Archive | Breastfeeding

New Strategies For Relieving Engorgement: Tips and Tools From Maya Bolman, BA, BSN, IBCLC

By Christine Staricka, BS, IBCLC, CCE, ILCA Medialert Team

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When Maya Bolman was a young girl in Russia, her godmother was known to all the women in her village as the one who could help with breastfeeding. People said her hands were “like magic.”

A young Bolman paid attention. She is now a well-respected clinical lactation care provider in the U.S. who uses her hands to help nursing mothers relieve the breast fullness that can interfere with their breastfeeding. In July, she brought her skills, clinical knowledge, and time-tested wisdom to the International Lactation Consultant Association® (ILCA®) 2014 Conference, and attendees returned home with a skill they could use immediately to help their own clients and patients.

Bolman observes that, since the breast has no fascia or muscle to aid in movement of fluids other than breast milk, congestion of the breasts is common during early lactation. As a new mother’s body sheds fluids from pregnancy and those given intravenously during hospital labor and childbirth, milk production begins in earnest. The breasts can become uncomfortably full or even swell to the point that milk ceases to flow. In addition, the skin covering the breast can become so taut and the areolae so swollen that the baby cannot latch. The simplest solution is a combination of gentle massage and manual milk expression, which softens the breasts and eases infant latch.

Evidence supporting the effectiveness of hand expression continues to mount. In locations lacking electricity for breast pumps, hand expression allows mothers to sufficiently maintain milk for premature and sick infants who are unable to feed directly at the breast. Teaching all new mothers to hand express ensures compliance with Step Five of the Ten Steps to Successful Breastfeeding, part of the Baby-Friendly Hospital Initiative.

“There is no right way to do hand expression, only the way that is gentle and that works,” Bolman explains. She has created a free video which she encourages to be shared with mothers (with appropriate credit to Bolman). Her work with Breast Feeding Medicine of Northeast Ohio confirms that even mothers who have already attempted these techniques on their own can still benefit from in-office treatment. The video provides an excellent introduction for new mothers and clinicians to hone their hand expression technique.

 

In her clinic, Bolman and her colleague, Dr Ann Witt, MD, FABM, IBCLC, teach mothers to use these techniques when they come in for hands-on treatment of engorgement and plugged ducts. She finds that mothers of the youngest babies typically ask for help with engorgement, while plugged ducts seem to peak around 10 weeks postpartum. During the session, Bolman shared videos of herself and her colleagues providing gentle, sweeping massage of the breasts. In a motion toward the axilla, they use the sides of their hands and a generous amount of olive oil mixed with a few drops of an essential oil. Mothers are encouraged to lie back at an angle similar to the position used for prone breastfeeding. If their babies are present and hungry, they feed on the opposite breast during treatment as desired.

Results of these treatment sessions are overwhelmingly positive. They produce relief of overall pain, resolution of plugged ducts immediately in at least half the cases, decreased levels of nipple pain and tenderness, reduced periareolar edema, and easier latching/feeding. This type of customized “touch care” of breastfeeding mothers is derived from the wisdom of the ages. It is also very appropriate and relevant for today’s mothers who frequently have little experience with physical touch to their breasts other than during intimacy.

Bolman firmly believes that mothers are empowered when they are taught techniques for hand expression and massage to relieve engorgement on their own. She insists that we cannot teach it enough times to the mothers in our care, regardless of the age of their babies.

“They really want to learn these techniques for self-care,” Bolman stated, “because they are not necessarily instinctive.” She firmly believes that lactation care providers should guide mothers’ hands through the process of hand expression by placing a hand over the mother’s hand rather than directly on mother’s breast. She observes that we can often find solutions to common challenges by looking to other cultures. Bolman’s background and personal experience of blending her native and adoptive cultures has provided the lactation field with a priceless treasure in her techniques.

For more information, please see Recapturing the Art of Therapeutic Breast Massage during Breastfeeding by Bolman, Saju, Oganesyan, Kondrashova, & Witt in the Journal of Human Lactation HERE.

maya-in-moscow

Maya Bolman, BA, BSN, IBCLC, was born and raised in Minsk, Belarus. Certified as  IBCLC in 2001. She has worked in both inpatient and outpatient settings and, since 2009, also worked as lactation consultant in a large pediatric practice and breastfeeding medicine practice. Bolman traveled to Russia in 2009, 2010 and 2012 to work with breastfeeding consultants and as the IBLCE Country Coordinator for Russia, Belarus, Ukraine and Latvia, helped to prepare 14 IBCLC candidates to pass certification exam and became the first IBCLCs in their countries. 

 

christineChristine Staricka is a hospital-based IBCLC. She became a Certified Lactation Educator through UCSD while facilitating local breastfeeding support groups. She studied independently while accumulating supervised clinical hours and passed the exam in 2009 to become an IBCLC. She holds a BS in Business Management from University of Phoenix. Christine is the co-owner of Bakersfield Breastfeeds, which provides lactation education to professionals and expectant parents. She has contributed to USLCA’s eNews as well as this blog. She enjoys tweeting breastfeeding information as @IBCLCinCA and maintains a blog by the same name. She is a wife and mother of 3 lovely and intelligent daughters and aunt to 4 nephews and 2 nieces, all of who have been or are still breastfeeding. She is partial to alternative rock and grunge music, especially Pearl Jam, and attends as many concerts as financially able with her husband of 18 years.

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Incorporating New Research In Your Practice: Guest Post By Sue Cox, IBCLC

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In part one of this series Sue Cox, AM, BM, IBCLC, FILCA, presented research to inform our discussions around how milk handling (including shaking expressed milk and/or breast massage) changes the components of the milk, including fat distribution.

In part two Sue presents research on other common questions, including whether to feed on one side or both and interventions including nipple shields and nipple creams.

Both breasts at each feed? Research: One or both breasts at each feed

In 1984 we carried out research (Cox, 1984) to find out whether mothers followed the suggested feeding regime or whether they developed their own. At that time mothers were told to only offer the breast five times each day. They were also told to always use both breasts at each feed-time.

Length of breastfeeds was strictly regimented. Mothers were told to only allow their baby to breastfeed for:

2 minutes, on the birth day, then

3 minutes on the second day,

5 minutes on the third day,

7 minutes on the fourth day, 

10 minutes on the fifth day,

And from then on just offer 10 minutes.

Mothers stayed in hospital for 5-7 days and rooming-in was rare. When the babies returned to the nursery on the third and fourth day we noted that many of them had very wet and dirty nappies (diapers), they vomited excess milk, and they sucked their hands and cried.

We had read of some of the newest research from the UK (Baum, 1980) which showed changes (increases) in fat levels from the beginning to the end of a feed. Therefore, we decided to suggest to the mothers that if their breasts were feeling really tight on the second or third day, or if they had used one breast per feed with a previous baby, that they might like to try just using one breast at each feed until they recognized their baby wanted more milk and/or their breasts were less firm.

Our findings showed that of the 155 mothers: 3% were discharged early; 27% fed from both breasts at all feeds; 8% fed from one breast during the period when their breasts were distended and were discharged feeding from both breasts; and 62% fed from alternate breasts at each feed before and after discharge (Cox, 1988).

Following further research on breast capacity (Daly et al., 1993; Cregan & Hartmann, 1999) and research on breast hypoplasia (Huggins et al., 2000) we now understand that we cannot give advice about one or both breasts per feed or the frequency of feeds because this is dependent on an individual mother’s breast capacity.

Point baby’s chin towards the area of the blocked duct? Research: ensure good breast drainage over every 24 hour period instead of concentrating on angle of baby’s mouth

Ultrasound studies of breast anatomy (Ramsay, 2005) show that the ducts do not radiate out through a breast segment in an organized way, but instead begin under the areola and travel out through the breast in a randomized fashion.

Nipple creams and lanolin? Research: short term relief only

In 1988 mothers were dissuaded from using anhydrous lanolin as pesticides were found in the lanolin. A purer form of lanolin later became available, but only one prospective controlled clinical trial has been done to support its use (Abou-Dakn, 2011.) This study indicates that it may be helpful in comparison to expressed breast milk in the first three days of treatment.

In my experience 1,800 mothers who birthed in our maternity unit annually chose to breastfeed their babies. After we stopped using lanolin and other nipple creams in 1988, our maternity staff became very skilled in finding the cause of nipple pain and strategies to prevent and/or treat nipple trauma and pain were developed instead of using the “quick fix” of lanolin.

Rubber nipple shields prevented weight gain in infants? Research: use of silicone shields in a small percentage of mothers could be effective if appropriate follow-up is conducted

The main nipple shield used 20 to 30 years ago was made of rubber.  Following research to quantify milk transfer, it was found that the poor areolar stimulation through the rubber shield led to only 42% of available milk being transferred to the baby (Woolridge at al.,1980).

In the hospital where I practiced as an IBCLC, two incidences of babies having been admitted to the pediatric ward with poor weight gain at 6 weeks of age led to further exploration of the issue of rubber nipple shield use. Both mothers had been given a rubber nipple shield during their maternity stay. Following discussions with staff, it was decided that nipple shields would no longer be distributed. This increased the midwives’ skills at assisting mothers with breastfeeding.

Some years later, following much discussion in the literature, we decided to do a pilot study to quantify how many mothers and babies could be helped by using the newer, thin silicone nipple shields (Cox & Paine, 1997). We found that silicone nipple shields were an advantage to 2.2% of mothers and their infants as long as they were followed up to ensure adequate output and that weight gain was continuing during all the time they were using a nipple shield.

These experiences confirmed for me that developing new policy and procedures should always be supported by current research.

Finally, Sue recommends that IBCLCs consider their rationale before making alterations to their current clinical practice or before creating new policies and procedures. Using new clinical skills and techniques can be extremely beneficial, and we should strive to remember that they are “in development” until the qualitative or quantitative research is produced to support them.  In fact, as a profession we are called to propose and conduct research in collaboration with other disciplines to further our ability to assist mothers and babies. Sue leaves us with this reminder: “Development and growth of a respected profession is based on evidence. Listen to new ideas and seek validation of what you hear from the evidence.”

Abou-Dakn M et al., (2011) Positive effect of HPA lanolin versus expressed breastmilk on painful and damaged nipples during lactation. Skin Pharmacol Physiol, 24(1):27-35.

Baum JD, (1980) Flow and composition of suckled milk. Medica Amsterdam

Joanna Briggs Institute (2009) The Management of Nipple Pain and/or Trauma Associated with Breastfeeding Best Practice, Evidence based information sheets for health professionals, 13(4).

Cox SG (1984 ) One breast per feed: A solution for the crying baby. Proceedings of the International Confederation of Midwives conference, Sydney, Australia.

Cox SG (1988) Why do some babies prefer only one breast at each feed? Breastfeeding Review 13:85-6.

Cox SG & Paine K (1997) The importance of follow-up of infants when the mother is using a nipple shield for breastfeeding. Unpublished data.

Cregan, MD & Hartmann PE (1999) Computerized breast measurement from conception to weaning: clinical implications. J Hum Lact 15(2):89-96

Daly SE, Owens RA, Hartmann PE. (1993) The short-term synthesis and infant-regulated removal of milk in lactating women. Exp Physiol, 78(2):209-20.

Huggins KE, Petok ES & Mireles O (2000) Markers of Lactation Insufficiency: A study of 34 mothers. Current Issues in Clinical Lactation, 25-35.

Kent JC et al., Breast volume and milk production during extended lactation in women. Exp Physiology, 84(2):435-47.

Ramsay DT et al., (2005) Anatomy of the lactating human breast redefined with ultrasound imaging. J Anat, 206(6):525-34.

Woolridge MW, Baum JD, Drewett RF (1980) Effect of a traditional and of a new nipple shield on sucking patterns and milk flow. Early Hum Dev, 4(4):357-64.

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New Resource to Encourage Normal, Healthy Birth

By Jeanette McCulloch, IBCLC

preagnant africanIn the introduction of Linda Smith’s book, “Impact of Birthing Practices on Breastfeeding,” Diane Wiessinger aptly sums up how we can help get breastfeeding off to a good start:

“It’s the birth, stupid!”

As lactation consultants, we know both anecdotally and through research the impact on breastfeeding of common birth interventions in the U.S, including: non-medical inductions; certain labor drugs; lack of freedom to eat, drink, or move about as needed; and unnecessary surgical delivery. While interventions can be lifesaving when medically appropriate, the number of routine interventions has meant an unprecedented impact on healthy, normal birth.

The result? According to Amnesty International: “It’s more dangerous to give birth in the United States than in 49 other countries. African-American women are at almost four times greater risk than Caucasian women.” And what do we know as lactation consultants? The same routine interventions that are impacting birth safety are also creating breastfeeding challenges.

Three leading midwifery organizations in the US formed a partnership to create educational materials designed to help those who are pregnant – or planning to become pregnant – learn about how a normal birth process can improve health of both mother and baby.

The International Lactation Consultant Association has signed on as a supporter of the project’s first handout, which guides women through the process of learning about normal birth and the choices they can make to increase the chances of a physiologic birth.

The handout is available as a PDF download here or you can purchase pre-printed packs at minimal cost here. The materials can serve as a helpful reference in your prenatal breastfeeding class packets. You can also share the link to the PDF widely on your own social media, helping as many mothers and mothers-to-be learn about normal, physiologic birth.

The handout was created in partnership between the American College of Nurse Midwives (ACNM), the Midwives Alliance of North America, and the National Association of Certified Professional Midwives. It has received endorsements from many of the leading organizations working towards increasing normal birth options, including Citizens for Midwifery and the International Center for Traditional Childbearing. For more information, visit the ACNM’s consumer education project here.

JeanetteJeanette McCulloch, IBCLC, is a lactation consultant in private practice in Ithaca, NY. She is also the co-founder of BirthSwell, which is improving infant and maternal health through digital skills for birth and breastfeeding pros and volunteers.

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Applauding Maryland’s Ban the Bags Initiative

The Maryland Breastfeeding Coalition has recently initiated a movement to “Ban the Bags” in Maryland. They sent the following letter and video outlining their efforts to to the CEOs of all birthing hospitals across the state, requesting the removal of all commercial infant formula discharge bags. We applaud their efforts and look forward to hearing how their actions support mothers and babies in Maryland. We hope that their letter and the influence it has can serve as a model for other states and countries to make the same changes in their communities.

banthebagsThe Maryland Breastfeeding Coalition lauds and strongly supports the recent release of the Maryland Hospital Breastfeeding Policy Recommendations by the Maryland Department of Health and Mental Hygiene (DHMH). As part of these recommendations, in an effort to protect and improve maternal and infant health in our state, we write today to urge your hospital to join with all hospitals in Maryland in discontinuing the distribution of commercial infant formula discharge bags. The initiative to ban the practice of marketing formula by health care institutions and professionals in all birthing hospitals is supported by DHMH’s recommendations, as well as other public health authorities, including the American Academy of Pediatrics, the Centers for Disease Control, and the 2011 Surgeon General’sReport.

Banning the bag is feasible!  Your hospital can join those hospitals that have committed to protecting breastfeeding and refuse to act as marketing agents of formula companies.  Several Maryland hospitals have already banned the formula company discharge bags without significant hardship or obstacles. In the process, they have been able to simultaneously increase their marketability.

  • Through working with their purchasing and marketing departments, some like Upper Chesapeake Medical Center and Shady Grove Adventist Hospital have designed and distributed their own discharge “gifts” which advertise their respective hospitals.
  • Johns Hopkins Hospital stopped giving out formula samples over three years ago as part of a hospital-wide effort to stymie the marketing of pharmaceuticals within its facilities.  The hospital administration has chosen not to give out a replacement bag.
  • Other hospitals such as Memorial Hospital at Easton discontinued distribution at the behest of Risk Management upon investigating their liability in the event of a formula recall or a baby getting sick from expired or contaminated formula.

While these hospitals and others no longer hand out formula bags upon discharge, banning the bag never prevents a mother from obtaining free formula samples if she so requests.   She can simply be directed to call the toll-free number on the back of every formula container to receive free bags, coupons, or samples. Your hospital aims to promote the health of infants and mothers, but when providing the bag and/or formula samples, the ongoing promotion of infant formula sends the inaccurate message that these products are medically approved, endorsed, and necessary.

The Maryland Breastfeeding Coalition has prepared a brief power point presentation to highlight the research regarding the effects of formula discharge bags and discuss further how hospitals can approach banning the bags. We encourage you to view and share it with your staff.

For more information, you can browse www.banthebags.org, and Public Citizen .  You can also visit the website of the Massachusetts Breastfeeding Coalition which has successfully led all 49 of Massachusetts’s birthing hospitals to ban the bag.  Our own Maryland Breastfeeding Coalition website will soon contain links to the You Tube video for staff and other resources. Help us make Maryland the next state to successfully put the health of our youngest citizens first by banning the formula discharge bags from all birthing hospitals. Please contact us if the Maryland Breastfeeding Coalition can be of further assistance to you, or if you have any questions.

Please share this information with other relevant departments within your hospital. We very much appreciate your time with this matter.

What is your community doing to eliminate the marketing of formula in your hospitals?

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Childbirth-Related Psychological Trauma: An Issue Whose Time Has Come

By Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA

I first became interested in childbirth-related psychological trauma in 1990. Twenty-three years ago, it was not on researchers’ radar. I found only one study, and it reported that there was no relation between women’s birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births. I was convinced that the researchers got it wrong.

To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley’s classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is “sudden, dangerous, and overwhelming.” That was a perfect framework for me to begin to understand women’s experiences of birth. It focused on women’s subjective reactions, and I used it to describe birth trauma in my first book, Postpartum Depression (1992, Sage). {ed. note – this book is now in its 3rd edition and is titled Depression in New Mothers (Routledge, 2010).}

Photo by Tristan Wallace via Flickr Creative Commons

Photo by Tristan Wallace via Flickr Creative Commons

Since writing my first book, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing:

High numbers of American women have posttraumatic stress symptoms (PTS) after birth.

Some even meet full criteria for posttraumatic stress disorder. For example, Lamaze International’s Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that “the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic” (Beck, et al., 2011).

If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).

Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.

In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt “invisible and out of control” (Elmir, Schmied, Wilkes, & Jackson, 2010). The women used phrases, such as “barbaric,” “inhumane,” “intrusive,” “horrific,” and “degrading” to describe the mistreatment they received from healthcare professionals.

“Isn’t that just birth?” you might ask. “Birth is hard.” Yes, it certainly can be.

But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009). Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011). Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.

How Does This Influence Breastfeeding?

Breastfeeding can be adversely impacted by traumatic birth experiences, as these
mothers in Beck and Watson’s study (Beck & Watson, 2008) describe:

“I hated breastfeeding because it hurt to try and sit to do it. I couldn’t seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.”

“The first five months of my baby’s life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.”

Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.

“Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.”

“My body’s ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.”

What You Can Do to Help

There are many things that lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. You really can make a difference for these mothers.

  • Anticipate possible breastfeeding problems mothers might encounter. Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.
  • Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers’ boundaries. Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able to handle it. But if she can’t, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin-to-skin, babywearing, or infant massage.
  • Refer her to resources for diagnosis and treatment. There are a number of short-term treatments for trauma that are effective and widely available. EMDR is a highly effective type of psychotherapy and is considered a frontline treatment for PTSD. Journaling about a traumatic experience is also helpful. The National Center for PTSD has many resources including a PTSD 101 course for providers and even a free app for patients called the PTSD Coach. In addition, the site HelpGuide.org also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.
  • Partner with other groups and organizations who want to reform birth in the U.S. Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection (take the opportunity to view their reports on the important issues regarding birth in the US HERE) , are working to reform birth in the U.S. 2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria will be released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.

There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices. I would also like to see our hospitals implementing practices recommended by the Mother-friendly Childbirth Initiative.

There is also a major push among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions.  And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers and care providers stand together and say that the high rate of traumatic birth is not acceptable, and it’s time that we do something about it. Amy Romano, of Childbirth Connection,  describes it this way:

As we begin 2013, it is clear from my vantage point at the Transforming
Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.  

There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.

Here are some helpful links to share with mothers:


Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president elect of the APA Division of Trauma Psychology. This post is a preview of her editorial in the Vol 3-4 of Clinical Lactation. You can read more about Kathy at www.KathleenKendall-Tackett.com.

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Providing Support for Mothers Who Wish to Relactate

By Tom Johnston, CNM, IBCLC

Editor’s Note: This was first published on Tom Johnston’s Facebook Page which seeks to provide breastfeeding information to mothers. He has graciously allowed us to republish it here.

Photo by miriamwilcox via Flick Creative Commons

The vast majority of women who wean prematurely do so out of fears of inadequate milk supply. New mothers are in an incredibly vulnerable state and tend to blame every hiccup, every cry, and every fussy baby on herself and her milk supply. This often leaves new mothers feeling that they are failures because they were unable to breastfeed their babies and guilty because they are giving their baby formula which is known to increase the risk of countless childhood diseases. Fortunately, the perception of inadequate milk supply is often more of a misperception rather than a physiologic fact. That means that most women who wish to breastfeed after weaning can relactate and resume breastfeeding with the proper support and coaching.

Most women who have prematurely weaned and wish to relactate are good candidates for success. There is a small pool of mothers who find breastfeeding nearly impossible due to physical factors. Those with developmental abnormalities affecting the glandular tissue of the breast, endocrine disorders (disorders of the thyroid or pituitary gland), mothers of premature infants, and mothers who have never nursed may find relactation difficult. Most women however are healthy, have healthy term infants, and are likely to succeed, particularly if they have successfully nursed in past. There is even evidence suggesting that breast development during the first pregnancy and breastfeeding attempt is enhanced following the birth of a second child, even if the mother did not successfully breastfeed her first child.

Keys to Successful Relactation

Realistic Goals: Relactation can be time consuming and stressful and it may take several weeks to reach exclusive breastfeeding. While many women can successfully re-establish exclusive breastfeeding, there will be women who are unable, for myriad reasons, to exclusively breastfeed. I encourage women to set realistic goals on how long it will take to achieve success and what success will mean to her but to never give up. After all, a mother who is partially nursing while supplementing is still breastfeeding her child, whereas the mother who quits entirely is not breastfeeding at all. Success in relactation however, must be determined by the goals set by mothers, not lactation professionals.

Support: Lack of support leads to lack of confidence; lack of confidence leads to infrequent suckling; infrequent suckling leads to breastfeeding failure. All three are associated with less successful relactation. Breastfeeding mothers who suffer with feelings of inadequacy due to milk supply problems must be supported by their family and social groups if they hope to successfully relactate. Breastfeeding cannot be one of the many chores a woman must do each day; it must be the priority of the entire family. Mothers who find themselves trying to work pumping, the use of an at the breast supplementer, and breastfeeding into their already full schedule will often find themselves unable to overcome the challenges of relactation.

Breast/Nipple Stimulation: There are several techniques for breast and nipple stimulation, perhaps the most successful is direct infant suckling. However, the mother can augment that with hand expression, breast massage, warm compresses prior to stimulation, and mechanical pumping. Some studies have shown that combinations of these techniques enhance success.

Milk Removal: Since the breasts synthesize milk based on the degree of emptiness, breast drainage must be a part of nipple stimulation. The mother may find that a period of trial and error is needed to determine the best strategy for breast emptying (infant suckling, hand or pump expression, etc…).

Galactogogues: Galactogogues are medications or herbal supplements that increase milk production/synthesis. The two most common medications used to augment milk synthesisare Metaclopramide (Reglan) and Domperidone. Both are anti-nausea medicines which increase prolactin production. Unfortuantely, scientific evidence demonstrating the effectiveness of galactogogues is weak. Both Reglan and Domperidone have been shown to increase prolactin levels and milk production. However, the studies demonstrating this lack credibility in the scientific community. As such, it is important that women who take these medication understand that while they may be helpful, they are by no means a magic bullet that will increase milk synthesis. The evidence in support of Mother’s Milk Tea, Fenugreek and Milk Thistle (all common herbal galactogues) is even more questionable. Given the subjective way that milk production is measured, it is possible that many galactogogues work through the placebo effect rather than by actually increasing activity at the molecular level. That said, the point is moot; the goal of relactation is to empower a mother to breastfeed her child and the exact physiology behind her success is not as important as her success. I therefore support safe and responsible galactogogue use under the supervision of a competent IBCLC.

Oxytocin: Oxytocin is the hormone that causes the Milk Ejection Reflex (MER), also known as the “let down” effect. It surges in response to nipple stimulation, and during pleasurable experiences (skin to skin contact, infant snuggling, and affectionate attention from a loved one). It is therefore, no surprise that stress, anxiety, fear, and pain all decrease oxytocin release. Oxytocin is also released due to conditioning responses, meaning that release is enhanced when mothers do things that remind them of breastfeeding. For example if you always sit in the same chair to breastfeed, the act of sitting in that chair will increase your likely hood of having an oxytocin surge. I often suggest that pump dependent mothers cover their breasts and pump with the baby’s blanket. Not only does this hide the pump and keep mothers from stressing over the actual movement of milk, but it also triggers a conditioned response to breastfeed due to the smell of the baby on the blanket. The important thing about oxytocin is to relax and enjoy the time spent breastfeeding, and as much as possible, the time spent pumping, hand expressing, massaging the breasts. A synthetic oxytocin is available in some areas through compounding pharmacies and can enhance the let down response.

Yes, you can relactate but you and your loved ones have to commit to it. The key physical factors needed for relactation are breast/nipple stimulation and milk removal. I can’t stress enough that in order to enhance the success of nipple stimulation and milk removal the mother must be confident in her abilities, comfortable and relaxed while nursing, and must have realistic goals. The mother must be supported and able to prioritize relactation. I strongly recommend that any mother having difficulty with milk production see a lactation consultant immediately to avoid weaning however, weaning does not have to be permanent. If you have stopped nursing and want to relactate, you can.

In the words of Winston Churchill “Never, Never, Never, Never, Never, Give Up!” You can do it!

References:
Thorley, V. (2012) Induced Lactation and Relactation. In Mannel R., Marten, P.J. and Walker, M. Core Curriculum for Lactation Consultant Practice 3rd Ed. Jones and Bartlett Publishers. Burlington MA.
Academy of Breastfeeding Medicine Protocol Committee. (2011). ABM Clinical protocol no. 9: Use of galactogogues in initiating or augmenting the rate of maternal milk secretion (first revision January 2011). Breastfeeding Medicine, 6, 41-49.
Agarwall, S., & Jain, A. (2010). Early successful relactation in a case of prolonged lactation failure. Indian J of Pediatrics, 77(2), 214.

Jarold (Tom) Johnston, father of eight breastfed children, has spent his career advocating for the rights of fathers in the perinatal arena and has spoken on a variety of topics at conferences around the world. He is uniquely placed as a father, midwife, and lactation consultant, and brings that one of a kind perspective to his writing. He is a budding author with many ideas on integrating fathers into the birthing and breastfeeding process.

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Breastfeeding Center of Pittsburgh’s Dr. Nancy Brent Named A “Pediatric Hero”

Dr. Nancy Brent, Medical Director of the Breastfeeding Center of Pittsburgh and a pediatrician at Kids Plus Pediatrics in Pittsburgh, has been named one of Baby Talk magazine’s seven national Pediatric Heroes for 2012. The award, announced at the recently concluded American Academy of Pediatrics National Conference and Exhibition in New Orleans, honors “the most innovative and inspiring doctors” in the country.

Dr. Brent was honored as a Pediatric Hero for her nationally acclaimed work in promoting and supporting breastfeeding, and in training physicians to do the same. A board-certified pediatrician since 1984 and an International Board Certified Lactation Consultant (IBCLC) since 1990, Dr. Brent has spent more than two decades at the forefront of Breastfeeding Medicine, leading the way both locally and nationally to bring critical, often hard-to-find services and support to breastfeeding mothers and babies, as well as to the doctors who care for them.

Ellen Rubin, an IBCLC who works at the Breastfeeding Center says,

“As a relatively new IBCLC, I could not have asked for any better opportunity than to work with Dr. Nancy Brent. She’s an an IBCLC-Pediatrician and an amazing teacher who always takes the time to share her knowledge and experience with me and the many residents and medical students who visit our clinic. Dr. Brent’s approach to breastfeeding is very well-rounded. While addressing each baby’s needs and well-being, she also takes into account each mother’s experience in the nursing relationship. Her medical expertise is a great asset, especially when babies are not gaining weight or are consistently fussy. So many complications are erroneously blamed on breastfeeding, and it makes a big difference when a medical professional can get to the root of a problem before breastfeeding is disrupted.”

Since 2006, Dr. Brent has served as the Medical Director of the Breastfeeding Center of Pittsburgh, the region’s leading resource for front-line breastfeeding medicine, support, and clinical care. Dr. Brent’s hard work and leadership have helped make the Breastfeeding Center of Pittsburgh a nationally recognized model in lactation services, and the first and only Advisor to the United States Breastfeeding Committee. Before joining Kids Plus Pediatrics and helping to create the Breastfeeding Center of Pittsburgh, Dr. Brent worked for 20 years in the department of Pediatrics at Mercy Hospital. During her time at Mercy, she created and directed the Maternal Infant Lactation Center, which provided patient care, research, and professional education for pediatric residents. Many of the pediatricians she trained in her time at Mercy are now her colleagues at Kids Plus: IBCLC pediatricians and a staff of Lactation Consultants who, under her direction, provide consults and medical care through the Breastfeeding Center of Pittsburgh.

Dr. Brent is a member of ILCA, the American Academy of Pediatrics, the Academic Pediatric Association, the Pittsburgh Pediatric Association, and the Academy of Breastfeeding Medicine. She is co-chairperson of the Allegheny County Breastfeeding Coalition and a member of the Pennsylvania Breastfeeding Coalition.

Join us in congratulating Dr. Nancy Brent, IBCLC for the stellar work she is doing to support mothers and babies!

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A Day in the Life of Breastfeeding Support and Promotion in Public Health

By Lisa Akers, MS, RD, IBCLC, RLC

I have worked in public health for over a decade and it never ceases to amaze me the number of people who truly do not understand public health or the work that public health officials seek to accomplish. Public health by nature is preventative medicine. Public Health can better be described as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals” (1920, C.E.A. Winslow). According the World Health Organization, public health is “an organized effort by society, primarily through its public institutions, to improve, promote, protect and restore the health of the population through collective action.” Public health seeks to prevent disease and is not in the business, necessarily, of treating disease. Breastfeeding, by nature, is disease prevention and by this fact alone, is positioned high on the national public health agenda.

It is important to understand these facts before understanding my role in breastfeeding promotion and support in public health. I am, in fact, the State Breastfeeding Coordinator for the Commonwealth of Virginia. My job is to manage breastfeeding support and promotion endeavors for the state. My responsibilities vary from day-to-day, but they typically includes such things as the development of public policy, media campaigns, curricula, publications and training; oversight of the Virginia WIC Breastfeeding and WIC Breastfeeding Peer Counselor Program; collaboration with numerous non-profit and academic entities, and service as the Virginia Department of Health liaison to the Virginia Breastfeeding Advisory Committee. This is by no means a comprehensive list, but simply a taste of the many things that I do from day-to-day.

Our emphasis in public health is on educating the practitioner as well as educating the general public in the support and promotion of breastfeeding. Since this article seeks to give readers an idea of what a typical day looks like in the field of public health, let me first start by painting a vivid picture for you.

You are a new breastfeeding mother, who has just given birth two weeks ago to a baby girl. You are a single mother, who receives no financial support from family or friends. You are concerned about making ends meet and providing for your daughter, so you plan to return to work within the next week. You currently work two part-time jobs at a retail establishment and a local restaurant. You make too much money to qualify for federal aid or entitlement programs, but luckily do quality financially to receive WIC benefits. Your biggest concern at the moment is continuing to breastfeed while returning to work and also being able to afford quality childcare that is supportive of breastfeeding for your daughter.

This is a typical scenario that is seen day-in and day-out both internationally and nationally. From the time that I start work every day, this is the scenario that continually plays in my mind. On a typical day, I am managing several million dollar budgets to ensure that this breastfeeding dyad is both supported and protected. These budgets help to run the breastfeeding support endeavors for the WIC program (including the WIC Breastfeeding Peer Counselor Program), support statewide policy initiatives related to breastfeeding, provide training opportunities and curricula to both clinicians and childcare providers, provide technical assistance to businesses and employers seeking to better understand and comply with the Patient Protection and Affordable Care Act, and provide training opportunities to public health personnel seeking to improve their knowledge of lactation management. On any given day, I handle correspondence from constituents, WIC participants, employers, childcare providers, clinicians, colleagues, and many others. A day in the life of public health breastfeeding support and promotion is ever-changing and never dull!

Public health gives me the autonomy and utilizes my creativity in many ways. One such way is in the development of numerous educational initiatives for clinicians and public health personnel. Most recently, this came to fruition in the development of two web-based educational opportunities for clinicians. The first is a web-based learning initiative, www.BreastfeedingTraining.org, which seeks to expand clinician’s knowledge of lactation management. The second web-based performance improvement initiative, www.BreastfeedingPI.org, seeks to improve the individual practice of clinicians. Both offer continuing education units and were developed in collaboration between the public and private sector in an effort to increase the knowledge base of healthcare professionals. Yet another avenue of education was in the development of an internship opportunity for WIC personnel. Most recently, we created an IBCLC internship for WIC personnel seeking to become IBCLCs with the ultimate goal of having at least one IBCLC in each WIC clinic site. This, not only, will help support the new breastfeeding mother in the above mentioned scenario, but will also aid in increasing the morale of WIC staff and WIC breastfeeding peer counselors, who seek job advancement and satisfaction.

Whether it be through education, policy, financial management of programs, or other avenues, my satisfaction in working to support and promote breastfeeding in public health comes from seeing the mother pictured in the scenario above reach her full potential.

Lisa Akers is a Registered Dietitian (RD) and an International Board Certified Lactation Consultant (IBCLC). She completed her Bachelor and Master of Science Degrees in Clinical Dietetics from James Madison University. Lisa has been working in the field of public health and human lactation for over 12 years. Her current position as the State Breastfeeding Coordinator. In addition, Lisa serves as the List Serve Coordinator for the Women’s Health Dietetic Practice Group (DPG) and is the Academy of Nutrition and Dietetics’ delegate to the United States Breastfeeding Committee. She also served as an Expert Workgroup member for the Academy’s Evidence Analysis Library, as a reviewer for the Academy’s most current position paper on the Promotion and Support of Breastfeeding, and as a reviewer for the reproductive section of the Nutrition Care Manual. Lisa is also the current 2012 World Breastfeeding Week Coordinator for the International Lactation Consultant Association.

In her spare time, Lisa enjoys sewing, quilting, and taking long motorcycle rides with her
husband in the Blue Ridge Mountains of Virginia where she currently resides.

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Supporting Active Duty Military Mothers as an IBCLC

By Robyn Roche-Paull, BS, IBCLC, and LLL Leader

As the author of the book, Breastfeeding in Combat Boots, I am often asked by my fellow lactation consultants how to best support active duty military mothers who wish to continue breastfeeding while serving their country. Currently, women comprise nearly 20% of the active duty force in the United States. Most women on active duty are of childbearing age, and at least 15% will become pregnant while on active duty. At this time, 38% of the women in the military are mothers (nearly 80,000 personnel) and, of the children born to active-duty mothers, nearly 40% are newborn to five years of age. As more women enter military service, the number of women planning to breastfeed while remaining on active duty will continue to increase as well. Many active-duty women are choosing to breastfeed because of the benefits for themselves and their infants. Unfortunately, most are not reaching the goals set by Healthy People 2020 and the American Academy of Pediatrics for breastfeeding because of a lack of information and support.

Throughout the United States and overseas, there are Active Duty, Reserve, and Guard military women who are interested in breastfeeding after their return to work at six weeks postpartum. In addition to full-time employment, military mothers also face body weight and physical training standards, uniform issues, hazardous materials exposure, long shifts and inconsistent work schedules, prolonged separations due to deployments, and a military culture that does not always value the role of a mother. However, just like their civilian counterparts, military mothers who are breastfeeding also need information on the basics of breastfeeding, common concerns and pumping. As lactation consultants, you can be on the front lines of providing this much-needed care.

Major Beth Lane,USAF, C-17 pilot pumping in the crew “Breast” area

Here are some of the most important things to know when helping a military mother (all of these topics and more are covered at my website):

  • Basics & Common Concerns: The basics of breastfeeding and mother’s common concerns are the same for everyone. Military women deal with sore nipples, engorgement, plugged ducts, thrush and mastitis just like the rest of us. The difference here is that they may not have the luxury of staying in bed for the weekend to recover. Keep in mind that they may be wearing heavy gear or not drinking enough fluids due to their work environment that can lead to some of the above problems.
  • Policies: Be aware of the breastfeeding policies of the various branches of the military, what they provide (and don’t provide) and where to find them. In a nutshell, the US Air Force, Army, Coast Guard, Navy and Marine Corps all provide at least 6 months deferment from deployment (the Navy offers 12 months) after the birth of the baby. The Air Force, Marines and Navy policies also specify a time and place to pump. More detailed information about each of the policies and downloadble PDFs can be accessed at www.breastfeedingincombatboots.com/militarypolicies.
  • Pumps/Pumping/Hand Expression: The average military mother works a 12-hour shift and will need to express her milk at least 3-4 times. She needs the proper pump, one that can last through a year’s worth of heavy-duty pumping and that will keep her milk supply up. Many enlisted mothers try to save money with cheap or used pumps. Steer them towards the personal-use pumps from companies who produce a powerful and efficient pump. Include teaching on hand expression, which is a lifesaver out in the field with no electricity and go over safe storage and handling guidelines according to the Academy of Breastfeeding Medicine protocol.
  • HAZMAT (Hazardous Materials): Many mothers in the military work in job specialties that require working with hazardous materials such as jet fuel, lead, or solvents. While there is a lack of information on the safety and transfer of these substances into breastmilk (the latest edition of Medications and Mother’s Milk has information on jet fuels and lead), take the opportunity to go over their exposure levels, ask for copies of the Material Safety Data Sheet, and remind them to wear their personal protective gear. It is important that mothers weigh the risks of theoretical contamination at work against the know risks of formula before making a decision to wean.
  • Physical Training (PT): All military members are required to pass semi-annual physical fitness testing and maintain weight standards. US Military mothers have 180 days from the birth to meet those requirements. While breastfeeding is known to help women lose weight, some mothers have difficulty losing the last 5-10 pounds until they wean. Go over safe weight loss tips, and myths regarding exercise and breastfeeding.
  • Deployments & Training: Deployments and training away from home are a fact of life in the military. While mothers are deferred from deployment for 6 -12 months (depending on the branch of service), they are not exempt from participating in training exercises or schools. Many mothers will face the prospect of leaving a fully breastfed baby at 6 months and will need information on pumping in the field or overseas and how-to ship breastmilk.

Robyn, with her own son at 3 months, in her uniform

There are many other ways that you can support military breastfeeding mothers such as setting up Active Duty Breastfeeding Support Groups or programs at your local clinic, hospital or private practice. Create or sponsor a loan program for hospital-grade pumps (this is especially useful for the junior and mid-level enlisted personnel, many of whom struggle due to their low pay). Provide education and training to the local military physicians and commanders of the base or post on the basics of breastfeeding and why it is in their best interest to support their breastfeeding mothers. The Business Case for Breastfeeding can be easily adapted for military commands, and has been used to great success at The Navy and Marine Corps Intelligence Training Center (NMITC) already.

Finally, advocate, advocate and advocate for these mothers. They are waging a never ending battle against a culture that values warriors, not breastfeeding mothers. Often these mothers are far from home, without any family nearby, dealing with unsupportive commands and supervisors that don’t understand breastfeeding at all. You may be their only source of information and support. Remind them that breastfeeding in normal and achievable. Due to regulations that disapprove of breastfeeding in uniform, many military women do not ever see another military mothers breastfeeding. Share positive breastfeeding success stories with the active duty moms you see, as they are going to hear plenty of negative stories from everyone from the clerk at the Commissary to their co-workers. Remind them that breastfeeding in the military is not all or nothing. Any amount of breastfeeding they can do, and any amount of breastmilk they can provide is better than nothing! Above all be flexible, supportive and understanding. Unless you have breastfed in a pair of combat boots you cannot know the amount of fortitude, determination and perseverance it requires to be successful. These women deserve our thanks for Giving the Breast for Baby and Country!

This article does not reflect the views nor is it endorsed by the US. Military.

Check out ILCA E-Globe for a feature about Robyn and her recent trip to Aviano Air Base. in Italy

Robyn Roche-Paull, BS, IBCLC, and LLL Leader is the author of the award-winning book Breastfeeding in Combat Boots. In her private practice she primarily helps military mothers balance returning to active duty while continuing to breastfeed. Robyn is not only an advocate for active duty military mothers who wish to combine breastfeeding with military service, she is also a US Navy Veteran who successfully breastfed her son while on active duty as an aircraft mechanic. Robyn frequently contributes to various breastfeeding publications and blogs about breastfeeding in the military at her website www.breastfeedingincombatboots.com and has been a guest blogger at Best for Babes, baby gooroo and The Feminist Breeder. Robyn can be found lecturing at breastfeeding conferences and military bases around the United States and overseas. Robyn is currently enrolled at Hampton University’s Accelerated Bachelor of Science Nursing degree program and lives in Virginia Beach, Virginia with her husband of 18 years, a Chief Petty Officer in the US Navy. She is the mother of 3 long-term breastfed children now 16, 13 and 9. Visit her at www.breastfeedingincombatboots.com and on Facebook at www.facebook.com/breastfeedingincombatboots, you can also follow her on Twitter at www.twitter.com/BFinCB.

3

American Academy of Pediatrics Section on Breastfeeding Launches New Facebook Page

By Jennifer Thomas, MD, MPH, IBCLC, FAAP, FABM

The internet has increasingly become a tool for people seeking health By Jennifer Thomas, MD, MPH, IBCLC, FAAP, FABM
information. A Pew Internet and American Life survey in 2011 showed that 80% of internet users have visited a website for information or support for a specific health problem, 19% of whom searched for information on pregnancy and childbirth.

Social media has increasingly become a tool for organizations, such as the American Academy of Pediatrics (AAP), to share information pertinent to the goals, mission, vision, publications and achievements. It has become a way to promote new products. It increases awareness about current issues, and can, unfortunately, generate misinformation which can be quickly disseminated widely. As the AAP is the recognized authority on the care of children, in addition to provide accurate information to physicians and breastfeeding mothers, we see this misinformation as a problem which needs to be addressed.

The American Academy of Pediatrics Section on Breastfeeding recently launched a new Facebook page.  It was created to:

    • Raise awareness of activities, products, and resources produced by the Section on Breastfeeding.
    • Highlight our members achievements.
    • Recruit new pediatricians to our membership.
    • Highlight pertinent evidence-based practices and publications.
    • Present evidence-based information in response to trends on social media which may be detrimental to the experience of new breastfeeding mothers.
    • Join in the discussions, currently occurring in social media about breastfeeding.

The Facebook page has the potential to be many things but it will not be a place for our section’s members to offer clinical advice.  It will be for the dissemination of information only. 

We invite IBCLCs and other breastfeeding professionals and volunteers to come “like” our page and engage in the conversation with us. A strong collaboration between pediatricians and other members of a baby and their family’s health care team is vital to their breastfeeding success.

Click HERE to connect with the American Academy of Pediatrics Section on Breastfeeding’s new Facebook page.

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