Lactation Management Training: From Novice to Expert

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Angela Love-Zaranka

Angela Love-Zaranka

Angela has been a La Leche Leader since 1990 and a Board Certified Lactation Consultant since 1997. She has served on several non-profit boards as a member of the finance committee and/or treasurer.


She received her undergraduate degree from Trinity College in Washington DC and her graduate work, also at Trinity, is towards a Master’s of Science in Administration, specializing in non-profit management.


She is an IBCLC in private practice in Alexandria, VA and is the lead Lactation Consultant at DeWitt Army Hospital in Alexandria, Virginia. Angela has been a valued member of the Lactation Education Resources teaching staff for over 6 years and is currently the Program Development Specialist for LER.

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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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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