Lactation Management Training: From Novice to Expert

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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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Continuing our series on the landscape of breastfeeding in the US, we’re shifting our focus westward to Oakland, California. We’ll quickly assess the challenges that exist, then highlight a lactation support group that is working to close gaps and reach families in innovative ways.

While it’s true that no other area is consistently underperforming as significantly as the South when compared to the CDC’s Breastfeeding Score Card, there is room for improvement in every direction. This is true even on the West coast, where state breastfeeding rates are excellent at a glance. Per the scorecard, California is outpacing the national average in nearly every measure. California has already reached the Healthy People 2020 goals, and is on a trajectory to continue to outpace most states in the coming years. The data highlights some of the many things that are working well in California, such as the high percentage of Baby Friendly Hospitals (which directly correlates to the percentage of babies who receive solely breastmilk during their first two days of life), and childcare regulations that support breastfeeding success in the long run. California gets it right in many ways. However, as much as it is an anomaly, some pockets of California are also plagued by the same obstacles to success that we saw in the deep South and in Appalachia. As we’ve seen, some key factors have a detrimental impact on whether babies get mother’s milk as early, as often, and for as long a duration as is ideal. These factors include race, economic status, and access to quality care. The scorecard shows a significant gap in the number of births to the number of lactation supporters statewide. For example, in terms of free or low cost support, there are only around 2 certified lactation counselors and less than one La Leche League leader per 1,000 live births. Both of these figures are lagging compared to national averages.

So what support is there for parents who need help breastfeeding but may not be in a position to hire an IBCLC? One such solution has been working well in Alameda County, and specifically East Oakland. We caught up with the renowned TaNefer Camara, to discuss her community support group, The Lactation Café (TLC).

California scored well on the last BFing ScoreCard. How does East Oakland compare?

Overall California's breastfeeding rates are impressive and in some areas exceed national averages. In East Oakland, breastfeeding rates do not reflect state averages. East Oakland is an area that is still very much segregated by ethnic and socioeconomic lines. Some areas - particularly the community where The Lactation Cafe is held - are largely Black and Hispanic. While there has been an increase in breastfeeding initiation and duration rates over the past 5 years in Alameda county, there remains pockets of community that could benefit from additional support. Many of the families are receiving the message that breastfeeding is important but they fall short of breastfeeding goals due to work conditions, lack of familial support, medical reasons or misinformation.

Can you tell us a little about the group’s inception and how it has grown/evolved since it began?

The Lactation Cafe began as a pilot program sponsored by First 5 Alameda County. We started off with maybe 4 participants and grew to serve 10-15 moms each group. We collaborated with local health programs, hospitals and clinics to engage new families. The next phase will focus on sustainability and community capacity building. We hope to develop group participants into leaders who will lead and facilitate future groups.

How is the community better off due to your presence?

The Lactation Cafe has been a safe place for families to receive concrete support in times of need, gain knowledge of child development, build social connections and get the support they need to meet their breastfeeding goals. Moms who attend TLC and other groups in our community are able to share what they learn with other mothers, they become advocates for themselves, their children and their community members and they support one another.

Could something like the The Lactation Cafe be duplicated elsewhere?

Absolutely! TLC can be duplicated. We used the Strengthening Families framework as our guide and in alignment with our breastfeeding curriculum. The key to a successful group is outreach, engagement and community partnership. Oh, and good food. Whole some food and nutrition was a major part of our group.

Wherever there are breastfeeding disparities, local activists like TaNefer Camara, Tiana Pyles, Jada Wright-Nichols and Ngozi Walker-Tibbs are rising up to meet the need. Their work is changing the landscape of breastfeeding throughout the United States in real and impactful ways. As a student or professional lactation supporter, you too, have an opportunity to make an impact and to reach communities that have a greater need or unique barriers. We’ll highlight one more group in the North to round out our four cities tour next month and to bring this series to a close. The conversation will continue in various ways as LER works to prepare the next generation of lactation supporters to be informed and equipped resources to all breastfeeding families.

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