Lactation Management Training: From Novice to Expert

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We all know what it takes to support a milk supply and help a baby grow.  When creating a care plan for families, we follow the sage advice from the pioneers of the profession, such as Barbara Wilson-Clay and Kay Hoover in their book the Breastfeeding Atlas:

  1. Feed the baby – ideally with human milk
  2. Protect the milk supply with expression
  3. Preserve the breast focus
  4. Fix the problem (my addition)

Rigid, structured “triple feeding” is exhausting for parents and is unsustainable for very long.

When a baby is having difficulty with weight gain or is born prematurely, many clinicians will suggest that a parent feed the baby every two hours, supplement the baby with X number of ounces at every feed and pump every two to three hours.  While the evidence to support the individual points of this care plan are well documented, my question is, “when does this end”?  A better question is “why start with such rigid recommendations”?

I work in both an in-patient and outpatient setting.  Occasionally, I am the last resort for families who are exhausted, sad, angry and want to stop breastfeeding or any work towards providing breastmilk.  I hear their frustration.  I believe there is a better way to provide competent care and empower them to do what is right for their family.

First, the suggestion to feed every two to three hours does not take into account the circadian rhythms of the baby.  In the first few weeks, many babies are nocturnal, and prefer more frequent contact and feeding at night.  A rigid schedule does not consider the times when a baby may be hungry or tired or overstimulated.  A baby who is ready for a feeding will be more efficient than one who is told when they are “supposed to” feed.  Teach parents about baby behaviors, including feeding cues, that will help parents decode their baby’s signals and empower them to be responsive to their baby.

 

Second, the recommendation to feed a baby X number of ounces at every feeding is to help a baby grow, our number one priority.  While this recommendation may be to ensure baby receives enough calories throughout the day, it does not allow for the rhythm of the baby’s hunger.  Granted, there are times a compromised baby is not obtaining enough calories and we need to temporarily override a baby’s lack of desire to feed.  While unusual, this situation is important to address.  Providing families with the goal of a total number of ounces per 24 hours is a more empowering suggestion.  For a majority of families, the baby and parent can decide when and how many additional ounces at each individual feeding.  They can gauge when the baby seems more or less hungry and adjust the volumes accordingly.  Some babies who are directly breastfeeding will consume more milk early in the morning or in the middle of the night and do not require supplementation.  The parents can reserve that milk and provide a bit more later in the day if the baby appears hungrier.  Providing a goal of X number of ounces per 24 hours can also help families who may be unintentionally overfeeding their baby find a more reasonable volume for appropriate growth. 

 

The third recommendation to pump 20-30 minutes, every two to three hours, is untenable.  While this schedule may work initially, keep in mind all the steps involved:

  • Find a good, private location to be comfortable and set up the pump
  • Wash hands
  • Gather all the pieces for the pump and put it together
  • Adjust vacuum/speed. This may need to be adjusted several times during a session
  • Implement techniques to elicit multiple milk ejection reflexes (MER), such as:
    • Massage (hands, baby brush)
    • Warm compresses (re-heating as needed)
    • Auditory stimulus (music or the baby’s cry)
    • Visual stimulus (pictures of baby or relaxing scenes)
    • Olfactory stimulus (smelling baby’s clothes or blanket)
  • Once pumping has ended, transfer milk into appropriate storage containers
  • Label milk
  • Wash pump parts

How long do you think it takes to do each of these steps?  Many of my clients report it can take anywhere from 30-45 minutes, EACH session.  They have 75 minutes between pumping to care for themselves (shower, eat, sleep) or attend to family needs.

A more reasonable recommendation is to pump 6-8 times in 24 hours, including once at night, for those who are exclusively pumping.  While this may appear to be the same suggestion, it empowers parents and provides them with more control over the exact timing of the milk expression sessions.  Many find it more effective to pump more frequently during the day/waking hours and allow for a longer sleep stretch at night.

Fixing the problem can be quite complex.  It usually includes a way to supplement the baby to provide the least interference to breastfeeding.  The recommendation should consider the parent’s desires and capacity to supplement in that manner for days or weeks.  Supplementing at the breast with a tube, syringe or supplemental device is what many clinicians recommend because it provides stimulation to the breast and helps the baby to equate the breast with nurturing and nutrition.  Cleaning these devices may take a bit more time than a bottle because of the size of the tubing, etc.  Parents need to know if there are special tools to keep everything clean.  Plus, these devices may need to be replaced frequently.  Is there a convenient and affordable way for parents to obtain replacement parts?  The solution for “how to” supplement the baby is to empower the parents to decide what method is best for them.  A shared decision-making model provides the parents with the pros and cons of different methods.  It allows them to pick and choose what method will work during different times of the day and the flexibility if they choose to go out with the baby.

Follow-up is crucial.  Providing the family with several opportunities for evaluating and modifying the care plan is important to increase the duration of breastfeeding.  Discharging a family without appropriate support is a disservice to the family.  Refer them to resources in the community for support, weight checks, and to providers who are covered by insurance. 

Provide families reasonable recommendations.  Many families are relieved and grateful to gain more control over their lives when the burden of a rigid structure is lifted.  Empower them to meet their breastfeeding goals.  Learning more about how to be responsive to their baby will aid their self-efficacy as parents.  Parenting is a marathon, not a sprint!  Giving them the tools to succeed will have long-lasting effects!

 

Resources:

Wilson-Clay B & Hoover K.  The Breastfeeding Atlas. 6th ed. Manchaca, TX: LactNews Press, 2017, p115.

Baby Behaviors from the California WIC Association, in collaboration with UC Davis Human Lactation Center. https://www.cdph.ca.gov/Programs/CFH/DWICSN/CDPH%20Document%20Library/Families/FeedingMyBaby/970027-Getting-To-Know.pdf

Campbell SH, et al. Core Curriculum for Interdisciplinary Lactation Care, 4th ed. Burlington, MA: Jones and Bartlett, 2019, pp. 427-437.

Stanford Medicine. Maximizing Milk Production with Hands-on Pumping. https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html

 

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Now parents are overwhelmed with well-meaning advice from a variety of sources on infant care as well and breastfeeding, before they leave the hospital.  As lactation consultants, we want to tell parents they are doing a good job.  We know that encouragement from a health care provider improves breastfeeding initiation and duration rates.  Yet many families worry about whether or not their babies are “getting enough”.  It is a common concern amongst mothers across the world.  Parents want to know what things to watch for in the early weeks and how to know they are being successful.  Lactation Consultants need to listen to parents concerns.  There are articles and blogs on the internet that scare parents about breastfeeding.  Their concerns are real and should not be dismissed as a “nervous new parent”.  After we listen, we can support them by providing the appropriate anticipatory guidance to give parents objective standards, so THEY can evaluate if their babies are “doing great”.

What does that mean?  Instead of saying, “you’re doing great, mom” as a parent is discharged from your hospital, describe to them what you see and how they compare to these objective measures.  Some scripts many nurses and lactation consultants find helpful are:

Evaluate hydration

*Show them how their baby is hydrated, “see how the baby’s mouth is wet and moist”.  Or “notice how your baby’s pee doesn’t smell like urine?  That is exactly what we expect.” Or “today your baby is one day old and you noticed those uric crystals.  You should not notice them when you are home.  If you do, you may want to contact your pediatric provider or lactation consultant”.

*“Continue to write down the pees and poops to know if your baby is transferring colostrum.  Remember, what goes in, comes out!  If the baby has >3-4 wet and >3-4 bowel movements per 24 hours, that is a good sign that the baby is transferring well.   The poop should be yellow in color by day four. Keep a chart by the changing table or use an app, which is shared by all who are caring for the baby, to help you keep track. Everyone is tired and may become forgetful in the first few days you are home.”

*“If, during the first week of life, the baby goes more than 24 hours without a bowel movement, contact the pediatric provider or lactation consultant.  It may be a sign that the baby is not sucking in a way to transfer the milk.” It is highly correlated in the research that if, during the first week of life, a baby does not have a bowel movement in 24 hours, the baby is not transferring adequately, and thorough evaluation is necessary.

 

Evaluate swallowing

*Show them how to tell WHEN their baby is swallowing, indicating a nutritive suck.

*Tell them HOW you know the baby is transferring appropriately.  “We expect babies to lose weight in the first few days.  Your baby has lost 5% of birth weight, which is in the range of normal weight loss.  The baby may continue to lose weight for the next 24 hours.  It is ok and we expect a baby to begin to regain birth weight around day 4 or 5”.

 

Sleeping patterns

*” The first night or two when the baby is home, it is normal for the baby to be awake at night.  Their circadian rhythms are opposite of yours.  They are a bit jet lagged! Expect the baby to wake at night and feed almost every hour on the hour.  It doesn’t mean that your baby isn’t getting enough.   The output is what tells you that.  Their wakefulness shows you they are ready for a feeding.  They will get into a better schedule to be up more during the daytime soon.”

 

Nipple pain

Nipple pain and trauma are a top reason why people stop breastfeeding.  Many families want a skilled nurse or lactation consultant to evaluate the latch prior to discharge or in the early days.  Instead of saying “the latch looks good to me”, explain how it looks appropriate:

* “You seem to be in a comfortable position to bring the baby to the breast.”

* “The pillows you are using have brought the baby up to the level of the breast.”

* “Keeping the baby’s nose near your nipple will help the baby to open more widely.”

* “Notice how your baby’s mouth is open wide before you bring the baby to the breast.”

* “Holding the baby’s neck with your hand can help to guide the baby to the breast.”

* “Creating a sandwich of your breast with your hand can help to orient the breast to the baby’s mouth and allow for a wide latch.”

* “You should feel tugging and pulling of the breast and nipple but not pain.”

 

If a mother is in pain, it doesn’t matter that the latch “looks good to you”.  It matters what it feels like to her.  Nipple discomfort in the early days is common but not normal.  She needs to find a solution otherwise, she will stop breastfeeding, either temporarily or permanently. Please refer to the appropriate lactation consultant for a more thorough evaluation.

 

Empower parents

Show them how they are capable to care for their baby.  Telling them they are doing a good job without demonstrating how you know it, puts their need for an evaluation into someone else’s hands.  Give them the tools they need to be successful.

 

What are some of the things that you say to parents to give them the confidence they need to know they are doing well with breastfeeding?

 


 

Provider encouragement increases initiation and duration rates:

https://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.PDF

https://www.researchgate.net/profile/Sharlene_Gozalians/publication/295102563_Evaluating_the_impact_of_provider_breastfeeding_encouragement_timing_Evidence_from_a_large_population-based_study/links/57b5ef6f08aede8a665bb8b2/Evaluating-the-impact-of-provider-breastfeeding-encouragement-timing-Evidence-from-a-large-population-based-study.pdf

 

Concern about whether baby is “getting enough”.

https://www.npr.org/sections/goatsandsoda/2017/06/26/534021439/secrets-of-breast-feeding-from-global-moms-in-the-know

 

International Lactation Consultant Association: Guidelines for the Establishment of Exclusive Breastfeeding (2014) (Can be found at ILCA.org)

https://breastfeedingusa.org/content/article/diaper-output-and-milk-intake-early-weeks

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The International Board of Lactation Consultant Examiners (IBLCE) has announced their plans for a new lactation support credential. The IBLCE is the organization that currently offers the certification credential for lactation consultants, the gold standard in lactation credentials, the IBCLC. The new credential will provide;

  • a credential for those who do not wish to pursue the full requirements for IBCLC certification
  • a stepping stone for those who seek a credential they can use for employment until they qualify for the IBCLC certification

This new credential will hopefully consolidate the many lactation credentials that are currently being offered by various groups. The United States Lactation Consultant Association has compiled a current list: Who’s Who in Lactation.
http://uslca.org/wp-content/uploads/2017/07/2-page-Whos-Who-updated-July-2017-Watermark.pdf


This plethora of course credentials is confusing for those aspiring to this field, as well as employers. With training at various levels, it is impossible for national organizations and health ministries who would like to measure the efficacy of breastfeeding services offered by those with differing levels of education and clinical experience.


In 1985, the IBLCE 1) developed a criterion-referenced examination for lactation support providers around the globe based on practice analysis survey (also known as a role delineation study), 2) defined clinical competencies and a scope of practice and 3) administers an accountability system for maintaining quality care. A similar system will be set in place for the second credential. One uniform testing organization will allow the standardizing of content of the curriculum taught to match the skills necessary to be a lactation support provider at both levels, current and proposed. The evidence demonstrates that integrated lactation care, provided by the appropriate provider, will help families meet their goals. The evidence also shows that skilled care provided at the time it is needed will improve national goals for initiation, exclusivity and duration.


There are situations and practice settings where access to an IBCLC is limited. Community health workers, peer support counselors, prenatal lactation educators, hospital bedside care providers all play a role in breastfeeding support. ALL lactation support providers deserve recognition of their education and competence to provide a standard of care which will support breastfeeding families. A global exam and credential created and managed by an organization which has done this for the past 30 years, is a benefit to those who want to provide service at a level below that of the IBCLC.


There are many for whom the IBCLC is out of reach due to the un-availability of training, cost of the college courses and lack of mentors available for clinical training. A entry-level credential will likely meet the needs of many world-wide.


Some are concerned and confused by the new credential. It was reassuring to see IBLCE listening to concerns at the ILCA conference and promising they will continue to dialogue with all stakeholders including IBCLCs, training organizations, government agencies, and health ministries. The creation of a new credential is a process and will not happen overnight. LER supports the IBLCE in their efforts to follow the process to bring a new credential to the landscape of lactation support providers.

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Katie Hinde is studying breast milk’s status as the first superfood, providing babies with invaluable microbes custom-tailored to their individual needs, via an incredible and unlikely dialogue between the mother’s enzymes and the baby’s saliva.  And in studying the marvels of human breast milk she strongly advocates for a society and health care system that will support the breastfeeding goals of all women.

Katie Hinde Associate Professor, Director of the Comparative Lactation Lab in the Center for Evolution and Medicine and the School of Human Evolution and Social Change at Arizona State University. Click the link below to view her TED Talk.

https://www.ted.com/talks/katie_hinde_what_we_don_t_know_about_mother_s_milk

Maybe her March Mammal Madness can be your inspiration for your next World Breastfeeding Week event!  http://mammalssuck.blogspot.com/

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Lactation Education Resources has exciting plans for enhancing our Lactation Consultant Training Course beginning in January 2017. We will add micro-learning sessions – short 5-15 minute classes on a focused topic available live as well as archived for viewing later. Another welcome addition will be Virtual Teaching Assistants. VTAs will be available to students to discuss topics and answer questions about the lessons or give career advice.


There will be a tuition increase beginning January 2017. The 90-hour Lactation Consultant Training Program will increase to $975 and the other courses will increase proportionately. We have not had an increase in tuition for over 5 years. If you, or a friend, were planning on taking the Enriched Lactation Consultant Course, you might want to sign-up before the price increase. Just a head’s up. ;-)

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