Courtesy, Lucile Stanford Children’s Hospital, Stanford University.

Over reliance on electric breast pumps may be associated with underproduction of breastmilk, the conclusion reached by Jane Morton and her Stanford colleagues in a study to be published by the Journal of Perinatology.  They report the effect on milk production of 2 manual techniques used by mothers of infants less than 30 weeks gestation. These mothers typically remain pump-dependent for weeks to months before they can rely on the breastfeeding infant to maintain their supply. This is the first report of a steady increase in production over 8 weeks, which surpassed reference levels for mothers of term infants.                                        

Demonstrated online, mothers were first taught hand expression of colostrum. (Hand expression: http://newborns.stanford.edu/Breastfeeding/HandExpression.html) Once milk came in, they were instructed in the second technique, “hands-on pumping”.  (Hands-on pumping: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html)  During instructional sessions, milk was collected into bottles placed on electric scales, which were computer-linked to record milk removal While simultaneously compressing their breasts and massaging firmer areas, mothers would observe sprays of milk in the tunnel of the breast shield, guiding them as to where and how to use their hands. Additionally, they could watch the computer screen demonstrate milk removal from each breast.  (See illustration) If study mothers were dependent solely on pump suction, stopping when the flow ended, available milk would have remained unexpressed.

 Most remarkable was the unfaltering and impressive milk output of these preterm infant mothers, who are considered to be at high risk for impaired milk production.  Production steadily rose over 8 weeks, exceeding published averages for mothers of term infants.  Frequency of hand expression in the first 3 postpartum days correlated with subsequent production. The self-selected mothers who used frequent hand expression (over 5 times per day) and then “hands-on pumping” once milk came in produced an average of 955 mL/day (about 32 ounces) by 2 months.  The average intake for a healthy 3-month-old breastfed term baby is about 27 oz/day.  Impressively, these mothers  were able to reduce time spent pumping and extend their unpumped sleeping interval. By the 8^th week, mothers pumped an average of 6 times a day with a 7 hour uninterrupted interval for sleep.

 The study underscores the long-term importance of the first 3 days when frequent and effective removal of colostrum is critical. Factors speculated to compromise production such as advanced maternal age, preterm delivery, high BMI, C-section delivery, IVF and primiparity had no impact.  Acceptance was so positive mothers volunteered to demonstrate these techniques and share their impressions for internet viewing posted by  Stanford.

 Morton does not challenge the importance of pumps, but suggests that suction alone may remove only a fraction of available milk, thus compromising production.   85% of mothers of infants less than 4.5 months rely on an electric pump. (Labiner-Wolfe J, Pediatrics 2008)  No electric pump comes with instructions for a “hand-on” approach.  In fact, the usual advice for a mother with low production is simply to pump more.

Impaired breastmilk production is a pervasive problem in our culture.  Insufficient milk supply is the most common reason given by mothers for discontinuing efforts to breastfeed over the course of the first year. (Ruowei Li, Pediatrics 2008) The most common reason for re-hospitalization of newborns relates to reduced breastmilk intake. Compromised production is 3 times more common in mothers of preterm vs. term infants.

 The AAP’s new Breastfeeding Curriculum for Residents recognizes hand expression as one of the key learning objectives for physicians to teach all new mothers.  There are many unforeseeable scenarios in which reliance only on the baby or the baby plus the pump may not be enough to stimulate or maintain a robust supply.  Ideally, expectant mothers could watch these videos to learn about the importance of the first 3 days and an effective technique which may possibly prevent subsequent production problems.

 Whether these preliminary findings can be duplicated to the advantage of a wider spectrum of mothers remains to be studied. Yet the solution at hand (literally) may be learning a simple skill which involves no cost, no paraphernalia, no discomfort, no drugs and no risk.