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


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.


Announcing the Journal of Human Lactation’s Cover Photo Contest!

Every year, we change the 4 photos on the Journal of Human Lactation’s (JHL) cover. JHL is your journal, and we want to feature your photos! The 4 photos portray the broad field of human lactation, from the IBCLC helping new mothers (picture: the caring professional with a breastfeeding mom; teaching a class, etc) along with the harder science of lactation (picture: test tubes of milk; microscope slides, etc). Please send us your photos! We are looking for shots representing a range of backgrounds, contexts, and cultures.


  • Keep photo clear with minimal background interference
  • Photos should be jpeg files: 300ppi .jpg; at least 2100 pixels wide x 1500 pixels high
  • Email photos to:
  • We may not be able to respond to each message separately, but as confirmation of your submission, you should receive an auto-response message
  • Include your name (assuming you are the photographer) and full contact information with preferably a second email address


  • Deadline – November 8, 2013: NO EXCEPTIONS!
  • If a recognizable person features in the photo (ie, face of mother/baby/clinician etc), you must have a photo consent form. If your photo is a contender for publication, we will require subjects to sign a specific consent form, so only send photos if you know you can obtain permission from the subject.
  • As the photographer you will need to sign non-exclusive copyright – in other words, you allow JHL to use the photo, but you are free to use it elsewhere as you choose.
  • If we believe the photo is a potential winner, we will contact you again before the deadline to talk to you and ensure we have the correct forms.

Questions? Email


Don’t Miss These FREE Articles from the Journal of Human Lactation

Even though we’ve wrapped up our World Breastfeeding Week celebration for 2013, The Journal of Human Lactation (JHL) is still celebrating all month long with FREE access to their journal. JHL is the premier quarterly, peer-reviewed journal publishing original research, commentaries relating to human lactation and breastfeeding behavior, case reports relevant to the practicing lactation consultant and other health professionals who assist lactating mothers or their breastfeeding infants, debate on research methods for breastfeeding and lactation studies, and discussions of the business aspects of lactation consulting.

JHL is offering free access to a number of their most-read articles through August 31, 2013. While ILCA members receive and have access to JHL as a member benefit, the availability of the free articles is especially beneficial for our colleagues from other disciplines.  Please share widely these resources to pediatricians, obstetricians, midwives, nurses, educators, researchers and general public.

Free articles from JHL (through August 31, 2013) include:

Breastfeeding and Telehealth

Breastfeeding Protection, Promotion, and Support in the United States: A Time to Nudge, A Time to Measure

Education and Support for Fathers Improves Breastfeeding Rates: A Randomized Controlled Trial

Impact of Male-Partner-Focused Interventions on Breastfeeding Initiation, Exclusivity, and Continuation

Provision of Support Strategies and Services: Results from an Internet-Based Survey of Community-Based Breastfeeding Counselors

Breastfeeding Duration in Relation to Child Care Arrangement and Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children

What are your favorite JHL articles from the past year?  How have they impacted your practice?


Research Matters: Get Involved!

By Cathey Horsfall

iStock_000017674946XSmallResearch lies at the heart of IBCLC practice, but only a small proportion of IBCLCs will actively contribute to the international research body during their careers.  This is a missed opportunity. Research not only provides a vehicle for changing opinions and practice, it is also a great way of showcasing the profession alongside the traditional medical disciplines. Essentially, it is a great marketing tool at a local and international level.

For those who don’t work within the health care facilities in their communities, breastfeeding supporters are often trying to change whole organizations from the outside. This is phenomenally hard and it can seem almost impossible to get other medical professionals to even consider that we might have something to offer.

Why is published research important?

Published research is obviously very important to drive improvements in our own maternal/neonatal care and breastfeeding practices but it doesn’t end there.

Published research is how we say to the rest of the world, “this is what our community can demonstrate is true,” and “our work has been examined critically” and “it has been found to be of caliber and importance.”  In short it is how we get others to take formal notice of what we are doing.

It is also how a group can demonstrate its superiority in a field.  Look through the recent research on breastfeeding.  How much of it has been done by a team with an IBCLC at the core? How much of it is truly innovative? If IBCLCs really want to be being considered as the pinnacle of breastfeeding knowledge, it is essential that they are heavily involved in pushing the boundaries of international knowledge into the subject.

Published research also gives us statistics.  Statistics can be extrapolated, correlated and most importantly costed. As a sales person, give me evidence of worth and I can sell the profession.  Give me none and I am left with nothing to sell.

In short, published research can be used to improve maternal care, raise respect for the field, and also to convince those on the inside of our medical institutions that IBCLCs are worth backing.

“We have all the evidence we need in practice-based observation”

The harsh realities of the sphere IBCLCs operate in is that companies and health services are never going to make financial decisions based on practice-based evidence.  Quite frankly, why should they?

In order to raise the overall chances of IBCLC employability within health services, the IBCLC profession as a whole will need to start to get a lot more of what they know documented.

Practice-based observations have their validity, but without documentation it is hard to share knowledge amongst yourselves reliably, let alone use it to convince the (doubtful) outside world of the benefits of a service etc.

The documentation required by external agencies needs to be in the form of good, sound research … the sort that will stand up to scrutiny.  It needs to be well planned, and well executed.  Ideally, it needs to be done in conjunction with other health professionals, including both the mainstream and the more alternative practitioners, working in the same research team.

This is way too much work/costs too much

It doesn’t have to mean a huge amount of work personally, nor does it have to cost a lot to do.

  • Begin with small scale studies – Use these to approach health professionals to look to broaden them out.  Approach your existing caseload if appropriate.
  • Choose your subject matter and methods with care – Clearly, you do not have the resources of a large research department so cut your cloth accordingly.
  • Pair up with other IBCLCs with similar interests Part of the difficulty in doing research is in getting good quality, larger scale data sets.  Perhaps this can be overcome by working with other IBCLCs etc.  This can also be a good way of building up skills in experimental design etc.
  • Look outside the IBCLC field for support You don’t have to limit your research team selection to IBCLCs.  Many volunteer breastfeeding supporters would be happy to get involved in research, if only we were asked.
  • Look for fundingYou don’t necessarily have to foot the bill yourself.  There are grants etc available out there that you may be able to access once you have done a small pilot or written a proposal.  You may even be able to approach your local University or teaching hospital in order to find resource to help you do the leg work.
  • Consider it an investment in the future The links that you form with your local educational institutions, medical organisations, and the like, may prove invaluable to increasing your involvement.  Consider it a marketing exercise for you and your skills.

Research really does matter

Research really does matter and can make a big difference.  Why not think about doing something? Most breastfeeding supporters have an area of knowledge in which they feel most comfortable.  Why not focus on that.  Perhaps ask yourself: “what basic questions are unanswered in existing literature, and what can I do to try and fill that gap?”

Cathey Horsfall is a trainee Breastfeeding Counsellor with the Association of Breastfeeding Mothers, UK.  She has two children under four and holds an eclectic set of qualifications including a B.ed (Hons) and a post graduate business qualification from Cambridge University, UK. She has spent the last ten years working in commercial organisations where the importance of good marketing and brand awareness were felt very keenly.  Most recently, she has written for a large UK public relations company, giving her a strong understanding of just how important it is to actively lobby and constantly ensure that potential customers are exposed the skill and strengths possessed.


The Milk Machine: Learning More about How Breastmilk Protects the Gut

Maryanne Perrin, MBA, and ILCA volunteer

Research over the last several decades has highlighted WHAT makes human milk so amazing — it’s associated with reduced risk of infections, asthma, obesity, diabetes, leukemia, and necrotizing enterocolitis (NEC), just to name a few. Determining HOW human milk delivers these benefits (referred to as “the mechanisms”) is less fully understood, though researchers around the world are working on these questions. A study published last month in the journal Pediatric Research gave some interesting insights on a potential human milk mechanism that is involved in protecting against NEC.

Photo by derPlau via Flickr Creative Commons

Photo by derPlau via Flickr Creative Commons

First, a little background information: Most of the fat in our diet is found in the form of triglycerides, a “suitcase” that carries three (thus the “tri”) fatty acids bound to a glycerol backbone. To absorb these fats, our bodies first break off the fatty acids, producing free fatty acids (FFAs), which are packaged into micelles and absorbed via the intestinal epithelial cells, and then repackaged into triglycerides for transport to other tissues.

Researchers at the University of California, San Diego wondered whether there was a difference in the toxicity of digested human milk (HM) compared to infant formula (IF), so they used an in-vitro model to study what happened to various cells when exposed to digested HM and IF. This involved mixing HM and IF in test tubes with various enzymes to simulate the digestive process, and then exposing three different cell types to the digested content: human neutrophil cells (a white blood cell that is involved in the early response to infections); cow heart endothelial cells, and rat intestinal epithelial cells.

What did they find?

Digested infant formula had significantly higher levels of FFAs than digested human milk (more triglycerides were cleaved) and it also had significantly higher death rates of neutrophils during a two hour exposure (ranging from 47 – 99% depending on the formula brand compared to a 6% death rate during exposure to digested human milk). Results were similar for the death of cow heart cells and rat intestinal cells. The likely mechanism for the cell death is the elevated level of FFAs which act as detergents and rupture cell membranes. When FFA levels were reduced by inhibiting the enzyme that cleaves triglycerides, cell death was also reduced.

Infant formula is designed to have a similar fat content to human milk, so what could cause the elevated FFAs levels that contribute to necrosis? The authors speculated on several things including the way triglycerides are delivered in human milk (they are in larger globules than in infant formula, potentially making them less digestible by lipase enzymes), the possibility that human milk deactivates enzymes that digest fat (or infant formula activates them), and the different structure of the triglycerides (human milk puts the long chain fatty acids in the #2 position on a triglyceride, making them less digestible, while in infant formula, the long chain fatty acids are primarily located at position #1 or #3 on the glycerol backbone, which is preferentially cleaved by digestion enzymes).

The mechanism described in this study is not pathogen driven, but instead driven by a cytotoxic environment that leads to premature cell death. Other potential NEC mechanisms were reported in the last year that involved bacteria; one study done in a rat model showed that the oligosaccharides in human milk bind pathogens that cause NEC, while another study showed that bacteria that grew on human milk formed a potentially protective biofilm. All of these studies were done in a test tube or in animal models, which means more research is needed to determine whether these mechanisms also operate in humans.

Collectively these studies suggest that human milk potentially has a variety of “tools in its toolbox” for protecting the immature and developing infant. Does this surprise you?!

MaryannePerrin3-2Maryanne Perrin loves all things related to food: growing it, cooking it, eating it, and now studying about it at the molecular and cellular level.  She has a BS in Industrial Engineering from Purdue University and an MBA from the University of North Carolina, Chapel Hill, and enjoyed a variety of career paths (information technology, management consulting, stay-at-home-mom, entrepreneur) before returning to school to obtain a PhD in Nutrition Science. She was quickly captivated by the amazing story of human milk and is focusing her research on understanding the nutritive and immunoprotective value of donor milk beyond one year postpartum.  When she’s not studying or helping ILCA with social media, she likes playing in the woods with her husband, three kids, and the family dog.  


How Often Does Breastfeeding Just Not Work? (from Dr. Alison Stuebe and the Academy of Breastfeeding Medicine Blog)

Occasionally on Lactation Matters, we find a blog post that is so incredibly important that we want to do everything in our power to make sure all ILCA members can read it.  This is just such a post from Dr. Alison Stuebe. Dr. Stuebe is a maternal-fetal medicine physician, breastfeeding research, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is also a member of the board of the Academy of Breastfeeding Medicine. So often, as we study lactation, we talk about the “HOW”…this post asks “WHY”.  Thank you, Dr. Stuebe for allowing us to republish your blog post here on Lactation Matters. It was originally published on the Academy of Breastfeeding Medicine blog.

How Often Does Breastfeeding Just Not Work?

By Dr. Alison Stuebe, MD, MSc

Jessica Isles posted a great question today on my blog, “When Lactation Doesn’t Work:

I was wondering if any comparative studies have been done on the statistics of lactation failure in various cultures both developed and less developed. Please post if you are aware of any – or any statistics on how many women’s milk never comes in (in the US), with a healthy full term new born, in an environment supportive of breastfeeding. We need to help mothers who struggle with this.”

That’s a great question – and a difficult one to answer. Marianne Neifert estimates that “as many as 5% of women may have primary insufficient lactation because of anatomic breast variations or medical illness that make them unable to produce a full milk supply despite heroic efforts.”   [Neifert MR (2001). “Prevention of breastfeeding tragedies.” Pediatr Clin North Am 48(2): 273-97.]

We are working on a research project to try to estimate the proportion of women in the Infant Feeding Practices Survey II who experienced unplanned, undesired weaning due to physiologic problems with breastfeeding. One challenge is what to call this condition. I’ve written a draft of the paper using the term “failed lactation,” but I don’t like it.  I have problems using the word “failed” to describe mothers who have gone to heroic lengths to sustain breastfeeding. We’ve also tossed around “lactation dysfunction” or “unwanted weaning,” but those don’t quite cut it either. I want a phrase that health care providers will take seriously and moms will perceive as a lifeboat in a storm, not as insult added to injury. My personal favorite is “Lactastrophe,” but I suspect that would not make its way into the medical lexicon. What do you think we should call it when lactation doesn’t work?

We’re also finding that it’s quite difficult to tease out the issue of “a supportive environment” vs biological problems with lactation. It’s a bit like trying to tease out how much of the type 2 diabetes epidemic is caused by “biology” vs “the environment.”  Over the past two decades, the proportion of our population that is obese has sky-rocketed, in the setting of decreasing physical activity, ballooning portion sizes, neighborhoods without sidewalks, and worsening economic inequality and job insecurity. Some people who live in this country have developed diabetes, and some have not.  It’s likely that some individuals have a biological predisposition that makes them vulnerable, whereas others do not. Regardless of the precipitating factor, however, these patients need help to control their blood sugars.

Similarly, for lactation, there are some mothers who are blessed with ample milk supplies and with babies who are born with a championship suck-swallow pattern, and they would be likely to breastfeed successfully in just about any environment. And there are other dyads for whom one piece of bad advice or a nasty encounter with a stranger while breastfeeding in public is enough to throw lactation completely off track.  Furthermore, it’s likely that women who have been socialized to mistrust their bodies are more vulnerable to interpreting early feeding challenges as evidence that their bodies can’t sustain breastfeeding– and they are thus more likely to wean and attribute their decision to a physiological problem.

From a health and wellbeing perspective, however, I’m not sure that it matters whether we “count” both “biological” and “perceived” insufficient lactation together. The total burden of this problem is enormous, and mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support.  We need mothers for whom lactation doesn’t work to know that they are not alone.  And we need to demand research to develop the tools that will identify the underlying problems and allow us to implement the appropriate treatment.

We also need to step back from assertions that every mother can breastfeed, if she just tries hard enough. As Neifert has written, “The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.’ The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes.”

Lactation is part of normal human physiology, and like all other human physiology, it can fail. It’s time to stop bickering about whether this mom tried as hard as that mom to breastfeed. We have too much work to do.

Please take the opportunity to visit the Academy of Breastfeeding Medicine’s blog and leave your comments.


First, Do No Harm: A Critique of Recent Research on “Controlled Crying” (Part 2)

Earlier in the week, we presented Part 1 of a commentary from Kathleen Kendall-Tackett on a recent study about the long-term effects of controlled-crying for infants. As infant sleep and breastfeeding are so closely tied together, we are so glad to share both Part 1 and Part 2 with our readers.  

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

Does Controlled Crying Cause Long-term Change to Cortisol Levels?

Critics of controlled crying have expressed concern that this technique alters infant cortisol level. To address this concern, the authors assessed the children’s cortisol levels at age 6 and found no significant difference between the intervention and control groups. Unfortunately, these findings alone do not mean lack of physiological harm. We need to look at short-term effects.

The question we need to ask is what happens to babies when their mothers do not respond to them? One way this has been studied is by examining the impact of maternal depression on infants. Maternal depression impairs mothers’ ability to respond to their infants’ cues, and raises Infant cortisol levels (Feldman et al., 2009). Even when non-response is temporary, babies still find it stressful. In the still-faced mother paradigm, mothers are asked to not respond to their infants’ cues in a laboratory setting. This research is designed to mimic the effects of maternal depression. The still-faced-mother experiments increase babies’ cortisol levels (Grant et al., 2009).

So why the concern about cortisol? Mainly, it’s this: cortisol is quite toxic to brain cells. If cortisol is elevated for short time, it likely causes no damage. But if cortisol levels are repeatedly elevated because the infants are experiencing long and repeated incidents of being ignored when they cry, it can be a problem. The brain is at its most vulnerable in the first five years, so soaking the developing brain in cortisol is not a good idea (Buss et al., 2012).

The lack of difference between the groups at age 6 does not mean lack of harm. Cortisol levels likely returned to normal in the intervening five years, unless there was ongoing adversity. Unfortunately, cortisol elevated in infancy could have still affected vulnerable brain cells, even if current levels are normal. The authors would need to use more sensitive measures to assess these potential changes.

What About Breastfeeding?

Photo by Alessandro Pinna via Flickr Creative Commons

The final limitation of this study is rather stunning. Price et al. did not measure the effect of infant feeding method on sleep or maternal depression. Yet feeding method has a direct effect on both maternal sleep and postpartum depression, which are the two main factors the authors claim to address with their sleep intervention. Exclusively breastfeeding mothers get more sleep and are less likely to be depressed than their mixed- or formula-feeding counterparts (Doan, Gardiner, Gay, & Lee, 2007Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009a2009bKendall-Tackett, Cong, & Hale, 2011).

Given these findings, isn’t it strange that breastfeeding was not even enquired about? If the study was conducted in a country with low breastfeeding rates, this omission would be somewhat understandable. But it makes no sense coming from a country like Australia, which has one of the highest breastfeeding rates in the world.


So what can we take away from the Price et al. study? Should we recommend the controlled-crying technique to parents? Based on the limitations of this study, I do not recommend this approach. The sample size is small, the follow-up sample is missing the children most likely to be negatively affected, their assessment of the intervention did not account for the Hawthorne/placebo effect, they have not measured dose of the intervention, nor have they accounted for feeding method, which recent research has soundly demonstrated as being related to both variables that are of key interest: maternal fatigue and postpartum depression.

My objections to this approach are not new. When I first encountered the Price et al. study, I remembered a study that this same group of researchers published 10 years ago in the British Medical Journal demonstrating that controlled crying lessened the risk of postpartum depression (Hiscock & Wake, 2002). I was specifically struck by this response from a German physician (Perl, 2002):

“As a German, I am unhappy to find fairly undiluted ideas of militaristic Nazi infant care uncritically repeated by these Australian care providers. The Nazis understood very well the crucial effect of letting young babies cry on their future development and made this a central theme in their child care. As a scientist, I find it hard to believe that all of the results of mother-infant sleep research of the 1990s completely escaped the authors’ notice.” 

In closing, Price et al. stated that organizations, such as the Australian Breastfeeding Association, were unduly negative towards controlled-crying techniques and need to update their recommendations based on more current research. Given recent findings in neuroscience, childhood trauma, breastfeeding, and maternal sleep, which are not accounted for in the Price et al. study, I’d respectfully advise the authors to do the same. I’d further urge healthcare providers who are considering recommending controlled crying to consider the limitations to the current study and alternative approaches that can meet the needs of both mother and baby.

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. She has authored or edited 22 books and more than 320 articles on family violence, postpartum depression, breastfeeding, and women’s health. Dr. Kendall-Tackett 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 a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. You can view her website at



First, Do No Harm: A Critique of Recent Research on “Controlled Crying” (Part 1)

Today, we present Part 1 of a commentary from Kathleen Kendall-Tackett on a recent study about the long-term effects of controlled-crying for infants. As infant sleep and breastfeeding are so closely tied together, we are so glad to share this with our readers. Check back on Thursday for Part 2.

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

A recent article in Pediatrics (Price, Wake, Ukoumunne, & Hiscock, 2012) reported on the long-term effects of a controlled-crying intervention for parents of infants 8 to 10 months old. The children were assessed five years post-intervention and showed no apparent harm. The media response to these findings has been overwhelming. Could this be the answer that weary parents have been waiting for? The authors certainly thought so. In fact, they concluded that practitioners could “confidently” recommend this approach.

Before we proceed, let’s step back and consider whether this recommendation is warranted. We must critically evaluate both the current study and where it fits within the larger literature in maternal-child health. In my view, there are a number of serious limitations to this study that call into question whether we should recommend this practice to parents.

Study Limitations

The Cumulative Effect of Childhood Adversities

Context is important to consider when evaluating potential harm caused by a parenting technique. In other words, how many parental missteps does it take for children to show evidence of lasting harm? Fortunately, children are resilient and don’t require perfect parenting. However, chronic bad parenting does harm children and the effects are cumulative (Centers for Disease Control and Prevention, 2010).

So does controlled crying cause infant harm? If it occurs in families with generally warm, responsive, and loving parents, probably not. I am more concerned about the impact of controlled crying when it takes place in high-risk families. A full 31% of the Price et al. original sample was lost to follow-up, most of them “high disadvantage.” In other words, the group most likely to be negatively affected by controlled crying was not in the follow-up study.

Assessing “Dose”: The Chronicity and Severity of the Experience

When assessing potential harm of a practice, it’s also important to consider chronicity and severity. This is a way of factoring in “dose” of an intervention. In terms of infant sleep, we need to know how often controlled crying was used in an average week, how many weeks or months that the parents employed these techniques, and in an average episode how many minutes elapsed before the parents responded to their babies. The longer they used it, the more pronounced the effects.

Information about “dose” was totally absent from the Price et al. study. From their article, we know little about what the parents actually did in either the intervention or control group. Even beyond the research protocol, parents could have implemented a controlled-crying program for themselves. We have no way of knowing. Given the wide range of practices that likely occurred in both the “intervention” and “control” groups, I am again not surprised to see no significant difference between groups.

Was the Intervention Actually Effective, Even in the Short Term?

Another problematic aspect of this study has to do with the research design’s inability to account for the Hawthorne Effect. The Hawthorne Effect was first noted by industrial psychologists who were testing the impact of minute changes in illumination on productivity in factory workers. When they raised the level, productivity increased. When they lowered the level, productivity also increased. In other words, any intervention was described as helpful. It’s basically a placebo effect for behavioral interventions.

The Hawthorne Effect could also be behind the positive results for the controlled-crying intervention. In earlier articles, the authors reported that controlled crying lowered rates of maternal depression and improved infant sleep. Did it? Perhaps it was simply a matter of the mothers having someone to listen to their concerns. A better test would have been to compare it to another intervention (such as educating mothers about the developmental normality of infant waking at 8 to 10 months, and brainstorming about ways the mothers could get more rest and cope with fatigue).

Check back on Thursday for Part 2 of this commentary. 

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. She has authored or edited 22 books and more than 320 articles on family violence, postpartum depression, breastfeeding, and women’s health. Dr. Kendall-Tackett 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 a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. You can view her website at


From JHL: How US Mothers Store and Handle Their Expressed Breast Milk

Written by Robin Kaplan, M.Ed., IBCLC

Image via Mistel de Varona

Breast milk storage guidelines can be incredibly complicated for mothers to decipher. With each pump company and breastfeeding website having its own storage and handling recommendations, how’s a mother to know which one to follow? Plus, throw in whether the baby is full-term, pre-term, healthy, or in the NICU, and we have quite a confusing situation.

In the most recent online publication in the Journal of Human Lactation, How US Mothers Store and Handle Their Expressed Breast Milk, Judith Labiner-Wolfe and Sara B. Fein analyze the data they collected from over 2,000 pumping mothers in the United States. Their findings will probably not shock any lactation consultants, yet the authors bring up very valid conclusions for how we can educate the breastfeeding and pumping mothers that many of us work with.

Here are some of the significant results of the study:

  • 95% of mothers either never stored their milk at room temperature or did so for less than 4hrs. Recommendations range from 1-10 hours.
  • Roughly 50% of mothers never refrigerated their milk for less than 1 day and no more than 4% left it in the fridge for more than 5 days. Recommendations range from 1-8 days.
  • 10% of mothers heated their breast milk in a microwave, a practice that can cause uneven heating, as well as destroy some of the nutrient and anti-infective factors in breast milk. The professional consensus is to never microwave breast milk.
  • 17% of mothers with babies under 6.5 months old reported that they occasionally only used water to rinse the bottle nipples, which the authors stated could cause the baby to ingest harmful bacteria. Recommendations range from rinsing in warm, soapy to sterilizing daily.

What are our professional guidelines?

There are also some discrepancies as to how long pumped milk stays fresh and viable, even in our own professional guidelines. While these recommendations are similar to one another, there is still enough variability to cause confusion for even the most educated lactation consultant. Here are the recommendations, for a healthy infant, according to the newest edition of the Core Curriculum for Lactation Consultant Practice (2012):

Room Temperature 77 º: < 6 hrs.
Refrigerator: < 8 days
Insulated cooler with ice pack: < 24 hrs.
Completely thawed in the refrigerator: < 24 hrs.
Freezer compartment in 1-door refrigerator: 2 weeks
Freezer door in 2-door refrigerator: < 6 months
Deep freezer: < 12 months

The Academy of Breastfeeding Medicine Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants states:

Room temperature 16-29ºC (60-85ºF): 3-4 hrs. optimal; 6-8 hrs. acceptable under very clean conditions
Refrigerator ≤4ºC (39ºF): 72 hrs. optimal; 5-8 days under very clean conditions
Freezer < -17ºC (0ºF): 6 months optimal, 12 months acceptable
Reusing stored human milk – There is little information regarding the issue of refreezing thawed human milk or the duration of time that human milk can be used once a baby has begun drinking from the bottle or cup.

Both resources recommend washing human milk storage containers in hot soapy water and
rinsing or washing in the dish washer. Sterilization is not necessary.

How do these findings impact our practices when we work with breastfeeding and pumping mothers?

When we are discussing safe storage guidelines for breast milk, it is important to review our professional recommendations, as well as include warming, safe handling, and pump/bottle cleaning recommendations to protect the integrity of the breast milk, as well as the health of the child.

Recommendations should be accompanied by rationale, so that the mother understands WHY her breast milk is less compromised following these standards.

Where do we go from here?

This study’s findings highlight the need for a more systematic, researched-based recommendation for the viability of breast milk and what constitutes safe handling and storage. With so many variables (temperature of the storage space, type of storage equipment, handling, feeding, and cleaning procedures, etc.) there are just too many options, which I, myself, find incredibly confusing. While there are many factors that go into keeping breast milk viable for consumption, there has to be some way that we can create guidelines that are easier for new parents, and lactation consultants alike, to navigate and follow.

Robin Kaplan received training to be a Certified Lactation Educator and an International Board Certified Lactation Consultant from UCSD. She holds a Masters in Education from UCLA, a multiple-subjects teacher credential from UCLA, and a BA in Psychology from Washington University in St. Louis, MO. In 2009, Robin started her own business, the San Diego Breastfeeding Center, where she offers in-home breastfeeding consultations, free weekly support groups, breastfeeding classes, and online support through her business blog.  In addition to her private practice, Robin was the founding Co-editor of theInternational Lactation Consultant Association’s (ILCA)blog, Lactation Matters, and a regular contributor toILCA’s E-Globe newsletter.  She also is the host/producer of The Boob Group online radio show and the Director of Marketing for  Robin lives in her native San Diego, where she enjoys cooking, hiking, trying new trendy restaurants, and traveling with her family.


Are Oligosaccharides a Key to Reducing HIV in Breastfed Babies?

One of the most fascinating mysteries of our time is the low rate of mother-to-infant transmission of HIV via the milk of an infected mother. In the absence of antiretroviral drug therapy (ART), 10-15% of babies born to infected mothers acquire the virus from breastmilk; when both mother and infant are treated with ART, this incidence can be reduced to 2% or less.

Several components of human milk have been shown to offer protection to those more than 85% of babies who don’t get HIV after repeated exposures. Immunoglobulins, like IgA, IgG, and IgM provide specific immune response to certain pathogens; lactoferrin accomplishes various tasks, to include killing bacteria and preventing  surviving bacteria from multiplying. In a study released earlier this year, researchers at Duke University in North Carolina reported that HIV-specific B-cells found in the colostrum of infected mothers actually neutralize the virus. An international team of researchers based in California, New York, Boston, and Zambia, in a study released on August 15 by the American Journal of Clinical Nutrition (Bode, et al., 2012) identifies yet another protective component: human milk oligosaccharides.

Oligosaccharides are plentiful in breastmilk, and there are over 130 of them (Smith, 2008). They are made from chains of simple sugars, and they do a few things that make them superheroes in the fight against pathogens – any invading virus or bacteria. Oligosaccharides are PREbiotics, which act like food for good bacteria in the baby’s gut. Prebiotics feed and promote the proliferation of PRObiotics, which crowd out pathogens. Another important, protective function of oligosaccharides is that they prevent pathogens from attaching to the gut lining. They do this either by attaching to the part of the bacteria or virus that would attach to the baby’s gut, or by themselves attaching to the gut epithelium and, in essence, occupying all of the “docks” where pathogens might seek to put down a mooring. Oligosaccharides are most plentiful in the earliest days, weeks, and months of breastfeeding, decreasing in number and volume as the baby gets older. Oligosaccharides are undigestible, which allows them to populate the baby’s intestine; the large volume of oligosaccharides is part of what causes a newborn to stool often, perhaps every time he breastfeeds.

This mechanism is also protective against HIV and other viruses, because the frequency of the bowel being emptied doesn’t give pathogens time to “set up shop” and get down to the business of infecting the baby. This is one possible explanation for why the protective effect of breastfeeding against HIV may wane as the baby gets older. Of the 12.1% of infants who acquired HIV through their mother’s breastmilk, 68.2% of those transmissions occurred after 6 months (Iliff et al., 2005). The addition of complementary foods may also cause or allow for breaches in the infant’s gut integrity; it is through these breaches that HIV can be acquired. The findings reported by Bode, et al. are exciting. We already knew that oligosaccharides play a significant role in keeping babies healthy and free from infection, but recognizing that, in high enough concentrations, they actually protect infants from a pathogen that is present in the milk is remarkable. In nations where the risk of infant death from gastrointestinal or respiratory infections is higher than the risk of transmission of HIV from an infected mother to her baby, understanding why and how a mother’s own milk gives her infant his best chance for survival can provide important teaching points for public health workers, especially when cautioning against mixed feeding of these vulnerable infants. Additionally, these innate protective factors in human milk offer insight into how a vaccine against HIV might be developed for use in adults at risk of acquiring the virus.


Bode, L., Kuhn, L., Kim, H., Hsiao, L., Nissan, C., Sinkala, M., Kankasa, C., et al. (2012). Human milk oligosaccharide concentration and risk of postnatal transmission of HIV through breastfeeding. American Journal of Clinical Nutrition (ePub ahead of print). doi: 10.3945/ ajcn.112.039503

Friedman, J., Alam, S. M., Shen, X., Xia, S. M., Stewart, S., Anasti, K., Pollara, J., et al. (2012). Isolation of HIV-1-neutralizing mucosal monoclonal antibodies from human colostrum. PLoS One 7(5). doi: 10.1371/journal.pone.0037648

Iliff, P. J., Piwoz, E. G., Tavengwa, N. V., Zunguza, C. D., Marinda, E. T., Nathoo, K. J., Moulton, L. H., et al. (2005). Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 19(7), 699-708.

Smith, L. (2008). Biochemistry of human milk. In R. Mannel, P. J. Martens, & M. Walker (Eds.), Core Curriculum for Lactation Consultant Practice (pp. 269-284). Sudbury, MA: Jones & Bartlett.

Diana Cassar-Uhl, IBCLC and La Leche League Leader, enjoys writing to share breastfeeding information with mothers and those who support them.  In addition to her frequent contributions to La Leche League International’s publication Breastfeeding Today, Diana blogs about normalizing breastfeeding in American culture at and has been a guest blogger at Best for Babes and The Leaky Boob.  Diana can be found lecturing at breastfeeding education events around the United States.  She is pursuing a Master of Public Health, and upon graduation hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition.  Mother to three breastfed children, Diana recently retired after serving as a clarinetist on active military (Army) duty in the West Point Band since 1995.


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