Breast pumping is a tool that makes it easier for mothers to maintain breastfeeding in different circumstances and to adapt to different stages of the baby’s development. To ensure successful extraction, it is important to follow proper techniques, prepare the environment and use correct tools.

Breast milk extraction is a useful and highly recommended practice for mothers who wish to provide the benefits of breastfeeding to their babies, and who for various reasons are unable to breastfeed directly, temporarily or for longer periods of time.

Let us not forget that the World Health Organization (WHO) recommends exclusive breastfeeding (EBF), for the first six months of life of infants, and, thereafter a combination of breast milk with appropriate and nutritious foods for each stage, up to 2 years of age.(Breastfeeding policy document, WHO, 2017).

There are several reasons why a woman extracts her milk. From decongesting the breasts when they are full, stimulating the breasts to increase production or collecting milk to feed the baby when the mother cannot be near, milk extraction is a process that can become very simple if done properly.

As noted earlier, mothers choose to express their milk in a variety of situations. According to Breastfeeding: A Guide for the Medical Profession (Ruth A. Lawrence, 1996), expressing breast milk is used to “trigger the ejection reflex to help the baby take the breast properly; at the beginning of lactation, if the baby is premature or sick; to express milk when it is not possible to breastfeed at a given feeding; to maintain production when breastfeeding is not possible; to save the milk and give it to the child at another time; or to donate it to a milk bank. This mechanism is also used to express and discard milk temporarily while taking a certain drug, to help drain the breast in case of obstruction, mastitis, and to initiate and establish milk production in case of breastfeeding or induced lactation”.

Extracting milk allows other people to feed the baby, thus facilitating the bond between the infant and other family members, especially the father, and providing opportunities for the mother to relax. It is also an excellent way for the mother to continue her work or studies without having to give up providing her baby with the best nutrition.

To ensure a successful extraction, it is important to follow proper techniques, prepare the environment and use correct tools. Adequate hygiene should be maintained beforehand, washing hands with soap and water before starting. If a mechanical pump is used, all pump components must be clean and sterilized, as well as the containers in which the milk will be collected.

It is essential for the mother to be in a quiet and discreet place, since avoiding stress helps stimulate milk production. It is also recommended to drink water before pumping and to maintain a balanced diet for optimal production (de Waal Foundation, 2024).

Abigail Monard, master in Epidemiology and Public Health, expert in the management of breastfeeding support groups, points out that the production of breast milk is a hormonal process that is determined by a single stimulus: suckling, which is why she indicates that all breastfeeding mothers are capable of starting and maintaining home milk banks. The professional explains the correct ways in which the processes of extraction and conservation of breast milk can be carried out.

Mothers can express their milk manually or with the help of a breast pump. In both cases, it is recommended to massage the breasts with gentle movements to stimulate the flow of milk.

Manual extraction is suggested because of the comfort with which it can be carried out, since in any discreet and comfortable space, the mother proceeds to massage her breasts and then place one hand on top of the areola and the other underneath. The area to be squeezed is about 3 cm from the base of the nipple. The movement should be done rhythmically and the fingers should be rotated to stimulate the different parts of the breast. The breast should not be stretched or squashed.

For a better understanding of this technique, we invite you to watch our FB Live: Breastfeeding without barriers, in which Abigail shares how to apply it.

In the case of mothers who use breast pumps, it is also important that they take time to perfect their own way of expressing milk. But in general, we can point out that manual pumps work with the pressure of the pump handle in a rhythmic way, since it imitates the baby’s sucking. And in the case of electric devices, they should be adjusted to an intensity and frequency that is comfortable for the mother,

We should note that each pumping lasts about 15 to 20 minutes per breast, or until you feel that the breast has emptied.

Safe storage of milk

In addition to proper nutrition, hydration, space, time and techniques, successful milk extraction is also based on proper milk storage.

For this purpose, it is advisable to use suitable containers, such as bags or containers specifically for breast milk. These must be perfectly clean and closed before starting the milk collection process.

After pumping, it is recommended that the containers be stored in the most suitable manner. According to UNICEF (8 Recommendations for Expressing Breast Milk), breast milk can be stored at room temperature of 25°C or lower for up to four hours. In the refrigerator, at 4°C or lower, it can be stored for up to four days. It can be frozen for up to six months if kept in a freezer at -18°C or lower.

It is recommended to mark each container with the date and time of extraction for better control.

To maintain optimal levels of milk production, it is recommended that the mother express her milk every 2 to 3 hours.

Expert opinion

Abigail Monard Sandoval, lactation consultant and Prenatal and Postnatal Health monitor at the de Waal Ecuador Foundation, talks to us about breast pumping, with the best tips for a successful process that is easy for the mother and meets the baby’s needs.

1. What does breast pumping consist of?

Breast milk is the means by which the immature baby continues its development outside the womb; and scientific evidence has shown that the best breast milk extractor is the nutritious sucking from a correct areola and nipple attachment. Among the different types of breastfeeding during the first 2 years of life and beyond, there is a type called delayed breastfeeding, which avoids early weaning. Deferred breastfeeding can also be exclusive, complementary and prolonged, allowing to maintain breastfeeding through a medium such as a syringe, cup and/or spoon instead of breastfeeding; avoiding the use of bottles and nipples since they modify the jaw movement of the infant, causing a “nipple-teat confusion”. This method is also used to implement the milk bank at home, allowing the mother to store her milk in glass containers or suitable plastic bags, refrigerated and/or frozen, according to the baby’s feedings; thus organizing her feeding, and guaranteeing the availability of breast milk with or without the mother’s presence. If the mother decides to express her breast milk, she should follow these recommendations:

• Start with frequent manual removal 8 times a day for the first 3 days.
• Continue with 8 to 10 pumps for the first 7 to 10 days, collecting 750 to 1000 ml, depending on the volume of breast milk production, being individualized.
• Try different manual and/or electric extraction techniques, choose the one that benefits the mother and allows her to express the greatest amount of breast milk during the day.
• Perform nocturnal extractions due to the prolactin peak, responsible for lactogenesis, between 02:00 and 06:00 in the morning, increasing milk production.

2. Why do mothers express their milk?

With the birth of the baby, the breastfeeding process begins as an instinctive and learned social behavior; in general, newborns should breastfeed 8 to 12 times a day during the first three months of life, and their sucking rhythm reaches 40 to 60 times per minute, where each feeding can take up to 1 hour, until the baby improves its latch-on and sucking. There are several reasons why the mother decides to express her milk, citing the most common ones that are attended in consultation and in the community:

• Painful breastfeeding due to poor latch-on and non-nutritive sucking
• Breastfeeding agitation that causes rejection of the infant when breastfeeding
• Feeling of guilt for little or no weight gain and poor breast emptying
• Time factor due to the mother’s return to school and/or employment
• Implementing a home milk bank to start deferred lactation
• Maintain or increase the production of breast milk.
• Relieve breast and nipple complaints (mastitis, swelling, cracking, engorgement, etc.)
• Aesthetic changes in the breasts due to direct breastfeeding
• Breast milk donation.

3. What are the benefits of expressing breast milk?

Breastfeeding allows the emptying of the breasts, avoiding ailments when milk is retained and accumulates, or a correct emptying is not achieved due to an inadequate transfer of milk. When there is no suction, the pump becomes the stimulus to maintain the production of breast milk, since the big industries are focused on simulating the baby’s suction with their range of manual and automatic or electric pumps; however, it has not been possible to perfect the suction rhythm based on the myofunctional balance and the coordination of facial muscle movements of the baby during breastfeeding. The benefits of expressing breast milk are cited:

• In the mother: less risk of milk pearls, obstructions, mastitis, engorgement, cracks or wounds in the nipple, which arise from poor latch-on and sucking of the areola and nipple.
• In the infant: prematurity makes it difficult to latch on to the breast and suckle effectively, so it is recommended to initiate colostrum therapy starting with prenatal colostrum extraction. In addition, during prolonged lactation, giving expressed breast milk serves as a supplement and has better nutritional value and bioavailability than formula or growth milks, being unnecessary for the growth and development of infants.
• In the family: greater involvement in the baby’s upbringing, no longer making the mother entirely responsible for producing the milk, promoting positive parenting and inserting her participation in the infant’s feeding. In addition, savings are achieved by maintaining breastfeeding instead of artificial feeding.
• In education and work: school and/or work reinsertion is not an impediment to suspend breastfeeding; nowadays there are certified lactation centers that facilitate the extraction and storage of milk, promoting milk banks at home, avoiding the discarding and waste of breast milk.
• In the industry: at present, there is a wide variety of electric, manual, double and single breast pumps, facilitating the extraction of breast milk, avoiding that, at the first complication in the baby’s sucking, artificial breastfeeding is initiated.

4. What breast pumping techniques are available?

Before starting to express breast milk, the mother’s state of health should be evaluated, since the technique to be chosen will depend on whether she had a pregnancy with or without risk. At present, there are different techniques to express breast milk without pain, allowing to choose the one that best suits and dominates, considering that at the beginning very little milk is collected, and as you continue stimulating and expressing, milk production will increase. Different breast milk extraction techniques have been patented since the end of the 70’s until now, they have sought to facilitate the process and reduce any discomfort that limits the extraction without pain:

• Marmet Technique: Chele Marmet – 1978

This is the best known and most used manual extraction technique worldwide, it does not require equipment and is practical to perform at any place and time, without causing pain even if the mother has some kind of injury to the breast and/or nipple. To perform it, first the breast must be stimulated to facilitate the milk ejection reflex by massaging with circular movements around the areola and towards the nipple, focusing on areas where there are lumps or milk retention. Then rub without exerting pressure from above towards the nipple while slightly tilted and shaking the breast so that gravity and movement help the milk to let down. Once the mother has finished stimulating both breasts, proceed to express with the hand in a “C” shape, pushing backwards, towards the ribs and nipple; starting to collect the first drops of milk, using both hands for each breast and rotating around the breast.

• Combined Extraction Technique; Jane Morton – 2009

Technique used to express large quantities of milk and maintain milk production when there are difficulties in maintaining direct breastfeeding. It is performed by massaging both breasts to stimulate milk ejection, and a combination of mechanical and manual double pumping. In addition, breast compression is performed, which is a pressure exerted on the breast in the form of “C” so that there is a greater flow of milk quickly and easily at the time of collection, shortening the time of duration.

• Hyperstimulation or Powerful Extraction Technique; Catherine Watson – 2011

Technique focused on increasing milk production through hyperstimulation with a pump in a few days, by producing several prolactin peaks within the first 48 hours. The first step is to use the pump for 10 minutes every 45 to 60 minutes during the day, and at night, pump every 4 to 6 hours, collecting a minimal amount of milk after the first 2 days of the technique. Once 15 to 20 ml of milk has been collected every hour, the extractions are spaced out, being 20 minutes every 2 hours. When you reach 40 ml of milk collected every 2 hours, continue to space them out until you maintain 6 to 8 extractions of 30 minutes in total during 24 hours. If the minimum amount of breast milk is not collected with powerful pumping, discontinue the technique and try another method.

5. How should expressed breast milk be stored?

Breast milk is a live, non-sterile fluid and the most important human food during the period of nutritional and immunological adaptation of the newborn, exclusively up to 6 months of age, complementary up to 2 years of age, and prolonged in infants older than 2 years of age. Since it is susceptible to any type of contamination, it is essential to carry out an adequate conservation at the moment of extraction, collection and storage; avoiding that its nutritional properties are lost or diminished by inadequate handling from the choice of the material where the breast milk is going to be collected, its previous sterilization and subsequent labeling, the number of extractions throughout the day and the control of the temperature at the moment of refrigeration and/or freezing, avoiding abrupt changes and respecting the following periods of time for its conservation:

• Refrigerator: less than 1 week, 6 to a maximum of 8 days in refrigeration.
• Freezer: it will depend on the size of the equipment, the larger the capacity, the longer the duration.
• Small and/or old: maximum 2 weeks
• Independent: 3 to 4 months frozen
• Industrial: can be kept for up to 1 year in optimum conditions
• Suitable materials for breast milk collectors should be BPA-free plastic (polypropylene), heat-resistant glass, aluminum-free screw cap, and/or tamper-evident bags.
• If the weather is hot and humid, freeze immediately if the expressed milk will not be used within 3 days.
• It is preferable to freeze in small quantities (50-100ml) so as not to discard the milk that has not been drunk, since it cannot be refrigerated or frozen once it has been heated in a Bain Marie.
• For better storage, use milk collection bags to organize feedings and save space in the refrigerator and/or freezer by individually labeling the date and time of extraction.
• It is normal for milk to separate due to its nutritional composition, and it should be stirred before giving it to the baby.
• If the frozen milk is not to be consumed immediately, leave in the refrigerator to thaw.

Sources

• Breastfeeding policy document, WHO, 2017.
• 8 recommendations for breast pumping, UNICEF, 2023
• Breastfeeding: A Guide for the Medical Profession, Ruth A. Lawrence, 1996.
• Successful breastfeeding depends on proper nutrition, de Waal Foundation, 2024
• Breastfeeding is best for your baby, de Waal Foundation, 2019.
• Guide to healthy habits for women during breastfeeding, Universidad Autónoma de Madrid , UAM, 2022.

Interview: Alejandra Abigail Monard Sandoval – Nursing and Pharmacology Assistant. Nutritionist-Dietitian of the Ministry of Public Health of Ecuador.