Frequently Asked Questions About Breastfeeding

1.       Are Used Breast Pumps a Good Option? Issues to Consider

What new mother wouldn’t like to save money on a breast pump?  That’s why we are often asked: “Do you have used breast pumps available?”  Some mothers have friends or relatives offering to lend them a used pump. Is a used pump a good option?

Open Systems vs. Closed Systems

Some mothers mistakenly assume that because rental pumps are safely shared by mothers that it is also safe to share purchase pumps. This is not true. Rental pumps and purchase pumps are designed differently. The collection kits (the bottles and tubing that attach to the pump) used with the rental pumps are designed so that the milk never touches the working parts of the pump that are shared with other mothers. This is considered a “closed system.”

Most purchase pumps, for example Medela’s Pump In Styles, DoubleEase, and MiniElectric, are “open systems.”  This means that the pump motor is “open” to contact with the mother’s milk particles. In a Pump In Style, for example, the breastshield (the part held against the breast) is open to the tubing that attaches to the back of the shield, which is also open to the diaphragm on the pump motor that creates the suction and release. This means that an invisible mist of milk particles can travel from the shield into the tubing and back onto the pump diaphragm. The diaphragm cannot be removed or sterilized, so it cannot be cleaned well enough between mothers to insure safety. When there are milk particles on the pump diaphragm, even with a brand new set of bottles, tubing and breastshields, with every suction and release another mother’s milk particles will be blown into your milk. Even if milk particles are not visible, they can still be there. (One sure sign is mold growing in the tubing, which sometimes happens with normal use.)

Health and Hygiene Issues

Does it matter if your baby receives another mother’s milk particles? Potentially, yes. Although your milk is without a doubt the best possible food for your baby, it is currently recommended that any donor milk a baby receives from a milk bank or from another mother be pasteurized to kill viruses. Your baby has already been safely exposed to the viruses in your system during pregnancy, so there is no risk. But if another mother carries a virus in her system that you do not, it can be passed to your baby via the other mother’s milk and your baby may become seriously ill.

A mother can have a virus in her milk without even knowing that she is a carrier. Some of the potentially dangerous viruses that can be transmitted through human milk include cytomegalovirus (CMV) and HIV (AIDS). Most mothers with CMV, for example, are unaware that they are a carrier. The FDA says:

There are certain risks presented by breast pumps that are reused by different mothers if they are not properly cleaned and sterilized. These risks include the transmission of infectious diseases...FDA believes that the proper cleaning and sterilization of breast pumps requires the removal of any fluid that has entered the pumping mechanism itself. If proper sterilization of the breast pump cannot be achieved, FDA recommends that it not be used by different mothers.

Legal and Liability Issues

These issues are serious enough that if a mother contacts Medela and tries to order a new set of bottles and tubing for a used Pump In Style, Medela will refuse to sell it to her. Medela does not want to be legally responsible if a baby should become seriously ill. On its Web site Medela says:

It is not advisable to use a previously owned breast pump. Breast pumps are single-user products, or personal care items, much like a toothbrush, and are registered with the FDA as single user items. For safety, breast pumps should never be shared, resold, or lent among mothers. Medela strongly discourages mothers from re-using or re-selling previously owned breast pump equipment....

What If a Borrowed Pump Breaks?

If in spite of the above health/hygiene/liability issues you decide to borrow a used pump, there are other issues to consider. Recently several mothers have come to us in the following unenviable situation: within weeks or months (in one case, days) of borrowing a pump, the used pump stopped working. It had reached the end of its natural life.

Because these mothers were good people, they felt they had to replace the pump so they could return it to the original owner as promised. This meant they ended up paying the full purchase price for a new pump but could not even keep it for their next baby. They had to return it to the original owner. As it turned out, it would have been much cheaper for them to rent or buy than to borrow.

When considering borrowing a used pump, also keep in mind that the best of these purchase pumps have a one-year warranty. And no matter how new the pump, its warranty is automatically voided if it is used by more than one person.

Also, even if the borrowed pump doesn’t fail while you have it, you have shortened the life of another mother’s pump. To calculate how much, subtract the length of time you have used it. How would you feel (and what would you do) if you returned the pump to its original owner in working order, but when she has her next baby, it breaks a week later? It’s important to be clear about these issues up front. What looks like a great deal could end up costing you more in the end than buying a new breast pump.

Nancy Mohrbacher, IBCLC (www.artofbreastfeeding.com)

From: LEAVEN, Vol. 40 No. 3, June-July 2004, pp. 54-55.

© Nancy Mohrbacher, 2004

2.       Exploring the World of Breast Pumps

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

b.       Efficiency

c.       Manual or electric

d.       Automatic or manual cycling

e.       Hygiene

f.         Intended use

g.       Availability and Support

h.       Cost

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

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.

3.       Can human milk be heated in the microwave?

"Do not heat milk in a stove or a microwave oven" states LLLI's BREASTFEEDING ANSWER BOOK, 7th Revised Edition, 2004 on page 122. Warming your stored milk in the microwave causes it to heat unevenly, creating "hot spots" that may burn your baby's mouth. Furthermore, valuable immunological components will be destroyed (p. 158).

Frozen or refrigerated human milk is best heated under cool then warm running water. If running water is not available, a pan of water can be heated on the stove. The container of milk can be placed in the warm water once it has been removed from the heat source. Milk can also be defrosted in the refrigerator overnight.

4.       Could my breast pump be covered by my insurance?

Coverage for breastfeeding-related expenses will vary widely among different healthcare insurance plans. In order for you and/or your lactation consultants to be reimbursed for the services and supplies provided, it is important that you understand the coverage and benefits of your health plan.

Your insurance company (or your employer’s benefits department) can provide you with a policy handbook detailing the benefits of your plan. If you have any questions regarding your coverage after reviewing the policy handbook, you should contact your health insurance plan’s member services department. Most insurance companies offer a toll-free customer service number that you can call with specific questions about your health plan. (This number is typically found on the back of your insurance card.) The insurance plan representative should be able to explain your insurance coverage for any of the products or services that you receive.

When calling your insurance company about your health insurance benefits and coverage, you may want to ask these questions:

·         Does my insurance plan cover this breast pump (indicate type: hospital rental, purchased electric, battery or manual)?

·         Does my insurance cover services provided by a lactation consultant?

·         Are there any restrictions?

·         Do I have to get the pump (or visits) approved first?

·         Are breast pumps covered only for certain medical reasons? If so, what are they?

·         Is my lactation consultant/doctor’s office in the network?

·         What will I need to pay?

·         Do I need to meet a deductible first?

(A deductible is the amount of money that you could have to pay before your insurance pays for or reimburses you for any medical care or prescriptions. Sometimes there are different deductibles for your family members, depending upon who is covered. An individual deductible would need to be paid before that person gets reimbursed or has their medical care paid for by the insurance company.

If the whole family is covered under one family member’s insurance, then a family deductible is the amount of money that the family would have to pay first before the health insurance company would pay or reimburse for medical care or supplies).

·         Is there a co-pay for the breast pump that I need or for the visits with the lactation consultant?

·         Is there a dollar limit on coverage for breast pumps? Is there a limit on the number of visits with a lactation consultant?

Sometimes the insurance company has set a limit on the amount of money that they will pay to cover your medical expenses. For example, you may have coverage for a breast pump, regardless of type, up to $100. Another example would be if your health plan covers only a specified number of visits to a lactation consultant.

This is called a benefit cap or benefit limitation or maximum benefit.

Benefit caps or limits can be for different time periods as well: annual or lifetime.

An annual benefit cap or limitation is for one year. It is important to ask your insurance company if you have an annual benefit cap and if so, what year do they use? Do they go by the calendar year (January to December) or do they use a fiscal year or plan year (for example, from when your policy became effective—i.e., August 1 to July 31).

A lifetime maximum benefit is the highest amount of money that your insurance will pay to cover you for healthcare expenses. For example, you may have a $1million lifetime maximum benefit. If your healthcare costs go over $1million, then you will not be reimbursed by that insurance plan for any portion of your medical expenses that exceed the $1 million limit.

If your plan covers the medical treatment you need, most plans will require that the treatment be considered “medically necessary” for the patient’s health condition.

Medically necessary is a term used by insurance companies to describe care that is appropriate and provided according to generally accepted standards of medical practice. In other words, the insurance company agrees that this medical treatment is needed for this condition. For example, if your doctor has indicated that your baby needs breast-milk (benefits of breast-milk, formula allergy) or if your baby has some other special need that requires you to pump your breast-milk, your insurance company would consider this as a “medically necessary” reason. Some health plans will reimburse for a breastpump (and related supplies and services) only if there is a “medical reason.”

One general medical reason is that the American Academy of Pediatrics, a highly respected medical organization, supports the medical benefits of breastfeeding. The AAP’s Work Group on Breastfeeding issued a position statement that asserts “human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions. When direct breastfeeding is not possible, expressed human milk, fortified when necessary for the premature infant, should be provided. Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth. It is recommended that breastfeeding continue for at least 12 months, and thereafter, for as long as mutually desired.”

Furthermore, the Surgeon General’s “Blue Print for Action” also recommends that infants be exclusively breastfed during the first four to six months of life, preferably for a full six months. Ideally, breastfeeding should continue through the first year of life.

Some other examples of the medical need for breastfeeding include:

·         Baby cannot suck well due to respiratory disease or other physical impairments

·         Baby is allergic to formula

·         Baby is chronically ill

·         Mother’s antibodies in breast-milk considered medically necessary

·         Multiple births

·         Premature birth

·         Physical separation of mother and baby

Many new mothers work outside the home. This presents a medical need for your baby as well. Antibodies in your breast-milk can be considered medically necessary to your baby. Because of your need to return to the workforce, you and your baby have a medical need for a breast pump. Your employer may support your need to breastfeed in several ways In fact, many employers support breastfeeding employees in the workplace by providing private areas or lactation rooms where pumping can occur during work breaks. Your employer can also help advocate with your insurance company.

If you are having difficulty with your insurance company in getting your breastfeeding-related supplies and services covered, you should tell your employer. Speak with one of your employee benefits representatives. Emphasize that being able to pump breast-milk will allow you to take less time off because your baby is healthier and/or you may have been able to return to work more quickly after the birth of your baby. Inform your employer of the need to expand health insurance benefits for breast pumps, supplies and services. If many breastfeeding families approach their employers, they have a much louder voice. Even one voice is better than saying nothing at all. In fact, employers may choose a different insurance company/plan if their employees express dissatisfaction with the current plan choices. Furthermore, insurance companies may not be aware of how important this benefit is to their customers. By raising their awareness, we all may have more thorough insurance coverage in the long run. You can make a difference.

Updated:  September 30, 2006