a normal situation, as long as the latch is comfortable, mom is nursing following baby’s cues, and you can hear swallowing, it is generally assumed that all is well with breastfeeding and that mom has plenty of milk. Nevertheless, infant weight gain is the most reliable indicator of milk supply, and weight checks at key points in the early days and weeks help to monitor for adequate growth and to identify red flags.

Often the baby’s slow weight gain goes unnoticed using the common “fish scale” that midwives use in their practice. The fish scale is easy to transport to the home and cradles the baby in a comfortable sling-like hold but measures in two- to four-ounce increments versus a digital scale that is calibrated to measure newborns in grams. Digital scales are much more accurate in assessing daily weight gain as well as breastmilk intake per feeding. Cases of low supply and slow weight gain can be too subtle and nearly impossible to detect with the fish scale, which may otherwise be adequate for its purposes in a normal breastfeeding situation.

When I detect slow weight gain, sometimes the response from the midwives or doulas is that the mom has plenty of milk and that the baby is just following his or her own weight gain pattern. Babies have been brought into the clinic for the first time still significantly below birth weight by two or even four weeks of age, or are still gaining weight far below the expected range by the two-month visit. Such cases of failure to thrive are sometimes diagnosed in the clinic by looking at the growth curve in the baby’s growth chart, following the completion of the six-week midwifery care, so in many cases the midwife is not ever made aware of this finding. In so many of these low supply cases, the moms themselves report that they believed they had full milk supply. They commonly say that they believed breastfeeding had been going very well because baby nursed with a pain-free latch “every 45 minutes to an hour around the clock.” When nursing a baby, this is actually often a sign that there is not enough milk, not a sign that there is plenty. I am concerned that the assessment and reporting of milk supply remains a complex issue. As a lactation consultant, I have seen enough direct cases that I have serious concerns about the increasingly popular practice of having postpartum women consume their encapsulated placentas.

The claim made by placenta encapsulators that these pills will increase milk production is certainly not based on valid current research, nor does it make physiological sense. With that said, I have spoken with several moms who have told me that they had previously consumed their placenta and never had milk supply issues, and I have been able to verify that their babies had gained weight normally. I am sure this is a part of the picture as well, as we also know that some women’s milk supply can withstand hormonal suppression from birth control pills while others don’t. In any case, this remains a high-stakes gamble.

In my postpartum support group, I have seen women struggle with profound postpartum depression after taking their encapsulated placenta, especially as they are dealing with such heartbreaking milk supply issues. Tragically, most of these women had decided to take their placenta pills primarily to prevent postpartum depression. I wonder about the reasoning behind this idea. Is this accurate or even ethical to tell women? Isn’t your body meant to flush out the pregnancy hormones after the birth to allow the lactation hormones to come in? This is the big hormonal shift during the ‘baby blues’ that is happening with the natural hormonal cycling, and by clinical definition is not postpartum depression.

happy pills
illustration by Ken Tackett

I am concerned that the popularization of the “Happy Pill,” as many encapsulators refer to it, is not only potentially risky but is giving women the message that their body is naturally set up for depression and that they need a hormonal pill to “prevent” this process. What happened to the advice for women to trust their bodies? What is a “balanced hormonal state” for a lactating woman? I am concerned that there is a lack of understanding among some healthcare providers about the hormonal cycling from pregnancy to lactation. Continuing to give yourself pregnancy hormones for days and weeks and months once you’re done being pregnant doesn’t sound to me like a balanced hormonal state. I can appreciate the likelihood that ingesting estrogen and progesterone, which are steroid hormones, could certainly cause the dramatic energy surge moms so often report after consuming their placenta, but who can be certain that this is a natural and healthy state for postpartum women?

As the popularity of placenta encapsulation grows, we are seeing new situations and new potential risks that deserve a closer look. Ingesting the placental estrogens may increase a woman’s risk for thromboembolism (blood clots, stroke) as we know estrogen-containing birth control pills can (Hayes, 2016; Academy of Breastfeeding Medicine, Protocol #13, 2015). In yet another new development, many moms are now even advised by encapsulators to give their infants and toddlers the placenta in powder or tincture form as medicine for colic or temper tantrums. What are the health implications for babies ingesting these hormones? The GBS Case Report that the CDC released this year on an infant hospitalized from an infection coming from the same strain of GBS found in the mom’s placenta pills (Buser et al., 2017) illustrates that infection is yet another potential risk associated with this practice.

Given the recent valid research studies that clarify that no human culture ever had postpartum women routinely consume their placenta begs the question whether humans have evolved to not eat their placenta for a good reason?  We can continue to experiment on our new moms and babies and find out, but I believe this raises an ethical dilemma.

Lastly, my concerns about this fad of placenta encapsulation becoming the ‘new normal’ for postpartum care are not just for the implications to the moms and babies. My concern is also for the future and legacy of ancient wisdom in women’s health care. Midwifery is based on a long history of trusting a woman’s body and a tradition of providing safe, natural, and effective care. Aside from a brief exploration in the US in the 1970s of consuming whole cooked placenta, extensive research into world cultures shows us that it has clearly not historically been a part of standard midwifery practice to give women their placenta to eat. The covert social marketing that certain entrepreneurs have developed has in essence hijacked the knowledge and role of midwives and integrated a new practice into women’s health care.

I see a similar disservice being done to Traditional Chinese Medicine (TCM). TCM is a highly complex system of medicine that has developed over thousands of years. Placenta encapsulation “specialists” are being trained online by business people, and after only watching a two-hour training video are told they will have “acquired experience in Traditional Chinese Medicine and placenta encapsulation.” Consequently, they are prescribing placenta pills under the name of TCM. Is there information included in the training that placenta consumption is actually in opposition to the medicinal properties indicated for postpartum women in TCM and that its use for postpartum care is actually not found in any of the traditional Chinese medicine texts? Will we allow a two-thousand-year-old system of medicine to get derailed this easily? There is much at stake in this new era of social media and cottage industries. Unfortunately, women’s bodies are the playing field.



I have made a handout that I provide pregnant women with so they can research this topic by consulting more credible sources and at a more critical level than merely “googling” it or relying on the advertising of the placenta business marketing and websites, in order to make an informed decision on whether or not to ingest their placenta. The handout is attached here. Please take a look, and feel free to pass it along.

In my hundreds of interviews I have done with women on this topic, the need to honor the placenta definitely became clear to me. I buried my baby’s placenta and it was a wonderful tribute with deep meaning to me. It is an inherent need in every culture and a missing piece in our modern one. The encapsulation does meet that need in a way, I have realized. I actually have another handout I made about a year ago that I give to all pregnant women that lists burial customs from every culture, and the meaning behind them. My patients LOVE that handout, and get excited about the idea of creating their own meaningful burial ceremony with their placenta. That has been a way I can keep the conversation positive and support them in meeting their need to honor their placenta, while offering an alternative to encapsulation.


Sarah Hollister, RN, PHN, IBCLC

Breastfeeding After Breast Reduction Surgery

Tess shares her challenging and rewarding story of breastfeeding after reduction surgery and three key messages that really helped.

Living my teens and early twenties with breasts that were disproportionately large for my body significantly inhibited my ability to exercise and find appropriate clothing, caused back pain, and impacted hugely on my self-confidence. At age 24, the decision to have breast reduction surgery was right for me and dramatically improved my quality of life. My surgeon assured me that the surgery wouldn’t reduce my likelihood of being able to breastfeed. He said that only 66% of women with breasts bigger than a ‘DD’ cup could breastfeed anyway and quoted a similar percentage for women who could breastfeed post-reduction surgery. With hindsight, experience, and personal research I now question the accuracy of those statistics!

Breastfeeding After Breast Reduction Surgery
Ken Tackett

Seven years later, when I fell pregnant, I was surprised by the intensity of my desire and my husband’s commitment toward the idea of breastfeeding. Throughout the pregnancy, we mentioned my breast reduction surgery and intention to breastfeed to every health professional we met, asking what we could do to maximize my chances of producing milk. The responses were consistent:

  • Strive for minimal intervention during the birth in order to establish feeding as soon as possible.
  • Think positively about my ability to breastfeed.
  • As breast milk is produced on a supply and demand basis, avoid giving formula as supplementation, which would be sure to decrease my milk supply.

Nell’s arrival was calm and uncomplicated. She was beautiful beyond words. Immediately after the birth, she was placed on my chest and crawled towards my breast as I began to leak colostrum. I was ecstatic. Although she was constantly at my breast over the next few days, she became increasingly unsettled. By the morning of our hospital discharge she had lost nearly 15% of her birth weight and the midwives reluctantly insisted we supplement with a small amount of formula. I felt I had failed my daughter.

Two days later, Nell had gained weight well and we were advised to stop supplementing with formula. This was music to our ears—I could exclusively breastfeed! But, over the next few days, her weight plummeted. So began an emotional rollercoaster and the upset was exacerbated by conflicting advice. Depending on which health professional we spoke to, we were either advised that, because of my reduction surgery, I should give up any hope of breastfeeding, or that my surgery was irrelevant and the only reason I had a low supply was because we had supplemented with formula.

We started and stopped supplementing many times over. Some days we supplemented with donor human milk from my sister and a close friend. However, on the days we needed formula, I heard the messages about its risks ringing in my ears. I felt I was giving my daughter poison, as well as ruining any chance of being able to breastfeed longer term. We were exhausted, devastated, and totally confused.

Help came just before Nell was two weeks old from a lactation consultant, who explained the crucial and often misunderstood differences between low milk supply as a result of reduced glandular tissue from surgery (which commonly requires some level of supplementation) and broader low milk supply issues (where supply can usually be increased solely through more frequent feeding and stimulation). We felt such a sense of relief to comprehend what was happening, as well as anger over the poor lactation advice we had received.

Our lactation consultant taught us how to supplement Nell through a tube in the corner of her mouth while she was at my breast (an at-breast supplementer), which enabled her to gain necessary weight while at the same time stimulating my milk supply. She outlined a range of strategies to increase my milk supply before it stabilized at the 12-week mark. When my husband and I confirmed our commitment to give it our best shot, she helped us draw up a breastfeeding plan.

I was prescribed domperidone [see Thomas Hale’s Medications and Mothers’ Milk for current safety rating] and started taking the maximum dose, as well as beginning a course of both osteopathic and acupuncture treatments. “Galactagogue” became a frequently used addition to our household vocabulary as my diet became centred on foods known to promote lactation and our cupboards filled with every herb, tonic, tea, and yeast we could find that might support our efforts.

Just after Nell’s birth we had hired a hospital-grade double pump and our breastfeeding plan involved waking Nell for a breastfeed and supplementary “top up” every four hours (which took about an hour), expressing for 15 minutes after each feed and doing a ten-minute “power-pump” between feeds. This feeding and pumping regime was exhausting, seldom allowing me more than 20 minutes’ sleep in any one block and requiring us to push back on almost all visitors. Slowly but surely there were gradual increases in my milk supply and by the time Nell was six weeks old, she had finally returned to her birth weight.

I cut back on one pumping session overnight (as I was in desperate need of a two-hour block of sleep) and one during the day, which allowed me to get out of the house daily for an hour. I finally summoned up the courage to attend a breastfeeding mothers’ meeting. Until this point, I had I felt like a fraud at the idea of going along, since I was not exclusively breastfeeding. In my sleep-deprived state, I became convinced they would kick me out if I pulled out a bottle of formula to feed my baby! However, I was desperate for the company of new mothers, so along I went.    

Other mothers spoke candidly about oversupply issues and how much easier feeding had become after six weeks. I couldn’t help being filled with envy. Feeding wasn’t becoming any easier for me. While I understood there were difficulties and pain associated with oversupply, it was so difficult to hear stories of excess milk that I would have given anything to be able to produce.

When it was my turn to share my experiences, as I opened my mouth to talk, my tears began to flow. I was touched by the sensitive, kind responses, particularly from the facilitator who assured me that all mothers were welcome, regardless of how they were feeding their baby. She scheduled a future meeting on “Mixed Feeding, Mixed Feelings” and sent me an article that captured well the shame I had been feeling.

There were three key messages I took away that really helped and have stuck with me ever since:

  • You don’t have “half a breastfeeding relationship” with your baby, even if you are partially breastfeeding.
  • Think of the breast as being half full!
  • The inclusion of mother’s milk within mixed feeding still provides benefits, even if they are not as pronounced.

Every drop of breast milk counts. I continued with my efforts to increase my milk supply and by the time Nell was 12 weeks old, I could produce 70–80% of her nutritional needs on any given day. However, my pumping regime and the effects of the high doses of domperidone were not sustainable for the longer term and, as Nell became more active, I was starting to resent the pumping time that took me away from her.

Breastfeeding After Breast Reduction Surgery
Ken Tackett

We revised our breastfeeding plan to reduce pumping to six times a day, slowly weaning off domperidone and supplemented Nell through a bottle rather than at the breast. I was sad that these changes saw my supply drop slightly, and I feared this signalled the end of our breastfeeding, though the increased freedom it afforded me gave me more time to enjoy with Nell.


Two months later, I am currently providing about 50% of her nutritional needs with breast milk. I hope we continue breastfeeding for some time yet, though I will consider our breastfeeding experience a success regardless. I have recently read about breastfeeding promoting the regeneration and growth of glandular tissue removed during surgery, resulting in an increased milk supply for subsequent children. I love the prospect* that my breastfeeding Nell may also benefit any future children we may have.

I have learned so much about the mechanics of breastfeeding after reduction surgery and about strength and endurance.

My experience has instilled in me the understanding that a breastfeeding inclusive society involves recognition of a definition of breastfeeding that is broader than the exclusive provision of breast milk. I vividly recall my feelings of isolation from other breastfeeding mothers in those early days. This isolation has since dissipated as a result of contact with other mothers who are breastfeeding after breast reduction surgery, in addition to the opportunity to discover similarities with other breastfeeding relationships that, on the surface, appeared to be vastly different to my own.

The obvious enjoyment and comfort Nell receives from breastfeeding is one of my proudest achievements.

*Tess is currently enjoying breastfeeding her second daughter who is now 17 months old.



Cassar-Uhl, D. (2014). Finding sufficiency: Breastfeeding with insufficient glandular tissue. Praeclarus Press

Sriraman, N.K., Evans, A.E., Lawrence, R., Noble, R., & the Academy of Breastfeeding Medicine’s Board of Directors. (2017). Academy of Breastfeeding Medicine’s 2017 Position Statement on Informal Breast Milk Sharing for the Term Healthy Infant. Breastfeeding Medicine13(1)1–3. doi 10.1089/bfm.2017.29064.nks

West, D., & Marasco, L. (2008). The breastfeeding mother’s guide to making more milk: Foreword by Martha Sears, RN (family & relationships). New York: McGraw Hill.

Breastfeeding after Breast and Nipple_Procedures

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