Size does matter....but bigger is not always better
Let’s talk flange sizing – it is something that could make or break your expressing journey.
My personal experience with using the wrong sizes
I was told to start expressing by an IBCLC for my daughter when she was 3 days old. My milk hadn’t come in and it looked like she had lost too much weight. I was initially told that I needed 27mm flanges. A week later I went for a follow up appointment and was told that I needed 30mm flanges because I wasn't expressing much. Having very little expressing knowledge I believed them (this was despite working in NICU for 8 years already - it certainly wasn't something we learnt much about).
By ~10days post birth I was barely expressing 10-20mls/session. Slowly it increased to about 30mls/session but would not increase any further. Using the 30mm flanges hurt and I kept going back to the 24mm flanges that I had as they were slightly more comfortable. I would also get more out (only about 10mls more and no more than 30mls total).
Around 6 weeks post birth I saw a different IBCLC who wanted to help me increase my supply and suggested I try a different brand of breast pump while I waited for my Spectra to arrive. And she suggested that I try 36mm flanges. In between all this, another IBCLC had agreed that 30mm flanges seemed to be correct.
I tried the 36mm flanges but quickly went back to the 24mm’s – they were definitely more comfortable and I got more with them. Although it definitely was painful to express I pushed through, wanting to give my daughter whatever breast milk I could get.
About 2 weeks before I ordered my Spectra I had tried a friends electric pump (a brand that you can buy off the shelves in Big W or Target) which had ‘comfort massaging inserts'. I got the most I had ever got – 40mls! When another friend told me about the Spectra I ordered it with their ‘massaging inserts’.
I also joined an Exclusive Expressing Facebook group on her recommendation. After a week or so I posted my story, desperately wanting to increase my supply. The main thing I was told was to increase the number of sessions I was doing (I was only doing 6/day whereas the minimum is 8). But someone in there also recommended checking my flange size. I didn’t pay too much notice to that suggestion as I was now using the Spectra 24mm’s with the inserts (which took them down to a 22mm) and it was somewhat comfortable and I was seeing an increase.
Over the next 8mths of exclusive expressing (I did my last session 3 days before my daughter was 10mths old) I saw numerous posts about flange sizing. And I came to realise just how important it was to get the correct size and that unfortunately those 3 IBCLC’s who had told me I was a 30-36mm were wrong.
“Your flange should fit your nipple like a shoe”
Professional experience with flange sizing
In March 2016 I started selling Spectra breast pumps as an authorized stockist. Flange sizing quickly became a ‘passion’ of mine (some might say obsession!). I realized that so many new mothers were being told the same thing as me – you need a 27, 30 or 36mm flange.
I started stocking Maymom flanges around the same time as the Spectras and I did a survey on the Exclusive Expressing group to work out what volume of stock I should be ordering. Most said they were between a 19 and 27mm flange, so that is mainly what I stocked. Over time I realised I was selling more 19mm’s than anything else and I was getting numerous requests for 15’s.
A fellow IBCLC from the USA, who I know went through similar expressing journey to me (she is in the Exclusive Expressing group), did a similar survey to me just recently and interestingly the vast majority said they were a 17, 19 or 21mm.
Results of the informal Facebook survey done by a fellow IBCLC. This is a screenshot taken from a presentation I am doing for a Breastfeeding conference - hopefully I can prevent some from giving out the wrong advice!
I have also seen numerous clients who have been told to use flanges that are too big for them with damage (usually around the areola or base of the nipple) and poor output. The vast majority of the time they say that using smaller flanges (ie ones that fit properly) are more comfortable and help them yield more milk.
In September 2020 I started allowing customers in Perth to come test out different sizes in person. Up to then I was 'eyeballing' sizes, using the guide of 'measure the diameter of the nipple (before expressing) and add 4mm'.
I was surprised to see that most people found sizing that were even smaller than this more comfortable. This is why I have revised my advice to measure and add only 2mm.
*JUST your nipple - not the areola. In case you do not know - your areola is the darker coloured skin on your breast, your nipple is the part that extrudes from that. If you have flat or inverted nipples - they are often more sensitive than your areola and can sometimes be stimulated to stick out by rubbing on them slightly
"But I was using a 24 or 27mm flange and it was 'too tight' or it was 'swelling up' - why would I go down a size?"
When you are using a size that is too big your breast tissue (usually the areola, sometimes the actual breast) gets pulled into the funnel - this makes everything swell up. The tissue is literally swelling to meet the diameter of the flange you are using. At some point the tissue can no long swell and so it feels like you are using the right size. However, very little of the areola should be entering the flange - so there would be no to very little swelling at all.
It actually seems that the less areola that gets pulled in, the better, even if this means that the nipple is rubbing on the side - as long as it is moving freely.
Another sign that you are using a size too big is if your breast loses contact with the flange for the first few minutes of expressing - the nipple should be pulled in and create a seal inside the funnel. You may also get milk running down your breast when this happens (although unfortunately expressing is not very ergonomic, so you will most likely have to lean forward regardless of what size you use).
I have helped size numerous clients/customers - quite a few have sent me follow up messages along the lines of ‘this size is so much more comfortable’ and/or ‘I’m getting so much more with this smaller size flange’, so I am pretty confident in my recommendations now.
You may need even smaller than what you originally thought
However, there can always be exceptions to this rule - the main point is to use a flange that is comfortable and effective. If your output is not what it should be, question if you are using the right size flange.
Here is another graphic to help you know where to measure.
In the 4 years I have been doing this I have seen only about 5 mothers who truly needed 30+mm flanges – and I have seen hundreds, if not over a thousand, of nipples – please trust me when I say that bigger is not always better. And I am saying this not to confuse you or to criticize other health professionals – please keep in mind that breast pump flange sizing is not a part of the midwifery training, or even the lactation consultant training. I had to learn this information from a Facebook group....
Like I said above, there are always exceptions to rules and it might take some trial and error. Using the analogy of it fitting like a shoe - you wouldn't walk into a shoe shop and just buy whatever takes your fancy in the size you think you are, or based on measurements, you would try it on, walk around the shop, and make sure it feels comfortable.
If you need help with flange sizing you are welcome to see me in person (in Perth) or send me a video of you using your current size - there is no charge for this. Or you can try my flange lending service - found under 'Shop Now' at the top of the page Send me a text or email if you need more assistance - 0405427998 or firstname.lastname@example.org