Rethinking Early Breast Pump Use for NICU Mothers: Lessons from the Healthy Breastfeeding Infant

By:  Paula Meier, PhD, RN

This article summarizes a Medela webinar led by Paula Meier, PhD, RN, titled “Rethinking Early Breast Pump Use for NICU Mothers: Lessons from the Healthy Breastfeeding Infant,” presented on May 19, 2026.

Breast pump dependency is a primary unmodifiable risk for insufficient mothers’ own milk (MOM) volume in mothers of NICU infants, especially those born prematurely.  Although breast pump dependency is not modifiable, the type, features and usage of the pump are modifiable, and should be leveraged to improve the nearly ubiquitous problem of insufficient MOM volume in this population.1,2 Unfortunately, only a handful of studies has addressed breast pump type, features and usage in a scientific manner,2-9 which has historically disenfranchised vulnerable mothers and infants.1,2  Non-lactation experts assume that a breast pump is only a MOM removal entity and that the same pump type is equally suitable for the occasional user and the breast pump-dependent mother.  However, for breast pump-dependent mothers who must use a breast pump ³ 5 times daily for weeks or months, “getting the MOM out” is not enough.  For these mothers, breast pump type, features and usage protocols must replace the infant’s unique contribution to ongoing MOM synthesis and secretion.10 Thus, the pump, its features and usage should mimic the healthy breastfeeding infant to the greatest possible extent from the time of birth through the transition to at-will breastfeeding after NICU discharge.2,10  This short review summarizes the complex interplay between the lactating mammary gland and the healthy breastfeeding infant, with implications for adapting the infant’s unique contributions to breast pump type, features and usage.

Breastfeeding Infant-Mammary Gland Synchrony

Historical studies conceptualized the lactating mammary gland as independently synthesizing and secreting MOM, with minimal or no input from the infant other than MOM removal.2  Gradually, the intricate synchrony between the breast and healthy breastfeeding infant became appreciated by researchers, who discovered that infant sucking and feeding patterns were essential for regulating MOM volume and for adequate infant nutrition.2  Unlike the bottle, the rate of MOM flow from the breast is highly variable, ranging from drops to rapid flow rates.11-13  The human infant responds to these changes by altering the sucking rate, rhythm and pressures, which in turn, provide regulatory signals to the mammary gland.  When MOM flow is slow, the infant sucks rapidly with intermittent pauses because there is little MOM to swallow.12,13  With rapid MOM flow, the infant sucks more slowly because time is needed to close the airway in order to safely swallow and then reopen the airway to breathe.12,13  Slow MOM flow rates such as those prior to milk ejection, result in rapid infant sucking which triggers the milk ejection reflex (MER).7,11,13  Similarly, very small amounts of MOM prior to the achievement of secretory activation result in the infant’s almost-exclusive use of rapid, irregular sucking patterns with very brief periods of higher-flow sucking.4 These uniquely human sucking patterns are thought to have an important role in programming critical biologic pathways that optimize short-and long-term MOM synthesis and secretion.1-4,10

Integrating This Synchrony into Breast Pump Technologies and Usage

Given the extensive research background that details infant inputs into lactation processes, how do we recreate comparable mammary gland stimulation for mothers of NICU infants who are completely breast pump-dependent?  For these mothers, the pump replaces the infant, so its features and usage should mimic the infant to the greatest extent possible.2,10 Similarly, maternal responses should be evaluated with scientific rigor.  Fortunately, a handful of studies integrating these unique infant sucking patterns into breast pump technologies informs best practice in this area.3-9

Biphasic Pumping Platforms

The biphasic pumping platform, featuring stimulation and expression phases, was first introduced in the Medela Symphony Pump in 2000 following extensive research in the Hartmann laboratory at University of Western Australia.6-7  Building upon the healthy breastfeeding infant’s use of rapid sucking prior to the onset of the MER, the biphasic platform integrates a stimulation phase characterized by a rapid rate and less strong pressures.7  At the onset of MER or after a 2-minute default, the suction rate and rhythm changes to the expression phase, which mimics a healthy term infant who is swallowing larger boluses of MOM while breastfeeding.6  When studied with mothers who had already established lactation with their healthy term infants, the biphasic pattern resulted in a shorter time between the onset of pumping and MER, when compared to a single-phase expression-only pattern.3

Our team was the first to evaluate the biphasic technology platform in 100 mothers of very preterm (VPT; <33 weeks of gestation) infants who had established lactation (>350 mLs/day of pumped MOM) using the single-phase (expression-only) pattern and then were randomized into single-versus biphasic comparisons.3  We found that the biphasic pattern performed equally to the single-phase with respect to effectiveness and efficiency, but maternal perceptions of comfort and effectiveness favored the bi-phasic pattern.  Most noteworthy, our mothers experienced a significantly quicker MER using the single-phase than the biphasic pattern, demonstrating that they had become conditioned to a breast pump suction pattern unlike the breastfeeding infant.  This finding was clinically important because mothers of preterm infants had often reported delayed and/or impaired MER when feeds at breast were initiated in the NICU. This important study also revealed that breast pump features could be improved to optimize lactation outcomes, setting the stage for more innovation in this area.1,2

Initiation TechnologyTM Platform

As the investigator leading the biphasic technology study with NICU mothers, I began to contemplate the significance of the uniquely human infant sucking rate and rhythm used during the first postpartum days when MOM availability is limited and flow is very slow and irregular.4,12,14  Classic studies had reported that breastfeeding infants sucked “abnormally” during the first four postpartum days (e.g., not a biphasic pattern), and consumed a mean of only 15 mLs of MOM during the entire first 24 hours of life. 4,12,14  What these and other researchers were describing was a brief critical window during which the suckling infant provides intensive stimuli to the breast but extracts small amounts of MOM. These findings suggested this early critical window was more about providing mammary gland stimulation than MOM removal, especially since the healthy newborn has ample fat and glycogen stores immediately postpartum, and requires very small MOM volumes.2,4  I worked with an engineer from Medela (Brian Silver) to design, beta-test and formally evaluate today’s Initiation TechnologyTM.

After 18 months designing and testing multiple prototypes, we conducted a randomized trial of 105 breast pump-dependent mothers of preterm infants who were randomized at birth to the standard biphasic pattern or the experimental initiation pattern.4  Upon removing 20 mLs of MOM from the two breasts combined on two consecutive occasions, all mothers used the same biphasic pattern through to postpartum day 14.  Our findings revealed that use of the initiation pattern for an average of 3.1 days significantly increased cumulative MOM volume over the first 14 postpartum days (approximately 7000 mLs versus 4000 mLs, p < .05).  Furthermore, over these 14 days, breast pump use became more efficient for Initiation TechnologyTM mothers—they removed more MOM, but spent less time pumping.  All other characteristics of the mothers were statistically similar, including number of pumping sessions and pumping minutes, strengthening the conclusion that differences in effectiveness and efficiency of MOM removal were a function of the Initiation Technology™ intervention.4

Since our initial study, three additional research studies—two RCTs8,9 and one observational study5—have shown similar results in breast pump-dependent mothers with preterm and term NICU infants.  Yuan et al. recently included measures of MOM sodium (Na), demonstrating that Initiation TechnologyTM users achieved secretory activation earlier than non- Initiation TechnologyTM users.8  In a separate paper, Yuan et al followed mothers who were randomized throughout the NICU hospitalization and into the home, reporting that Initiation TechnologyTM users were more likely to exclusively breastfeed at three months postpartum (83% and 87%) than non- Initiation TechnologyTM users (39%).9 These findings link Initiation TechnologyTM to favorable long-term lactation outcomes, suggesting improved health outcomes and cost savings.

Breast Pump Features and Usage Protocols

The type of breast pump alone does not guarantee optimal outcomes, because an understanding of pump features and the implementation of usage protocols are needed to implement evidence-based lactation practices.1,2  For example, mothers may have received a lesser-model personal pump as a baby gift, and do not understand why it is not adequate for breast pump-dependency.  Features of the breast pump important to NICU mothers may not be universally available in all pump types.  Mothers value: 1) ease of use (e.g., suction platforms function automatically without mothers’ manipulating them), 2) ability to fine-tune suction pressures, 3) saving time (e.g., simultaneous versus serial pumping), and 4) having access to an array of breast shield sizes.  These specific features need to be detailed so that mothers—new to breast pump-dependency—can make an informed decision.  Table 1 in Which Pump for Which Mother2 and the education sheet, Does the Type of Pump Matter for a NICU Mom?, 15 provide the clinician with evidence-based talking points about breast pump features to share with mothers.

A special caution about wearable pumps is warranted here because they are so popular with mothers of healthy breastfeeding infants and their convenience is lauded on social media.  Wearable pumps should not be substituted for Initiation TechnologyTM, biphasic suction patterns, personalized breast shield sizing and other features that are critical for early MOM synthesis and secretion.  Wearable pumps make it nearly impossible to assure proper placement of the breast shield over the nipple and areola, setting the mother up for ineffective or painful pumping.  The education sheet, What Should I Watch for When I’m Pumping for My NICU Baby?15 can be used to emphasize the importance of observing the breasts during early pumping sessions.  A suitable compromise—similar to the use of hand expression during this critical window—is that the mother can use the wearable pump in addition to the ³ 5 times daily that she uses a pump with Initiation and bi-phasic technologies.  However, neither hand expression nor a wearable pump should count as one of the 5 or more critical pumpings each day.  The NICU mother can also be reminded that the wearable pump does not replace the healthy infant for breastfeeding—it is used alongside the effective MOM remover (the infant)—for brief separations or to augment MOM volume.  For the breast pump-dependent mother, the effective MOM remover is the plug-in breast pump with initiation and biphasic technologies.

Protocols for appropriate usage are equally important.  The breast pump may have initiation and biphasic technologies, customized suction pressures, simultaneous pumping and many breast shield sizes.  However, if these features are not used properly, lactation outcomes will not be optimized.  This logic informed My Pumping Pathways, Parts 1 and 2, intended to standardize and personalize breast pump usage so that it mimics the healthy breastfeeding infant to the greatest possible extent.  Our original research with the My Pumping Pathways (under review for publication) shows that mothers perceived significant gains in knowledge and confidence with both pathways. Similarly, we found that lactation care providers covered only about 50% of content in the My Pumping Pathways during a standard consultation.  Both Pumping Pathways Parts 1 and 2 were completed in less than half an hour, after an average of six practice sessions, alleviating concerns that the time commitment would be burdensome for mothers and lactation care providers.

Summary

Receipt of MOM through to and after NICU discharge reduces a multitude of potentially preventable complications of prematurity and the NICU hospitalization itself.  However, insufficient MOM volume precludes the achievement of this evidence-based outcome, despite mothers’ goals to continue MOM provision.16 While some lactation risks are not modifiable, the type, features and usage of the breast pump represent important modifiable opportunities and deserve wide-scale study and implementation.

About the Author

Paula Meier, PhD, RN, is a Professor of Pediatrics and Nursing at Rush University Medical Center in Chicago. Dr. Meier has worked as a practitioner, researcher, and educator in the area of human milk, lactation, and breastfeeding for premature infants and their mothers since 1975. She spearheaded the multidisciplinary Rush University NICU Human Milk Research Team, which has conducted numerous externally funded translational research and demonstration projects focused on removing barriers to high-dose, long-exposure mothers’ own milk feedings for NICU infants.

References:

  1. Meier PP, Johnson TJ, Patel AL, Rossman B. (2017). Evidence-based methods that promote human milk feeding of preterm infants. Clinics in Perinatology, 44(1), 1-22.
  2. Meier PP, Patel AL, Hoban R, Engstrom JL. (2016). Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology. Journal of Perinatology, 36, 493-499.
  3. Meier PP, Engstrom JL, Hurst NM, Ackerman B, Allen M, Motykowski JE, Zuleger JL, Jegier BJ. (2008). A comparison of the efficiency, efficacy, comfort and convenience of two hospital-grade electric pumps for mothers of very low birthweight infants. Breastfeeding Medicine, 3(3), 141-150.
  4. Meier PP, Engstrom JL, Janes JE, Jegier BJ, Loera F. (2012). Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent on pumping for breast pump-dependent mothers with premature infants. Journal of Perinatology, 32, 103-110.
  5. Post EDM, Stam G, Tromp E. (2016). Milk production after preterm, late preterm and term delivery; Effects of different breast pump suction patterns. J Perinatology 36: 47-51.
  6. Mitoulas L, Lai CT, Gurrin LC, Larsson M, Hartmann PE. (2002). Effect of vacuum profile on breast milk expression using an electric breast pump. J Human Lactation 18: 349-356.
  7. Kent J, Ramsey (Geddes) DT, Doherty D, Larsson M, Hartmann PE (2003). Response of breasts to different stimulation patterns of an electric breast pump. J Human Lactation 19: 179-186.
  8. Yuan S, Li Q, Wang H, Xu X. (2023). The utilization of sodium concentration in human milk from pump-dependent mothers of preterm infants as a measure of milk production. Breastfeeding Medicine 18: 506-513.
  9. Yuan S, Wang H, Xu X, Li Q. (2025). A randomized control trial of early breast milk pumping interventions for mothers of moderately preterm infants. Breastfeeding Medicine
  10. Krebs NF, Belfort MB, Meier PP, Menella JA, O’Connor DL, Taylor SN, Raiten DJ. (2023). Infant inputs, issues and interactions: A Report from the breastmilk ecology and genesis of infant nutrition (BEGIN) working group 3. American J Clinical Nutrition, 117, S43-60.
  11. Bowen-Jones A, Thompson C, Drewett RF. (1982). Milk flow and sucking rates during breast-feeding. Developmental Medicine and Child Neurology 24: 626-633.
  12. Mathew O, Bhatia J. (1989). Sucking and breathing patterns during breast- and bottle- feeding in term neonates. Am J Diseases in Children 143: 588-592.
  13. Mizuno K, Udea A. (2006). Changes in sucking performance from nonnutritive sucking to nutritive sucking during breast- and bottle- feeding.  Pediatric Research 59: 728-731.
  14. Santoro W, Martinez FE, Rico RG, Jorge SM. (2010). Colostrum ingested during the first day of life by exclusively breastfed healthy newborn infants.  Journal of Pediatrics 156: 29-32.
  15. Meier PP. The PROVIDE Training Compendium, available at:  www.lactahub.org/nicu-training.
  16. Hoban R, Bigger H, Patel AL, Rossman B, Fogg LF, Meier PP. (2015). Goals for human milk feeding in mothers of very low birth weight infants: how do goals change and are they achieved during the NICU hospitalization? Breastfeeding Medicine, 10(6), 305-311.

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The material presented in this blog represents the opinion of the author(s) and not necessarily the views of Synova Associates. Synova Associates does not endorse any specific products or organizations but strives to connect its industry partners with leaders interested in product/educational innovation.

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