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This article is full of conjecture as opposed evidence, to get people's attention. To use inflammatory statements like "nursing staff typically refuse exhausted mothers to take care of their babies" and "rigid and rule bound" elicits a negative response to the evidence-informed practices of the international baby friendly designation. Baby friendly is not just about breastfeeding. It is about helping the newborn transition to extra uterine life in the most physiologic appropriate way. ALL babies. Skin to skin, rooming in, listening to the baby, are the what these practices reinforce. For example, rooming in has been the standard of care in military medicine for over 15 years and it is what parents expect. Educating staff members and providing them the skills to support all families is a piece of the process.

This article puts the emphasis on the comfort of the mother, not newborn and his adjustment to life outside the womb. During this critical time in the newborn's life, shouldn't the emphasis be on the baby's needs for care by the most familiar person to him for transition to the new world? Adults can understand, rationalize and make adjustments to their sleep patterns, knowing it is a challenge but temporary. The baby cannot.

Part of the onus of responsibility is upon the obstetric providers to educate mothers during their pregnancy about what to expect in the immediate post-partum phase in the hours and days after delivery. Evidence shows that rooming in allows for MORE sleep by the mother baby dyad. Appropriate education about normal newborn circadian rhythms being OPPOSITE of the mother's in the early days can help them to understand that their baby should wake frequently at night. It's healthy and normal. Understanding the second and third night of life as ones which will entail a wakeful baby and to encourage the mother to plan ahead for this eventuality, will help them to be prepared. Appropriate anticipatory guidance, especially for the families with a history of anxiety and depression, will help them to be proactive in their own self-care and to plan ahead. 24-72 hours after birth, the family needs these skills to help them welcome the new member(s) to their family. Providing them with the supportive environment during this transition and the education they need to care for their baby 24/7, will empower them to do what is best for them and their family AFTER discharge.

It takes a team to support and educate everyone in adapting to their new roles as a family. To blame the baby friendly practices as being mother ‘un-friendly’, doesn't allow for the opportunity for the parent to embrace their new role in a supportive environment. Continuing paternalistic hospital practices from the 1950's, in light of new evidence from around the globe, is a disservice to our families who expect and deserve more. Quoting Dr. Maya Angelou, "I did then what I knew how to do. Now that I know better, I do better". Implementing every aspect of baby-friendly practices helps hospitals to be friendly to all families.

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(Addressing the Healthy Beginnings Partnership of Greater Prince William VA & Alexandria VA Breastfeeding Promotion Committee celebration, April 7, 2015)

There is a perspective you achieve having been in the lactation field for most of a career; for me it has been more than 30 years.  I took the IBLCE certification exam the first time it was offered, in 1985.  Back then there were no pre-requisites, just a desire to offer breastfeeding support.  Eat your heart out - those of you who are taking 90 hours of training and hundreds of hours of clinical practice!  But the changes have been good for the profession as there is so much more to know now, and we hit the ground running as a new IBCLC with a much better background.

Thank you to the La Leche League Leaders here who kept the torch burning during the years when breastfeeding rates hit their low point and the medical professionals were seduced by the claims of the artificial baby milk companies.

We have since developed organizations to foster information sharing and program collaboration; The International Lactation Consultant Association (ILCA) and the United States Lactation Association (USLCA) for lactation consultants.  The Academy of Breastfeeding Medicine (ABM), is specifically for physicians.

We have international organizations also working to promote breastfeeding and limit the use of artificial breast milk worldwide.  The World Alliance for Breastfeeding Action (WABA) promotes World Breastfeeding the first week in August each year.   And the International Baby Food Action Network (IBFAN) keeps track of compliance with the World Health Organization Code of Marketing of Breastmilk Substitutes.  The “Code” limits the marketing of artificial baby milk.

The Baby Friendly Initiative has made huge strides in promoting the hospital conditions that promote the successful initiation of breastfeeding.  There are now 250 hospitals designated as Baby Friendly which amounts to about 12% of babies being born in “ideal” breastfeeding circumstances.  So there is certainly work to be done here as more hospitals address their policies and procedures to improve breastfeeding support.

The Office of Women’s Health (part of the Federal Government’s Health and Human Services) has primarily supported employed breastfeeding mothers and encouraged employers to provide facilities and time to enable breast pumping at work.

The Centers for Disease Control (CDC) has developed a “Breastfeeding Report Card” benchmarking policies and procedures in hospitals.  This allows administrators to compare their services and outcomes to other hospitals in their state and the nation.

Back in the day, we used to lament that there was no research on breastfeeding issues.  That has certainly turned around.  Now there is so much lactation related research in so many health science journals, it is hard to keep up.

Breastfeeding Coalitions, sponsored by the United States Breastfeeding Committee and the CDC, are active in all states and sometimes several coalition and workgroups are active in an area.  I congratulate you in your efforts here in Northern Virginia to expand breastfeeding advocacy and support.

Laws ensuring the right of a breastfeeding mother to feed her baby in any public place have been enacted in almost all states.  Congratulations to you for moving this through the Virginia legislature.

So, over the past 30 years, there have been tremendous changes in the breastfeeding landscape that is gratifying to see.  I am sure I have not mentioned all of the groups involved or activities of concerned professionals.  When you have a bad day, you encounter an “uneducated” health professional or a breastfeeding mother who did not receive the support she needed at the time she needed it, just think about all the improvement that has occurred over the past 30 years and keep the faith.  Working together we are making progress!  

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We all know how important skin-to-skin (STS) contact is for a newborn and his mother.  Most hospitals are moving towards immediate skin-to-skin for all newborns (breastfeeding mothers or not) in our delivery rooms!   But what about the operating rooms? 

At a time when families are under the additional anxiety of a surgical delivery, skin-to-skin care increases family togetherness and satisfaction with the birth.  We have known for years that a cesarean delivery delays lactogenesis II and negatively affects breastfeeding duration.  With a cesarean rate of 33% in many areas, this is an issue that affects many families. 

A systematic approach makes this change more acceptable to all involved: nurses, obstetricians, anesthesiologists and lactation consultants.  An organized process of planning, testing a pilot protocol, staff training will reduce the anxiety of all staff.  Involve stakeholders from all disciplines in planning and executing the changes.  An influential champion can provide the leadership to engage staff and create enthusiasm for the process of change.   Finally, implement a preliminary protocol and refine it as needed, then make it policy.

Continual surveillance is needed to assure that the procedural changes are incorporated into practice and maintained and that there is no back-sliding into old habits.  Analyzing the improvement in Quality Assurance measures can reinforce the hard work of the staff.

How this skin-to-skin procedure is implemented will vary from hospital to hospital depending on their facility and their staff.  But Moms, infants and families will benefit as skin-to-skin becomes a normal and routine practice.

Want to explore this further?

Facilitating Skin-to-Skin Contact in the Operating Room After Cesarean Birth.

Stone S, Prater L, Spencer R.  Nurs Womens Health. 2014 Dec;18(6):486-99.

Early skin-to-skin after cesarean to improve breastfeeding.

Hung KJ, Berg O.  MCN Am J Matern Child Nurs. 2011 Sep-Oct;36(5):318-24

An interprofessional quality improvement project to implement maternal/infant skin-to-skin contact during cesarean delivery.

Brady K, Bulpitt D, Chiarelli C.  J Obstet Gynecol Neonatal Nurs. 2014 Jul-Aug;43(4):488-96

Skin-to-skin contact after cesarean delivery: an experimental study.

Gouchon S, Gregori D, Picotto A, Patrucco G, Nangeroni M, Di Giulio P.  Nurs Res. 2010 Mar-Apr;59(2):78-84

Postcesarean Section Skin-to-Skin Contact of Mother and Child.

de Alba-Romero C, Camaño-Gutiérrez I, López-Hernández P, de Castro-Fernández J, Barbero-Casado P, Salcedo-Vázquez ML, Sánchez-López D, Cantero-Arribas P, Moral-Pumarega MT, Pallás-Alonso CR.

J Hum Lact. 2014 May 20;30(3):283-286

Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature.

Stevens J, Schmied V, Burns E, Dahlen H.  Matern Child Nutr. 2014 Oct;10(4):456-73.

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At this time of year, when we are scrambling around to find the perfect present for everyone on our gift list, let’s remember that breastmilk is the gift that lasts for many holiday seasons.

In fact it is a whole pile of gifts for everyone in the family: the baby, mother, and family as well as the community at large.  And these gifts are free!  Now where do you get a gift, that keeps on giving, for free?!

Here is wishing a years’ worth (or more) of breastmilk for every baby, mother, family!

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Hospitals which are attempting to initiate Baby-Friendly practices have received a lot of press recently.   Not always does the reporter get the details right.  Sometimes the headline is negative, but the story is essentially positive. 

But at least people are taking notice of the movement!  Here is just a sampling of what has been published recently.

Hospital Support for Breastfeeding: On the Cusp of Big Changes, Time to Step It Up

'Baby-friendly' hospitals: Moms give new measures mixed reviews

Local hospitals strive to offer a balance of maternity options

UNM Hospital receives prestigious “Baby-Friendly” designation

No Nursery, No Formula, No Pacifier:  Are “baby-friendly” hospitals unfriendly to new mothers?

 In the article published in Slate, the journalist quotes a study that says formula use promotes breastfeeding by relieving maternal stress.

But she neglects to address the main reason why exclusive breastfeeding is so important, the changes in the newborn gut from even limited amounts of formula.  Here are just a few selected research articles related to the importance of gut flora and how it can be impacted by breastmilk or formula.

Effect of breast and formula feeding on gut microbiota shaping in newborns

 Effect of formula composition on the development of infant gut microbiota.

 Maternal factors pre- and during delivery contribute to gut microbiota shaping in newborns.

 Human gut microbiota: onset and shaping through life stages and perturbations.

 The long-term health effects of neonatal microbial flora

 I suspect, as more and more hospitals become Baby-Friendly and institute policies that promote exclusive breastfeeding, the rhetoric will heighten even further.

Congratulations to those over 215 hospitals who have achieved Baby-Friendly Hospital designation.  Lactation Education Resources is proud to have been a part in the educational preparation for designation in many of these hospitals.  There are currently 250+ hospitals using the LER training. 

At present, only 9.4 of the births in the US occur in Baby-Friendly hospitals.  Let’s not stop until we have 100%!!

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Let your imagination go wild!  What would the world look like if breastfeeding was ultimately supported?

  • Every mother has breastfeeding education during pregnancy
  • Pregnant women are encouraged to breastfeed by their friends and family and are offered positive stories
  • All health care workers mention breastfeeding in a positive light
  • Every maternity shop promotes breastfeeding bras, tops and night gowns
  • All new mothers chose to breastfeed and plan on it for at least a year
  • Every hospital makes skin-to-skin care the norm after vaginal and cesarean deliveries
  • Rooming-in is standard in all hospitals
  • Formula and pacifiers are not available in hospitals except for true medical need
  • Visitors are limited in hospitals to “immediate family” only
  • Every mother has erect nipples that are easy for latch
  • Every mother’s milk comes-in in 24-48 hours
  • No breastfeeding mother has sore nipples
  • Mothers are able to breastfeed around the clock as long as their baby requests that and are not tired the next day
  • Engorgement is mild and viewed as a good sign that the milk “is-in”
  • Breastfeeding mothers do no need a support group because everyone is supportive
  • All mothers have an abundant milk supply
  • No mother ever leaks, especially when she is in the company of strangers or co-workers
  • Slings and carriers replace “baby buckets”
  • Most employers have day care facilities in-house and encourage mothers to feed 2-3 times per day
  • Other employers offer private breast pumping facilities
  • Every store, restaurant, office, airport and airplane the breastfeeding mother visits, encourages her to stop, relax and feed her baby
  • All babies gain weight at an appropriate rate (WHO standards)
  • Everyone who encounters the breastfeeding mother says “You are still breastfeeding, aren’t you?”
  • Formula manufacturers are in danger of going out of business
  • There is a rainbow over every breastfeeding mother’s residence

And all babies get the benefit of breastfeeding for at least a year

What would you see in Lactopia?

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Posted by on in General

Why is change so hard?  Whether it is something as simple as adding a new skill to our “tool box”, or a big project such as Baby Friendly Hospital designation, it can be hard.  It puts us outside of our comfort-zone.  That safe feeling of confidence, security and being free of risk.

For some of us, adapting to change is easy.  It may be uncomfortable for a short time, but basically not a big deal and we move on doing things the “new way”.   We are sometimes called the “innovators, or the early adopters”.   We view a new way of doing things as a challenge and we find it exciting.  We welcome the change.

For others of us, adapting to change is difficult.  And down-right scary.  We find any and every reason not to make change.  We are in the group called the “late adopters or the laggards”.  We dig in our heels and won’t listen to reason. 

There is, of course, the group in the middle who see the majority of people making the change and who will go along with the crowd.

My mother-in-law was a late-adopter.   Microwave ovens have been common place in kitchens since the 1960’s.  She refused to have one.  Even when her adult children bought one for her at Christmas years later, she refused to use it.  It sat in the garage.  “I can’t see any reason for it.  The stove works just fine”.    No way would she explore what benefits it might have for her.

So when change is thrust upon us by our supervisor, or maybe by the management’s decision to become Baby Friendly, how do we handle it?  Embrace it or resist it?  Or maybe wait to see what everyone else thinks first.

Getting un-stuck

  • Know why you are making the change
    • Gather the relevant research and review it.  Discuss it in a committee meeting.  Decide how the research aligns or doesn’t align with your current policies and procedures
    • What could be the upside of making the change?
  • Know how to make the change
    • Let people vent and grieve the loss of the old way
    • Change policies and procedures based on your analysis of the research
    • Get needed resources whether those are people resources or equipment
    • Orient staff to the new policy and procedure
    • Start small – make a small change, then several small changes, then you will have a big change
  • Avoid failure.  Nothing is more discouraging than working on a project just to have it fall apart.
    • Plan carefully to avoid unintended consequences
    • Be ready for set-backs whether in the form of the laggards who give you resistance or the administration who change their support/resources.
  • Making it stick
    • Keep the enthusiasm going with staff meetings, supervisory sessions, posters,
    • Use peer support for those who need coaching
    • Use peer pressure for those who are resisting


Let’s look at the concept of delaying the newborn bath that is usually done soon after delivery.   I have heard nurses say, “We do the bath when the mom is transferred to her post-partum room.  She can’t hold her baby then anyway”.  Or, “Moms don’t want to hold a gooey baby”.  Or, “how could a bath make any difference in initiation of breastfeeding?”

Why should a hospital make the change to delaying the bath?  Search up the research.  Here are a couple of specific articles, but there are many more on the consequences of delaying skin-to-skin contact for mom and baby.  Skin-to-skin is essential for a good start to breastfeeding and it is often delayed or interrupted for the baby bath.

A delayed newborn bath was associated with increased likelihood of breastfeeding initiation and with increased in-hospital breastfeeding rates.

Preer G, Pisegna JM, Cook JT, Henri AM, Philipp BL.  Delaying the bath and in-hospital breastfeeding rates.  Breastfeed Med. 2013 Dec;8(6):485-90.

In this review of the literature, procedures beneficial to initiating breastfeeding such as drying, skin-to-skin contact, delayed cord clamping, and delayed bathing were either omitted or inappropriately sequenced in the time immediately after birth in a significant number of institutions.  Sobel HL, Silvestre MA, Mantaring JB, Oliveros YE, Nyunt-U S.  Immediate newborn care practices delay thermoregulation and breastfeeding initiation.  Acta Paediatr. 2011 Aug;100(8):1127-33.

Does the research support the policy and procedure on the timing of bathing?  If not, what is the best way to modify it.  Delay the bath for two hours or for four hours, wait until the baby wakes up from his first deep sleep, wait until the nurses routine bathing time, wait for 24 hours, or wait until hospital discharge?  A bath demo could be done with the parents in the discharge teaching.  What will work for your hospital?  Maybe little steps would be a good start.  So start with a delay of 2-4 hours.  When that is working well, make it 24 hours or at hospital discharge.  Explain to parents what the policy is and why you bath babies the way you do.  Enlist their support.  The vernex is good for the baby’s skin and can be massaged in.

What could be the upside of changing to delayed bathing?  It saves nurses time, babies don’t have to spend extended periods of time under the radiant warmer warming up after the bath and the bathing procedure can be used as a teaching tool with new parents.

If there are several people who are not embracing this new procedure, let them vent.  Acknowledge that change is difficult and the old way of doing things seemed to be working well.  Help them move past this.

Have your pediatric committee or breastfeeding committee review the policies and procedures based on the research that was reviewed and make the needed revisions.  Communicate the revision to the staff so everyone is aware of the change.

Think about what resources might be needed.  Are there any?  How can in-servicing of the new procedure be done most effectively?  Will you use staff meetings or have a skills station?  Posters?

What unintended consequences may happen?  Do your homework.  Know what pitfalls there could be and plan to avoid them.  Will babies become chilled?  Make sure that babies are dried and placed skin-to-skin immediately after birth.  Are warmed blankets available?  What other unintended consequences might arise?

Involve everyone in evaluating how the new procedures are going.  Make any adjustments that are necessary.   Maybe you can give your laggards a key role in supporting the new procedure.  That just might help them become your strongest innovators.

Keep the ball rolling!  Who are your innovators who can give encouragement and training to the rest of the staff?  Have them lead by example.  And then you can use a little peer pressure to bring around the rest of the staff.

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The Baby Friendly Hospital Conference is an annual event sponsored by the New Mexico Breastfeeding Task Force held in Albuquerque, New Mexico.  The over 150 delegates attending the conference were eager to hear KimMarie Bugg, Jane Morton, Molly Pessell, Kittie Frantz and others as they informed us of current research and helped build enthusiasm for the Baby Friendly Hospital movement. 

As an exhibitor at the conference, we at Lactation Education Resources, were pleased to present our online training to hospitals looking for training resources.  Representatives of interested hospitals were thrilled to hear that online training can be very affordable, is easy to use and streamlines the tracking process.

For hospitals using HealthStream, the program files can be loaded and run on the hospital system.

For further information, please go to or contact Juanita at  A free course trial is available here

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