Lactation Management Training: From Novice to Expert

Lactation Education Resources Blog

You get a call from a prenatal client who discloses that she is living with HIV. She asks you whether she can safely breastfeed her baby. Do you know how to answer?
On a new client history form, a mother includes antiretroviral therapy (ART) on her medication list. She tells you she is feeding her baby her milk but would like to also feed formula. Do you know whether this is a safe option?
An exclusively breastfeeding client asks for your help with sore and damaged nipples. She tells you she is HIV positive, and she’s worried that her damaged nipples may put her baby at risk for HIV transmission. Do you know how to counsel her?
Dayna Hall, BS, IBCLC, ICCE, ATC, a researcher with extensive experience working at a hospital in Africa in an area where one-third of the population was living with HIV and the instructor in a new Lactation Education Resource class shares some information and strategies with lactation consultants here.
What does U = U mean?
When a person undergoes antiretroviral therapy (ART) and effectively suppresses their viral load to the point that the virus cannot be detected, they can no longer transmit HIV to another person via sexual contact. In 2016, a campaign was launched that assigned the shorthand “U = U” to this concept (standing for “undetectable equals untransmittable.”) The term has been accepted by 800 groups, governments, and organizations in more than 100 countries.
“For people taking ART as prescribed and achieving and maintaining viral suppression, there is effectively no risk of transmitting HIV through sex,” Hall says.
Does U = U apply to breastfeeding?
Unfortunately, the answer is not an automatic yes—it’s more nuanced than that. “The U = U campaign, for the time being, is specific to sexual transmission,” Hall says. “People living with HIV, adhering to their ART, can safely conceive because the virus is suppressed. But ART is not a cure.”
What do major health organizations recommend?
At the moment, that depends on what organization you ask.
WHO and UNICEF recommend that parents living with HIV exclusively breastfeed their infants for six months and continue breastfeeding for at least 12 months or longer while being fully supported for ART adherence.
The CDC, however, recommends that parents with HIV in the United States not breastfeed their babies at all. National organizations in Britain, Australia, and Canada have similar policies.
Why the discrepancy?
Simply put, WHO has adjusted its recommendation based on ART, while others have not.
Recommendations by the CDC and others are still based on the concept that when safe formula feeding is possible, it is less risky than breastfeeding with HIV, regardless of ART treatment and viral suppression.
“This is in marked contrast to the WHO, which recognized that the demonstrated gains in the availability and use of ART in all resource settings warranted a change to their global recommendations for infant feeding,” Hall explains.
What is the bottom line?
With the availability and effectiveness of ART, the balance of risks and benefits of breastfeeding with HIV has dramatically changed, according to Hall, and lactation support provider’s recommendations need to reflect that new reality—while always considering the entire picture for each unique family and collaborating carefully with the family’s entire care team.
Says Hall: “It is ethically justifiable and frequently safer for providers to participate in a shared decision-making process to develop a feeding plan that may include exclusive breastfeeding for infants whose mother is living with HIV.”
Hall offers an in-depth look at the complex, ever-changing landscape of lactation and HIV and outlines the science and politics behind conflicting recommendations in “WHO Says What,” a new course at Lactation Education Resources. To learn more, register for the full class here.
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Is your community ready to support infant and young child feeding in emergencies? The emergence of COVID-19 has shone a light on the need for advance planning to ensure the wellbeing of the youngest people during natural and man-made disasters.
Here are six questions to explore in your community:
Can your community define IYCF-E?
IYCF-E stands for “infant and young child feeding in emergencies,” and it refers to meeting the nutritional needs of children from birth to 2 years old during a disaster. Disasters can be natural or manmade, and they can be personal or public. Examples range from hurricanes and earthquakes to the sudden homelessness of one family due to changing financial circumstances. “These various types of emergencies are similar in that they completely disrupt daily life and one’s ability to meet basic needs,” explains Malaika Ludman, MPH, CLC, doula, and instructor for Infant Ready: Infant and Young Child Feeding in Emergencies, a new online course.
Does your community have an IYCF-E plan?
Although it is often ignored in a country, state, city or province’s disaster preparedness plan, IYCF-E is critical. Globally, the total mortality rates for children under one year of age in emergencies are as high as 53 percent.
“We find that the disease and death rate among infants and young children in emergencies is high,” Ludman says. “The leading causes of illness and death are respiratory illness, diarrhea, and malnutrition. . IYCF-E merits a lot of attention, because many children are living in areas affected by emergencies. In the US, emergency response training and preparedness do very little to address infant feeding.”
Infants and young children are uniquely vulnerable in emergencies for three reasons:
  • They are very susceptible to illnesses
  • They can’t care for themselves
  • and
  • They have very specific nutritional needs
Does your community hold misconceptions about breastfeeding during emergencies?
The absolute safest food for a baby during an emergency is his or her own parents’ milk. Unfortunately, misconceptions about breastfeeding during a crisis abound, and families are likely to receive these messages from the media and other sources. They may hear that parents who are under stress cannot or should not breastfeed, that malnourished mothers won’t make enough milk, and that infant formula is a better choice. If breastfeeding has been interrupted by the emergency, they may be told it can’t be started again. If a baby develops diarrhea, the family may be told to stop breastfeeding.
Does your community know the impacts of protecting breastfeeding during emergencies?
A baby who gets breastmilk during a crisis receives disease protection from a safe, accessible food source. It offers complete nutrition at the perfect temperature, keeping the baby warm and reducing stress. On the other hand, formula-fed babies are at much higher risk of infection during an emergency, due to the risk of contamination of the water, surfaces, or supplies used to mix the formula.
Take the stunning example of a flood in 2005 in Botswana. After the flood, there was an outbreak of diarrhea that took the lives of more than 500 children, most under 5 years old. Formula-fed babies were 30 times more likely to present for hospital treatment for diarrhea than breastfed babies. In one village, 30 percent of formula-fed babies died, while no breastfed babies died.
Overall, “hundreds of formula-fed babies died, compared to only a handful of breastfed babies,” Ludman says. “We assume that none of the breastfed infants in this village died because of the protective nature of breastmilk and because these infants were not exposed to contaminated formula, water, or surfaces.”
Is there a plan for assessing and supporting safe formula use?
While doing all you can to advocate for and support breastfeeding during a disaster, you also need to be prepared to effectively help non-breastfeeding families to safely feed their babies and young children. Very often, as a lactation support provider, you will have more knowledge of safe formula feeding practices than anyone else on site. “Caregivers of formula-fed infants need special attention and support because babies who cannot be breastfed during emergencies are at greater risk.”
The first step is to help the family determine whether formula feeding is necessary. When disaster strikes, unsolicited donations of breastmilk substitutes often pour in, making formula readily available and potentially attractive. But it’s important to make sure other options have been exhausted.
“Families should receive help in assessing their feeding options,” Ludman says. “The cleanest and safest food for a baby in an emergency is its mother’s own breastmilk, first from the breast, and second, from a feeding implement. The second safest choice is donor breastmilk. The third safest choice is liquid formula … and the least safe choice is powdered formula, because of the risk of infection.”
When formula is needed, lactation support professionals need to be prepared to educate families on why ready-to-use formula is safer than powdered in emergencies; supply appropriate feeding implements, clean water, fuel, and education; and offer healthcare and monitoring.
Ready to learn more?
With the New Orleans Breastfeeding Center’s 1.5-hour class, Infant Ready: Infant and Young Child Feeding in Emergencies, you will learn the basics of how to support breastfeeding and formula feeding families in any kind of crisis.
Taught by Malaika Ludman, MPH, CLC, and doula, and by Latona Giwa, BSN, RN, IBCLC, co-founder of the New Orleans Breastfeeding Center, the class delves deeply into how lactation professionals and first responders can support both breastfeeding and non-breastfeeding families during an emergency, using real-world examples and lessons from several global disasters.
The course is ideal for first responders, emergency managers, public health departments, medical volunteers, WIC offices and staff.
Infant Ready: Infant and Young Child Feeding in Emergencies
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Dear LER community member:

As we move into 2020, I want to take this opportunity to catch you up on changes for me, Doug, and the Lactation Education Resources (LER) community.

As you may know, Doug and I retired this year. After more than 30 years of educating future lactation consultants, we are grateful for the opportunity to enjoy this new phase of our lives together. (If you are in the Maryland area, you might catch a glimpse of me enjoying a morning kayak trip!)

Before we could make this transition, it was important to us to ensure that the LER community was in capable hands. We were thrilled when Kirra Brandon stepped forward with her desire to lead and support LER’s students and instructors.

Kirra Brandon is a physician and, like so many of us in the field, inspired by her own breastfeeding experience (she has nursed all five of her children for more than 113 months and counting!). She also brings considerable experience with online education. She and her husband, Gus Stern, bring experience in providing online education for health care professionals. As LER’s Medical Director, Kirra will be focused on expanding lactation education for all through increasing access around the globe and to a wide variety of health care professionals. We are so grateful that she has chosen to lead LER into the years to come. You can reach her at kbrandon@lactationtraining.com.

Of course, Kirra holds a deep commitment to LER’s mission, vision, and core values. She has been working closely with staff to make sure there has been a seamless transition of the high quality education and customer service that have always been central to the LER community.

Many of you may already know Angela Love-Zaranka, BA, IBCLC, RLC, who has worked with LER for over 15 years. She brings her deep knowledge of the profession to her new role as LER’s Program Director. In her role, Angela will continue the work I started in 1990. You can reach her at alove@lactationtraining.com.

I hope you will join me in welcoming Kirra to LER. I have no doubt that her leadership means that you will continue to enjoy the education and support for which LER is known.

Finally, I would like to share my gratitude with you for being a part of the LER community. Our students, instructors, advisors and staff together have provided evidence-based support to countless families thanks to your shared commitment to education. Thank you for all that you do on behalf of lactating families.

Sincerely,

 

Vergie Hughes, RN MS IBCLC FILCA LER Founder

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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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