Lactation Management Training: From Novice to Expert

Lactation Education Resources Blog

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A parent schedules a prenatal consult with you and explains, “I am expecting a baby via surrogate, and I’m interested in inducing lactation. But I’m not really interested in taking medication. Is it still possible?” Or a parent who is planning to adopt says, “I’d love to induce lactation. I could be matched with a baby tomorrow and bring them home next week… or I could be waiting for a year or more. How do I plan for that?” Alyssa Schnell, MS, IBCLC is an experienced lactation consultant and the author of the book “Breastfeeding Without Birthing.” Her new Lactation Education Resources course, “Individualized Approach to Lactation,” shares her extensive research and clinical experience - as well as her own personal experience - with induced lactation. Below, she shares some key points about the importance of understanding and customizing a plan for each family:
Moving beyond medical protocols
A medical protocol to induce lactation was developed years ago, and many people have used it successfully. It is often the default protocol recommended when someone is interested in inducing lactation. But as Schnell counseled more and more families, she realized the protocol wasn’t a good fit for everyone. She was discouraged when some interested patients felt that because they were unwilling or unable to follow that exact protocol, they wouldn’t be able to induce lactation after all. “I thought wait, wait, that can’t be right - there can’t be just one way that we induce lactation,” Schnell says. “I started doing a lot more research and discovered that there are other protocols out there for inducing lactation.” She’s combined her research, our fundamental understanding of how inducing lactation works, and her own extensive clinical experience to develop a three-step plan for inducing lactation that can be used by any parent wanting to induce. Each step is flexible and can be modified and customized - or even skipped - to fit the parent’s needs and circumstances.
There are alternatives to prescription medication
Some patients are unable to or unwilling to take prescription medications that are commonly used to induce lactation. At each step, there are non-medication approaches if medication is not right for that individual parent. Those same approaches can also augment protocols that call for medication. Herbs, alternative therapies like acupressure and acupuncture, and manual techniques like breast massage are all ways to support milk production. Each should be customized to the parent’s specific situation, goals, and health history.
It’s not just adoptive parents interested in inducing lactation
The most frequently discussed scenario for inducing lactation is that of an adoptive parent. But there are many other people who may contact an IBCLC for support with inducing lactation, including an intended parent (baby arriving via surrogacy); the partner of a gestational parent; a transfeminine parent; and more. “I want to walk attendees through each of these circumstances and help you understand what the different needs and nuances are for each of them,” Schnell says.
A parent does not need to induce lactation to nurse!
Schnell explains that while parents and lactation consultants can often become very focused on the goal of milk production, it is not necessary to induce lactation to establish a nursing relationship. Without making any particular effort to establish milk production, the parent may choose to comfort-nurse the baby (for example, nursing to sleep, nursing after the baby has had a bottle, and/or feeding the baby using a nursing supplementer at the breast/chest). “The intention is to have the benefits of the closeness and the physical components of baby feeding at the breast or chest, and not emphasize about getting the parent’s milk,” Schnell notes. While those approaches may encourage the body to make some milk, the focus is on the bonding and nurturing that come from the nursing relationship.
Both sharing her own story and the stories of the many patients she has worked with, Schnell illustrates the many different ways induced lactation can look, and provides specific tools and strategies for the IBCLC counseling any family interested in inducing lactation. And beyond induction, “I also hope that this information will help you with other situations as well,” Schnell says. “This information applies to relactation, insufficient glandular tissue, breast reduction surgery, and any other low milk production issue.”
And Schnell is offering two additional courses that will provide you with even more resources and skills to support patients who are building milk supply: “Tools for Supplementation,” and “The Proficient Pumper.” All three courses are included in her new online conference, now available at Lactation Education Resources.
Enroll Now
Looking for other resources on relactation?
Check out our free fact sheet
Here
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Posted by on in General
So many people who are excited about working in the lactation field begin by earning a certification like Certified Lactation Educator, Certified Lactation Specialist, Certified Lactation Counselor, WIC Breastfeeding Peer Counselor, LER’s own Certified Breastfeeding Specialist, or one of the many other “mid-level”, shorter lactation trainings out there.
Many then use that training to help families through work or volunteer experience, getting hands-on time providing clinical lactation support. While they would love to take the next step by becoming an IBCLC, they know more education and training is involved, so it seems like a dream for “someday.”
Sound familiar? If the description above fits you, the IBCLC may actually be closer than you think!
To be eligible to take the IBCLC exam, you need to complete three components: clinical hours, general health science education, and 90 hours of lactation education.
Clinical Hours
If you are providing lactation support through your work, or if you’re a trained counselor for a peer support organization, you may already be earning Pathway 1 clinical hours without realizing it! And if you are seeking to earn your clinical hours through mentorship in Pathway 3, you may be interested in LER’s internship program. (Not familiar with the Pathways? Read more about the different options here.)
General Health Science Education
If you’re already a health care professional like a nurse, dietitian, physician, or midwife, you’ve automatically fulfilled the general health science education requirements with your prior training. Even if you’re not, the list includes many classes you may already have taken, like biology, nutrition, and statistics. (You can find a full list here, as well as links to LER partners offering courses you may still need to complete.)
90 Hours of Lactation Education
The final step is simply to complete your 90 hours of lactation education. Your current training has given you a good foundation in lactation support basics via 45-55 hours of didactic education - so you’re already at least halfway to the 90 hours! That’s where LER’s new Lactation Consultant Bridge Course comes in: you can complete your education hours, prepare for the IBCLC exam, and most importantly, prepare for the advanced practice knowledge and skills required for IBCLC professional practice.
To create the Bridge course, we took a deep dive into what was covered in the course for our basic credential, the Certified Breastfeeding Specialist. We considered the additional necessary topics to provide a truly well-rounded IBCLC education. When you walk into a room as an IBCLC, the expectation is that you have a comprehensive, in-depth education to be prepared for almost any question or scenario. We compiled our cutting-edge workshops and lectures into the Bridge course, with a focus on compelling topics that lactation consultants face in practice.
Bridge topics include working with multiples, premature infants, relactation and induced lactation, infant feeding response in disasters, and so much more. In total, the Bridge course offers 45 hours of amazing content to prepare you for a wide range of practice situations. We hope it will enable you to complete your lactation education and that once you’ve “crossed the bridge” to IBCLC, you’ll realize it really was closer than you thought!
Common questions about the Lactation Consultant Bridge Course:
Does the course confer a certification like Certified Breastfeeding Specialist?
No - the Bridge course doesn’t give you the foundational parts of your lactation education, but builds on a basic course you have already taken. To enroll in the Bridge course, you should have already completed a basic education course/certification l (often 45-55 hours long).
Don’t you need to go through a specific educational program to become an IBCLC?
You can source your 90 hours of lactation education from a variety of places! While you can “piece together” your education from different sources, IBLCE recommends that your education cover all the topics on the IBCLC Detailed Content Outline. The Bridge course is intended to fill in gaps in your education beyond your original training, and to help prepare you thoroughly for the exam and for practice.
Where can I complete the 5 hours of communication skills education that is now required by IBLCE?
We’ve got you covered! A communication and counseling skills course will also be available from LER for those who still need to complete that requirement. (It will be offered separately from the Bridge course.)
Tagged in: IBLCE
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Posted by on in General
IBLCE Exam Prep: Tips for Medication Questions
For those of us who are preparing for the IBLCE exam this September, especially those without a medical background, the medication questions can be particularly nerve-wracking. In this blog post, Angela Love-Zarenka, IBCLC, RLC shares tips for demystifying this part of the exam.
Start by understanding the categories of medications.
All medications can be organized into categories, such as antibiotics or anti-inflammatories. A good place to start - especially if you do not have a medical background - is to review an outline on those categories, known as classes. Learn which are the most commonly used during the time of pregnancy through weaning and familiarize yourself with those.
Identify the medications that are contraindicated for breastfeeding.
As you know from your lactation training, most medications are compatible with lactation, but some are absolutely contraindicated. Be sure you know which those are.
Learn the generics.
The exam will use generic names of medications. Be sure you are familiarizing yourself with, for example, sertraline (the generic name) and not Zoloft (the trade name).
Don’t forget vaccinations.
Learn which vaccinations are contraindicated in lactation and when. Remember, if a topic is on the exam blueprint, it may be on the exam!
Understand the why behind the guidelines.
When you are studying medication, try to not just memorize whether the medication is acceptable, but truly understand why. For example, if a mother is receiving heparin via IV, can she continue to breastfeed? The interesting thing about heparin is that it does not pass into breastmilk because the molecular weight is too big. (That is why she is receiving it via IV, not orally.) Knowing these nuances can help.
Feel Prepared to soar through your IBLCE Exam. LER offers two exam prep courses designed to help you study efficiently and effectively.
Enroll Now
Tagged in: IBLCE Exam Prep
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Posted by on in Uncategorized
Angela Love-Zaranka has been involved in lactation education for many years, and has an insider’s take on the IBCLC exam: in the past, she helped write the exam for IBLCE. Here, she shares some thoughts about studying for some of the challenging parts of the exam, and how you can plan your studying now to avoid stress later! Check back at LER blog all month for more study tips.
Find and study images you don’t usually see in training
Start by making sure you are studying images you might not have seen in your training. If you are training in a community-based setting, search out hospital-based images, like a baby in the NICU. If you are hospital-based, you are more likely to be familiar with the early stages of the nursing relationship and could benefit from images of older nurslings. Not familiar with two year olds that breastfeed? A toddler latch does not look the same as a newborn latch!
Get creative with finding practice images
The Breastfeeding Atlas is a great place to start, and will be a great reference for your practice. Ask your colleagues who can connect you with images from their practices. It’s also very helpful being on social media, looking at pictures people are willing to share. Engage in the conversations people are having about those images, and practice your clinical thinking skills. The LER online Facebook group is a great place to find those images and discussions.
Plus of course there’s practice images in the LER exam prep course!
Spend extra time on “ages and stages” images
Many people struggle with the “ages and stages,” which require the test taker to identify a baby’s age based on a photo. It’s helpful to look at pictures of babies in general - scroll through Instagram feeds, flip through old photo albums. Look at pictures of babies, see what they are doing, and see how closely you can estimate the baby’s age. For example, if a baby is holding a cup, ask yourself: at what age do babies usually hold a cup? At what age would you see crawling, cruising, or walking? Then check your guess and see how close you got. The more you practice this one, the more confident you’ll get.
Be prepared for less-than-optimal photo quality
When you’re looking at the images on the test, sometimes the images are grainy or the lighting is poor. Don’t let it throw you off! Why the less-than-studio quality photos? Because it isn’t possible to plan a photoshoot for an image like “mastitis in a person with a dark complexion.” Instead, the exam relies on the lactation community to provide clinical photos, and we’re not professional photographers working in perfect conditions! That being said, the examiners have determined that a lactation consultant should be able to answer the question based on the image and the rest of the question.
You’ve got this!
Remember to think like a lactation consultant. If you hold other credentials or training, be sure to set that aside when answering exam questions. Focus on the training you received in clinical skills. Think back to the patients you’ve already worked with, and bring your best assessment of the situation. You are ready to step into this role - and we’re here to support you!
Angela Love-Zaranka, IBCLC, RLC, is LER’s Program Director. In the past, she has volunteered with IBLCE as a question writer for the IBCLC exam.
Feel Prepared to soar through your IBLCE Exam. LER offers two exam prep courses designed to help you study efficiently and effectively.
Enroll Now
Tagged in: IBLCE Exam Prep
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Epigenetics is a hot topic these days and discussed more and more in the lactation world - but what IS it? Why is it relevant to the perinatal period? And as experts in lactation, how should we understand and explain the role human milk might play in “programming” the epigenome?
Laurel Wilson, IBCLC, RLC, BSc, CLE, CLD is an experienced lactation consultant and speaker on perinatal health topics. Her new Lactation Education Resources class shares leading-edge research discoveries in the exciting new field of epigenetics. These discoveries are changing how we think about human milk. Below, she shares some key points about epigenetics and infant feeding:
Our DNA is not destiny: it’s just a starting point.
Only a small percent of disease comes directly from genetic origin. Many people are born with a genetic predisposition to disease; common examples include diabetes, heart disease, and many types of cancer.
But not all people born with the genes placing them at higher risk for a disease will develop it. Why?
“Epigenetic” literally means “above the gene.” Epigenetic changes take place when cellular elements interact with our genes to “flip the switch:” turn genes on or off, or increase or decrease how active they are. Environmental factors like how we are fed as infants, what we eat later in life, what physical activity we do, and how much stress we experience can all flip the switch on genes that affect our health. These epigenetic changes can persist throughout life. In some circumstances they can even be inherited by following generations.
There are multiple ways that genes can be turned on or off.
One example of a way genes can be turned on or off is through the function of molecules called microRNAs. The primary role of these regulators is to turn genes off and on.
MicroRNAs can survive very difficult conditions: they can survive pasteurization and even boiling, freezing, and acidic environments - like say, a baby’s stomach.
There is a very high level of microRNAs in human milk for the first 6 months after birth - this is a stream of genetic instructions passing from parent to baby via milk. In fact, microRNAs in human milk is the only time outside of sexual reproduction that genetic material is transferred from one person to another!
Breast/chestfeeding does not just affect the epigenetics of a baby: it also affects the parent.
There are over 700 maternal genes expressed during the postpartum period! Many of the hormones and hormonal changes involved in lactation - including prolactin, oxytocin, estrogen, and progesterone - communicate to the brain that parenting is happening, and alter gene expression in the brain.
No surprise: “Many of these genes are linked to reward pathways, to promote bonding and connection between parent and child,” says Wilson.
It is vital for us to understand and communicate about this research accurately.
We are often called upon - by the families we serve, other health professionals, journalists, and others - to discuss the unique properties of human milk and breast/chestfeeding. Is it just food? Why work hard to promote and protect human milk feeding?
We all know that beyond nutrition, milk provides a multitude of immune factors, hormones, prebiotics, probiotics, and anti-microbials, many of which play a role in the numerous lifelong health effects of human milk feeding.
But we are now learning that factors in milk may be doing something more: changing the very genetic expression of both baby and parent in ways that may have lifelong health effects.
Wilson is skilled at translating research findings in a clear and accessible way, so you can easily understand and communicate this information yourself. And it’s important that more people understand the epigenetic implications of infant feeding. "The good news is that the epigenome is changeable,” she says, “and once we begin to make changes we can see positive changes for our future generations.”
Learn more about epigenetics, the infant microbiome, and more in “Activate: How Human Milk and Breast/Chestfeeding Activates Our Genes Through Epigenetics”, a new course at Lactation Education Resources.
Enroll Now
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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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Posted by on in Diversity in Breastfeeding
Image credit NPR

Many watched in agony as George Floyd was mercilessly killed at the hands of police last week.

He’s one of the most recent in an untold number of Black Americans whose lives were cut short by state-sanctioned violence since this country’s inception. The list includes the enslaved, the free… the old, the young…in all walks of life... at work and in play.

Breonna Taylor was asleep in her bed. Tamir Rice was playing in the park. Atatiana Jefferson was babysitting her nephew at home.

Countless others have narrowly escaped harm, or have suffered from the psychological effects of surviving or witnessing these repeated and devastating events at the hands of a society that sees them as unequal and unworthy of justice.

At LER, we want to center the voices of those who have lost loved ones, who live under the crushing grip of fear, who feel this burden the heaviest in this moment. Those whose anger is palpable and whose indignation is most righteous.

We stand in solidarity with our Black employees and students and their loved ones. We hear their grief and honor the ways they, time and time again, embody resilience in the face of oppression. We stand behind our partner organizations, ready to act in the ways they tell us are most appropriate at this time.

We commit to doing more, doing better. In the coming days, we’ll unveil some key new programs specifically for Black aspiring lactation consultants. It’s the least we can do to help stem the tide of anti-Blackness and oppression in our field.

But now, in this moment, we amplify the voices of the unheard. And we state unequivocally that Black. Lives. Matter.

#saytheirnames #Blacklivesmatter #amplifymelanatedvoices

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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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Posted by on in General

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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"It was going natural as well as with my 1st baby, but things did not seem to be well. Lots of pain, suffering with each feed, frustration and upset most of the time wondering what's going on? It was an easy issue with chronic suffer. It was poor latch. This tiny baby of 35 wks gestation couldn't latch appropriately causing crushing of the nipples and inducing sever pain. Thanks God it was resolved within few days after correction. After 10 months, I received a training of breastfeeding management I found that it was poor latch. Here came the passion to help other moms who are suffering for nothing and decided to become an IBCLC."

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'I became a pediatrician because I wanted to help children and their families. After almost a decade spent in private practice, I realized that I would never have enough time to properly support my breastfeeding babies and their mothers in a busy practice. Ten minutes per appointment is not enough, especially for a newborn or infant who is having problems breastfeeding! I decided to become Board Certified as a Lactation Consultant. Now, I have a job where I get to spend one hour with new babies and their mothers and can have appropriate follow ups. I feel amazing that I can help mothers not give up on breastfeeding and give their babies all of the benefits we know they get through breastmilk, or "liquid gold!"'

Tagged in: Guest Blog
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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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I am a birth coach, Lactation Consultant, physician, a mother of two. I failed to breastfeed my first born, despite of all my resolves and intentions. It was a matter of great disappointment for me being a physician to not be able to breastfeed. When my next child was born, the situation was the same. Luckily, there was internet then & I found great info and read stories of women who like me had struggled with breastfeeding. All this info and my efforts finally made me feed my younger child exclusively on the breast for six months. I and she decided to wean when she was almost three. My own experiences with breastfeeding made me volunteer to support fellow moms and I started helping other women breastfeed successfully. This led me to formally study breastfeeding and certification as an LC.

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I was a breastfeeding mother. I have two children who are now 10 & 8. What motivated me to do the CLC course was the fact that I got loads of advice from everyone but many of it was wrong information. I wanted to go out and help other moms like me by giving them the right information and helping them when they need it. I also realized there was not much help in this field in my country, India. I would like to help mothers make an informed choice of what is best for them and their babies.

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"Given a chance, I could have been a Lactation specialist right from the word go. 
Having an exposure with HIV positive mothers for over seven years,and I could discharge HIV negative breastfed babies from the program, I wanted to empower all moms regardless of the HIV status to make informed decisions about how to feed the baby. Impact with the breastfeeding goals, armed with good and adequate information, and most of all, with compassion and love."

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My name is Bobbi Jo Hudson and I have worked in a busy pediatric office as a LPN for the past 14 years. I work under 9 providers and we are located in the hospital but a separate practice. The lactation consultants within the hospital stay very busy and can not see all of our nursing moms after they are discharged. The need for lactation services is great due to the volume of patients we have in our practice. First time nursing moms become easily discouraged when there is a breast feeding issue and often times just need to discuss it with a professional. It has become a passion of mine to provide additional assistance to our mothers who are breast feeding and hopefully will be an asset to the practice. I am new to the program and hope to have this complete by May!

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Posted by on in Diversity in Breastfeeding

Reaching our Sisters Everywhere (ROSE) holds an annual Summit to engage and educate breastfeeding leaders who are on the front lines of supporting families in their communities.  Breastfeeding rates amongst Black and Latinx families are lower than their white counterparts.  https://www.cdc.gov/breastfeeding/data/reportcard.htm and https://www.cdc.gov/breastfeeding/resources/breastfeeding-trends.htm

This year’s theme was achieving health equity through breastfeeding

NAPPLSC sponsored a “retreat” prior to the ROSE summit.  A retreat sounds nice, right?  Discussing real issues facing our communities, being inspired, maybe some self-care involved for lactation support providers.  The event was called the Amazing R.A.C.E.: Rejuvenating A Community of Excellence.   I should have realized that it would not be what I envisioned, when the organizers told us to wear comfortable shoes!

Teams were randomly chosen and we were told to get to know each other quickly because we would need all the skill sets of our members, to succeed.  The goal was to come up with an innovative program to support breastfeeding families.  To brainstorm, create a vision, operationalize and implement with measurable outcomes. Final presentation was the next day. 

Five people in our group with many years of serving breastfeeding families, this project should have been a piece of cake.  HOWEVER, the organizers found creative ways to get us out into the city.  They would tempt us with additional funding if we won a contest.   They would provide a clue via Facebook LIVE.  Our team would need to figure out where the next grant opportunity announcement would be presented, and RUN to that location.  To win the funding for the mini-grant, we had to create and upload social media videos, MEMEs or participate in a spoken word competition.   Clues were given at all times of the day and night. Therefore, we had to break up into smaller groups to sleep or work on creating those products to win contests.

This experience was a real-life example of how challenging writing grants to fund breastfeeding projects can be.  We don’t live in a bubble and exclusively write grants.  We have work responsibilities, family

obligations and LIFE.  While this event was completely different than what I expected, I had a good time getting to know others from around the country.  To listen to each other, add our skill sets and background to create a fantastic final presentation.  I can’t wait to see what NAPPLSC will create next year.  I hope to see you ALL there!

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Posted by on in General

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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Posted by on in Uncategorized

https://womensmentalhealth.org/posts/baby-friendly-mom-unfriendly/ 

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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