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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:
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:
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!
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
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:
*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.
*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”.
*” 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 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.
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:
Concern about whether baby is “getting enough”.
International Lactation Consultant Association: Guidelines for the Establishment of Exclusive Breastfeeding (2014) (Can be found at ILCA.org)
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;
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.
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.
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.
Maybe her March Mammal Madness can be your inspiration for your next World Breastfeeding Week event! http://mammalssuck.blogspot.com/
In the initial installment of this series, we discussed the swinging pendulum of breastfeeding rates across the nation, as highlighted by the CDC’s most recent Breastfeeding Report Card. Among the data are outliers on both ends of the spectrum that warrant a closer look. Over the course of the next four installments, we’ll hear from lactation supporters who are in the trenches in four cities that are performing demonstrably different compared to the total US average and compared to the Healthy People 2020 benchmarks. We’ll discuss what is working to reach families in a unique way in each city, then at the end of the series, we’ll explore state and national efforts to increase accessibility to lactation support across the nation.
As we delve into the challenges and victories occurring in various areas, one factor that is hard to ignore is demographics. Do extenuating factors such as the mother’s sphere of influence or race or line of work directly impact breastfeeding? In short, absolutely! Income, age, education, race, and even language spoken impact healthcare experiences. This is consistent with breastfeeding and the types of support that are available in some communities as well. Breastfeeding success today requires a delicate balance of support and encouragement from many parts of a community; access to current, evidence-based information provided by relatable and available sources; and a work environment that supports pumping breaks and milk storage. The absence of any one of these factors can upset the entire system and almost certainly lead to failure.
Without question, the worst performing area in this country in terms of breastfeeding initiation and duration is the deep south. With consistent averages of 10-20 points below the US average of 81.1% of babies ever breastfed, Georgia, Alabama, Louisiana, Mississippi and Tennessee together represent a cluster of states where unique challenges like those listed above create a dearth of support and a veritable first food desert. Take Mississippi, as an example. The Breastfeeding Report Card assessed Mississippi as simultaneously having the lowest breastfeeding rates AND the lowest number of lactation support providers available (both free and paid). Success and support go hand in hand.
In the face of the lowest ratings in the nation, there are some methods that seem to be making progress. Taking a closer look at what is working allows for some insight into some of the tangible challenges, and allows for some exploration of replicating that success in further parts of this region. Looking at Tennessee specifically, we find that breastfeeding initiation rates are trending 10 points behind the national average. Not surprisingly, the data also shows a consistent lag across all the measured categories, including the number of lactation supporters per 1,000 live births. Per the TN.GOV site, some obstacles that exist within the state to prevent mothers who have the intention to breastfeed from achieving success are:
How Does Race Factor In?
Sadly, breastfeeding trends are often illuminated when broken down by race. Using almost any breastfeeding metric in the US, White mothers outperform their Latina and Black counterparts. This is even more true in communities that are segregated, which often translates into differing levels and quality of care for those mothers in underserved groups. Latino breastfeeding rates lag White mothers, but the gap is narrowed or widened depending on their country of origin and level of assimilation. This layered and complicated phenomenon will be a focus when we turn our attention to the western region.
Black mothers lag behind the general US population, white mothers, and Latina mothers in every breastfeeding metric, from a national to a local level. This creates a dire situation in many majority-Black cities where ill newborns could be greatly helped by the benefit of mother’s milk, and Black mothers could also be helped by the benefits of breastfeeding. Efforts like Black Breastfeeding Week were created to overcome the obstacles that Black mothers face and to highlight breastfeeding within the Black community to normalize it. With a Black population of over 950,000, Tennessee has a need for year-round, focused breastfeeding support that gets to the heart of the Black community and its specific challenges.
BSTARS: Memphis, TN
To gain a first-hand perspective of the impacts this type of focused programming and initiative could have on the lives of mothers at the local level, I had the opportunity to speak with Ms. Jada Wright Nichols, one of the founders of BSTARS in Memphis. She provided insights to better understand her program and the challenges that necessitated its inception. BSTARS’ mission is to support, protect, and promote Black women as they choose to breastfeed. Their work is impacting Black families in Memphis by combatting several of the listed obstacles to breastfeeding success in Tennessee. They are working to build a supportive community armed with confidence and solid information about breastfeeding. The template they have developed is tailor-made to fit the needs of mothers in Memphis, yet is flexible enough to plant elsewhere, and expect similar success.
Can you tell us about the inception of BSTARS?
Breastfeeding Sisters That Are Receiving Support (BSTARS) began in Memphis, TN out of the need to address the low breastfeeding rates amongst mothers of color in the city, while also highlighting those who do breastfeed, but often go unnoticed. Memphis has some of the lowest breastfeeding rates, highest infant mortality rates, highest breast cancer (and diabetes, and obesity) rates, highest poverty rates, and highest segregation rates in the country. We hope that helping to improve breastfeeding rates through consistent and accessible education and support, will also help to bring some of these other social and health issues into balance. We were created through the generous cooperation of the Shelby County Department of Health, Shelby County Breastfeeding Coalition, and Atlanta-based Reaching Our Sisters Everywhere (ROSE).
How has the organization grown/evolved since it began?
We began with a hearty level of interest. At our first official meeting, we had certified lactation counselors, WIC peer counselors, lactation consultants, nurses, and physicians of color all eager to support pregnant and nursing moms.
At each meeting, we discuss a health topic and how it relates to breastfeeding, while also offering skilled breastfeeding support. We have had speakers from the community to address nutrition, exercise, postpartum mood disorders, smoking, birth control, safe sleeping, and family support. We have a solid group of attendees, but as the topics change, so does the make-up of each month's group, depending on the needs and interests of the families. We love being able to support the entire family. We regularly have partners, sisters, mothers, and grandmothers present to hear the same information as the mothers. We always have a lite meal, and an area for children to play or do homework. We are in our second year and growing strong, heading toward becoming our own 501c3 organization.
How is the community better off due to your presence?
Thanks to several of our signature events, Memphis has a greater awareness and appreciation of breastfeeding moms within the city. We have a community baby shower where we distribute pack-n-plays, car seats, nursing pillows, and pumps to 30 families. We have an annual walk along Historic Beale Street and throughout downtown Memphis to promote breastfeeding, health, and sisterhood. We have many community sponsors for this event, including Hooters - our favorite. Perhaps most impactful, we organized a one day breastfeeding symposium, which attracted healthcare providers from 4 states to gather to hear about current research and initiatives in breastfeeding. We were greeted by city officials excited about supporting breastfeeding, and we heard from some of the top voices in the field of lactation. We also have an intimate Facebook group, wherein moms of color ask questions and document, with pride, their breastfeeding journeys.
Could something like BSTARS be duplicated elsewhere?
Absolutely! We are already discussing its replication in a few communities and we are happy to help any others who are interested.
It’s a little too soon to see empirical data on the effectiveness of BSTARS. However, historically, the type of focused attention that BSTARS provides yields notable increases in mother confidence, breastfeeding initiation, and duration. Anecdotally, Memphis physicians have already noted that Black mothers seem to be inquiring more about breastfeeding, and breastfeeding for longer periods since BSTARS launched. There is great promise and potential at the local level for closing gaps in breastfeeding and BSTARS is one shining example of how it can be done. Next up, we’ll look at trends in the Western US and explore a program that is focused on groups that are still challenged, even amid high breastfeeding rates in their state.
If you would like more information about BSTARS, please contact founder and director, Tiana Pyles at firstname.lastname@example.org or Memphis BSTARS on Facebook.
I started Nursing at a very young age and still I have several years to work. My experience includes 30+ years working OB. What a wonderful way to finish my last trimester than helping new Mom's to perfect their God given ability to nourish their babies.
I breastfed my first 2 children with ease for almost 9mo each. When I had my third child I got a very serious nipple wound from improperly pumping. Every time I nursed my daughter it would tear open and bleed. I didn't know what to do or how to help myself. I kept thinking that if I just placed her properly on my breast it would heal.I was up day and night, reading, researching and trying to figure out how to help myself but it kept getting worse. I remember calling LLL and asking if someone could come out and help me, they could offer me phone advice but I needed someone to come to me. I was too tired to go out and get help. I did get that help, and went on to nurse my daughter for over a year. I became an IBCLC to help women in their homes, but am still based in the hospital!
Why an LC?
I read everything I could about breastfeeding before the birth of my first child. He would not nurse in the hospital, and I was told I was starving my baby. At one point he was brought to me and spit up formula, despite me having told them he was to be exclusively breastfed. My anger which I was unable to articulate at that time turned to research and study about breastfeeding. I nursed my son for a year. I’ve dedicated my professional career to breastfeeding women and their babies. It is great to see the progress that has been made.
(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!
I heard a quote recently that “Breastfeeding is part of mothering, not the point of mothering”. And I thought back on all of the mothers I have worked with over the years who desperately wanted to breastfeed but were running into problems; some easy to resolve, others seemingly unsurmountable complications. There have been mothers who endured sore nipples for months, breastfeeding/pumping/cup feeding around the clock, or repeated bouts of thrush or mastitis. Hero’s? Yes!
I have, at times, given a mother “permission” to supplement or to stop. Some have gratefully accepted the out, and others have done so with overwhelming guilt and sadness. Some have hung in there despite the problems. It seems some mothers have gotten the message that it is imperative to breastfeed. Exclusively breastfeed; supplement at your baby’s peril. Breastmilk is magic, to be sure. However, pushing moms to the edge is not part of mothering, and it is not the point of lactation consulting. Suggesting alternatives until we come upon the one that fits for this mom and baby is the point of lactation consulting.
We have a breastfeeding dyad here. Both must benefit physically and emotionally. What can we each do to prevent the kind of difficulties that get moms into those unsurmountable complications to start with? And what can we do to resolve them quickly? That is the point of lactation consulting.
Breastfeeding is a (REWARDING) part of mothering but, not the point of mothering!