Breastfeeding and the Working Mother

Leana Habeck B Cur (Stell) RN, RM, RPN, CHN, Dip Peri Ed (UJ), IBCLC

International Board of Lactation Consultant Examiners (IBLCE) SA Office

Importance of bf:

We all know the importance of bf – diverse and compelling, immediate and long term,

physical, emotional and cognitive for babies and well as mothers, doing everything from

boosting baby’s immune system to raising their IQs, while simultaneously decreasing mom’s

risk of breast cancer, helping her relax and stay connected with her baby. Breastfeeding and

human-milk, it is simply not “just a food” but rather a complex, human infant support system.

Unfortunately returning to work is the number-one reason moms quit breastfeeding their

babies, though more and more working moms intend to continue breastfeeding), most give

up within 3 months. Stay-at-home moms breastfeed at significantly higher rates and for

longer duration, than moms who work outside the home. (See research on slide)

We as health care professionals are a major key to greater success of prolonged

breastfeeding in mothers who have to, or choose to, work outside the home. I will attempt to

provide you with background information and practical tips to help you come up with

individualised solutions to help protect the working bf mother’s milk supply and the bf

relationship she has with her baby.

(The word `counselling' is not new but it can be difficult to translate. Some languages use the

same word as `advising'. However, counselling is different from simple advising. When you

advise someone, you may tell the person what you think he or she should do. When you

counsel a mother, you do not tell her what to do. You help her to decide what is best for her,

she makes the decisions. You listen to her, and try to understand how she feels. You help her

to develop confidence, so that she remains in control of her situation.

Please keep in mind that when ever I talk about working mothers today I am referring to

those who have a paid job outside the house, (with the understanding that mothering

requires as much and more effort and skill as any paid job).

1. What does the policy say?

2. Support in the workplace ~ making Plans with your Employer

3. Other preparations in pregnancy

4. Get bf off to a good start, 10 steps, exclusive bf, etc.

5. Practical tips: Choosing and Buying a Pump, Hand Expression, Pumping Basics, Milk

Storage, reheat, Starting Bottles

6. Day care, how much milk does my baby need?

7. Routine back at work

8. Support after returning to work IBCLC, LLL

1.What does policy say? In a nutshell….these policies tells us as HCP that we have to ensure

that all mothers are supported to exclusively breastfeed their infants for six months and

thereafter up to two years of age and beyond….

International policy instruments addressing

the urgent need to protect, promote and

support optimal breastfeeding and infant and

young child feeding practices

How does South Africa compare?

SLIDE International Code of Marketing of

Breastmilk Substitutes adopted by the World

Health Assembly (WHA) in 1981.

The aim of this Code is to contribute to the

David Clark said at the National

Breastfeeding Consultative Meeting, (held 22

& 23 Aug 2011): “There is currently NO law in

place in SA to protect babies, parents and

provision of safe and adequate nutrition for

infants, by the protection and promotion of

breast-feeding, and by ensuring the proper

use of breast-milk substitutes, when these are

necessary, on the basis of adequate

information and through appropriate

marketing and distribution.

www.babymilkaction.org/regs/thecode.html

health workers against the aggressive

marketing of formula companies”. The code

is currently classified as a voluntary measure

and the work on a draft regulation started in 2000. The draft (FOODSTUFFS, COSMETICS

4ND DISINFECTANTS ACT, 1972 (ACT 54 OF

1972). REGULATIONS RELATING TO

FOODSTUFFS FOR INFANTS AND YOUNG CHILDREN) has been published in 2007 and

March 2012 in the Government Gazzette but

not yet finalized. Note regulation “14 (1) iv:

that working mothers can breastfeed

successfully, (2) b v (bb) cup feeding is

preferred rather than bottle feeding; (3) (c)

the superiority of exclusive breastfeeding for

6 months followed by sustained

breastfeeding with the introduction of

appropriate complementary foods for at

least two years and beyond”

SLIDE The Innocenti Declaration on The

Protection, Promotion and Support of

Breastfeeding produced and adopted by

the WHO/UNICEF in 1990.

The Declaration affirmed that improved

breastfeeding practices are a means to fulfil

a child's right to the highest attainable

standard of health and called on

governments to:

� establish national breastfeeding

coordinators and committees,

� ensure appropriate maternity services

(inspiring development of the Baby-friendly

Hospital Initiative),

� renew efforts to give effect to the

International Code of Marketing of Breastmilk

Substitutes, and

� enact imaginative legislation protecting

the breastfeeding rights of working women.

http://innocenti15.net/

The Innocenti Declaration (which was signed

by South Africa), states that "...all women

should be enabled to practise exclusive

breastfeeding and all infants should be fed

exclusively on breast-milk from birth to 6

months of age. Thereafter, children should

continue to be breastfed, while receiving

appropriate and adequate complementary

foods, for up to two years of age or beyond.

This child-feeding ideal is to be achieved by

creating an appropriate environment of

awareness and support so that women can

breastfeed in this manner... All

governments... should have... enacted

imaginative legislation protecting the

breastfeeding rights of working women and

established means for its enforcement."

SLIDE The Baby-Friendly Hospital Initiative

launched 1991.

The aim of the Baby-friendly Hospital Initiative

is to implement the Ten Steps to Successful

Breastfeeding and to end the distribution of

free and low-cost supplies of breast milk

substitutes to health facilities.

BABY-FRIENDLY HOSPITAL INITIATIVE Revised

Updated and Expanded for Integrated Care

SECTION 3 BREASTFEEDING PROMOTION AND

SUPPORT IN A BABY-FRIENDLY HOSPITAL A 20-

HOUR COURSE FOR MATERNITY STAFF.

http://www.unicef.org/nutrition/files/BFHI_200

9_s3.1and2.pdf

South Africa adopted the BFHI in 1993. Dr

Lesley Bamford said (Breastfeeding

Consultative Meeting): in 2008 41% facilities

was accredited Baby Friendly and 73% of

mothers initiated breastfeeding. At 10 week

follow-up almost half were not breastfeeding

anymore. Reasons given why they stopped:

not enough milk, baby did not want to,

advised to stop by family/health worker.

From DoH March 2012 Tshimi Lynn Moeng,

Director Nutrition: Annual targets for Mother

and Baby friendly Facility and training more

health workers on skills to support mothers

have been “increased”.

SLIDE The Global Strategy for Infant and

Young Child Feeding developed in 2002.

The aim of the Global Strategy is to improve –

Infant and young child feeding policy (2007)

6.3.1 Follow-up Support of breastfeeding

mothers who are HIV-negative or of an

through optimal feeding

– the nutritional status, growth and

development, health, and thus the survival of

infants and young children.

It supports exclusive breastfeeding for 6

months, followed by timely, adequate, safe

and appropriate complementary feeding,

while continuing breastfeeding for two years

and beyond.

It also supports maternal nutrition, and social

and community support.

BABY-FRIENDLY HOSPITAL INITIATIVE Revised

Updated and Expanded for Integrated Care

SECTION 3 BREASTFEEDING PROMOTION AND

SUPPORT IN A BABY-FRIENDLY HOSPITAL A 20-

HOUR COURSE FOR MATERNITY STAFF.

http://www.unicef.org/nutrition/files/BFHI_200

9_s3.1and2.pdf

unknown status Every effort should be made

to support mothers to exclusively breastfeed

up to six months and to continue

breastfeeding up to two years and beyond

in combination with appropriate, nutrient

dense and easily ingested complementary foods. 9. Health care personnel should

promote, protect and support exclusive

breastfeeding for six months and continued

breastfeeding up to two years of age or

beyond. + Policy and guidelines for the

implementation of PMTCT programme (Feb

2008)

4.2.1 HIV-negative women

At every antenatal visit HIV negative women

or women of unknown HIV status should be

counselled to exclusively breastfeed their

babies during the first 6 months of life and

continue breastfeeding for at least 2 years.

Millenium Development Goals (2002) The

Millennium Project was commissioned by the

United Nations Secretary-General in 2002 to

develop a concrete action plan for the world

to achieve the Millennium Development

Goals and to reverse the grinding poverty,

hunger and disease affecting billions of

people. In 2005, the independent advisory

body headed by Professor Jeffrey Sachs,

presented its final recommendations to the

Secretary-General in a synthesis volume

“Investing in Development: A Practical Plan

to Achieve the Millennium Development

Goals.”

www.unmillenniumproject.org/

“The promotion of breastfeeding” is part of

government’s poverty reduction strategy to

reduce childhood malnutrition and under-nutrition, to achieve MDG 1 by 2015

(ERADICATE EXTREME POVERTY AND

HUNGER).

SLIDE Maternity Protection Convention 2000 held in Geneva, by The International Labour

Organization (ILO) - adapted the following

Convention: Maternity leave for more than 18

weeks- 6 weeks compulsory after birth, daily

breaks or reduction in working hours for

breastfeeding mothers, facilities in workplace

for nursing mothers, payment of leave not less

than 2/3 rds of salary

The International Labour Organization was

founded in 1919 sets out basic principles and

rights at work.

www.ilo.org

SA has not fully adopted ILO

recommendations

The Basic Conditions of Employment Act of

1997, Section 25,

Female employees have a right to four

months maternity leave. This leave can start

four weeks before the expected date of

birth and the employee cannot be forced to

go back to work for six weeks after the birth

of the child unless their doctor or midwife

says it is safe. Maternity leave may be paid

or unpaid. If the employee has been

contributing to the Unemployment Fund, she

will be able to claim benefits during the

period that she is on maternity leave.

Published in the Government Gazette 13

November 1998,

In SA mother are protected by the BASIC

CONDITIONS OF EMPLOYMENT ACT, 1997,

CODE OF GOOD PRACTICE ON THE

PROTECTION OF EMPLOYEES DURING

PREGNANCY AND AFTER THE BIRTH OF A

CHILD

Which states: 5.13 Arrangements should be

made for employees who are breast-feeding

to have breaks of 30 minutes twice per day

for breast-feeding or expressing milk each

working day for the first six months of the

child's life.

From DoH March 2012 Tshimi Lynn Moeng,

Director Nutrition: DPSA (Department of

Public Service and Administration) have

drafted guidelines for establishment of

workplace creches

SLIDE THE TSHWANE DECLARATION OF SUPPORT FOR BREASTFEEDING IN SOUTH AFRICA

committed them and called on all stake-holders to support and strengthen efforts to

promote breastfeeding. They resolved (among other things) Legislation regarding maternity

among working mothers to be reviewed in order to protect and extend maternity leave, and

for measures to be implemented to ensure that all workers, including domestic and farm

workers benefit from maternity protection, including enabling work place; comprehensive

services are provided to ensure that all mothers are supported to exclusively breastfeed their

infants for six months and thereafter to give appropriate complimentary foods and continue

breastfeeding up to two years of age and beyond.

www.info.gov.za

2. Support in the workplace

For a mother, working and breastfeeding requires at a minimum; time to remove milk from

her breasts, a place to do this, and a way to do it.

A mother/baby-friendly workplace provides benefits to the mother, the baby and the

employer. Companies with an employee lactation support program experience less turnover

and lower losses of skilled workers after childbirth. Additionally, these companies are

rewarded with lower employee absenteeism, higher employee satisfaction, loyalty, morale,

and productivity. (Cohen R, Mrtek MB, Mrtek RG. Comparison of maternal absenteeism and

infant illness rates among breast-feeding and formulafeeding women in two corporations.

Am J Health Promot. 1995;10(2):148–153. Ortiz J, McGilligan K, Kelly P. Duration of breast milk

expression among working mothers enrolled in an employer-sponsored lactation program.

Pediatr Nurs. 2004;30(2):111–119)

Various models and guidelines exist for implementing support for lactation and direct

breastfeeding in the workplace. One example is the comprehensive resource kit, The Business

Case for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line

Benefits, which was developed by the Health Resources and Services Administration (HRSA).

Kit includes booklets for business and human resource managers, an employee’s guide to

breastfeeding and working, reproducible resources, and a CD-ROM Available at:

http://www.ask.hrsa.gov/detail_materials.cfm?ProdID=4135&ReferringID=4121.

And Investing in Workplace Breastfeeding Programs and Policies: An Employer's Toolkit

http://www.businessgrouphealth.org/benefitstopics/breastfeeding.cfm

SLIDE Basic service Advanced State of the art etc.

Can download it from the internet….

If a mother’s workplace has an Equal Employment Opportunity (EEO) Officer, or Human

Resources Department, or she is a member of a union, she could check their attitudes and

knowledge of breastfeeding policies. Most South African companies do not have a

Workplace lactation programs maybe this mom can help start one.

A Pregnant mother can talk with her employer and try to negotiate one of the following:

Bring the work to baby. Part-time employment is associated with higher rates AND longer

durations of breastfeeding. (Breastfeeding Mothers Returning to Work: Possibilities for

Information, Anticipatory Guidance and Support from US Health Care Professionals, Michelle

A. Angeletti, MSW, PhD, J Hum Lact May 2009 vol. 25 no. 2 226-232)

Bring baby to work. Breastfed babies are very portable. Wearing baby in a sling-type carrier

to keep baby close while mom assist customers, sort papers, work at the computer, or even

attend meetings. Eventually, when the "sling baby" becomes a toddler explorer, mom may

have to make other arrangements, but by then, baby will not be depending on mom for all

his nutritional needs.

On-site daycare - eliminates the need for pumping, as she can be called to come feed

baby whenever he is hungry. In 2008 a state-of-the art daycare centre, for the benefit of the

children of its staff members, opened in a Pinelands office of a long-term savings group –

(Old Mutual)

Nearby daycare providers. Mom might be able to go to baby and feed one or more times

during the day. She can also feed baby at the daycare center, before and after work. This

will cut down on the amount of pumping she needs to do while separated from baby.

Visits from your baby. Maybe it's possible for her baby to come and visit her while she is

working, during her lunch break or at other times during the day. Mothers who make this

option work for them often have dad or grandma as chief childcare provider--someone

who's willing to go an extra mile (literally) for baby's health and happiness.

A study published in PEDIATRICS looked at 4 strategies that mothers used to combine

breastfeeding and work:

(1) feed directly from the breast only;

(2) both pump and feed directly;

(3) pump only; and

(4) neither pump nor breastfeed during the work day, bf at night, formula during the day

CONCLUSIONS

Feeding baby from the breast during the work day is the most effective strategy for

combining breastfeeding and work (average length 32 weeks). Ways to enable direct

feeding include on-site child care, telecommuting, keeping the infant at work, allowing the

mother to leave work to go to the infant, and having the infant brought to the work site.

The strategy of neither directly feeding nor pumping during the work, day was associated

with the shortest breastfeeding duration after return to work, an average of 11.8 weeks shorter

than when directly feeding the infant. (Success of Strategies for Combining Employment and

Breastfeeding, Sara B. Fein, PhDa, Bidisha Mandal, PhDb, Brian E. Roe, PhD, PEDIATRICS Vol.

122, 2 October 1, 2008 pp. S56 -S62.)

DPSA (Department of Public Service and Administration) have drafted guidelines for

establishment of workplace crèches.

If having baby nearby is not possible, she will need to pump at work to protect her supply

and provide EBM for baby during there seperation.

- A “pumping room” can be created in any area that provides privacy. The area should

contain a comfortable chair and working electric outlets. A sink is helpful for cleaning

up after pumping. A refrigerator is helpful for storing expressed breast milk.

A health care professional can write a letter of support to the mother’s employer that

includes the benefits to the breastfeeding mother, her child, and the employer. (sien laaste

p)

Now that she has spoken to her employer, organizing more flexible working hours, space

and time to pump, lets look at

3. Other preparations in pregnancy

Keep in mind: Variations of Breastfeeding: does not have to be all or nothing and every drop

is precious!

Total Breastfeeding: Baby may be brought to her at work or she goes to baby.

Total Breast Milk Feeding: Breastfeeding and feeding pumped breast milk only.

Partial Breast Milk Feeding: Breastfeeding, feeding pumped breast milk and using some

formula.

Partial Breastfeeding: Breastfeed when at home, use an artificial breastmilk substitute during

work.

Reverse Cycle Feeding: Breastfeed more in the evening and at night so less feedings, (breast

milk or artificial breastmilk substitute) are needed during the day.

What more can a woman do during pregnancy to make her transition back to work easier?

Make a commitment to breastfeed. Once she makes a commitment to continuing to

breastfeed, with your support, she’ll find a way to do it.

Research also shows that mothers viewed breastfeeding as the key to continued

“connection” with baby in spite of seperation. (ASSISTING THE EMPLOYED BREASTFEEDING

MOTHER by Kathleen G Auerbach, Journal of Nurse-Midwifery Volume 35, Issue 1, pages 26–

34, January-February 1990).

It will help if a new mother can plan to take as much maternity leave as possible. Let me just

stress that maternity leave is NOT a vacation for some women it’s a period of huge

adaptation and hard work to take care of a new baby. She might consider taking an unpaid

leave to stay home longer with baby. (Sacrificing some income at this point in her life could

turn out to be the one of the best investments she will ever make.) Having the time to really

get attached to her baby and build her milk supply, will help her work hard at maintaining

that close relationship after returning to work. By the way in Sweden most mothers don’t own

pumps because they have 18md paid maternity leave. (GOLD12 talk by Kathy Abbott on

Stories & misconceptions from BFH in USA & Scandinavia).

(If there is a compelling reason why her baby must receive breastmilk, perhaps because of

prematurity or allergies, she may be able to prolong her leave time by getting a letter from

her doctor.)

A pregnant mother can educate herself and her partner (and other main support) about

breastfeeding basics to get breastfeeding of to a good start by attending antenatal classes,

reading good books.

Antenatal education should preferably include information about

the importance of breastfeeding,

importance of skin-to-skin contact immediately following birth,

importance of rooming-in,

how to recognise when babies are ready to breastfeed,

importance of feeding on demand,

how to assure enough milk

and the positioning & attachment of baby.

So by the time baby is born she will be comfortable about breastfeeding and be confident

about what she has to do. (ILCA evidence based guidelines for breastfeeding management

during the 1st 14 days (2005), World Health Organisation (1998) Evidence for the Ten Steps to

Successful Breastfeeding. Division of Child Health and Development, WHO.)

Birth plan: can help minimize intervention (and its effect on bf) during labour and delivery.

After birth: She can make sure she has a support network ready to support her in

breastfeeding, especially if she is not having her baby in a Baby Friendly accredited hospital.

She should consider the purchase of an electric breast pump (while she is still spending

money) and with the help of her pump and her baby she should take full advantage of her

maternity leave to establish a good supply of milk before going back to work. It is suggested

that establishing lactation before the return to employment is a key to enabling

breastfeeding to continue as long as the mother wishes. (ASSISTING THE EMPLOYED

BREASTFEEDING MOTHER by Kathleen G Auerbach, Journal of Nurse-Midwifery Volume 35,

Issue 1, pages 26–34, January-February 1990.)

Choose a work wardrobe with a breastfeeding baby in mind. Select prints and loose-fitting

blouses that camouflage leaking. Two-piece outfits gives her easier access for pumping and

for breastfeeding.

Get breastfeeding off to a good start

To start with, doing everything she can to make breastfeeding work well in the early weeks is

important to breastfeeding success after she returns to work. Successful breastfeeding = Lots

of milk + good latch from baby + confident mother + all in a basket of support.

Milk supply equation: GOOD MILK PRODUCTION (lots of milk) = Sufficient glandular tissue +

intact nerve pathways & ducts (anatomy) + adequate hormones & hormone receptors

(physiology) + adequate frequent, effective milk removal & stimulation (mom & babe role-

players: Mom= how long feed, how often feed, how bring babe to breast, effect of meds on

milk supply. Babe=ability to remove milk effectively)

Because of their extreme importance to milk supply and prophylaxis against breast problems,

correct attachment and positioning should be clearly recognisable to every health worker

and each one should be competent to teach mothers how to get their babies onto the

breast correctly and comfortably. (Whole talk on its own!) (WABA Activity Sheet 8, Training

Health Workers in Breastfeeding Management,

http://www.waba.org.my/resources/activitysheet/acsh8.htm)

Just a reminder that:

Poor latch result in

Pain – sometimes

Nipple damage – sometimes

Inefficient milk transfer – ALWAYS

→ ↓milk production → baby develop poor suck habits → early weaning

To meet a breastfeeding mother’s goals after retuning to work she needs to maintain her milk

production. But maintaining milk production is not always easy for employed mothers,

especially when they don’t know the basic dynamics affecting how much milk they make.

You might need to share some of these basic dynamics with a mother.

Some basic dynamics:

Clinical Lactation, 2011, Vol. 2-1, p15-18, Nancy Mohrbacher, IBCLC, RLC

Breastfeeding answers made simple: A guide for helping mothers (2010, Amarillo, TX: Hale

Publishing) Nancy Mohrbacher refers to the Magic Number.

These basic dynamics determines the number of times each day an individual mother needs

to remove milk from her breasts to maintain her milk production, is the degree of breast

fullness and breast storage capacity.

Degree of Breast Fullness

Mothers are sometimes told to wait until their breasts feel full before expressing or

breastfeeding. This advice reflects a basic misunderstanding of how milk production works.

Research has found that the fuller breasts become the slower milk production. More milk out

= more milk in. These are factories, not container.

(FIL: Milk contains a small whey protein called Feedback Inhibitor of Lactation (FIL) – the role

of FIL appears to be to slow milk synthesis when the breast is full. Thus milk production slows

when milk accumulates in the breast (and more FIL is present), and speeds up when the

breast is emptier (and less FIL is present). (J Mammary Gland Biol Neoplasia. 1996 Jul;1(3):307-

15. Feedback control of milk secretion from milk. Peaker M, Wilde CJ. Hannah Research

Institute, United Kingdom).

In one study, for example, after 6 hours without milk removal, one mother’s rate of milk

production per breast was 22 mL per hour (Daly, S. E., Kent, J. C., Owens, R. A., & Hartmann,

P. E. (1996). Frequency and degree of milk removal and the short-term control of human milk

synthesis. Experimental Physiology, 81(5), 861-875.). By breastfeeding from that breast every

90 minutes and removing milk from her breasts more completely, her rate of production per

breast increased quickly within the same day to 56 mL per hour. So you see, more milk out =

more milk in.

Breast Storage Capacity

A mother’s breast storage capacity refers to the maximum volume of milk available to her

baby when her breast is at its fullest. (Ramsay, D.T., Kent, J.C., Hartmann, R.A., Hartmann, P.E.

2005, 'Anatomy of the lactating human breast redefined with ultrasound imaging', Journal of

Anatomy, 206, pp. 525-534). Unrelated to breast size, breast storage capacity is determined

by the amount of room in her milk-making glandular tissue. Breast size is determined primarily

by the amount of fatty tissue (Geddes, D. T. (2007). Inside the lactating breast: The latest

anatomy research. Journal of Midwifery & Women’s Health, 52(6), 556-563.). The maximum

volume of milk in the breasts each day can vary greatly among mothers. Two studies found a

breast storage capacity range among its mothers from 74 to 606 g or ml. (Daly, S. E., Owens,

R. A., & Hartmann, P. E. (1993). The shortterm synthesis and infant-regulated removal of milk in

lactating women. Experimental Physiology, 78(2), 209-220. & Kent, J. C., Mitoulas, L. R.,

Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency

of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-

395.).

Breast storage capacity affects how long it takes for mother’s breast to become full. For

example, a woman with a small storage capacity may become so full with 75 mL of milk in

her breasts that her rate of milk production slows. However, in a woman with a larger breast

storage capacity this same 75 mL, would not cause milk production to slow. This larger-

capacity mother could, therefore, go for longer periods between feedings without her rate

of milk production slowing. Although breast storage capacity can affect feeding patterns, it

does not affect a mother’s overall ability to produce ample milk for her baby. All 3 my

children fed 2h day and night for 6 months and grew well on exclusive bm. (Kent, J. C.,

Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume

and frequency of breastfeedings and fat content of breast milk throughout the day.

Pediatrics, 117(3), e387-395.). Depending on her breast storage capacity, a mother’s Magic

Number (number of daily milk removals needed to keep milk production stable) may be as

few as 3-4 or as many as 10-12. But when a mother’s total number of milk removals

(breastfeedings plus milk expressions) dips below her Magic Number, her rate of milk

production slows.

To get an idea of an employed mother’s Magic Number (assuming she is exclusively

breastfeeding a thriving baby), ask her, how many times every 24 hours her baby

breastfeed? If her answer is 8 (which seems to be average), she can assume that to keep her

milk production steady long term she will need to continue removing milk from her breasts at

least 8 times each day. If she’s expressing milk 3 times during her work day, this means she

would need to breastfeed 5 times when she and her baby are together. A change in routine

can bring down the Magic Number, slowing milk production.

5.Practical tips: Choosing and Buying a Pump, Hand Expression, Pumping Basics, Milk

Storage, Starting Bottles

Choosing and Buying a Pump

(Breastfeeding and Human Lactation, Jan Riordan, Karen Wambach 2009). The breast pump

market offers a bewildering range of devices to choose from. Grouping them we can

choose from manual or hand pumps that generate suction manually (squeeze handle and

cylinder type), single or double electric / battery-operated pumps and hospital-grade

electric pumps. The "bicycle horn" style manual pump is NOT recommended.

Things to consider when buying a pump: How old is baby going to be when mom returns to

the “work force”? How much can she afford to spend on a pump? Other considerations,

portability, noise level, ease of use, ease of cleaning, ease of assembly, the number and

complexity of parts to assemble, automatic or manual suction - release cycle, instructions

accompanying the pump, comfort of the mother and efficiency.

Most current breastpumps are based on a study by Einar Egnell (et alia). These studies have

established that a total negative (vacuum) pressure of about 220 to 230 mmHg (millimeters

of mercury) is typically produced when a baby is breastfeeding and the maximum pressure is

usually held for less than one second.

Nipple damage is most likely to occur when the initial phase of creating suction lasts longer

than one to two seconds. Breast pumps with automatic cycling will usually do so at a rate of

40 to 60 cycles per minute. Breast pumps with small motors which can take from 10 to 50

seconds to reach maximum vacuum, and may cycle fewer than 10 times per minute–this

exposes nipple and areolar tissue to increased trauma from prolonged unrelieved suction.

Pumping is not supposed to hurt. Factors influencing comfort is how the pump works, looking

at amount of suction applied (measured using: mmHg millimeters of mercury), the length of

time that maximum suction is applied before it is released (ideally 1-2sec, and that

determines the cycles per minute), and how well the mother’s breast fits into the pump

flange and tunnel (tunnel size in mm.).

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. It is not always possible to determine the best

flange size without actually pumping.

The size of the nipple, not the breast size, determines flange size.

When she pumps, her nipple should move freely in the flange. If it rubs the side, she

needs a bigger flange. If her areola is pulled into the flange, she needs a smaller size.

She many need a larger sized flange if:

pumping is painful, even at very low suction.

She is having a difficult time removing milk with her breast pump.

She has pain or soreness on the nipple, particularly around the edges of the nipple.

the nipple is squished into the tube of the flange and is not able to move freely.

ongoing trouble with plugged ducts due to the ducts not emptying well.

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, important for employed mothers with time constraints.

A big step forward in the development of breast pumps, was 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). (J Hum Lact. 1996 Sep;12(3):193-9. The effect of sequential

and simultaneous breast pumping on milk volume and prolactin levels: a pilot study. Hill PD,

Aldag JC, Chatterton RT.) Double-pumping has also been shown to stimulate a greater

release of prolactin than single pumping. (J Hum Lact. 1996 Sep;12(3):193-9. The effect of

sequential and simultaneous breast pumping on milk volume and prolactin levels: a pilot

study. Hill PD, Aldag JC, Chatterton RT.)

Research done by Professor Hartmann's resulted in the development of a pumping pattern

called 2-Phase Expression, or the “Natural Expression Pumping”, an attempt to more closely

simulate what a baby does during a bf session. (Pediatrics 113 (2) 2004, "Ultrasound Imaging

of Milk Ejection in the Breast of Lactating Women" Donna T. Ramsay, Dip; Jacqueline C. Kent,

PhD; Robyn A. Owens, PhD; and Peter E. Hartmann, PhD. / Journal of Human Lactation 19 (2)

2003, "Response of Breasts to Different Stimulation Patterns of an Electric Breast Pump",

Jacqueline C. Kent, BSc, PhD; Donna T. Ramsay, DMU, PGDip; Dorota A. Doherty, PhD;

Michael Larsson, MBA; Peter E. Hartmann, BRurSci, PhD. / Journal of Human Lactation 18 (4)

2002, "Effect of Vacuum Profile on Breast Milk Expression Using an Electric Breast Pump", Leon

R. Mitoulas, PhD; ChingTat Lai, MSc; Lyle C. Gurrin, PhD; Michael Larsson, MBA; Peter E.

Hartmann, PhD).

Dr. Peter Hartmann’s showed that a breastfeeding baby has a characteristic sucking pattern

that begins with rapid, high frequency sucking and changes abruptly to a slower

suck/swallow pattern at the time of milk ejection. Hartmann’s research also demonstrated

that a breastpump using two-phase cycling, is more effective in breast milk removal than

single-cycling breastpumps. During the “Let-Down” mode, the pump mimics a breastfeeding

baby’s initial rapid nursing action that stimulates the milk ejection reflex (MER) or “let-down”

and quickly begins milk flow. Once milk begins to flow, moms switch to the

second mode, called “Expression,” which mimics the infant’s longer

feeding cycle in which slower, deeper suckling helps to maximize milk flow

in less time. (AC alternating current – electrically powered / DC direct

current – batt powered)

Please note that breast pumps are considered "single-user" products, because of the risk of

contamination (there is a chance that milk can be aspirated into the pump mechanism,

which cannot be sterilized), it should thus not be borrowed or shared. Manual pumps that

can be autoclaved are an exception. Keeping the pump at chest level help protect against

aspiration of milk into the pump mechanism. Closed/open pump system: closed system

breast pump has a barrier in between the milk collection kit and the pump mechanism, while

an open system does not have a barrier of any kind. This can cause many unwanted

problems, including contamination of precious breast milk. Since any open system does not

contain a barrier between the milk collection kit and the pump mechanism, the milk is

exposed to the outside air, which is drawn through the pump system. Allows impurities that

may be found in the air such as dust, smoke, pet dander, pollution, airborne bacteria, and

viruses to contaminate the breast milk. There is also a possibility that milk particles can be

sucked into the pump’s tubing, as well as parts of the pump that cannot be cleaned and

mold can begin to develop.

Webpage to check out for http://www.breastpumpcomparisons.com/breast-pump-

specs.html. Since breast pumps are personal hygiene products any of the pump parts that

are exposed to the previous user’s milk may harbor viruses that were present in the mother’s

system. Baby could become ill if these viruses are passed to him. Cytomegalovirus (CMV),

hepatitis, human immunodeficiency virus (HIV) and human T-cell leukemia virus type 1 (HTLV-

1) are some of the most common viruses that are transferred through breastmilk. The

potential health risks may be increased if the previous user experienced a fungal infection

(thrush), cracked nipples or bleeding nipples.

When pumping time is limited and larger milk volumes are needed, or if a mother needs to

pump to increase her milk supply, the hospital-grade rental pumps are the preferred option.

These full-size, automatic hospital grade electric piston pump, have a suck-release cycle that

is closer to the pattern of a baby than the continuous suction of some smaller pumps. Many

women report they are quite efficient and quiet, although not quite as portable. These are

usually rented (although the equipment that attaches the mother to the pump must be

purchased) and cost varies. Biagioli says in Returning to work while breastfeeding : Electric

piston pumps may be the most suitable type for mothers who work outside the home for

more than 20 hours per week; however, when a mother is highly motivated, any pump type

can be successful in any situation. (Am Fam Physician. 2003 Dec 1;68 (11):2201-8. Returning

to work while breastfeeding. Biagioli F.)

To summarize:

A breast pump should simulate, as realistically as possible, a baby feeding at the breast.

Remember research has shown that normal healthy newborns achieve up to 220 mm Hg of

suction while breastfeeding and have a suck-swallow cycle of about 40 - 60 times per

minute. A little faster when they first begin breastfeeding, and a little slower after the let-

down reflex occurs. The pump should meet these criteria. The flange (the part of the pump

that fits over the breast) should cover the areola to support the tissue and the opening

should fit loosely around the nipple and allow the nipple to stretch freely into the nipple

tunnel during the suction phase of the cycle. Most pumps have several sizes of flanges

available to accommodate different sizes of nipples.

Some ideas for Hands free pumping: For bras which do not have compatible clasps to fasten

the loop over, it is still possible to use this system. Wrap one loop over around the bra strap

and pull through the other loop. Permission to use:

http://kellymom.com/bf/pumpingmoms/pumping/hands-free-pumping.

Hand Expression

When researchers looked at methods of milk expression for lactating women, (Methods of

milk expression for lactating women Genevieve E Becker, Felicia M McCormick, Mary J

Renfrew, Editorial Group: Cochrane Pregnancy and Childbirth Group, Published Online: 8

OCT 2008) mothers appear to obtain greater total volumes of milk in six days after birth using

the electric powered pump tested compared to hand expression, and a greater volume at

one expression during the second week when provided with a relaxation tape. Simultaneous

pumping took less time compared to sequential pumping.

(Compared with hand expression, one study found a significantly greater total volume of milk

expressed over six days both with the electrical pump (373.10 ml, 95% confidence interval).

Mothers provided with a relaxation tape produced a greater volume of milk at one

expression than women not provided with the tape (34.70 ml, 95% CI). Simultaneous pumping

took less time than sequential pumping in one study (3.50 hours/week, 95%). No evidence of

difference was found in volume with simultaneous or sequential pumping, or for milk

contamination, breastfeeding at discharge, fat content of milk, serum prolactin by method

of pumping.)

It is however possible to hand express very effectively.

Stanford University in California has a great website which includes an excellent video clip of

explaining and demonstrating how to hand

express. http://newborns.stanford.edu/Breastfeeding/HandExpression.html

Donna Ramsey Geddes's Ultrasound studies have profoundly changed our understanding of

breast anatomy. The breast has a number of milk-producing glands in grape-like clusters, all

connected to ducts that exit the breast at the nipple. There are no visible "sinuses" in the

lactating breast. Instead, the entire duct opens during the milk -ejection reflex, which lasts

about 1-2 minutes. The “trick” of milk expression is focusing on triggering a milk let-down

reflex, then expressing a substantial amount during the moments of peak flow. (Pediatrics.

2004 Feb;113(2):361-7. Ultrasound imaging of milk ejection in the breast of lactating women.

Ramsay DT, Kent JC, Owens RA, Hartmann PE.)

The basic technique for hand expressing is to: loosen the milk from the little alveoli, stoke that

milk towards the nipple, get milk to let down and then hold the breast with the thumb and

fingers about 3cm behind the areola. Imagine the breast as a clock, place thumb and

fingers at the numbers 12 and 6. Then gently press back towards the chest wall, and then

together. And repeat! After a few minutes she can rotate her hands to place her thumb and

fingers in the 9 and 3 o’clock positions. At some stage she might squeezes gently to the front

like squeezing out toothpaste. Breast compressions can help as well.

Pumping Basics (we have covered most of this by now!)

It is recommended that a mother begin expressing breast milk after the baby is about 4

weeks old, since by then, a mother's milk production is usually well established. It is also best

to delay a return to work until at least that time, and longer if possible. (Am Fam Physician.

2003 Dec 1;68(11):2201-8. Returning to work while breastfeeding. Biagioli F.) Prior to this time,

the mother and her baby should be developing their breastfeeding relationship.

Freezer Supply

Providing your baby with fresh breastmilk should be your ultimate goal. Fresh breastmilk

maintains nutrients at optimal level. Cooling milk will reduce those and freezing will further

reduce them. Regardless of the manner in which your breastmilk will be stored, it is definitely

a far superior choice over formula. I consider a freezer stash to be a matter of “insurance”

and a bit of a stress reducer for mom in knowing that there is an “extra” stash in case it is

needed. If your caregiver is not in your own home, consider leaving a small stash in their

freezer for emergencies. The last thing that a mom needs to be worried about at work is

whether the EBM (expressed breastmilk) she left is going to be enough. Alleviate this concern

with a small freezer stash. Once you’ve returned to work, a good way to create a freezer

stash is to pump on your days off during baby’s naps.

Expressing: an Australian study of 28 breastfeeding mothers with established and ample milk

production found 11% were unable to express much milk using any of the 7 pump cycling

patters tested. (Kent JC, Ramsay DT, Doherty D, Larsson M, Hartmann PE. Response of breasts

to different stimulation patterns of an electric breast pump. J. Hum. Lact. 2002;19(2):179–187).

For many women, milk expressing is a learned skill that takes time and practice to master (Is

not the same relationship that with a baby). Even when the most effective types of pump

(the rental pump) is used, factors unrelated to milk production (such as fit and

responsiveness) can affect the volume a mother is able to pump.

When she first starts pumping, she might get very little milk. This is normal. After all, she has just

spent the first weeks of baby's life getting her milk supply into an exact balance with baby's

needs. There's not supposed to be any extra. She might need some time to get the hang of

pumping, worried about whether she will be able to pump enough. Reassure her that that's

why she is practicing. Time pumping at home teaches her how to set up her pump, how to

set it so that she gets the most milk in the least time, and most importantly, how to relax when

pumping, so the milk will let down.

How often to pump: Once back to work, the common guideline is pumping for each missed

feeding. In general this works out to about three times in a standard eight hour work day. But

she will have to adjust it according to her baby's needs, her schedule and her Magic

number.

Mom can pump on one side during that first morning breastfeed while the baby feeds on the

other. This takes advantage of the baby establishing MER for her and is a good way to get

maximum mls in a brief period of time

If baby feeds every two hours, she may need to spread out her pumping sessions a little

more, but make them a bit longer than baby typically feeds. If she doesn't have time for

enough pumping sessions during the day, she can pump when she gets up, before work,

after baby goes to bed, or during the night - it can be done!

How long to pump: It is recommended that a mother who is working full time express 2-3

times for approximately 15-30 minutes per session, but because 76% of the total milk

expressed occurs during the first 2 milk ejections (during a typical bf milk lets down between

0-9 times), if the mothers in under time restrictions, expression for a little as 8 minutes may be

sufficient. (Breastfeeding Mothers Returning to Work: Possibilities for Information, Anticipatory

Guidance and Support from US Health Care Professionals, Michelle A. Angeletti, MSW, PhD, J

Hum Lact May 2009 vol. 25 no. 2226-232).

Some babies begin sleeping more while they are away from mom and breastfeeds more

when they are together (usually at night). Gale Pryor, author of Nursing Mother, Working

Mother, calls this "reverse cycle breastfeeding". If baby adopts this pattern, mom might be

able to eventually pump less when she is away from baby. Keeping baby close at night

allows baby unrestricted access to the breasts while mom gets as much sleep as possible.

When babies and moms sleep near each other, their sleep cycles start to synchronize. That

means that when mom is in a deep sleep, so is baby, and when mom is in lighter sleep, her

baby will be more likely to wake up. Mom wakes up easier and fall back to sleep faster. If

baby is right near her, she will wake up at the first little noises, instead of waking because

baby is crying.

Pumping: Most mothers that struggle to pump milk are under the impression that stronger

suction means they will get out more milk. BUT the pump does not get the milk out of the

breasts by brute force. These are factories NOT containers. You have to knock at the door;

ask milk to come out…etc. Stronger suction might result in excruciating pain, or that

damaging the breasts. Again an important factor in being able to express breastmilk, is

the let-down reflex or MER. This causes the milk to be released from the little alveoli. When

baby sucks at the breast, nerves send a message to the brain, which causes the hormone

oxytocin to be release, coming back to the breast in the bloodstream and contracting the

muscle cells around the alveoli squeezing out the milk.

Relaxation skills It is possible to start this MER without a baby sucking, because the brain is

wired in such a way that the nerve pathways for milk ejection run through the emotion-

processing area of the brain, it is thus also possible that the MER can be slowed by things like

pain, tension or stress, (The Breastfeeding Mother’s Guide to Making More Milk by Diana

West, Lisa Marasco, 2009).

SLIDE When expressing, a mother can help the let-down reflex work by: relaxing (her shoulder

and chest muscles) and taking deep breaths; involving as many of her sense as possible:

listening to music; thinking about baby, a photo sometimes helps; or some record baby’s

gurgles & play it during there pump-break. Some mothers respond very strongly to the smell

of her baby, and bring the clothes to work, that baby wore the previous day. Placing a warm

(not too hot) face washer over the breast; massaging breast with smooth strokes from the

chest towards the nipple and drawing her nipple out gently between her fingers (like

foreplay on herself); sitting in a comfortable position will all help.

Warning: sometimes the best way to stop a let-down in its tracks is to watch the bottles. The

stress of watching the millilitres is enough to severely limit anyone’s ability to pump. Look at

something else – anything! She can chant to herself “any breastmilk at all is a precious gift to

my baby” and visualize waterfalls, baby’s contented face after a feeding – whatever relaxes

her.

As mentioned in research done, what the pump needs to do to get the most milk out is

imitate baby. Mom can pay attention to baby’s sucks and the strength of that suckling at

the beginning of a feed and a few moments later (when the milk has let down). She should

then try to adjust her pump to match her baby. From there, she can experiment to see if

slightly more, less, faster or slower suction feels better and produces more milk. What’s the

best setting? The one that works for her, so she should rather not pay attention to how other

people’s pumps are set. It’s a personal thing.

During a growth spurt, baby drinks more expressed milk than usual, making it harder for mom

to provide enough expressed milk. Growth spurts are temporary – mom can try adding a

feeding session or two at home until the growth spurt is over. Menstruation or ovulation could

result in a temporary drop in milk supply. She should remember that the amount of milk that

she pumps is not a measure of her milk supply and it is normal for pumping output to vary

from session to session and day to day. Having an occasional low volume day is not unusual.

Many times a decrease in pumping output is because pump parts need to be replaced. Has

she checked her pump and replaced any parts that are worn or that haven’t been

replaced in the last 3-6 months? If mom feels her supply needs boosting, is will help if she can

take a few “sick days” to stay home and do plenty of breastfeeding.

Relaxing while Pumping

To some people, relaxing while pumping is like asking them to relax during a root canal, but it

can be done. Relaxing is important, because it’s really hard to have a let-down if she is

tense. Some tips for relaxation: if adrenaline is up, oxytocin can’t do it work. (Tracy Donegan,

The Better Birth Book: Taking the Mystery (And Fear) Out of Childbirth, March 2006, Liffey

Press).

Breast Compressions

Doing breast compressions while pumping can help stimulate additional let-downs, and

helps to thoroughly drain all of the milk ducts, it also increases the amount of milk & fat

content expressed (J Perinatol. 2009 Nov;29(11):757-64. Epub 2009 Jul 2. Combining hand

techniques with electric pumping increases milk production in mothers of preterm infants.

Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD) and studies have found that

mothers combining manual techniques with pumping, expresses higher levels of fat-rich,

calorie-dense milk (Journal of Perinatology , (5 January 2012) | doi:10.1038/jp.2011.195

Combining hand techniques with electric pumping increases the caloric content of milk in

mothers of preterm infants J Morton, R J Wong, J Y Hall, W W Pang, C T Lai, J Lui, P E

Hartmann and W D Rhine.).

While she is pumping, she uses one hand to massage her breast from the armpits towards the

nipple (or as close as she can get without dislodging the pump flange). She can gradually

increase the pressure, and finish with a few firm squeezes of her breast, like when she’s hand

expressing.

The mother then removes the pump once the milk stops flowing and massages each breast

from the armpit to the nipple, then again from the centre of her chest towards each nipple.

Stroking each breast gently towards the nipple a few times. She then bends over and cup

her breasts in her hands. Giving each a good shake (a relaxing shake, not a painful shake).

And then put the pump back on – she should see more milk begin to flow.

(Effect of Warm Breastshields on Breast Milk Pumping, Jacqueline C. Kent, DipEd, PhD, Donna

T. Geddes, Postgrap Dip(Sci), DMU, PhD, Anna R. Hepworth, BSc(Hons), DipEd, Peter E.

Hartmann, PhD). This study looked at the effect of using a warm breastshield on the

efficiency, effectiveness, and comfort of expressing milk with an electric breast pump was

assessed. The authors tested a standard breastshield at 25°C and a breastshield warmed to

39°C on 25 mothers using their maximum comfortable vacuum or −125 mm Hg. Using a warm

breastshield effectively warmed the nipple and areola and, combined with maximum

comfortable vacuum, decreased the time to remove 80% of the total milk yield and

increased the percentage of available milk removed after 5 minutes of expression, with no

change in the percentage of available milk removed after 15 minutes of expression

compared with an ambient-temperature breastshield. The data confirmed that use of the

mother’s maximum comfortable vacuum was more efficient than a vacuum of −125 mm Hg.

Using a warm breastshield with an electric breast pump was comfortable and showed it

improved the efficiency of milk removal.

(Importance of vacuum for breastmilk expression. Kent JC, et al. Breastfeed Med. 2008

Mar;3(1):11-9). This study tried to determine the effect of the strength of applied vacuum on

the flow rate and yield of breastmilk using an electric breast pump.

Twenty-one breastfeeding mothers and two expressing mothers expressed their breastmilk for

15 minutes using an electric breast pump set at their own maximum comfortable vacuum,

and at one to three softer vacuums. Milk yield and flow rate were measured. RESULTS: At the

maximum comfortable vacuum (-190.7 +/- 8.8 mm Hg) 4.3 +/- 0.4 milk ejections occurred

during 15 minutes of expression and yielded 118.5 +/- 11.4 mL of milk (65.5 +/- 4.1% of the

available milk). Milk flow rate was greater during the first milk ejection than the third or

subsequent milk ejections (p < 0.001). Cream content of the milk was highest after expressing

for 15 minutes using the mother’s maximum comfortable vacuum. CONCLUSIONS: Use of the

mother’s maximum comfortable vacuum enhances milk flow rate and increased volume of

milk expressed. The cream content of the milk at the end of the expression period was an

indicator of how effectively the breast had been drained. So mom should pump at a level

that is comfortable for her not a high setting.

T

To summarize: If a mother is using a hand pump, it’s a bit more work than using an electric

pump, but the plan is still the same (although the timing varies slightly – 10 to 20 minutes). It is

not necessary to sit and pump until the last little drop is forced out. We need to simulate a

typical feed and approximately 10 to 15 minutes (electric) should be sufficient.

- Wash hands before using the pump.

- A mother should clean and assemble a breast pump using the maker’s written

instructions that comes with the pump.

- Before starting to pump she should try to stimulate her let-down by using some of the

ideas mentioned.

- When putting on the breast cup or flanges, she needs to make sure the nipple is in the

centre and that the cup has good skin contact all around to stop air leaking in. If her

nipple hurts when she start expressing with the pump, she need to stop and check to

make sure the nipple is centred in the breast cup

- Start the suction on the lowest suction setting. Remember the baby’s suck starts off

slow and low, not fast and high

- After a minute she can move the suction to a higher, comfortable setting.

- If she is not double pumping she can consider switch pumping, 5min, 5 min, 5 min, 5

min, starting on the min setting every time she switches.

- Some mothers find it useful to change breasts several times during the session. In the

first few days she might only express small amounts of first milk, but she will be able to

express more milk as her body gets used to expressing.

- It can be helpful to finish off each session with a few minutes of hand expressing. This

will help to empty her breasts and help increase her milk supply.

Cleaning information

Mothers should generally follow the cleaning instructions provided with the pump.

If she is expressing several times a day and if her baby is healthy, breast pump parts (which

comes in contact with the milk) could be: cleaned well once a day when in frequent use, or

if used only occasionally, after each use.

How to clean well (this might be at the end of a working day)

1. First wash hands well, with soap, and dry them on new paper towel or a clean, unused

cloth towel.

2. Take the breast pump kit apart, and separate all pieces. Rinse in cold water all the parts

that have been in contact with milk.

3. Take care to remove all traces of grease, milk and dirt with a small amount of

dishwashing liquid and hot water. Use a brush kept only for this purpose. Harsh

chemicals and abrasive scrubbing shojuld not be used so that small scratches are not

created that could harbor bacteria or mold.

4. Rinse all parts in hot water, at least twice.

5. Drain pump parts upside-down on new paper towel and cover with more paper towel

while they air dry. Finish drying all containers with new paper towel before putting away.

Store the dry kit in a new plastic bag, plastic wrap, more paper towel or clean, covered

container until next use.

Milk Storage

What is the freezer stash for, anyway? Here are some examples:

She spills a whole bottle down her best suit while pumping at work, baby’s day care has just

heated and started a bottle as mom arrives, and that whole bottle has to be tossed so baby

can rather breastfeed, mom missed pumping one day, she will pump enough the next day,

and but she will just have to add a little bit to cover. BUT she will have to pump extra the next

day so this doesn’t get to be a habit.

http://www.llli.org/docs/0000000000000001WAB/laleche_ch_20_tear-sheet_toolkit.pdf

Safe Handling and Storage of breast milk

HUMAN MILK STORAGE – QUICK REFERENCE CARD

Temperature Storage

Time

Freshly expressed milk Containers covered and kept as cool as possible

Warm room 25°C 4-6 hours

Room temperature 19-22°C 10 hours

Insulated cooler bag / icepacks Keep ice packs in contact with

milk containers at all times, limit opening cooler bag. 15°C 24 hours

Refrigerated Milk (Store at back, where temperature is most constant. Away from door)

Refrigerator (fresh milk) 0-4°C 8 days

Refrigerator (thawed milk) do not refreeze 0-4°C 24 hours

Frozen Milk (Do not refreeze! Store at back, away from door/sides)

Freezer compartment Varies (± - 2 weeks

inside refrigerator (older-style) 15°C)

Self-contained freezer unit

of a refrigerator/freezer

Varies (± -

18°C)

3-6

months

Separate deep freeze -19°C 6-12

months

These guidelines are for milk expressed for a full-term healthy baby.

If baby is seriously ill and/or hospitalized, discuss storage guidelines with baby’s doctor.

Academy of Breastfeeding Medicine Protocol #8: Human milk storage information for home

use for healthy full-term infants

STORAGE CONTAINERS

Several studies have been done to evaluate storage containers.

Advances in Nutritional Research, Volume 10, Immunological properties of milk, Bill

Woodward, New York: Kluwer Academic/Plenum Press, 2001)

1. Hard-sided containers, such as hard plastic or glass, are the preferred containers for long-

term human milk storage. These containers should have an airtight seal and not made with

the controversial chemical bisphenol A (BPA)

2. Plastic bags specifically designed for human milk storage can be used for short-term (less

than 72 hours) milk storage.

Use of plastic bags is not recommended for long-term storage as they may spill, leak, or

become contaminated more easily than hard-sided containers, and some important milk

components may adhere to the soft plastic and be lost.

GENERAL GUIDELINES

At work, most women express their milk on Monday for Tuesday’s feedings, on Tuesday for

Wednesday’s, and so on, refrigerating it or keeping it in a cooler with “blue ice” containers at

work until they take it to the sitter’s.

Friday’s milk is saved for the next Monday, and over the weekend they don’t pump at all.

Chill the newly expressed milk for at least 1 hour in the main body of the refrigerator or in a

cooler with ice or ice packs, and then add it to previously chilled milk expressed on the same

day.

Do not add warm breast milk to frozen milk because it will partially defrost the frozen milk.

Do not fill the container; leave some room at the top because breast milk expands as it

freezes.

Milk containers needs to be labelled, with waterproof labels and ink

Indicate the date that the milk was expressed and the child’s name (for daycare).

The color of milk may vary from day to day, depending on maternal diet. It may look bluish,

yellowish, or brownish. Frozen breast milk may also smell different than fresh breastmilk. There

is no reason not to use the milk if the baby accepts it. Breastmilk is not spoiled unless it smells

really bad or tastes sour.

Thawing or warming milk

The oldest milk should be used first.

Thaw breastmilk by placing it in the refrigerator the night before (this takes about 12 hours) or

for quicker defrosting, container can be held under running water from the tap – start cool

and gradually increase temperature or just reheat in a bowl of warm water.

Milk may be kept in the refrigerator for 24 hours after it is thawed. Do not refreeze. Once

frozen milk is brought to room temperature, its ability to inhibit bacterial growth is lessened,

especially by 24 hours after thawing.

The duration of time the milk can be kept at room temperature once the baby has partially

fed from the cup or bottle would theoretically depend on the initial bacterial load in the milk,

how long the milk has been thawed, and the ambient temperature. Based on related

evidence thus far, it seems reasonable to discard the remaining milk within 1 to 2 hours after

the baby is finished feeding. Brusseau R. Bacterial Analysis of Refrigerated Human Milk

Following Infant Feeding. May 1998. “This study examined bacterial levels in expressed,

partially consumed breastmilk that was stored for 48 hours at 4-6° C. A portion of

unconsumed milk was examined as a control. Samples were taken every 12 hours for

bacterial analysis. Tests were performed to identify total colony counts, pathogenic

Staphylococci, coliforms and b-hemolytic Streptococci. This study showed no significant

difference between bottles that were partially consumed and those that were not exposed

to the baby’s mouth for 5 out of 6 participants. All milk samples had colony counts in the

acceptable range of < 105 colony forming units per 18avourite18 (CFU/ml). Although this

project provides evidence that it may be safe to 18avour a child a bottle of breastmilk, due

to the small sample size, further tests should be performed.” One of the best tests of whether

the milk is spoiled is to do what you do with cow’s milk: Smell it and taste it.

Never use a microwave oven or stovetop to heat human milk. Studies done on defrosting

human milk in a microwave demonstrate that controlling the temperature in a microwave is

difficult, causing the milk to heat unevenly. Although microwaving milk decreases bacteria in

the milk much like pasteurization does, microwaving also significantly decreases the anti-

infective quality (living immune cells that fight disease) of human milk, which may reduce its

overall health properties for the infant (The Effect of Microwave Heating on Vitamins B1 and

E, and Linoleic and Linolenic Acids, and Immunoglobulins in Human Milk, International Journal

of Food Sciences and Nutrition, 1996, Vol. 47, No. 5 , Pages 427-436, L. Ovesen, J. Jakobsen, T.

Leth and J. Reinholdt). Microwaving any beverage can also create hot spots that can burn

your baby’s mouth.

Expect that the milk will separate during storage. The cream will rise to the top of the milk and

look thicker and whiter. Before feeding, gently swirling the container of milk, milk in a gentle

“tornado-like” fashion, will mix the cream back through again. Avoid vigorously shaking the

milk.

As with all foods, do not re-freeze breast milk once it is thawed or partially thawed??

Starting Bottles GLOBAL STRATEGY FOR INFANT AND YOUNG CHILD FEEDING states: “The vast majority of

mothers can and should breastfeed, just as the vast majority of infants can and should be

breastfed. Only under exceptional circumstances can a mother’s milk be considered

unsuitable for her infant. For those few health situations where infants cannot, or should not,

be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own

mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk

substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends

on individual circumstances.”

So unless a mother is able to find a care giver willing to cup-feed her baby while she is at

work, in her absence, her baby will probably be fed by bottle.

Kearney, M. H. and Cronenwett, L. (1991) “Breastfeeding and employment”, Journal of

Obstetric- Gynecologic and Neonatal Nursing, Vol. 20, No. 6, pp.471-480. Had found that

most babies will take the bottle easily whether started at 1, 2 or 3-6months.

Feeding breastmilk from a bottle is not the same as breastfeeding. For one the close physical

contact with baby helps moms body create antibodies to germs in baby’s environment.

When she breastfeeds baby directly, her body responds to cues from baby’s saliva and other

secretions. After exposure to new pathogens, her body can make targeted antibodies

available to her baby within the next several hours. While a bottle of milk from a previous

date will provide baby with beneficial anti-infective factors, it will not contain antibodies to

germs he was exposed to today. (Chirico, G. et al (2008) Antiinfective Properties of Human

Milk Journal of Nutrition 138, 1801S–1806).

Breastfeeding also directly supports the normal development of a baby’s jaw, teeth, face,

and speech. The activity of breastfeeding helps exercise the facial muscles and promotes

the development of a strong jaw and symmetric facial structure. Several studies have shown

breastfeeding to enhance speech development and speech clarity. An increased duration

of breastfeeding is associated with a decreased risk of the later need for braces or other

orthodontic treatment. One study showed that the rate of misaligned teeth (malocclusion)

requiring orthodontia could be cut in half if infants were breastfed for one year. (Palmer, B.

(2008) The Influence of Breastfeeding on the Development of the Oral Cavity: A

Commentary Journal of Human Lactation, 14(2), 93-98).

Infants who are bottle-fed in early infancy are more likely to empty the bottle or cup in late

infancy than those who are fed directly at the breast. (Do Infants Fed From Bottles Lack Self-

regulation of Milk Intake Compared With Directly Breastfed Infants? Ruowei Li, Sara B. Fein

and Laurence M. Grummer-Strawn, Pediatrics 2010). Infants fed at the breast learn and

develop better control of their milk intake, whereas bottle-feeding may decrease infants’

abilities to selfregulate milk intake.

Regardless of bottle contents, infants who often emptied their bottles in early infancy also

had increased odds of having excess weight in late infancy, relative to those who rarely

emptied their bottles. (Association of Breastfeeding Intensity and Bottle-Emptying Behaviors

at Early Infancy With Infants' Risk for Excess Weight at Late Infancy, Ruowei Li, Sara B. Fein and

Laurence M. Grummer-Strawn, Pediatrics 2008).

Differences between Breast and Bottle

In order to understand the difference between the way a baby uses a bottle nipple and a

human nipple, one lactation consultant suggests this vivid demonstration:

Put your index finger in your mouth, closing your lips on the first knuckle. Begin sucking. Feel

how your tongue flattens your fingertip up to the roof of your mouth. Now feel how your lips

close around your finger very tightly. Feel the strength of your jaw and how your teeth make

contact with your finger. This simulates the way a baby sucks from most artificial nipples. It is

also the same way a baby sucks when he is latched shallowly on the breast.

Now, put your finger in your mouth to the second knuckle. Notice that the tip of your finger

almost touches the back of your soft palate. Begin sucking and feel the motion of your

tongue, which is now elongated, curved around your finger, and massaging it. Feel they way

your lips are slightly open and completely relaxed. Feel the way your jaw is more open and

relaxed. Feel the way your teeth on your finger are now barely or not at all touching. This

sucking technique approximates the use longer nipples with a round end. It also

approximates the way a baby sucks when he is latched deeply and correctly on the breast.

When a baby is feeding at the breast, he has complete control and is able to stop and start

when he wishes. Breastfeeding relaxes him thoroughly, which is evidenced by his gradually

relaxing hands and body posture. His oxygen levels are stable and high because he can

breathe more deeply and regularly. He extends his tongue and cups it around the nipple

and areola. His lips are open, wide, and relaxed. Fed by bottle, most babies are cuddled in

an almost lying-down position, which greatly accelerates the rate of flow from the bottle. The

milk or formula gushes out quickly and the baby must swallow rapidly in order to avoid

choking. He has very little control and his oxygen levels are low. These babies have a very

tense body posture during bottle-feedings for this reason. In order to exert control of the flow,

they quickly learn to retract their tongues and press it up against the tip of the bottle nipple.

Their lips will be tight and pursed around the bottle and they do use a jaw motion to move

the milk. Because they are swallowing without any effort, their facial muscles cannot develop

in the same way as breastfed babies will.

In my experience, mothers who are exclusively breastfeeding prior to returning to work can

find bottle feeding their baby in the days before returning to work very emotionally stressful.

A lot of mothers are told “Give your baby a bottle by two weeks of age, so he’ll get used to

it. Otherwise, he may never take it.” But it is best to avoid bottles, as mentioned until

breastfeeding and mom’s milk production is well established. Offering a bottle at the time

baby is learning the fine art of latch-on and mom is building up her milk supply, runs the risk of

interfering with both of these processes.

Some babies switch back and forth from breast to bottle without difficulty, others quickly

learn that it’s easier to get milk from a bottle and have difficulty returning to the breast. Of

course, we don’t know if mom has this kind of baby until after the bottle is introduced and

baby is unwilling to take the breast. It’s wiser not to take the risk, especially if baby has had

difficulty learning to take the breast so rather give him some time to consolidate what he’s

learned about breastfeeding before presenting him with a new challenge.

If the bottle is introduced too soon, some babies develop nipple confusion; others may not.

Nipple confusion happens when a baby given artificial nipples or pacifiers forgets how to

breastfeed. He starts to root for the breast but either can’t latch or doesn’t move his tongue

correctly when he does latch. Flow preference is when baby arch, cry, scream or actively

push away or simply turn away in disinterest after exposure to bottle. Once baby has

become accustomed to the instant gratification of a bottle that flows immediately and

never stops until its empty, it can be harder for the breast to compete. The most important

factor in minimizing flow preference is slowing the flow rate of the bottle. Nipple preference

can happen when there is a significant mismatch between mom’s nipple shape and the

shape of the artificial nipple. E.g. when mom has very small nipple that protrude only slightly

and the artificial nipple is large and long. (The Breastfeeding Mother’s Guide to Making More

Milk by Diana West, Lisa Marasco, 2009).

Select a Nipple

Nipple selection begins with three considerations: flow, shape, and texture.

The rate of flow will influence baby’s coordination while bottle-feeding. Most breastfed

babies begin with a “size 1” or “slow-flow” nipple.

The shape of the bottle nipple determines mouth placement. When baby breastfeeds, the

nipple reaches toward the back of the baby’s mouth, and baby’s mouth accepts the nipple

and areola. When baby bottle-feeds, the nipple length needs to approximate a similar

placement, reaching toward the back of baby’s mouth. Baby’s lips should be open,

accepting a portion of the nipple base. When looking at a bottle nipple, consider how the

length transitions to the base. A gradual transition between the nipple length and base

typically provides better mouth placement.

In selecting a nipple, mom can also consider. How does a mother’s breasts feel? Baby

might be more successful on a bottle nipple that has a similar texture to mom’s breasts. Many

bottle nipple manufacturers advertise their brand of nipple as soft, yet when compared with

other brands, they feel stiff. Apart from texture, every mother’s breast also has a unique

shape and flow and every baby has a unique suck/swallow cycle. What works well for one

baby might be terrible for another. Parents need to observe their own baby sucking on a

bottle nipple and analyze if the latch and swallow look similar to that on the breast.

(Balancing Breast and Bottle: Reaching Your Breastfeeding Goals, Amy Peterson, Mindy

Harmer, Hale Publishing, 01 Nov 2009)

Dee Kassing suggests selecting a nipple with a long shank, medium sized base 2,5cm (for a

newborn, large for older and larger infants) and small holes preferably on the top rather than

the tip. The baby should be able to finish a feeding in 15-20 minutes. Use either smaller or

larger size holes or more holes in the nipple to achieve this. If the baby can finish a full bottle-

feeding (as opposed to a partial supplementation after time at the breast) in 5 to 10 minutes,

the flow is too fast. If it consistently takes the baby 30 to 45 minutes to finish a full bottle-

feeding (not counting the first or second attempt when he might still be learning the new

technique), the flow is too slow for his abilities at that time. She says to try using a soft nipple

when possible. The silicone nipples available in my area seem to be softer than latex nipples.

Palmer noted that placing anything firmer than the breast in a baby’s mouth may cause

distortion of the palate. Using a softer nipple will hopefully do less damage. (Palmer B. The

influence of breastfeeding on the development of the oral cavity: a commentary. J Hum

Lact. 1998;14:93-98.)

Dee Kassing’s recommendations for bottle nipples: “I don’t recommend the Dr Brown bottle.

When young babies are not sitting upright, there is more tendency for their tongue to fall

back towards their throat, where is doesn’t belong. I really don’t care what brand as long as

baby can sit upright for feeding, the nipple is a slow flow, and the nipple has a narrow base

about 2.5cm in diameter that tapers to a long straight shaft that’s round on the end. Not

orthodontic, not short and stubby and doesn’t have a wide base like Avent or look like a

miniature breast (because silicone doesn’t stretch in the mouth the way flesh does). One

brand can’t be like bf for every baby because every baby has a unique suck and every

mother has a unique shape, and texture to her breast and nipple, and a flow unique of her

milk.

Using the bottle nipple correctly:

Position the baby so that he is sitting upright. The mother or caregiver can use one hand to

support the baby’s head and neck. Hold the bottle horizontally. This position removes gravity

from the feeding picture. Without gravity helping to pour food into the baby’s mouth, baby

will have to work harder for his meal.

Gently brush the nipple down over the midline of baby’s lips. This will help the baby to open

wide, like a yawn. Then pop the entire nipple into the baby’s mouth. Never force the bottle

into baby’s mouth. Although an artificial nipple can be pushed into baby’s mouth even if he

only opens a little bit, mother cannot do that with her nipple. It is important to keep bottle-

feeding as close to breastfeeding as possible. Baby’s lips should seal on the nipple so that no

milk is leaking and baby’s lips need to be on a portion of the nipple base AND baby’s lips

should be rolled slightly outward. Once the nipple is entirely in baby’s mouth, tip up the

bottom of the bottle just enough so that there is no air in the nipple. Toward the end of the

feeding, when the bottle will need to be almost vertical to keep air out of the nipple, it is

important not to hyperextend baby’s chin and neck. During swallowing, the larynx lifts to seal

the trachea. When the head and neck are hyperextended, the larynx may be unable to lift

far enough to completely close off the trachea. This could cause the baby to aspirate.

Instead, toward the end of the feeding, lean the baby’s body back approximately 45

degrees so that his head and neck stay in proper alignment.

When babies are fed using this method of bottle feeding, they will use the same deep, jaw-

dropping sucks they use for breastfeeding. This method of bottle feeding puts babies in

control of their feeding, as they are when breastfeeding and they do not need to be burped

(winded) frequently during the feeding. Because they are in control of the feeding, they are

more likely to quit sucking when they are full and should not become overfed. (Dee Kassing,

Bottle-Feeding as a Tool to Reinforce Breastfeeding, J Hum Lact. 2002 Feb18(1):56-60). Babies

should be held often at times when they are not being fed, to avoid the baby being trained

to eat in order to be held. Feed baby with a switch from one side to the other side midway

through a feed; this provides for eye stimulation and development, and thwarts the

development of a side preference which could impact the breastfeeding mother.

Check baby’s swallowing when using a bottle:

• Baby’s swallows should be rhythmic—swallowing after every one or two sucks

• Baby will not choke, gulp, or gag

• Baby will naturally pause and rest after 15-20 swallows

• Bottle-feedings will usually take 10-15 minutes; faster is not better

• Baby will look relaxed while feeding

Caregivers need to be sure the nipple is not dripping when the bottle is offered to the baby.

Allow the bottle to stop dripping or keep the milk tipped down in the bottom of the bottle,

dripping bottles given before a baby begins sucking usually cause the baby to pull back or

flat out refuse the bottle.

A few weeks before mom returns to work, she can begin offering baby the bottle and let him

get familiar with it. Not obsessing about baby accepting the bottle, and not forcing the issue.

If baby takes the bottle, fine; if he doesn’t, okay. Some babies refuse to take bottles from

their mother (a sort of “what’s wrong with this picture?” feeling), yet take the bottle from

another caregiver. Some babies will refuse to take the bottle when hungry; others will only

take it when hungry. Some say a mother is the perfect person to introduce the bottle

because she is the only person who is acquainted with what her baby's latch looks like on her

breast.

Daycare

From a baby’s point of view, there are no boundaries between himself and his mother. No

one can replace a mother. From all the evidence, from all that is known about how babies

grow and learn to live and to be competent adults, it can be said that a mother is the one

most perfect suited to be nurture in the early years. (WAB). A child’s early years hold the clues

to his future behaviour as an adult. Society stands to gain or lose, depending on the

soundness of the mother-baby attachment. A baby’s need for his mother’s loving presence is

as basic as his need for food.

Choose a breastfeeding-friendly caregiver. A supportive caregiver whose mothering style

matches her - someone who will hold or wear her baby as much as possible, especially

during feedings, who will use mom’s milk and check with mom before offering anything else,

who will be flexible, and who will avoid giving baby a big meal just before mom is due to

arrive.

So how much milk does a breastfed baby at daycare need during the day? It’s important

that the caregiver is on moms team with this concept.

Most employed and exclusively pumping mothers think that as their baby grows bigger and

heavier they will need to increase their milk production. They assume that—like babies fed

formula—their breastfed babies will need more and more milk as they grow. These mothers

are usually tremendously relieved to learn that the amount of milk breastfed babies consume

daily between 1 and 6 months of age stays remarkably stable, on average a litre in 24hours.

So if a baby is thriving on exclusive breastfeeding for his first six weeks that mother is set. She is

already producing as much milk as her baby would ever need. All she needed to do is

maintain it. For example: at a month baby will just be poohing out the excess of that liter he is

not using, from there on they usually start poohing less and less as they use more and more

milk and at 6 months they are using all the breastmilk they take in over 24hours and might

only pooh once a week. (Butte, N.F., Lopez-Alarcon, & Garza, C. (2002). Nutrient adequacy

of exclusive breastfeeding for the term infant during the first six months of life. Geneva,

Switzerland, World Health Organization. http://

whqlibdoc.who.int/publications/9241562110.pdf). (Kent, J. C., et al. (2006). Volume and

frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics,

117(3), e387-395.). (Volume and Frequency of Breastfeedings and Fat Content of Breast Milk

Throughout the Day, Jacqueline C. Kent, PhD, Leon R. Mitoulas, PhD, Mark D. Cregan, PhD,

Donna T. Ramsay, PhD, Dorota A. Doherty, PhD, Peter E. Hartmann, PhD, NEOREVIEWS Vol.

117 No. 3 March 1, 2006). This means that when breastfeeding is going normally, after 1

month milk production doesn’t need to increase by much. After reaching this level, a mother

can focus primarily on maintenance until 6 months, when her baby’s milk intake will

decrease with the introduction of solid foods (Islam, M.M, Peerson, J.M., Ahmed, T., Dewey,

K.G., & Brown, K.H. (2006). Effects of varied energy density of complementary goods on

breast-milk intakes and total energy consumption by healthy, breastfed Bangladeshi

children. American Journal of Clinical Nutrition, 83(4), 851-858.).

It can be helpful to suggest employed mothers keep their focus on the 24-hour-day as a

whole. By considering their baby’s overall daily milk needs, it quickly becomes obvious that

the more times each day the baby breastfeeds directly, the less expressed milk he will need

while they’re separated. Every missed breastfeeding at home equals an average (90-120 mL)

more milk the baby needs while the mother is at work. Many mothers lose sight of the fact

that encouraging babies to sleep more at night adds to the volume of expressed milk they

need to leave during the day.

So on average baby will take anything from 800-1200ml over 24hours from 1-6months. So

mom just needs to count how many times a day baby breastfeeds and divide that into 800

and 1200 to get the average amount per feed: e.g. 800/8=100ml and 1200/8=150ml, mom

then knows to have between 100-150ml / feed for baby.

Routine back at work

To ease transition back to work, a mom can make the first week back to work a short one by

returning late in the week that way she only has a few days before the weekend.

Before the first day back to work, a mom can have a practice day. She can get up at the

time she would to go to work, and duplicate the morning routine, leaving with baby and

bottles and lunch and all of the various things she will need during the day. She can arrange

for baby to have a half-day with his care provider so mom can practice leaving him for a

short time. Then she goes home and tries to duplicate her work schedule. Pump when she will

have breaks at work, and try to get by on only what she had packed (so she can figure out if

she has forgotten anything). She can also see if what she chose to wear works for pumping,

or if it shows milk stains if she leaks. At the end of the day or half-day, she can see if she

pumped as much as baby drank – if not, maybe the care provider was pushing too many

bottles, or maybe she will need to pump more often.

She can do as much as possible the night before like: prepare the nappy bag, pack pump

bag, lay out everyone’s clothes, set the breakfast table, use the crockpot for suppers. Take

the baby to the sitter’s in his pajamas.

If she can plan to breastfeed at least once before she leaves in the morning and as soon as

she can after her return home, or when she reaches the daycare facility, it will maximizes

baby’s feedings at the breast and minimizes the amount of pumping she’ll have to do.

A typical schedule

6am: Wake up and feed baby

Shower, dress, eat a healthy breakfast, pump if needed

7:30am: Leave for work with baby

8:00am: Drop off baby at daycare, talk about baby’s needs with care provider,

8:15am: Breastfeed baby before leaving

8:45am: Arrive at work (this can be another time to pump

10:00am: First pumping break

12:30pm: Lunch and second pumping break

3:00pm: Third pumping break

5:00pm: Leave to pick up baby

5:30pm: Arrive at childcare, breastfeed baby and discuss baby’s day

6:00pm: Arrive home, prepare and eat dinner

7:30pm: breastfeed baby and put him or her to bed

8:00pm: Clean pump parts, get bottles ready for the next day, pack own lunch and get out

the next day’s dinner from the freezer

10:00pm: Go to bed. Pump before bed if baby sleeps through

Support after returning to work IBCLC, LLL

Breastfeeding related problems working mothers might encounter are a drop in supply or not

pumping enough, baby refusing the breast, blocked ducts, mastitis, milk blisters and thrush.

Are you available to help mothers , through support, information, education and

encouragement?

If lactation support is not available at work (e.g. the Occupational Health Nurses does not

have training in the support of breastfeeding), you should provide a working mother with a

support helpline like LLL or an IBCLC because they are usually reachable after hours as well.

IBCLC stands for International Board Certified Lactation Consultant. IBCLCs have the highest

level of skill. IBCLC certification is the premier global credential in this important health care

specialty. IBCLCs have passed a rigorous examination that demonstrates their ability to

provide competent, comprehensive lactation and breastfeeding care. They are the only

"helper" required to stay current in their knowledge by receiving continuing education and

re-certifying every 5 years. Some IBCLCs are employed through the hospital or in private

practice. There is often a fee for service. IBCLCs may have different areas of expertise, so

the mom might have to seek further help if her needs are not met. You can email

southafrica@iblce.edu.au for a list of IBCLCs in SA.

A La Leche League Leader is a mother who has successfully breastfed her own child for at

least a year, and has been trained by La Leche League International in helping other

mothers breastfeed. La Leche League Leaders are excellent in answering breastfeeding

questions over the phone, and they are a perfect resource for older-baby breastfeeding

question. Find a LLLL here: http://www.llli.org/southafrica.html.

Online info/support:

www.llli.org/nb/nbworking.html

www.kellymom.com/category/bf/pumpingmoms/

www.workandpump.com/

Facebook: Lactation Consultants (ibclc) South Africa

Facebook: groups/lalecheleaguesouthafrica

Facebook: Breastfeeding ClinicWebsites:

Books:

Hirkani’s Daughters: Women Who Scale Modern Mountains to Combine Breastfeeding and

Working. (LLLI 2005)

The Milk Memos: How Real Moms Learned to Mix Business with Babies-and How You Can, Too

by Cate Colburn-Smith, Andrea Serrette (2007)

The Breastfeeding Mother's Guide to Making More Milk by Diana West, Lisa Marasco (2009)

Nursing Mother, Working Mother: The Essential Guide to Breastfeeding Your Baby before and

after your return to work, Gale Pryor and Kathleen Huggins (2010)

Balancing Breast and Bottle: Reaching your Breastfeeding Goals. Amy Peterson, Mindy

Harmer, Nov 2009Amarillo, TX: Hale Publishing

Magazines for working mothers (none in SA yet, will be great though!): Working Mother

magazine (USA) reaches 2.2 million readers and is the only national magazine for career-

committed mothers. Headquarters in New York. Webpage:

http://www.workingmother.com/. Facebook: Working Mother Magazine

END:

The path to health is created—or diminished—over an individual’s lifetime. It blends the

things we are exposed to, our experiences, and our interactions with others. What happens

today influences tomorrow’s health. A new baby who is breastfed is well on his or her way to

enjoying a life with good health! (La Leche League International (LLLI) and the World Alliance

for Breastfeeding Action (WABA)

In Celebration of – World Health Day, April 7, 2012: Good Health Adds Life to Years).

A mother should not have to choose between having a career and being a mom.

We as HCP are key people in helping a working mother be confident in the value she brings

to her work and in her natural ability to love and nurture her child.

By pumping breast-milk at work she will

- keep providing her baby with the ultimate sustenance for him,

- help maintain her supply

- so they can breastfeed when they are together

- and she will remain intimately connected with her baby in a way only she can be.

(The Milk Memos: How Real Moms Learned to Mix Business with Babies-and How You Can, Too

by Cate Colburn-Smith, Andrea Serrette (2007).

(What YOU Can Do to Support & Protect Breastfeeding

We are “key people” in the success or failure of lactation

Promoting breastfeeding contributes to the long-term health and economic interests of a

society

Encourage mothers who want to breastfeed

Be knowledgeable about the risks of not breastfeeding, there is no real alternative to

breastmilk

Be supportive of women who are breastfeeding

Be willing to breastfeed your children

Stir the water to create ripples to help shape the laws to protect, promote and support

breastfeeding and help change society with social support.)

Please email me if you want a copy of this beautiful pamphlet compiled by Penny Reimers.

I would like to thank the following parent and babies for the use of their beautiful photos: Sannelize & Marc Mariella Leila & Retief Riley Kate Zoya & Eugene Hannah Eva Máreli & Inus Dehan Lindie & Deon Saskia Lynne & Ernie Lea Elsje & Andre Jeandre, Andries, Lienke Mariaan & Jannie Le Roux Zani & Andrew Nina Ida & Chris Melissa Melissa & Barney Madison Toni Liam Vanya Aidan Nicolas (Vida de Voss*) Ané & Harold Annebelle Yvonne & Mark Mark Bernard & Annabel Ellen & Jannie Lara Lisa & Thomas Olivia Grace & Duncan Lieshen & JC Joshua Nanine Adam Corlia & Faure Lambert

Elizna Anria Susana Anouk

*Photographer

Thank you ;-), any questions?

Q&A

Why do employed mothers find returning to work is a barrier to breastfeeding?

- inflexibility in work hours and locations

- lack of privacy for breastfeeding or expressing milk,

- no place to store expressed breast milk,

- unable to find child care facilities at or near the workplace,

- fears over job insecurity,

- limited maternity leave benefits

Basic Conditions of Employment Act and Amendments

Applies to all employers and workers and regulates leave, working hours, employment

contracts, deductions, pay slips, and termination

Application

The Basic Conditions of Employment Act applies to all employers and workers, but not

members of the -

• National Defence Force,

• National Intelligence Agency, or

• South African Secret Service; or

• unpaid volunteers working for charity.

The section of the Act that regulate working hours does not apply to:

• workers in senior management

• sales staff who travel and regulate their own working hours

• workers who work less than 24 hours in a month

• workers who earn more than R115 572 per year

• workers engaged in emergency work are excluded from certain provisions.

http://www.labour.gov.za/legislation/acts/basic-conditions-of-employment/basic-

conditions-of-employment-act-and-amendments, www.services.gov.za

Code of Good Practice on Pregnancy: The objective of this code is to provide guidelines for

employers and workers concerning the protection of the health of women against potential

hazards in their work environment during pregnancy, after the birth of a child and while

breast-feeding. 2.1 This code is issued in terms of section 87(1)(b) of the Basic Conditions of

Employment Act (BCEA) 75 of 1997.

5.13 Arrangements should be made for employees who are breast-feeding to have breaks of

30 minutes twice per day for breast-feeding or expressing milk each working day for the first

six months of the child's life.

ODOR What does breastmilk look like?

The color of human milk can vary. Breastmilk can be thin and watery looking, and may have

a blue or yellow tint to it. Color of mature milk may change because of mother’s diet or

medications. Food dyes used in carbonated sodas, fruit drinks, and gelatine desserts have

been associated with milk that is pink or pinkish orange. Greenish milk has been linked to

consuming green- colored sports beverages, seaweed, or large amounts of green

vegetables. One woman consuming a certain prescription medication reported black milk.

Frozen milk may look yellowish. Occasionally milk may take on a “pink” color. This is often a

result of a broken capillary or surface abrasion to the nipple. The pink color is a result of a

small amount of blood, and it will not hurt the milk at all.

Note that sometimes the blood will settle at the bottom of the bottle. If it really bothers mom

to offer milk with a bit of blood in it, she has the option of pouring off the top portion of milk

once the blood has settled to the bottom. Rest assured that it won’t affect baby or moms

milk at all if she chooses not to.

FLAVOR of EBM A crucial element to using expressed breastmilk for your baby is to take the

time to do a taste test. There is a situation involving the lipase in a mother’s milk that does

alter the flavor. Lipase is what breaks down the fat in breastmilk, and the presence of high

lipase content can cause the milk to take on a soapy flavor. It can be noticed not long after

expression, after cooling or after freezing. It is for this reason that I recommend a taste test

prior to returning to work.

Experiment by expressing some milk and letting it set at room temperature for thirty minutes.

Express some fresh EBM and compare the taste. If there is no difference in taste, refrigerate

the EBM. After the EBM is cooled, repeat the taste comparison with fresh EBM. Continue in this

manner through the process of freezing and thawing. The predominance of women will find

that the milk may taste slightly different, but does not take on an unpleasant flavor. Allow the

EBM to thaw in the refrigerator prior to warming it in a cup or bowl of hot water. If the milk still

has a strong soapy flavor, you may need to give your EBM a very, quick scald prior to

cooling. Be careful not to bring it to a boil. Heat it quickly to just this side of boiling and take it

off the stove immediately, pouring it out of the pan into a heat safe glass container to cool.

When the EBM is cooled, you may place it in the storage container of your choice and put it

into the refrigerator to cool further, before transferring it to the freezer if needed.

LIPASE A few mothers find that their refrigerated or frozen milk begins to smell or taste soapy,

sour, or even rancid soon after it’s stored, even though all storage guidelines have been

followed closely. The speculation is that these mothers have an excess of the enzyme lipase

in their milk, which begins to break down the milk fat soon after the milk is expressed. Most

babies do not mind a mild change in taste, and the milk is not harmful, but the stronger the

taste the more likely that baby will reject it.

Lipase is an enzyme that is normally present in human milk and has several known beneficial

functions: Lipases help keep milk fat well-mixed (emulsified) with the “whey” portion of the

milk, and also keep the fat globules small so that they are easily digestible. Lipases also help

to break down fats in the milk, so that fat soluble nutrients (vitamins A & D, for example) and

free fatty acids (which help to protect baby from illness) are easily available to baby. The

primary lipase in human milk, bile salt-stimulated lipase (BSSL), “has been found to be the

major factor inactivating protozoans”. So what can be done? Once the milk becomes sour

or rancid smelling/tasting, there is no known way to salvage it. However, newly expressed

milk can be stored by heating the milk to a scald to inactivate the lipase and stop the

process of fat digestion. Scald the milk as soon after expression as possible. (Breastfeeding: A

Guide for the Medical Profession, Fifth Edition, Ruth A. Lawrence MD, Robert M. Lawrence

MD, 1998)

To scald milk: Bile salt-stimulated lipase can also be destroyed by heating the milk at 62.5 °C

for one minute or at 72 °C for up to 15 seconds. Heat milk until little bubbles around the edge

of the pan appears (not to a full, rolling boil). Quickly cool and store the milk. Scalding the

milk will destroy some of the anti-infective properties of the milk and may lower some nutrient

levels, but this is not likely to be an issue unless all of the milk that baby is receiving has been

heat-treated.

THRUSH If mom or baby has a thrush or yeast/fungus infection, they can continue to

breastfeed during the outbreak and treatment. While being treated, she can continue to

express her milk and give it to baby but needs to be aware that refrigerating or freezing milk

does not kill yeast. After treatment is finished, any leftover milk that was expressed during the

infection should be discarded.

STORING A lactating mother should face no restrictions storing her milk somewhere other

than her own home, such as a workplace or day-care refrigerator. No special precautions

apply. If an employed mother does encounter resistance from co-workers, it may be

lessened if the milk is placed in an opaque, secondary container, suggests Laurie Nommsen-

Rivers in the Journal of Human Lactation (1997). There are several sources of information a

mother can use to educate others not only about the benefits of human milk but to alleviate

any concerns they may have about safe storage of a “body fluid.”

According to THE BREASTFEEDING ANSWER BOOK, page 228, research indicates that human

milk has previously unrecognized properties that protect it from bacterial contamination.

One study, Pardou 1994, found that after 8 days of refrigeration some of the milk actually

had lower bacterial levels than it did on the day it was expressed.

Many frost-free units use a periodic heating of the walls of the freezer to defrost. In that case,

do not store EBM against the walls of the freezer, but stack them in a container kept in the

center. It’s also a good idea to keep an ice cube in a small ziplock bag in the freezer to

identify, in the event of a power outage, if defrosting has occurred.

TIPS to get baby to take bottle

Dripping is different than flow; they are not related. Most breastfeeding books suggest turning

a bottle over to see how fast it drips in an effort to select a bottle with a slow flow. This

suggestion is not accurate. We tested a nipple that dripped an average of 56 times when

tipped over, but had a slow flow. Then, we looked at a no-drip nipple and much to our

surprise, found it flowed 10.6 times faster. Big difference! Dripping is not related to flow. The

term “slow” is not standardized. Nonetheless, it is important to begin with a slow nipple. If a

nipple flows too quickly, a baby’s suck will become disorganized. For breastfeeding babies, it

is best to choose a flow that mimics mom’s flow. For this reason, it is hard to say one or two

brands are “best” since flow varies from mother to mother. Likewise, a nipple might be too

slow for some babies.

Some signs of a poor bottle-feed include gulping, catch-up breaths, fast feeds, leaking milk

from the sides of the mouth or down the chin, baby who has a furrowed brow looking very

concerned, and a baby who pulls away from the bottle.

Some babies take to the bottle like a fish to water, others need a little more coaxing.

Practicing” isn’t a guarantee that a baby will accept the bottle later. There is no single best

bottle, there are no magic tricks to making a bottle like a breast. Babies should never feel

unsafe or not in control while feeding. Mom can try different temperatures, try different

nipples but stick to newborn nipples or slow-flow nipples (expensive exercise!), alternate

feeding methods, there’s no law that says babies have to be fed from bottles. In fact,

avoiding bottles reduces the risk that your baby will learn to prefer the bottle. From the day

they’re born, babies are able to drink from a cup – just not like you or I do. Very small babies

can lap up milk from a small medicine cup held so that the milk is at the level of their lower

lip. babies can drink milk from a spoon – just use the spoon to tip a little at a time into their

mouths.

Mom’s attitude is important. Staying happy and positive – even playful – and making it a

game. Baby should not sense any frustration.

Try offering the bottle when baby isn’t starving. This may seem illogical, but when a baby is

frantically hungry, he is going to be in no mood to try something new. He just wants to

breastfeed. Give the baby a bottle after a nap, before the baby is fully awake, or before the

baby is overly hungry. The more mellow the baby, the greater the possibility of accepting

something new. The old adage “if the baby is hungry enough he or she will take it” really

doesn’t work.

Let someone else offer the bottle at first. Baby associates moms smell and touch with

breastfeeding, and may insist on the real thing if mom tries to give him a bottle. She might

have to leave the room entirely in order for the effort to be successful.

Many babies associate the cradle hold, where they are cuddled against the breast, with

breastfeeding, and will refuse to accept the bottle as a substitute. Although some babies will

accept a bottle more readily in the cradle hold, most will do better if propped up on a knee

as explained above.

Offer a small amount at first –40ml fresh breastmilk, then it will only be the bottle that’s new,

frozen, reheated breastmilk tastes a little different. If he takes it readily, she can always offer

more. If he doesn’t take it, she won’t have wasted much.

Make sure the nipple isn’t cold when offering a bottle. Run it under luke warm water before

giving it may help.

Older babies sometimes get set in their ways and don’t want to settle for anything but the

real thing. As long as you wait until your supply is established and your baby has started

gaining weight well, you should be able to combine breast and bottle feeding without much

difficulty. An older child’s sippy cup can also be used – babies usually have better luck with

them without the valve – just tip the milk gently into their mouths, letting them suck it out of

the cup. When sucking needs are satisfied at the breast, some breastfed babies never take

bottles. They may transition to a sippy cup with a little help at four or six months and skip

taking bottles altogether.

Some mothers have had the experience that the baby will initially consume a large quantity

of supplement from the bottle. This is usually not because the baby is so very hungry or thirsty.

The baby is either simply using that strong tongue and jaw movement that he knows from

breastfeeding or was being fed in a fully-reclined position so that the milk flowed very rapidly

and the baby had no choice but to rapidly swallow. When this happen, it can leave a

mother with the conclusion that her poor baby was starving and she really must not have

had much milk at all. In most cases, this is not an accurate measure of her milk supply.

MILK needs Sometime between six months and a year (as solids are introduced and slowly

increased) baby’s milk intake may begin to decrease, but breastmilk should provide the

majority of baby’s nutrition through the first year. Because of the great variability in the

amount of solids that babies take during the second six months, the amount of milk will vary,

too. One study found average breastmilk intake to be 875 ml/day per day (93% of total

intake) at 7 months and 550 ml/day (50% of total energy intake) at 11-16 months. Several

studies have measured breastmilk intake for babies between 12 and 24 months and found

typical amounts to be 400-550 mL per day. Studies looking at breastmilk intake between 24

and 36 months have found typical amounts to be 300-360 mL per day. (J Pediatr

Gastroenterol Nutr. 1984 Nov;3(5):713-20. Breast milk volume and composition during late

lactation (7-20 months). Dewey KG, Finley DA, Lönnerdal B.)

Breast Refusal

Breast refusal (also called a “nursing strike”) is a normal thing that can happen to any baby,

but it is particularly heart breaking for the working mother. She worries that her baby is

rejecting her because she is working. She thinks that it is her fault that the baby won’t take

the breast.

The challenge is that baby is probably getting bottles all day, which makes the treatment for

breast refusal a little harder, and it may take a little longer, to get baby back to the breast.

So-called “flow confusion” is the primary culprit – the baby gets used to the fast flow of milk

from a bottle, and loses patience waiting for milk from mom, or doesn’t want to do the extra

work to get it.

Other theories are that at around 4 months, baby just starts paying a lot more attention to

the world around her, and is more distractible during feedings. It may be that she’s bottle-fed

facing out where she can see what’s going on, and doesn’t want to miss out on anything at

the breast. She may just be busier and not want to sit still when it is feeding time.

Treating Breast Refusal

With bottle feeding, the flow is instant and continuous. The baby is required to work very little.

Once a baby has had a bottle, especially a lot of bottles, she may begin to prefer the ease

of bottle-feeding over the work of breastfeeding. She may become frustrated at the breast

after the first let-down occurs and the flow of milk begins to slow. It can be helpful to do

some breast compression when this fussiness starts or right before you expect it to. This will

help speed up the milk flow again. Once compression stops helping, try switching baby to

the other side when she begins to fuss and back and forth again (after using compression) as

you need to. When ever mom and baby is together mom can make the breast available all

the time, in a non-pressuring way.

With mom at work all day and baby at the daycare, we need to keep in mind that baby still

has a biological urge to suckle, to seek milk, to touch mommy. If mom is open to making up

for lost time at night, baby may well feed & cuddle before dinner, feed skin to skin all night

and make up for lost time on days off. It doesn’t matter so much to baby or when the

feeding happens, just if & how it happens! If mom is topless, available, skin to skin, relaxed

during quiet times, baby will find her hard to resist. Sharing bath & bed, putting baby in a

position to discover & request the breast are always better than forcing the breastfeeding on

the baby. Try offering the breast when baby is sleepy and relaxed. She may be less

distractible and more willing to feed at these times. On weekends stay in bed for a morning

with baby – lie around with an open shirt, just have the breast there for whenever baby

shows interest.

Drop in supply:

Has she reduced the number of pumping or breastfeeding sessions recently, or cut back on

feeding/pumping in other ways? How many times does she express or feed per day? Milk

production is a demand-supply process. More breastfeeds/pumping results in a greater milk

supply. If she consistently decreases feeds or pumping for several days, her overall milk supply

will decrease and she can expect to see a decrease in pumped amounts. How can she

increase pumping output? To speed milk production and increase overall milk supply, the key

is to remove more milk from the breast and to do this frequently, so that less milk

accumulates in the breast between feedings. And to ensure that the pump removes an

optimum amount of milk from the breast, keep pumping for 2-5 minutes after the last drops of

milk. Is there any way you can add a pumping session at work? If necessary, when pumping

times are very limited, adding even a short 5 minute pumping session is better than not

pumping at all. Some moms find it helpful to take a “breastfeeding holiday” with pumping

added in, every couple of weeks to “super charge” their milk supply. On these days, get lots

of rest, feed very frequently and pump after as many breastfeeding sessions as possible.

How long does she breastfeed or express each breast at each session? Has this changed

recently?

What is her longest stretch between breast drainings? A consistent stretch longer than 8hours

causes some mothers’ production to slow over time.

What brand /model does she use to pump with at work? Is it effective enough for her

situation?

How much time does she spend STS with her baby each day? Time spend touching and

holding enhances milk-making (Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L: Skin-to-skin

holding in the neonatal intensive care unit influences maternal milk volume.

J Perinatol 1997, 17(3):213-217)

Has baby started solids recently? As baby eats more solids and takes in less milk, overall milk

supply naturally decreases and mom may see a decrease in pumping output.

Hormonal causes of decreased milk supply: Has she started hormonal birth control recently,

particularly that containing estrogen, which can significantly decrease milk supply. (M. C.

Neville and C. T. Walsh (1996). Effects of drugs on milk secretion and composition. In P. N.

Bennett (ed.), Drugs and

Human Lactation, Elsevier, Amsterdam, pp. 15–45.). Is she expecting either ovulation or her

period soon, or has it recently started?

Has she started a strict diet? Is she getting enough calories? Snacking during the day on

healthy, protein-rich foods may be helpful. Is she drinking to thirst? Some moms, particularly

when they are at work, will get busy and forget to drink enough fluids. Many working and

pumping moms have found that eating oatmeal is very helpful for increasing pumping

output. Many moms have gotten good results using fenugreek or other herbs to increase

supply, either on a short- or long-term basis. This is most effective when combined with

increased nursing/pumping.

Is she getting enough rest? Maybe go to bed a little earlier and to take a nap each day on

her days off. Consider co-sleeping so she can get more sleep. Just a little added rest may

make a big difference. Has she been under an unusually large amount of stress? Stress can

affect let-down and pumping output. Has she been sick? Illness, especially if she has a fever,

mastitis or get dehydrated, can result in a temporary decrease in milk supply. Some

medications can also decrease milk supply (hormonal birth control, pseudoephedrine,

ethanol/alcoholic beverages, bromocriptine, ergotamine, cabergoline).

END

James Grant, (3rd Executive Director of UNICEF, 1980 – 1995) said: "The promotion of

breastfeeding must not be seen as an excuse to exclude women from the labour force. The

burden should no longer fall on women to choose between breastfeeding and work. The

burden is on society to facilitate breastfeeding and indeed child care".

The Global Strategy for Infant and Young Child Feeding developed in 2002;

The global strategy is built on Baby Friendly Hospital Initiative, the International Code of

Marketing of Breast Milk Substitutes and the Innocenti Declaration on the Protection,

Promotion and Support of Breastfeeding. It emphasises the need for comprehensive national

policies on infant and child health feeding including guidelines on ensuring appropriate

feeding of infants and young children in exceptionally difficult circumstances and to ensure

that all health services protect, promote and support breastfeeding exclusively for first 6

months and then timely and adequate complementary feeding with continued

breastfeeding for two years or beyond. Thus the strategy is to improve nutritional status,

growth and development, health and survival of infants and young children. It recognises

that mothers should have adequate information and support within their families and

communities and should be free from commercial influence.

Predictors of breastfeeding duration: evidence from a cohort study. Scott JA, Binns

CW, Oddy WH, Graham KI. Division of Developmental Medicine, University of Glasgow,

Scotland.

At 6 months of age, fewer than one half of infants were receiving any breast milk (45.9%),

and only 12% were being fully breastfed. By 12 months, only 19.2% of infants were still

receiving any breast milk. Breastfeeding duration was independently, positively associated

with maternal infant feeding attitudes and negatively associated with breastfeeding

difficulties in the first 4 weeks, maternal smoking, introduction of a pacifier, and early return to

work. CONCLUSIONS: Relatively few women achieved the international recommendations

for duration of full and overall breastfeeding. Women should receive anticipatory guidance

while still in the hospital on how to prevent or manage common breastfeeding difficulties

and should be discouraged from introducing a pacifier before 10 weeks, if at all. Improved

maternity leave provisions and more flexible working conditions may help women to remain

at home with their infants longer and/or to combine successfully breastfeeding with

employment outside the home.

Dear Employer:

I am writing on behalf of ______________________ and _________________________.

Mother’s Name Baby’s Name

This mother will soon be returning to work at your facility. I have strongly advised her to

continue providing breast milk to her baby after she returns to work.

Breastfeeding is a natural part of the birthing cycle, and significantly lowers the mother’s risk

for breast cancer, ovarian cancer and osteoporosis the longer she is able to breastfeed.

Breastfed babies continue to receive antibodies to protect them against infection and

disease for as long as they breastfeed. This is especially important for babies in childcare

centres. Babies receive most of their nutrition from their mother’s milk, even after they begin

eating solid foods. Breastfeeding provides protection against chronic childhood illnesses,

Sudden Infant Death Syndrome (SIDS), respiratory problems and certain childhood cancers.

Breastfeeding is recommended for at least two year and beyond to protect babies against

diabetes, obesity, and osteoporosis. Breastfeeding also enhances brain development and

increases I.Q.

As an employer who supports your employee’s decision to provide her baby with the optimal

infant nutrition, you will ensure a more loyal and productive employee, happy in knowing she

can contribute to her child’s health even when apart. She will have less absenteeism from

her job because of infant illnesses--her baby will have fewer earaches, gastrointestinal and

other infant health problems.

All major health organizations, including WHO, UNICEF, and the American Academy of

Paediatrics, support breastfeeding and encourage employers to do the same.

Sincerely,

_______________________________ ___________________

Physician Date

Sample text of a workplace breastfeeding policy

Business Name:

Date:

It is our policy to encourage all of our pregnant and postpartum employees to consider

breastfeeding their children as a means of promoting the health of both child and mother.

We encourage and support employees in their efforts to combine working and

breastfeeding.

1. This workplace breastfeeding support policy recognizes that breastfeeding is the most

healthful, natural and economic method of infant nutrition. It is our policy to support the

needs of breastfeeding mothers when they return to work.

2. Maternity leave planning will address the transition from fulltime maternity leave to fulltime

work and the impact that this may have on breastfeeding.

o Maternity leave is sufficient to establish breastfeeding, generally 68 weeks.

o Options include: a combination of fulltime and part-time maternity leave, a flexible work

schedule to accommodate breastfeeding needs, break times to use a breast pump at work.

3. Breastfeeding employees are allowed a flexible schedule for nursing or pumping. The time

allowed will not exceed the normal time allowed for lunch and breaks. For time above and

beyond normal lunch and breaks, sick/annual leave must be used or the employee can

come in earlier, leave later or take a shorter lunch.

4. An appropriate room will be provided where nursing women can:

a. Nurse an infant brought in during lunch or breaks.

b. Pump breast milk to be stored for later use.

§ The room will be a private area for breastfeeding or pumping located in an area where a

crying infant will not be disruptive to other employees.

§ The room will have accessible electrical outlets for electric breast pump use and a sink

close by with a clean, safe water source for hand washing and rinsing out breast pump

equipment.

§ The room will contain a comfortable chair with arms for nursing, a nursing stool could be

optional, a table or desk and a chair for pumping.

5. If needed, a sign up sheet will be posted to ensure that all those needing the room will

have the opportunity to use it.

6. A small refrigerator will be available for safe storage of breast milk. Breastfeeding women

will provide their own containers and milk stored in the refrigerator will be clearly labelled with

name and date. Those who use the refrigerator shall be responsible for keeping it clean.