Lactation Management Training: From Novice to Expert

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I just got home from the AWHONN conference in Orlando.  We heard speakers talk about their plans to have an all IBCLC staff on their maternity units.  Now that is an exciting idea and what a great benefit for all of the breastfeeding mothers.   Expert help, at hand, whenever needed!

Other speakers talked about a mix of skills.  Some Breastfeeding Resources Nurses, some IBCLC’s.  But these managers recognized that everyone needs to have beyond the basics of lactation management training.

Recommendations from USLCA (and endorsed by AWHONN) have calculated the following recommendations for IBCLC staff:

Tertiary Care Facility (Based on 20% preterm delivery rate) - 1.9 FTEs/1000 deliveries

Hospital with Level II Neonatal Service - 1.6 FTEs/1000 deliveries

Hospital with Level I Neonatal Service - 1.3 FTEs/1000 deliveries

 The Joint Commission Accreditation Surveys now include Perinatal Core Measures that every hospital over 1,100 deliveries per year must monitor.   Through experience with high preforming hospitals, the Joint Commission believes that hospitals can achieve a 90% exclusive breastfeeding rate.  As more and more hospitals adopt the Baby-Friendly Hospital Initiative, they also are challenged to improve exclusive breastfeeding. 

The role of the hospital IBCLC is not only to provide care to breastfeeding mothers wherever they are in the hospital (maternity, pediatrics, emergency suite, surgical or medical units), but to train, coach and motivate the rest of the nursing and medical staff.  The other key role for the IBCLC is to influence unit policy and procedures.  The best way to improve breastfeeding exclusivity is to have an abundance of staff well trained in lactation support. 

In order to meet the mandates to improve breastfeeding initiation and duration rates, it is imperative that expert lactation support be readily available during the hospital stay.  The best way to achieve this is with an all IBCLC staff!

References:

AWHONN  Guidelines for Professional Registered Nurse Staffing for Perinatal Units.2010.  p.31

http://www.ilca.org/files/USLCA/Resources/Publications/IBCLC_Staffing_Recommendations_July_2010.pdf.  Accessed July 2014.

https://manual.jointcommission.org/releases/TJC2013A/PerinatalCare.html.  Accessed July 2014.

https://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps.  Accessed July 2014.

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I recently spent 3 days in Omaha Nebraska doing a 3 day Train the Trainer Program for the Lactation Consultant leaders in the hospitals.  It was designed to improve the breastfeeding support in their hospitals and move towards Baby Friendly Hospital status.  This was a group of exceptionally well prepared IBCLCs whose passion for the success of breastfeeding for the mothers and babies was evident.  

The evening after our second day, tornadoes moved through Omaha, with torrential rain, flooding and baseball sized hail causing widespread damage in parts of the city and surrounding areas.  None the less, everyone was present for class the next morning.  It didn’t matter that for one student all of her windows were broken by the hail.  Now that is commitment!

Each of the students in the Train the Trainer class taught two of the modules comprising the 15 hour Baby Friendly Hospital training.  In addition, they each taught an aspect of the skills fair preparing  to lead the 5 hours of hands on clinical experience.

Bravo for the Lactation Consultants in Omaha and the breastfeeding mothers and babies in the Omaha hospitals!

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Those of you who are sitting for the IBLCE exam for the first time this year, the countdown has begun.  There are 76 “study days” left.    So how will you spend your time?  You may think, I don’t have to start yet, there is plenty of time.  Or some of you may be panicked thinking there is so much material and so little time.   Deep breathe. 

And if you have taken the exam previously, but are at your 10 year or 20 year mark and have to re-sit the exam, take heart.  Remember, the exam is an entry level exam and if you have been actively practicing as a lactation consultant, then you have the advantage.  You have passed the exam at least once and you have experience.  Those case study questions will make more sense now.  ;-)

Here are some suggestions:

Start now

Plan a strategy for how you will review all of the material.  Use the IBLCE Exam Blueprint to categorize the topics and plan to study one each week.  http://iblce.org/wp-content/uploads/2013/08/iblce-exam-blueprint.pdf

You will be more confident during the last week before the exam, if you have reviewed everything and feel in control.

Gather compatriots

Group study is always more fun, so gather some local people who will be studying also.  Plan to meet a few times to go over strategies, practice test questions, and share anxieties.

For those of you who have taken the LER Lactation Consultant Training Program, we have a FaceBook page for the IBLCE Exam 2014.  If you did not get an invitation, email LER@LactaitonTraining.com for access.

Make flash cards

Jot down facts that you feel are important and “testable”.   Writing helps you remember, and you can also review them later.

The ones developed by Lactation Education Resources are good for medical/lactation terms.    http://quizlet.com/5315866/iblce-exam-review-2013-lactation-education-resources-flash-cards/

Study in short bursts

Don’t study for hours on end.  Things begin to fall out of your head after long stretches with the books.   Take a break and get your blood moving again.  Do some stretches, drink something.  Study for a few hours, review what you studied and do something else, or sleep.

Choose a quiet place

Make sure you have a place conducive to study: quiet, good lighting, comfortable, snacks if you like.  Sometimes going to someplace helps, like a library or coffee shop or a friend’s quiet space

Set up a place that is your study nook that has all of your reference books, paper, pens, etc. so you don’t have to waste time searching for study materials each time.

Some people find studying with soft music helps, others find it detracting.  A headphone or earplugs prevent bothering others and keep out distracting noises, even without the music.   If that quiet hum of background noise helps you block out distractions, but a coffee shop is not handy or is too busy, try listening to http://coffitivity.com/.   You can choose your favorite “noise”.

Negotiate with your family

Plan for study time where everyone agrees to not bother you – for anything.  You will be able to concentrate better knowing you have uninterrupted time ahead of you.

Positive affirmations help

“I can learn this material easily”, “I remember everything I read”,  “This material is interesting to me”,  “I am good at taking tests”, “I recall everything I study”, more….

Feed your brain

Skip the junk food and eat foods known to aid concentration and memory such as fish, nuts, seeds, yogurt and blueberries.   Have lots of water available to sip on.

Have good reference materials

There are several good books useful for studying for the IBLCE Exam. 

  • Your class power point handouts of each lecture
  • Breastfeeding & Human Lactation by Riorden and Wambach

The lactation consultants “bible”

  • The Core Curriculum by ILCA

Excellent, comprehensive book in outline form

  • The Breastfeeding Atlas by Hoover

Great for pictures

If you have, or have access to, other books use them all.  Look up controversial topics up in several references so you have the consensus of the authors.

Practice exams

Take the exam at the end of your lactation consultant Training Program, again.  First time, do it as an open book exam and look up what you need to.  Then time yourself and see if you can do it faster.  Push yourself a little.  The IBLCE exam is not a “speed” test, but practicing with a little pressure makes it more realistic.

If you want additional test questions to practice with, consider signing up for the IBLCE Exam Review program https://www.lactationtraining.com/iblce-exam-review

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Some people you encounter for a day, others you remember for a few months, and others influence you for a lifetime.  I have been blogging recently about “making change” in your own practice and in your institution, “leaning in” to your career, and “finding a way” to accomplish things even though the odds may not be in your favor.  All of those things Barbara did daily in her practice as a lactation consultant, a woman's health nurse practitioner and integrative medicine specialist.   She was always up to date on the latest research, willing to go the extra 10 miles for her patients and had a cheerful word for everyone.

Those of us who worked at Georgetown University Hospital in the Lactation Center and Milk Bank in the 1990’s formed a special bond: Barbara Boston, Silvia Ochs, Karen Rechnitzer,  Maire Hewitt and I.   Though none of us are still working at Georgetown, we have worked together in various configurations at several local hospitals and lactation centers.  Some of us have moved away and come back during the intervening years.  But our group endured.  When Barbara lived in Switzerland or Denver, she always returned to speak at the Lactation Consultant Training Program.

Perhaps many of you reading this remember Barbara and her lectures on sexuality.  Always funny and always right on point with a deep understanding of the impact on the family.  Thank you, Barbara, for all you have given to everyone you have influenced.

Barbara died April 28 after more than a year of cancer treatments.

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

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

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

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

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

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

Getting un-stuck

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

Example:

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

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

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

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

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

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

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

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

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

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

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

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

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

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I have been alternatively aggravated, inspired, confused and exasperated since listening to the TED talk by Sheryl Sandberg, “Lean In”.  I bought her book to understand better her concepts for women in leadership careers.

“Lean in”.  As lactation consultants it seems we do this daily.  We “Lean In” with our clients.  We give attention and we show interest.  We help problem solve and create strategies.  That seems natural.

I think most of us went into lactation consulting thinking that our role would be to help new mothers be successful with breastfeeding.  Our main challenges would be difficult latch-on, flat nipples or helping moms with engorgement or previous breast surgery.

But once we get into our work, we learn that those clinical challenges are what we prepared for in our lactation consultant training.  They are no less difficult for the mother and no less of a challenge for us, but they are usually solvable.

The bigger challenge is managing a career with all of the other responsibilities that working women generally have, juggling children, work hours, partner’s needs and social obligations.  And we all need a little fun and relaxation from time to time.

But the biggest challenge we encounter is influencing change among co-workers in our hospitals, agencies or communities.  No matter where we work, we likely don’t experience optimal support for our skills and expertise.  We may even experience disparaging comments, unrealistic workloads, or out-right resistance.

Let’s “Lean In” to our careers.  What does that mean?   

  • Make suggestions for change
  • Do library research to share with others
  • Speak up even when not asked ;-)
  • Quote reliable authorities, (The Surgeon General, The Centers for Disease Control, the American Academy of Pediatrics, The Joint Commission and others)
  • Volunteer for committees
  • Learn something new, teach something new
  • Do a quality assurance project, survey or a research project
  • Sit at the table and actively engage (as Sheryl would say)
  • Pick an informal mentor for yourself
  • Accept leadership positions in lactation related organizations
  • Mentor (formally or informally) aspiring lactation consultants
  • Grow in your abilities to influence others

I have known many lactation consultants over the years, working in many different settings.  Most did their jobs and went home.  They were good at assisting breastfeeding moms and passionate about the importance of breastfeeding.  They weren’t engaged in moving the breastfeeding agenda forward – whatever that may mean for the setting.  They had a lactation job, but the primary focus was their children and family, not career.  

Lactation Consultants CAN balance their family goals and needs with a career where they “Lean In”, whether working full time or part time.  And the future of breastfeeding support in our country needs these kinds of lactation consultants!

Watch Sheryl Sandberg’s TED talk http://www.ted.com/talks/sheryl_sandberg_why_we_have_too_few_women_leaders to get inspired about how you can “Lean In” to your career.

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

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

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

For further information, please go to www.FirstLatch.net or contact Juanita at BFHI@LactationTraining.com.  A free course trial is available here

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Well no, after ducklings hatch from their shells, they usually don’t eat for the first 24 hours, and then they start on small pieces of food and sips of water.  But as we see from this charming video of a mother cat turned mother to ducklings and kittens, unusual things can happen.

http://funnycatsgallery.com/mom-cat/the-cat-and-the-ducklings/

That oxytocin circulating right after birth is certainly powerful for bonding for both mothers and their off-spring.  Those newly hatched ducklings arrived just at the peak of the mother cat’s post-partum oxytocin surge.  Lucky for them, she took them “under her wing”, kept them warm and even offered them the only food she had, mother’s (cats) milk.  Oxytocin lives up to its nickname, “the mother love hormone”!

Successful reproduction in mammals demands that mothers become attached to and nourish their offspring immediately after birth. It is also important that non-lactating females do not manifest such nurturing behavior. The same events that affect the uterus and mammary gland at the time of birth also affect the brain. During parturition, there is an increase in concentration of oxytocin in cerebrospinal fluid, and oxytocin acting within the brain plays a major role in establishing maternal behavior.

It may be best to view oxytocin as a major facilitator of parturition and maternal behavior rather than a necessary component of these processes.  

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Legislation to mandate exclusive breastfeeding?!?  Yes, in the United Arab Emirates.  A new law has been passed mandating women to breastfeed their babies for 2 years, and if they are unable a wet nurse will be provided for them.

The BBC published an online discussion of many leaders around the world about this topic.  http://www.bbc.co.uk/programmes/p01qh9dk, click on the icon next to the picture.

Of course there are supporters on each side,

  • women should not be coerced to do anything with their bodies that they do not choose to do, including breastfeed
  • those who feel that it is such an important health issue, it should be mandated.  There certainly is enough research to back this up.

I agree with both sides.  Law is probably not the best way to promote maternal infant bonding and make women want to breastfeed.

Unfortunately, the discussion left out the important aspect that the birth process plays on initiation of breastfeeding.  Numerous research studies show the impact of immediate skin-to-skin.  Skin-to-skin contact can unlock the new mothers’ desire to nurture her baby and to breastfeed.  Mothers who hold their newborns skin-to-skin after birth have increased maternal behaviors and show more confidence in caring for their babies.  Women, with uninterrupted access to their babies, WANT to be with them and they find separation distressing.  This closeness fosters a good start to breastfeeding and we see that these mothers have a better breastmilk supply and breastfeed for longer duration.  They are more committed to solving any difficulties along the way. 

Skin-to-skin holding at the time of birth helps the transition from fetal to newborn life with greater respiratory, temperature, and glucose stability and significantly less crying indicating decreased stress.  Being skin-to-skin with mother protects the newborn from the negative effects of separation, supports optimal brain development and facilitates attachment.

Let’s start by making the birth process ideal for all mothers and for infants and see what that does for improving breastfeeding initiation and duration rates.

 

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I recently listen to a TED talk from Diana Nyak About her swim from Cuba to Key West at age 64. On her 5th attempt to swim the channel she succeeded after 54 grueling hours. 

For those of us who have been working in the lactation consultant field it can feel no less grueling.  Not as dangerous to be sure, but just as challenging.

Her challenges:   Jelly fish with vicious stings

Our challenges:    Unsupportive coworkers who can undermine our efforts

Her challenges:    Sharks

Her challenges:    Hypothermia

Our challenges:  Working alone with no support from colleagues

Our challenges:   The formula industry

Her challenges:    Exhaustion

Our challenges:  Years of struggle to make even the smallest policy change

Her challenges:    Navigation

Our challenges:  What is the best strategy to make change or educate co-workers?

Her challenges:    Food and drink 

Our challenges:  Recharging with suggestions from coworkers or conference attendance.

The prize for her.   Walking up on the beach in Key West

For us it might be finally becoming certified as an IBCLC, or helping a mom with a particularly difficult situation or bringing your hospital through the Baby Friendly Hospital designation process

Don't give up when the difficult seems impossible. 

Find a way

By the way, if you are not plugged into the TED talks, you will find them fascinating

http://www.ted.com/talks

 

 

 

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Time to plan for what your intentions are for 2014.  What are your dreams?  You have been thinking about it for a long time - Is it finally time to step up and become an IBCLC?  Is it time to look for that ideal Lactation Consultant job?   A job that will challenge you or a job that will give you experience in an aspect of lactation consulting that you haven’t tried yet.  Maybe it is time to return to school for your RN or advanced degree credential.  Maybe you are ready to hang out your own shingle and start a private practice.

We all need to move forward.  They say, “if you are not moving forward, you are moving backward”.  It is easy to do the same thing day after day, in a groove that is comfortable to you.  Let’s move out of our comfort zone this year and move forward.

They also say put your intentions “out there” and they will be realized.  So put your goals out there by telling friends and family, write a note to put on your mirror or make a picture of yourself in your new work setting.  Join an organization or online community that will help you get closer to your dreams through volunteering or helping you to build skills.  Get involved in your local ILCA chapter http://uslca.org/membership/chapters or US Breastfeeding Coalition Directory.  Meet the movers and shakers in your area.  Just see what happens in 2014!

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As I look back on an almost 30 year career as a lactation consultant, I have witnessed a huge amount of change for the support of breastfeeding. It is heartening to see support from every corner; the federal, state and local governments, professional organizations, workplaces, and the Affordable Care Act. Even new mothers are better informed and more are choosing to breastfeed. But we still have a ways to go before we reach optimal breastfeeding nationwide.

There are pockets where breastfeeding rates are low and exclusive breastfeeding rates are even lower. Historically, areas that have the lowest rates are the US southeastern states. Also areas where African American, Hispanics and Native Americans live, rates are low.

Lactation Education Resources trains about 350 students to take the IBLCE certification exam each year. But we realize that often the areas that need it most do not have access to a certified lactation consultant. This year we have given four scholarships for our Enriched Lactation Consultant Training Program to individuals who indicated they intend to work in underserved areas once certified.

The winners of this year’s scholarships are:

  • Gloria Bauta, Miami, FL who will be providing low-cost lactation services to area mothers at MilkWorks

  • Jill Olds of Monroeville, PA who will be providing lactation services through her WIC clinic

  • Charlene Parrish of Whiteriver, AZ will be on the Fort Apache Indian Reservation, Whiteriver, AZ

  • Chanel Porchia of Brooklyn, NY will continue to offer infant feeding classes and free/low cost lactation services in her area.

Best wishes to these four winners who will be part of the next generation of Lactation Consultants.

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