Breastpump Selection & Breastshield Sizing
Bring up the topic of breast pumps and an interesting discussion is sure to follow. Are they a blessing or a curse? Mothers in many parts of the world breastfeed quite nicely without any breast pumps at all; they even hand-express milk for their premature babies. Those of us who were breastfeeding 20 years ago or more did not have a wide range of choices for pumps, but we were still able to help mothers find a way to provide their milk for their babies. Regardless of how we may feel sometimes about the presence of breast pumps and other gadgets in the world of breastfeeding, the fact is that mothers are very interested in them and we sell a variety through our LLLI Catalogue and Web site. Many mothers have found these tools to be an integral part of their ability to provide human milk for their babies. Therefore, even Leaders who may not have used pumps themselves need to be able to give mothers accurate and usable information when they ask about these products.
Breast pumps can be categorized and analyzed in many different ways, some of which are overlapping. These include:
a. Comfort and fit
c. Manual or electric
d. Automatic or manual cycling
f. Intended use
g. Availability and Support
Let’s talk about comfort. We tell mothers that pumping is not supposed to hurt. What does that really mean? The most important factors influencing comfort are the amount of suction applied, the length of time that maximum suction is applied before it is released, and how well the mother’s breast fits into the pump flange and tunnel. These factors are measured using: mmHg (millimeters of mercury), cycles per minute, and tunnel size in mm.
Studies by Einar Egnell and others have established that a total negative (vacuum) pressure of about 220 to 230 mmHg is produced when a baby is breastfeeding and the maximum pressure is usually held for less than one second. This information about maximum pressures and cycling times has subsequently been used by breast pump companies to calibrate their pump settings in order to minimize the possibility of pain and/or breast damage during pumping. Most good quality pumps cannot exceed approximately 250 mmHg of maximum pressure. Nipple damage is most likely to occur when the initial phase of creating suction lasts longer than one to two seconds. Thus, breast pumps with automatic cycling will usually do so at a rate of 40 to 60 cycles per minute. With pumps, the phase including the creation and release of pressure is relatively short and then accompanied by a longer relax phase where no pressure or slightly positive pressure is being applied to the nipple. Many of the battery-operated breast pumps have small motors which can take from 10 to 50 seconds to reach maximum vacuum, and thus may cycle fewer than 10 times per minute–this exposes nipple and areolar tissue to increased trauma from prolonged unrelieved suction. Some mothers can tolerate higher pressures more than other mothers.
Another aspect of comfort is how the pump works. Generally speaking, automatic cycling electric pumps are considered easier to use because the mother only has to hold the flanges in place on the breast (or use a hands-free option such as tucking them inside of a modified bra or using special accessories for that purpose). Those with arm or hand problems, such as carpal tunnel syndrome, may find some manual pumps uncomfortable to use. The pedal-operated pump from Medela can be a good option for those mothers. Some mothers find the gentle pulsing of the Whittlestone to be extremely comfortable, likewise the Whisper Wear.
Fit is another big factor in pumping comfort. Ideally, when the pump is operating, the nipple is drawn into the tunnel and the areola is gently squeezed against the flange. In a good fit, the nipple moves freely within the tunnel. If the nipple is too large for the tunnel, it will be dragged along the sides of the tunnel, causing friction, damage, and pain. If the nipple is small and the tunnel too large, a portion of areola tissue may be drawn into the tunnel and there is often a ring shape imbedded into the breast when it is removed from the pump flange. Breast pump companies are looking for solutions to the fit problem (See below):
Nipple Tunnel Diameter
Flange Brand/Type Diameter
Ameda Custom Flange 30.5 mm
Ameda Custom Flange with Insert 28.5 mm
Ameda Standard Flange 25.0 mm
Ameda Standard Flange with Reducing Insert 23.0 mm
Ameda Standard Flange with Flexishield 21.0 mm
Medela SoftFit 25.0 mm
Medela PersonalFit Standard 24.0 mm
Medela PersonalFit Large Breastshield 27.0 mm
Medela PersonalFit Extra Large 30.0 mm
Medela Extra Large Glass Breastshield 40.0 mm
Both Ameda and Medela offer a variety of different sized flange/tunnels and inserts, which can further change the interior diameter. However, not all flanges are available with all breast pumps.
Many breast pumps include an optional soft silicone insert or soft flange, which can give a better and/or more comfortable fit; the Avent Isis has a particularly comfortable and effective insert.
Medela has a template, which can be used to estimate the probable best flange size based on nipple size (remember that nipples often increase in size during pumping).
Whisper Wear reports good results with a wide variety of breast sizes as long as the pump maintains good contact with the breast tissue. Some women find that a sports bra keeps these pumps in place better than a regular bra.
Efficiency is another way of rating breast pumps, and this can also go hand in hand with comfort. An efficient pump will stimulate a milk-ejection reflex (MER) or let-down and remove milk thoroughly and quickly, an especially important consideration for employed mothers with time constraints or those pumping frequently to maintain a milk supply for a baby who is sick, was born prematurely, or is not sucking properly. The biggest step forward in this area was the development of breast pumps that can drain both breasts at one time, better known as double-pumping. A mother who lets down easily with a good pump can be finished in as little as 10 minutes rather than at least twice that time for pumping one breast at a time. Double-pumping has also been shown to stimulate a greater release of prolactin than single pumping. Some mothers will respond better to pumps that can simply achieve the most suction. Other mothers do better with pumps offering a wider range of pressure and cycling options. The “Natural Expression Pumping” now available on some Medela pumps is an attempt to more closely simulate what a baby does during a nursing session. The Whisper Wear also includes an option for more rapid cycling to stimulate the milk ejection reflex.
Hygiene and possible contamination can also be an important consideration. Breast pumps with special traps built in, such as the Ameda and the Nurture III, prevent pumped milk from entering the tubing and then getting into the pump motor itself. The Medela pumps do not have such a system and milk can go into the tubing and even get into the motor, which is very difficult to clean. The diaphragm of the Pump in Style often becomes contaminated. This is one reason why buying a used Pump in Style may not be a good idea (see sidebar). Mothers need to be careful while pumping in order to prevent this from happening; keeping the pump at chest level helps protect against contamination.
Intended use of the breast pump is another important way of determining what might be the best choice for any particular mother. The chart below gives an idea of the most commonly accepted ways of categorizing pumps according to use. Be aware, however, that every mother is different. In general, full-size automatic cycling pumps are recommended for use by mothers whose babies are not yet nursing well and who are trying to use the pump to establish and maintain a full milk supply. However, some mothers have accomplished this using manual or inexpensive electric pumps or even hand expression. This is most likely to be an option if the mother is able to pump easily and quickly using the lowest setting on the hospital grade pump. A mother already using high settings on a big pump will most likely see a drop in production when switching to a smaller model. The Whisper Wear is proving to be very useful to mothers who are busy with other children or work and are trying to provide for a premie or sick baby. Because they can pump while driving to or from the hospital or while doing things around the house or with other children, they may be pumping with the Whisper Wear significantly more times each day than was possible with a full-sized hospital grade breast pump. This increased frequency is important, as long as the breast pump is doing a good job of emptying the breasts. In general, for frequent use, double-pumping is very desirable and the better the pump the more likely that the milk supply will remain robust. However, good manual pumps may suffice for some women. (“Types of Pumps”)
Even with a good breast pump, mothers will find that their milk supply will stay robust longer if they nurse the baby frequently when they are together, especially at night. No pump can empty a breast as well as a healthy baby can.
Availability and support as well as cost are other considerations. Medela probably has the most extensive sales and support staff throughout the country, as well as a very useful Web site. Ameda, now owned by Hollister, is the original hospital grade pump, the manufacturer operates a customer service department, and these pumps are carried by many retailers. Some of the other pumps mentioned in this article, are available through the LLLI’s print and online Catalogue. If a pump is not available from LLLI, you can locate a distributor at each company’s own Web site. Remind mothers to check for warranties and return policies. When considering cost, the amount of money spent on any pump will almost never exceed the amount of money that would have been spent on buying formula if that baby were not receiving human milk instead. It is all relative and most mothers report that it is money well spent. Some companies, including Ameda and Medela, have grant programs for supplying pumps to low-income mothers.
Helping a mother to choose the best breast pump for her situation is only the first step. No matter what pump she chooses, the mother will need to work on a plan for a pumping routine which will take into consideration her unique circumstances. It does little good to jump from breast pump to breast pump when things aren’t going well if the mother hasn’t already tried the usual methods for stimulating her milk ejection reflex so she can pump milk effectively and efficiently. It may be a little different for each mother and baby you are trying to help. Use your Leader resources, including your Professional Liaison Department, to help you find the kind of information that the mother needs. You might want to review the sections on pumping in THE BREASTFEEDING ANSWER BOOK (pp. 212-215 and 641-650, 2003 edition) and THE WOMANLY ART OF BREASTFEEDING (pp. 117-122, 2004 edition), and the LLLI publications Choosing a Breast Pump and A Mother’s Guide to Pumping Milk. For more information on individual pumps, you can visit company Web sites or speak with local sales representatives who can provide you with technical information as well as suggestions for best use of each product. Talk with other Leaders or lactation consultants in your area who are active in pump rentals and/or sales. Use the Leader Speciality File, looking under the category “Pumps, Breast” for Leaders who specialize in pump questions. (This section of the the LLLI Web site is password protected; see box on page 55 for more information.) The bad news is that as the market expands, you may need to spend more time keeping up with the latest and greatest in the breast pump world. The good news is that mothers and babies will benefit from the increasing diversity in the products that they may need in order to maintain their breastfeeding relationship.
Pumping Requirement Types of Pumps Available
High-quality rental pumps Personal use electric Battery-operated/ manual cycling Hand pumps
One to three times monthly X X
Weekly X X X
Two to three times weekly X X
Daily X X
Complete pumping X
(ill or premature baby)
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