During my three-month maternity leave, I struggled to develop a successful nursing relationship with my son. Breastfeeding felt like the obvious choice, but before we even left the hospital, we were forced to supplement with formula when my son kept losing weight. After a difficult labour and an unplanned C-section, I felt like my body was failing me in the last way possible, depriving me of the ability to nourish my son.
I felt guilty about giving my son formula, knowing that my body produced the perfect food for my baby. I was determined to make it work. Over the next few weeks, while I was suffering from toe-curling nipple pain, swollen breasts and exhausting feeding and pumping sessions to boost my supply, my son was also having trouble taking in enough milk at the breast.
His latch was fine and he had no visible tongue or lip tie, but at five weeks, one of the specialists I saw finally diagnosed the problem: oral motor difficulties—more specifically, weak jaw, tongue and cheek muscles. Try as he might, my son’s little muscles weren’t strong enough to nurse efficiently, which explained my engorgement and his frustration. For three weeks, I did the recommended at-home exercises to strengthen his muscles while continuing to supplement with formula as needed. On the advice of one of the certified lactation consultants, I tried to pump after every feeding to stimulate milk production. Between feeding and pumping, my days were consumed.
Despite everything I was doing to make breastfeeding work, my supply suffered, along with my will to keep fighting. Nearly every time my son nursed, he inevitably cried for a bottle of formula afterwards. I knew some of his issues were improving when the pain subsided, but I couldn’t keep up with his demand for milk.
One night, I finally admitted defeat. Direct nursing seemed too fraught with anxiety to continue—I would just pump and bottle feed. Pumping allowed me to hang onto the last shred of breastfeeding I had left. I stubbornly clung to this idea as I cursed a system where it took weeks to get the help I needed to correct my feeding issues. Although I felt relieved to take the guesswork out of feedings, I also felt like a complete failure for not being able to nurse my baby directly.
Meanwhile, my entire schedule revolved around my next pump. I also faced people who questioned my choice, admonishing me for “taking the easy way out” or telling me that formula would make my life easier. For nine long months, until a noticeable supply dip prompted me to wean, I pumped five or more times a day to provide my son with roughly 18 ounces of breastmilk and kept supplementing with formula. I stopped feeling guilty about the top-ups with formula—it was a crutch that took the pressure off my output goals—and started thinking of it as the “protein shake” of my son’s diet, not a replacement for the main source of his nutrition.
In doing so, I didn’t realize that I had joined the ranks of thousands of other women just like me who had chosen, for various reasons, to pump exclusively instead of breastfeed. Moms who pump exclusively often fly under the radar in cultures that view feeding as a dichotomy—my own doctor’s office still asks whether moms breastfeed or bottle feed (that is, formula feed). There’s little understanding of the hard work and dedication to find something that works in between those two choices.
Why pump exclusively?
“Mothers who pump exclusively may or may not actually initiate this based on their personal choice,” says Jenn Foster, an international board-certified lactation consultant (IBCLC) based in Georgia. She says that mothers of preterm babies often pump exclusively after working to supply breastmilk to their babies in the neonatal intensive care unit (NICU). Historically, mothers of preterm and low-birth-weight babies comprised the bulk of mothers who pump exclusively. Now, the improved quality and availability of electric pumps make the option more viable for other groups of women.
Mothers of full-term babies often choose to pump exclusively when they struggle with latching or supply issues and when they don’t receive enough support in the early days of breastfeeding—both of which happened to me. Some moms choose to pump because it’s the best decision for their families, while others simply prefer to monitor their milk intake—which you can’t really do when you’re nursing directly. There are also women who have very limited maternity leaves, so they start pumping and bottle feeding rather than spending precious time perfecting their babies’ latches. Abuse survivors may choose to pump if the demands of nursing their babies trigger adverse physical or emotional reactions that they are unable to work through. In such cases, pumping instead of nursing directly may help them dissociate the breastfeeding experience from past abuses.
How exclusive pumping works
Newborn babies nurse eight to 12 times a day on average, so a mother who pumps exclusively should pump that often to keep up with the demand for milk. Foster encourages mothers to pump every two or three hours. “It is not recommended to go longer than three hours at a time without expressing your milk,” she cautions. During the first month of a baby’s life, too much variation from this around-the-clock regimen signals the body to reduce milk production, says Foster. I believe that deviating from this schedule throughout my early struggles contributed to my supply issues.
As with direct nursing, pumping sessions should be timed from the beginning of one session to the beginning of the next. Most general guidelines suggest 15 minutes per session, but the exact amount of time varies based on individual responses to the pump. Foster stresses the importance of draining the breasts. “Milk needs to be removed to be made,” says Foster. Pumping several minutes past when milk stops flowing will ensure that a woman removes enough milk to maintain her current average output and avoid clogged ducts and mastitis.
While the number of daily pumping sessions should correspond to the frequency of a baby’s feeds, moms who pump exclusively can follow whatever schedule works for them as long as they follow it like clockwork while establishing their supply. After establishing their supply, they can continue to adjust their routine. There are various pump logging apps that allow women to monitor the time, duration and yield of each pump. Depending on the app, additional features may include monitoring totals, averages and trends and calculating when to wean based on freezer stashes.
Which breast pump to choose
Not all pumps are created equal, and what works for occasional use may not endure the rigours of pumping exclusively. Foster recommends that women who pump exclusively look for a quality, closed-valve, hospital-strength pump. Any pump rated 250 mmHG or higher is hospital strength. Pumps with customization settings for vacuum pressure and speed can be adjusted to individual needs.
Closed-valve systems prevent milk from passing through tubing to the motor, making them the most sanitary choice. They are especially important for women who are considering rentals or used pumps, as the inner motors of most pumps can’t be completely sanitized. Women who rent or buy used pumps should also consider the motors because they may not be designed for multiple users. To be rental-quality, a pump should be labelled as “multi-user.” Milk collection kits (tubing, breast shields and collection bottles) can’t be thoroughly sterilized at home and should always be purchased new.
Foster also recommends using a double pump. “Double pumping allows for your hormonal peaks to occur more frequently during your pumping experience,” says Foster. The hormones that Foster refers to—prolactin and oxytocin—signal the body to produce and release milk.
Multi-user rental pumps are usually available from hospitals, medical supply centres and authorized lactation consultants. Spectra, Philips Avent and Lansinoh make closed-valve, single-user pumps that range from $150 to $300 or more. These single-user pumps may be covered by some insurance plans.
How to maintain your milk supply
Since moms who pump exclusively measure the amount of milk expressed, output volume can easily become a source of stress. Some new mothers panic when their initial output is as little as two ounces combined per session, but Foster stresses that this is normal. If all goes well, women can expect an average daily output of anywhere from 19 to 30 ounces. Moms who struggle to make sense of their output should work with lactation consultants to determine best practices and receive personalized guidelines.
Foster says that a woman’s supply naturally starts to self-regulate and the milk composition changes (often to a higher fat content) around the four- to six-month mark. A similar shift occurs around the eight- to 12-month mark. If a mom has kept pace with her baby’s feeding schedule, she should find that her supply continues to meet her baby’s needs. She can take further steps to ensure that her baby’s appetite doesn’t exceed her supply by using slow-flow nipples, practising a variety of paced feeding techniques and stretching bottle-feeding sessions to closely mimic breastfeeding.
Other common culprits for supply fluctuations are worn, damaged and incorrect parts. Moms should inspect and replace the parts, especially valves and membranes, regularly. When used frequently, these parts should be replaced every one to two months or at the first sign of wear and tear. Moms should consult an IBCLC to help select the correct breast shield, or flange size, and eliminate issues that stem from incorrect pumping techniques.
Concerned moms may seek galactagogues (dietary and herbal remedies), which are thought to increase milk supply. Common over-the-counter galactagogues include fenugreek, moringa, blessed thistle and some herbal teas. In some countries, including Canada, health providers may prescribe domperidone (a pill used for gastric issues that has proven to be effective at boosting milk supply). Foster recommends consulting your primary caregiver before starting any dietary regimen or supplement. She cautions that some products may react with other medications and medical conditions. “A full medical history is needed to assess [each] mother and baby,” says Foster.
Where to find support
According to Foster, moms who pump exclusively are often ostracized from support groups that are geared toward solely breastfeeding or formula feeding. “These mothers often deal with feelings of inadequacy, which should not be the case,” says Foster. “[Pumping] is actually a great dedication of love.”
Fortunately, support groups for moms who pump exclusively do exist. I connected daily with moms in the Facebook group I joined. They welcomed me into their ranks, offering advice and encouragement when I needed it most. Throughout my journey, they taught me that moms who pump exclusively haven’t failed; they’ve simply chosen an alternate route that takes as much—if not more—hard work and dedication as direct nursing. Now, when I look at my happy, thriving 18-month-old, I marvel at the lengths I went to breastfeed him and how far our journey has taken us.