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Gathering More Voices: The African American Panel at the 2014 Lactation Summit

4The 2014 Lactation Summit was designed to listen and learn from the missing voices of the profession so that strategies for dismantling institutional oppression within the profession can be developed.

Much was learned from the 2014 Summit, but there is still listening to be done. Over the next few weeks, Lactation Matters will be breaking out the Summit findings from each community that spoke at the Summit. Our goal is two-fold: to shine a brighter light on the concerns raised in each session, and to solicit other voices who were not present at the Summit.

The 2014 Summit was the result of a year-long planning effort by a 22-member design team made up of diverse representatives from seven countries of the world. It was hosted jointly by International Board of Lactation Consultant Examiners® (IBLCE®), International Lactation Consultant Association® (ILCA®), and Lactation Education Accreditation and Approval Review Committee (LEAARC).

The design team recommended a structure to hear from 26 individuals representing the following categories:

  • African Americans in the U.S.
  • Hispanics in the U.S.
  • Native Americans in the U.S.
  • North and South America
  • Asia Pacific
  • Russia and Europe
  • Communities that cross geographic and ethnic lines (males, lay breastfeeding support groups, those working in remote regions of the world, and the LGBTQI community)

While there are specific barriers unique to various racial, ethnic, geographic, and other groups, several general themes emerged that were common to many of the groups. These findings will help guide future discussions and action plans needed to dismantle institutional oppression.

The following is a summary of the assessments made by individuals representing the panel on African Americans in the U.S. To access information on each of the panels presented, read a complete summary of the report here.

In future posts, we will be highlighting the assessments made by other communities in the order they were presented in the Summary Report.

We hope that, after reading, you will consider sharing your comments, ideas, and suggested solutions. Please click here to offer your input.

U.S. – African American Panel

Racism in the United States permeates all aspects of American society. As Cynthia Good Mojab wrote, “Eliminating inequity in the field of breastfeeding requires that we understand that racism and all other systems of privilege/oppression exist at various levels: personally mediated, internalized, institutional, and systemic.” Racism is evident where white privilege affords opportunities that are disproportionately less available to people of color.

In the lactation profession, the original systems and processes set up to develop the IBCLC credential were based on values, understandings, and resources common among whites, the dominant racial group in the United States. Rethinking those systems and processes based on other values, understandings, and resources will be critical to begin an authentic process of dismantling barriers and welcoming people of color into the lactation profession. This goes beyond simply having diverse representation in the leadership of the lactation organizations, although this is a critical element. It also requires facilitating a process whereby people of color are actively engaged and taking the lead in addressing those barriers.

Many participants described overcoming intense struggles to attain and retain the IBCLC credential, and expressed that many African Americans are unable personally to fight the challenges that make it so difficult. Common barriers include:

  • Lack of diversity – on all of the lactation profession organization boards and within the profession itself. With no African Americans at the table when processes and structures are developed that affect people of color, assumptions continue to be made based on the dominant race: white. The lack of diversity within the profession often leaves African Americans feeling uncomfortable and not truly welcomed.
  • The application process – needs to be simplified. One person put it this way: “Trying to figure out how to get into the lactation profession was like going on a road trip across the country without a map or a GPS.” Suggestions were made to create an interactive smart-logic website to allow applicants to chart their best course and track their progress toward designation based on their background/prior learning and experience in a simple format.
  • Educational and clinical prerequisites – are elusive to those who cannot afford postsecondary education or return to college to acquire the required courses. Suggestions were made to develop high-quality, affordable educational modules that do not require college enrollment. It was further suggested that verifiable work and life experiences could count toward educational requirements.
  • Recertification process – is confusing to maintain, CERPs are difficult to track, and the cost is often out of reach to many in the African American community. Suggestions were made to regularly update current IBCLCs with information about their status obtaining and maintaining certification requirements with an online tracker system similar to the one instituted by the American Board of Pediatrics when it transitioned to a complicated Maintenance of Certification process.
  • Significant cost barriers – for all aspects of obtaining and maintaining the IBCLC credential and participating in the life of the profession. Some must sacrifice multiple paychecks to afford coursework and pay for exam fees. Because many African Americans are underpaid and must work more than one job to make ends meet, this poses significant financial hardships. Suggestions included providing scholarships for lactation courses, high level advocacy by the lactation organizations for employer reimbursement of exam fees, and improved marketing of the importance of the IBCLC credential so aspiring African American IBCLCs will value it enough to make it a priority.
  • Clinical pathways – have become so structured that they are now obstacles to anyone outside the medical field. One person said, “Women have been breastfeeding since the beginning of time. When did something so natural become so clinical?” The highly structured approach makes assumptions that devalue the role of community and social support that has been a vital part of the African American community for generations.
  • Accessing clinical hours – is difficult for African Americans who do not hold professional credentials. The medical field is dominated by those of privilege (for example, over 83% of nurses in the U.S. are non-Hispanic whites), adding layers of inequity to African Americans wanting to become IBCLCs. Many hospitals are unwilling to hire aspiring IBCLCs seeking clinical hours, and many African Americans do not have the professional credentials to be hired in the health care field. Opportunities for volunteer positions are scarce. Other potential sources of clinical experience (for example, the WIC program) are often not sufficiently funded to hire peer counselors who simply need to work long enough to obtain clinical hours. Many WIC agencies hire Caucasian peer counselors, even in predominantly African American communities, so there are inherent inequities within WIC, as well.
  • Recognized lay breastfeeding support organizations – have been touted as one way aspiring IBCLCs can gain their needed clinical hours, working as volunteers or paid staff. Historically, many lay breastfeeding support organizations have not been racially inclusive or diverse; thus many African Americans do not feel comfortable seeking support through currently recognized organizations. Additionally, the process of a lay breastfeeding support organization becoming certified by IBLCE is based on a structure that does not value the role of experience and peer learning. This adds layers of inequity through processes that are not attainable to African Americans participating in newly developed lay support organizations geared toward the needs of underrepresented minorities.
  • Clinical mentors – are scarce among the African American community. Finding relational mentors is pivotal for African Americans to be able to relate culturally to those in their community. In addition to identifying African American mentors, it was recommended that lactation conferences, including ILCA, make a concerted effort to have non-dominant lactation consultants speak on clinical topics, not just topics related to diversity and cultural issues.
  • IBCLC exam – features photos that primarily depict Caucasian mothers and babies. Summit attendees were reminded that many clinical conditions manifest differently depending on the degree of pigmentation of breasts. The exam needs to reflect cultural sensitivity and the diversity of families served.
  • Inherent racism – continues to exist throughout American society. The ramifications are seen throughout the African American community, impacting their ability to become IBCLCs. Some Caucasian families do not want to be cared for by an African American breastfeeding counselor, making it difficult for an African American to obtain the needed clinical hours or to practice in the field after becoming an IBCLC. Some white lactation consultants make assumptions that African Americans will not be able to pass the IBCLC exam, and therefore do not provide the needed mentorship support.
  • Lack of jobs – remains a significant barrier. Some African American IBCLCs reported that navigating the changing requirements was difficult enough, and some colleagues made assumptions that they would not be able to achieve them. Yet once they overcame these obstacles and achieved the IBCLC certification, they then faced new hurdles to employment. The doors to employment are often disproportionately closed to African Americans. Many hospitals continue to require additional professional credentials such as R.N. While this is a common concern of other ethnicities, it adds another layer of difficulty for African Americans who are underrepresented within the nursing profession, as well. Achieving employment thus means they must face the additional obstacles of penetrating yet another system of inequity within the nursing profession before they can practice as an IBCLC. Many WIC agencies do not have funding or internal structures to allow former peer counselors who have attained the IBCLC credential to do the work they are educated and qualified to do. Those who are able to get limited employment within WIC find that they must continue to work as peer counselors within the peer counselor scope of practice and at peer counselor pay even though they now have the IBCLC credential.

We welcome your comments, ideas, and suggested solutions. Please click here to offer your input.


Breastfeeding Interventions: Miriam Labbok, MD, MPH, FACPM, FABM, IBCLC

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

Screenshot 2015-01-22 09.55.20One of the amazing things about attending a live conference with lactation professionals is hearing the history of our profession from the people who have made it happen.  Dr. Miriam Labbok, MD, MPH, FACPM, FABM, IBCLC has significantly advanced the field of lactation over her career, and her presentation at the 2014 ILCA Conference, Breastfeeding Interventions: What We Know and Do Not Know, reflects her deep knowledge of our field.

This presentation has now been made available as a study module through the International Lactation Consultant Association® (ILCA®)’s CERPs on Demand portal and is worth 1 L-CERP and 1 contact hour.

Dr. Labbok’s presentation is an excellent primer on how to critically read research and includes plenty of examples to drive home the concepts.  She shares that her personal interest and pathway into research came from learning that, “clinical medicine turned out to be less about patient support and more about rote prescription of medicines, and [I] turned to public health to allow me to think outside the box.”

In the presentation, she also shares insights into why certain questions about breastfeeding have been studied and from where the motivation and funding arise for these studies.  She discusses the classic question for lactation professionals reading research, “What is the definition of breastfeeding?”  She leads the audience through a consideration of the challenges of ethics in research, provides a helpful how-to on setting up a study, ponders the problems with data mining, and ends with an inspiring call to action for new research.

In a written interview after the conference, Dr. Labbok shared her thoughts on the most pressing needs for research:

CS: Hearing historical perspectives on issues around breastfeeding (such as the history discussed in this presentation surrounding the definition of breastfeeding) is so influential for newer IBCLCs [International Board Certified Lactation Consultants®] like me; in fact, it is a huge motivator to invest in attending conferences such as ILCA.  How can the next generation hold on to these stories in a meaningful way?

ML: Honestly, this is a question that might better be answered by someone in the next generation! I would suggest that the next generation be encouraged to keep an open mind to what came before. Today, much of this is available on the web, IF you know what to look for. Actively asking for history is also good; trying not to take things at surface value, but asking “How did that come about? How was that decision reached?”  Again, I think you would have a better answer to this than I.

CS: Did you ever face a choice between spending your professional time and energy on clinical work vs. focusing more on research? How did you choose?

ML: My own decision to do research on breastfeeding was actually quite circuitous. My interest began before I even finished medical school and public health school, as Dr. Cicely Williams was my adviser.  At the time, unfortunately, I thought of her as being old and out of touch (she was in her 70s, and I, in my 20s), just as many of my students today find me.

As time has passed, I have realized that her approach, which was always to ask for dialogue and to liberally share anecdotes, still serves me today when I try to illustrate a point or challenge folks to try original thinking.  I found that clinical medicine turned out to be less about patient support and more about rote prescription of medicines, and I turned to public health to allow me to think outside the box.  In public health, the entire population is your patient!

CS: What research would you love to see in the next 5 years?  What research do you think would be most useful for helping today’s mothers?

ML: At least 5 areas of research are needed immediately to support today’s new mothers:

  • Safe, long-acting contraception for use during breastfeeding that does not have any negative impact on breastfeeding.
  • Value of breastfeeding in economic terms including the costs of alternatives, excess DALYs, and hospital/medical costs. These could be used to help sway policy towards paid maternity leave.
  • Cost to the environment of formula feeding, including the carbon footprint of the dairy industry, wasted plastics, excess pharmaceutical use, trucking, etc.
  • Differential impact on women’s and children’s health of expressed milk feeding vs direct breastfeeding.
  • Identification and reduction of remaining barriers to breastfeeding success, including continuity of care, prenatal prophylactic education, etc.

As a leader in policy research, Dr. Labbok’s presentation is highly enlightening and inspiring. It will certainly be viewed as a seminal conversation between the newest and the most experienced IBCLCs — a way to forge strong connections between what has been done and what is to come in the future.

CERPs on Demand from ILCA conferences are a great way to catch conference presentations that you missed while earning CERPs. You can access CERPs on Demand at the times that work best for you!

ILCA Members receive a 50% discount on all CERPs on Demand.

CERPs on Demand Button

Dr. Miriam Labbok, MD, MPH, FACPM, FABM, IBCLC, is currently a professor at the University of North Carolina Gillings School of Global Public Health. She also serves as the Director of the Carolina Global Breastfeeding Institute, which offers a comprehensive program of research, service to the greater community, and education related to breastfeeding and optimal reproductive health.


Christine2Christine Staricka, BS is a hospital-based IBCLC. Christine is the co-owner of California Advanced Lactation Institute, 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.



Lactation Support for Pediatric Trainees: Q & A with the Authors

Pediatric TraineesDrs. Avika Dixit, MBBS, MPH and Lori Feldman-Winter, MD, MPH recently published an article (with co-author Dr. Kinga A. Szucs, MD, IBCLC) in the
Journal of Human Lactation (JHL) titled, “Frustrated,” “Depressed,” and “Devastated” Pediatric Trainees: US Academic Medical Centers Fail to Provide Adequate Workplace Breastfeeding Support, a study of pediatricians who parent during their medical training and the substantial obstacles they face in achieving their own breastfeeding goals.  

Drs. Dixit and Feldman-Winter were interviewed by Marie Hemming, IBCLC, a member of the International Lactation Consultant Association® (ILCA®) Medialert Team.

MH: What led you to investigate the issue of breastfeeding support at United States academic medical centers?

LFW & AD: There is an increased focus on improving work and life balance during medical training. We have seen that more pediatric residents are having children during residency and wondered what their breastfeeding experiences have been, given the rigors of residency, and the presumption that they may have difficulty.

We wondered how trainees balance the needs of their baby, specifically breastfeeding, with the demands of their profession and how this experience affects their practice. This led us to explore this issue more.

MH: What was the most surprising finding from the research?

LFW & AD: We were surprised to see just how strong the emotions related to barriers and challenges of breastfeeding [were]. It was really disheartening to see how passionate and negative these emotions were, upon not meeting their breastfeeding goals, as well as the finding that many agreed that this affected their interactions with their own patients.

AD: There is an obvious disconnect between what the profession preaches as an optimal health behavior, exclusive breastfeeding, and what the training institutions do in terms of supporting this choice. The word cloud here was striking; the bigger the word the more often it appeared in the responses. Words like disappointed, sad, guilty and frustrated [were] prominent.Words for Pediatric Trainees

MH: Pediatricians are at the forefront of supporting the mother-baby dyad during breastfeeding. What changes do you think can be made to improve the ability of pediatricians to provide effective support?

LFW: Graduate medical education (GME) programs, especially in pediatrics, need to be more proactive in making sure their trainees who have children during training are supported to meet their breastfeeding goals. This could mean longer leaves, more options for flexible schedules upon return, more apparent places and facilities to express milk, or onsite child care to facilitate breastfeeding during the workday. Successful trainees will be the best spokespersons for their colleagues seeking ways to support breastfeeding mothers.

AD: I agree with Dr. Winter. Pediatric training programs can lead the way for other GME programs in developing support for breastfeeding trainees with changes such as longer parental leaves, flexible schedules upon returning, easily accessible and good quality facilities for breastfeeding mothers at the workplace, etc.

MH: Were you able to look at the correlation between the breastfeeding support provided for pediatric trainees and the Baby-Friendly hospital designation of the facility where they were trained?

LFW & AD: We did not look at this, as we did not have these data, but, at the time of the study, there were very few academic medical centers designated [as Baby-Friendly hospitals]. Over the past few years, the number of Baby-Friendly hospitals that train pediatric residents has increased dramatically, with multiple national initiatives helping hospitals achieve designation, so a follow up study looking at this factor would be interesting.

MH: Working and breastfeeding is a well-documented challenge, and yet, economic pressures and inadequate leave policies leave many families with wage-earning breastfeeding parents. Pediatric training programs can lead the way in resolving this conundrum, beginning with their own family leave policies. What role can healthcare practitioners play in resolving this critical issue affecting the health of our society?

LFW: It is vital for health care organizations as well as private practices to model optimal leave policies, including paid leave and flexible options for return to work. There should be national policies that incentivize these accommodations.

AD: There is increasing impetus nationally to revise parental leave policies. Healthcare practitioners can be advocates both at their workplace and by supporting changes in national leave policies. At the workplace, not only can they support patients and co-workers, but [they] can advocate for leave policies and improvement of facilities; while, at the national level, healthcare practitioners can write to their representatives about changing leave policies.

avikaDr. Avika Dixit, MBBS, MPH, is a third year pediatric resident at Indiana University School of Medicine. She is the AAP Section on Medical Students, Residents, and Fellowship Trainees (SOMSRFT) liaison to the Section on Breastfeeding (SOBr). 



feldman-winterLori Feldman-Winter, MD, MPH, is Division Head of Adolescent Medicine at The Children’s Regional Hospital at Cooper and Professor of Pediatrics at Cooper Medical School of Rowan University in Camden, NJ. Dr. Feldman-Winter is recognized nationally and internationally for her work related to breastfeeding education programs and nutrition policy. She is the chair of the Policy Committee for the AAP Section on Breastfeeding, member of the AAP Task Force on SIDS, AAP representative to the United States Breastfeeding Committee (USBC), and National Faculty Chair for the National Initiatives for Children’s Healthcare Quality (NICHQ) Best Fed Beginnings Project. Most recently, she is consultant to the Kellogg funded CHAMPS Project Communities and Hospitals Advancing Maternity Practices, and the NJHA Mother-Baby Hospital Initiative.

Marie ipad photoMarie Hemming, IBCLC is the mom of three breastfed children (now 21, 17, and 16 years of age). She developed and taught a 20-hour breastfeeding class at the Florida School of Traditional Midwifery. She is currently volunteering as an IBCLC and lay community counselor at Birthline of San Diego, serving families living in poverty.


In Remembrance: Patricia Martens, IBCLC, PhD, FILCA, CM

Pat Martens oct 2007 high resThe International Lactation Consultant Association® (ILCA®), along with the lactation profession as a whole, grieves the recent passing of Patricia Martens. Pat has been instrumental in the advancement of our field and her contributions will be missed.

We reached out to Dr. Anne Merewood, the editor for the Journal of Human Lactation (JHL) to share some stories and memories of her relationship with Pat. She shared:

There are several stories that stick in my mind about Pat that go beyond the research and teaching at which she so excelled. Pat and her husband had a farm (as well as an airplane), and some of her animal stories were her funniest. She told one about a sheep that had fallen over, and could not get up. The sheep was lying in her barn and no matter what she and Gary did, it was lethargic and refused to move. They fed it and cared for it as it was lying there declining, and they were sure it wouldn’t make it. They asked a local farmer who obviously had more experience than they did, what to do. The man looked at them as if they were mad and said, “Just stand up the sheep.” Those who knew Pat can imagine her description of this activity. Sure enough, Pat and Gary lifted up the sheep, stood it on its four feet, and off it ran.

She also loved to tell a story about a cow that had bloat and gas problems on Christmas, and a local farmer (there were a lot of them about, apparently) told them to feed it a bottle of soapy water. So there was Pat on a freezing cold Canadian winter Christmas Day, pumping a bottle of soapy water into the cow. The cow did an enormous burp and all its problems vanished.

Pat had ways of telling these simple funny stories and laughing along with you that were quite unique. She permeated all her research talks with humor. One can just imagine, as she told it, all her statistics students sitting in their exams, furtively waving their arms about and putting their fingers to their noses to remember the action-packed mnemonics that helped everyone to recall the complex statistical concepts she was so good at teaching. She combined humor, common sense, and research acumen to prove that you can lead an outstanding academic center without being aloof or pretentious. It was Pat who persuaded me to apply for the position of JHL editor. While I received plenty of wise counseling from many people during that application process and in the position ever since, it was Pat who looked at me with a big smile and said, “But of course you should do it.” She was always at the end of the phone with pragmatic, down to earth, straightforward advice.

When Pat first told me about her cancer, we knew it was bad news. “Now if I had to choose, this would NOT be my choice of a cancer to get…hoping I’m a friendly outlier. It’s weird to be sitting here working, feeling pretty good and looking just like I always do (except slimmer), and knowing that it is a flip of the coin if I survive the next 9 months.  But my emotional/spiritual state of mind is just fine, so don’t worry about me.  I’m a do-er, not a worrier, and I approach this as a very interesting scientific research project on the qualitative experience of cancer.” Pat lived 22 months after this email. She also said, “I couldn’t ask for a better more loving environment of support at work, home, and around the world.”

Good people should live longer. It will be hard to manage without Pat.

Barbara Wilson-Clay also offered the following remembrance:

We lectured together at several conferences, and got to know one another over dinners. Pat was one of the most talented teachers I’ve ever observed. Her wit and humor brilliantly transformed subjects like interpreting statistics. I once saw her make a crowd of several hundred health care professionals act out the nursery rhyme “I’m a Little Tea Pot” to clarify a statistical concept. Pat was kind enough, on several occasions, to look at manuscripts I was working on to check whether my conclusions about the research were sound on the basis of the numbers cited. She contributed hugely to our profession, to mothers and babies, and I’m sure her students at the university were changed forever by her instruction. I’m heart sick to hear she has passed away. I would have loved to tell her how I valued her.

DSCN6526In 2013, at the ILCA Conference in Melbourne, Australia, it was announced that JHL would begin awarding the JHL Patricia Martens Annual Award for Excellence in Breastfeeding Research. As was only appropriate, the inaugural award was given to Pat herself for her incredible body of research in the lactation field. While accepting the award, Pat graciously said,

“Thank you to all of my ‘journey friends’. I call you ‘journey friends’ because you don’t come to success without the persons, the places, and the times being fortuitous in your lifetime. We want to make those persons, places, and times fortuitous for everyone so that we may allow success for everyone. This is not an individual award. It is an award because I have such a wonderful community around me of ILCA, La Leche League, and all of the people who are my ‘journey friends’.”

We are so grateful for Pat and what she gave to our field and those around here. We are honored to be her “journey friends”. You may read Pat’s obituary HERE.

How did Pat’s work impact your practice? Do you have memories to share or a reflection to offer? We would love to hear from those who were influenced by Pat, not only for her research and teaching, but also for the care she provided to breastfeeding families. Please comment below or on our Facebook Page. These comments would be treasured memories for all who cared for Pat.



Shaken Or Stirred? How Does Handling of Breastmilk Impact Composition? Guest Post by Sue Cox, IBCLC


Incorporating new evidence-based information about putting lactation into practice is a critical component of the role of the IBCLC.  As additional information becomes available, it is a challenge to place it in the context of what has already been established both in the field of lactation and in the broader fields of anatomy and physiology. 

Our guest blogger Sue Cox, an IBCLC since 1985 and the author/presenter of over 80 papers, addresses the research in hot topics in the IBCLC profession today, including questions about breastmilk composition when shaken, agitated, or left in the breast between long feedings. Watch for part two of this post next Wednesday where she will share her reflections on the research on other commonly asked questions about breastfeeding.

On Listening, Then Reviewing/Pondering What We Read and Hear

In this blog post, I will be commenting on some of the discussions I have read on the Internet and heard in professional conversation lately. I hope these quotes – on which I have based my professional life as an IBCLC – will help guide your thinking.

. . . Continued learning requires that we seek new knowledge and [accept] the challenge that takes place when our own interpretations on ways of doing things are questioned by others. That is the price we must pay if we are to hone our skills, increase our knowledge and strive to keep to the best of our abilities for those women who seek our assistance and depend upon us for guidance.

Kathleen Auerbach, (1987) J.Hum Lact 3(4).

Receptiveness to what we hear is vital, but what we hear needs always to be backed up by physiological/biochemical/ anatomical/endocrinological and/or psychological understandings.

Sue Cox 2014.

Note from the editor: Much recent research has addressed how best to handle expressed human milk, with the goal of maintaining the integrity of the milk components and more evenly distribute the components within the liquid. This has, in turn, generated conversation about ways to more evenly distribute nutrients, especially human milkfat, throughout milk during breastfeeding. Read on for the research that Sue provides to further discussion in each of these areas.

Will agitating a syringe of expressed breastmilk for infusion to premature infants homogenize the milk?

Ultrasound has previously been shown to homogenize cow milk (Ertugay & Sengul, 2004).

Ertugay, FM, Sengul, M (2004) Effect of Ultrasound Treatment on Milk Homogenisation and Particle Size Distribution of Fat. Turk J Vet Anim Sci 303-308.

In the recent study by Garcia-Lara and colleagues (2014) the researchers sought to extend knowledge of the most appropriate routine to decrease fat loss in infused expressed breastmilk for premature infants. The word homogenization occurred in the title: “Type of homogenization and fat loss during continuous infusion of human milk.” Three methods were used to mix the milk in the syringe: baseline agitation, hourly agitation and ultrasound. The first two methods simply reconstituted the milk but did not make every drop the same as in homogenization. 

Garcia-Lara et al., (2014) Type of homogenization and fat loss during continuous infusion of human milk. J Hum Lact  0890334414546044, first published on August 13, 2014 as doi:10.1177/0890334414546044.

Could shaking the breast homogenise milk?

Breastmilk in the alveoli is a suspension of fore- or skim- milk with small amounts of fat suspended in it, but most of the fat is bonded to the epithelial lining of the alveoli.

If breastmilk were to be homogenised it would require a “factory setting” in which it would be altered from a suspension to an emulsion where every drop would be the same.

Homogenisation is a process in which the fat droplets are emulsified and the cream does not separate

Even after centrifuging, all of the fat globules do not separate and fat is seen in the skim fraction of the milk (Czank et al, 2009)

Czank, C, Simmer K, and Peter E Hartmann, PE  (2009) A method for standardizing the fat content of human milk for use in the neonatal intensive care unit. Int Breastfeed J. 2009; 4: 3.

Could shaking the breast or breast massage increase the fat content earlier in the feed?

Whittlestone (1953) hypothesised that the fat globules adhered to the walls of the alveoli and ducts.

Whittlestone WG (1953) Variations in the fat content of milk throughout the milking process. J Dairy Res 20: 146–153

Foda (2004) found that when samples of expressed milk were taken within 30 minutes  before Okatani massage and then the breast was fully hand expressed after massage that there were increased fat levels in the post-massage breastmilk but this only occurred after lactation was well established which in that study was after three months. No reference was made to the effect that the massage may have had on milk ejections occurring which increase fat levels in milk, nor was there mention of degree of fullness or time since the previous feed.

Foda et al., (2004) Composition of milk obtained from unmassaged versus massaged breasts of lactating mothers. J Pediatr Gastroenterol Nutr.;38(5):484-7.

Morton et al (2012) found that when mothers who were expressing for their premature babies used hand expression and breast compression during pumping that their milk exceeded normal fat and energy levels after the first week postpartum.

Sue notes here that the breasts would have been well drained at each expressing and pumping session.

Morton J, et al., (2012) Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants.  J Perinatol. 32(10):791-6

Would altering breastmilk so that the infant received creamier milk earlier in the feed be an advantage to the baby?

Karatas (2011) suggested that the weight patterns in healthy breastfed infants at their second and fifth months is based on the satiety from changes in breastmilk ghrelin, leptin, and fat levels between the foremilk and hindmilk.

Karatas Z et al., (2011) Breastmilk ghrelin, leptin, and fat levels changing foremilk to hindmilk: is that important for self-control of feeding? Eur J Pediatr. 2011 Oct;170(10):1273-80.

Various theories have been suggested about how/why the fat detaches including: the decrease in surface area as the alveoli are being drained of milk during a feeding (Atwood & Hartmann, 1992; Neville, Allen & Watters, 1983; Hytten, 1954); the effect of hormones oxytocin and prolactin and/or alteration in gene expression as the alveoli is drained (Hassiotou et al., 2012; Hall, 1979) .

Atwood CS, Hartmann PE (1992) Collection of fore and hind milk from the sow and the changes in milk composition during suckling. J Dairy Res 59: 287–298.

Neville MC, Allen JC, Watters C (1983) The mechanisms of milk secretion; Neville MC, Neifert MR, New York and London: Plenum Press. 49–102.

Hytten FE (1954) Clinical and chemical studies in human lactation. I. Collection of milk samples. Brit Med J 23: 175–182.

Hassiotou F, Geddes DT, Hartmann PE (2012) Cells in human milk: State of the science. J Hum Lact 29: 171–182.

Hall B (1979) Uniformity of human milk. American Journal of Clinical Nutrition 32: 304–312.

Does milk separate in the breast if there are long gaps between feeds?

The greater portion of the milk is stored in the alveoli until required (Geddes, 2009). High-resolution ultrasound images (Geddes, 2009) show the flow of milk as the ducts dilate in the breast following oxytocin-mediated milk ejection (shown by flecks in the milk in the duct as the milk is ejected as well as in the infant’s oral cavity). When milk removal ceases the residual milk returns to the alveoli.   

Geddes D (2009) The use of ultrasound to identify milk ejection in women – tips and pitfalls. Int Breastfeed J. 2009; 4: 5. doi:  10.1186/1746-4358-4-5

Hassioto et al., (2013) found that when milk was expressed before, after and then at 30- minute intervals for three hours after breastfeeds that the highest fat levels were found 30 minutes after the end of milk removal. This supports the utrasound findings of Geddes (2009) that showed how residual fat returns to the alveoli after milk removal.

Hassiotou F, et al., Breastmilk cell and fat contents respond similarly to removal of breastmilk by the infant. PLoS One. 2013; 8(11): e78232. Published online Nov 6, 2013. doi:  10.1371/journal.pone.0078232

In conclusion, the suggestion that homogenization can be achieved by simply shaking or agitating breastmilk in the breast or in another receptacle is an incorrect use of the word homogenize. The use of the word homogenize in the context of human lactation and breastfeeding requires scholarly review.

Watch for Sue’s next guest post, where she presents the research on other key areas of breastfeeding practice today.


Catch up with the #ILCA2014 Conference


Missed the ILCA conference this year? There’s still a number of ways to catch up with conference highlights!

Thanks to the efforts of the ILCA Medialert Team (including Christine Staricka of @IBCLCinCA) and other conference goers, highlights of the conference plenaries and some of the breakout sessions were broadcast on Twitter. One of the Medialert Team members, Jodine Chase of @humanmilknews, captured and summed up those tweets which you can find here:

Wednesday 23 July 2o14

Heinig Plenary

Summary of other tweets on 22 & 23 July

Thursday 24 July 2014

Smillie Plenary

Gagneux Plenary

Summary of other tweets on 24 July

Friday 25 July 2014

Singleton Plenary

Summary of other tweets on 25 July

Saturday, July 26

Ball Plenary

President’s Address: Decalie Brown

Glass/Wolf Plenary

Stuebe Plenary

Clark Plenary

Labbok Plenary

Find ILCA and all its stories here on Storify.

Note that we were not able to catch the Lactation Summit via Storify. We’ll keep you up-to-date on a summary that is being prepared.

And of course, many of the most popular talks from the #ILCA2014 conference will be available via CERPs on demand. Watch here – we’ll let you know when they go live!


JHL Cover Photo Contest!

JHL (3)

Every year, the Journal of Human Lactation (JHL) hosts a photo contest for the coveted cover spot on each edition. The JHL is a quarterly, peer-reviewed journal publishing original research, insights in practice and policy, commentaries, and case reports relating to research and practice in human lactation and breastfeeding. The annual photo contest is your opportunity to contribute to the journal and highlight your community. We’ve invited the JHL staff to tell us more about how you can join in the contest.

The four photos on JHL’s cover are changed annually. JHL is your journal, and we want to feature your photos! The four photos portray the broad field of human lactation, from the IBCLC helping new mothers (picture the caring professional with a breastfeeding mother, 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 – October 15, 2014: NO EXCEPTIONS
  • If a recognizable person features in the photo (e.g., the face of a 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


Keep Infant Formula Marketing Out Of Healthcare Facilities: Action Day

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Guest Post by Jodine Chase

In 2012 Jennie Bever Babendure, PhD, IBCLC, a mother, IBCLC in private practice and breastfeeding research scientist, became an overnight advocate for the protection of mothers and children from predatory marketing practices. It happened after she learned that the representative for the World Health Organization (WHO) in the Americas, the Pan American Health Organization, had accepted $150,000 from infant food manufacturers Nestlé.

Jennie spearheaded a social media campaign that drew global attention to the need for all who work in maternal and infant health to speak out about predatory marketing practices that erode breastfeeding.

[editor’s note: We often hear confusion at Lactation Matters between the marketing of infant breastmilk substitutes and the availability of these substitutes for families who, for whatever reason, need them. Jennie’s work, and that of others who uphold the WHO’s  International Code of Marketing of Breastmilk Substitutesfocuses exclusively on marketing. To learn more about the impact of predatory marketing on families, check out this piece by Norma Escobar here or this video from Public Citizen here.]

Shortly after Jennie’s campaign drew attention to Nestlé’s involvement in funding health campaigns in the Americas, IBFAN Latin America denounced Nestlé’s sponsorship of the hiring of 15,000 women to give nutritional advice on infant feeding in Mexico. The IBFAN action comes on the heels of a successful move in the US to curb infant formula advertising in hospitals by banning the distribution of infant formula giveaways to new moms.

The success of these efforts, such as those in New York City and the state of Massachusetts, means moms in those states are no longer exposed to formula gift packs in hospitals. A 2012 survey by Best for Babes found the practice is declining, and a 2013 survey by Public Citizen and Ban the Bags has found top-ranked hospitals in the US no longer distribute infant food product manufacturer gift bags.

Public Citizens says 75 percent of hospitals in the US still distribute formula gift packs. And many mothers are finding they are targeted before they even get into the hospital to give birth. Advertising that targets pregnant women by offering prenatal education in conjunction with formula giveaways at doctor’s offices and ultrasound clinics is on the rise. 

Jennie learned this first hand during her second and third pregnancies. I interviewed her as she prepares to join families who are responding to Public Citizen’s call for a Day of Action to end infant formula advertising in hospitals and health clinics. After the interview, learn more about the Day of Action and about efforts worldwide to support breastfeeding families by reducing predatory marketing.

Jodine Chase: As an IBCLC who has worked as an advocate to end predatory marketing, you are very aware of the tactics that infant food product companies employ to increase their market share. But you’re also a mother expecting your third child. During this pregnancy what marketing tactics were you personally exposed to?

At 10 weeks into this pregnancy, my husband and I went in for our first prenatal visit. A medical assistant handed us a “gift bag” when she ushered us into the exam room. While we were waiting to see the nurse practitioner, my husband opened the bag and started pulling things out. Along with information from the obstetrician on diet and scheduling our visits, there was a small makeup bag from Abbott containing samples of their Prenatal vitamins along with an invitation to join the Similac Strong Moms website, as well as a portable cooler bag from Mead-Johnson with the label “Powdered Formula for Nursing Moms,” with a can of powdered Enfamil newborn formula.

Breastmilk substitutes Jennie received during pregnancy

Breastmilk substitutes Jennie received during pregnancy

The Enfamil package also contained 2 Breastfeeding Guides: the “New Mother’s Breastfeeding Essentials” with a label from the American Academy of Pediatrics and “Breastfeeding: The Best Start for You and Your Baby” produced by Enfamil. My husband was perusing these guides with the bottles of formula on his lap when the medical assistant re-entered the room. When he asked her how giving formula to new moms was supposed to support breastfeeding, she gave a wry smile and said, “Yeah, that is a little strange, isn’t it?” When he further queried how these things ended up in the bags, she said, “Well, the reps bring us lunch along with boxes of these samples, and we put whatever they give us in the gift bags for moms.”

We had our next visit at another office of the same practice. On the front counter was an

Breastmilk substitutes at Jennie's OB's office

Breastmilk substitutes at Jennie’s OB’s office

11×14 gift basket filled with every type of formula Enfamil makes, wrapped up in cellophane with a bow on top. Looking at this, my 7 year old son asked me “Mom, what is that doing there? Aren’t they supposed to help moms breastfeed?”

2) Was it easy for you to see how the ad campaigns are designed to undermine breastfeeding?

This one is tougher, as the formula companies have gotten very slick at marketing themselves as supporters of new moms. They’re so slick that they’ve obviously got many healthcare providers convinced that they are only providing free samples to help, not to hurt breastfeeding.

By providing booklets about breastfeeding, breastfeeding support phone numbers and saying “breastfeeding is best” at every turn, they make it look like they’re really out to help moms, and only step in when needed. But how can you support breastfeeding by giving moms cans of formula?

The formula companies are very aware that putting formula into a mom’s hands makes it more likely she will use it. Having a physician or hospital give the formula samples to moms makes it look like a health recommendation.

In my second pregnancy I received 8 cans of formula by mail and over 200 advertisements/coupons for formula. I definitely didn’t need my healthcare providers to hand me more of this in the guise of breastfeeding support.

3) Did you ever find the tactics influencing or swaying you personally?

No, but I was very lucky. I delivered my first baby with a midwifery practice that was affiliated with a Baby-Friendly Hospital, and was not given any formula marketing material by healthcare providers or the hospital. Perhaps that is why receiving such a huge amount of these materials so early in my 2nd and 3rd pregnancies really shocked me.

Like many new moms, I really struggled with breastfeeding my first, who was a little early and had lost some weight. If I had been handed samples of formula by my midwife or hospital, I might have considered using it.

4) What do you see that a woman expecting her first baby may not have noticed? What do you want pregnant women to know about these practices?

Despite what formula companies would have you believe, the research shows that mothers who are given samples of formula by their healthcare providers are more likely to give supplementary formula to their breastfed babies, more likely to buy the brand of formula given in the sample, and more likely to introduce solid foods (which are often also made by formula companies) earlier than recommended.

There is nothing altruistic about these samples the formula companies provide, they are a wise investment in future sales. Yes, some moms and babies may need or want to supplement, but the formula marketing is aimed at all moms, setting them up to expect to need formula and doubt their abilities to breastfeed before they even start.

The only way for us to stop this from happening is to speak up. With enough pressure from consumers (us!!), the hospitals and healthcare facilities will get the message.

5) What will you be doing on Public Citizen’s Day of Action?

I have already signed Public Citizen’s petition. Since I can’t be there to help deliver the petition in person, I will be posting pictures of myself and my sons on social media asking healthcare facilities to stop acting as marketing arms for the formula companies. My older son is already very aware of these tactics, and I’m proud that he is learning to be skeptical of marketing campaigns. My hope is that by the time he has children, formula marketing in healthcare facilities will be a thing of the past!

Day of Action

Public Citizen, a nonprofit organization dedicated to championing citizens interests in the face of corporate abuse, is calling on infant formula makers to stop using hospitals and healthcare providers as marketing tools.

A Day of Action takes place on May 21st, both on social media and at Mead Johnson’s Chicago headquarters. Mothers holding hand-made signs with messages like “no ads in hospitals,” “keep ads out of my doctor’s office” and “follow the WHO Code” will be posting their pictures and videos on social media. They’ll be sharing on the Facebook event page as well as on Twitter and Instagram with the hashtag #NoFormulaAds. And thousands of people have signed the petition for Public Citizen to delivery to Enfamil maker Mead Johnson. The petition currently sits at over 17,000 signatures, with more rolling in each day.

Marketing of Breastmilk Substitutes Worldwide

The Public Citizen campaign focuses on changing practices in the United States. The marketing of infant formula impacts families worldwide. To learn more about efforts around the world, check out the links here.

IBFAN Africa
IBFAN Afrique (French Speaking West Africa)
IBFAN Arab World
IBFAN América Latina y el Caribe
IBFAN Europe
Baby Milk Action/IBFAN UK
INFACT Canada/IBFAN North America

This is, no doubt, an incomplete list. Share your local efforts in the comments and we’ll be sure to add them to this post.

Jodine Chase owns a public relations firm that specializes in news analysis for a select clientele. She is the curator of Human Milk News and with her husband has parented eleven children and stepchildren. She has three grandchildren and two more on the way, and she wants infant food product companies to stop targeting her daughter Rose and her unborn granddaughter (photo) with unethical marketing campaigns. She joined the Best for Babes Foundation board in 2014 to support the BfB C.A.R.E.-WHO Alliance, and she helps run INFACT Canada ‘s Facebook page. She is a founding member of the Breastfeeding Action Committee of Edmonton (BACE).

photo credits:

image of Jodine’s daughter Rose holding sign, courtesy Jodine Chase
images of breastmilk substitutes received during pregnancy, courtesy Jennie Bever Babendure

Do you have a story to share about your efforts to enforce and/or enact the WHO International Code of Marketing of Breastmilk Substitutes in your country? Would you like to share it at Lactation Matters? Please e-mail us at media at ilca dot org.


New Research: Direct Correlation Between Labor Pain Medications and Breastfeeding

New Research_ Direct Correlation Between

Jennifer Lind, PharmD, MPH is an Epidemic Intelligence Service Officer assigned to the Nutrition Branch in the Division of Nutrition, Physical Activity and Obesity at the CDC. Dr. Lind’s research is focused on research and surveillance issues related to infant and young child feeding practices. Before joining the CDC, Dr. Lind worked as a community pharmacist which led to her deep commitment to public health and fostered her interest in chronic diseases. Dr. Lind and her colleagues recently published a ground breaking study in the Journal of Human Lactation that demonstrates an association between use of labor pain medications and a delay in the onset of lactation (DOL) (defined as milk coming in >3 days after delivery).


Jennifer Lind, PharmD, MPH

Dr. Lind was recently interviewed by Marie Hemming, IBCLC, a member of the International Lactation Consultant Association® (ILCA®) Medialert Team.

Marie Hemming: What led you to study the effect of labor medications on the onset of lactation?

Dr. Lind: As a pharmacist, labor pain medications are of interest to me and there is very little research done on the association between labor medications and how it can potentially affect the onset of lactation. So many women (estimate of 83%) use labor pain medications and we know that a delay in the onset of lactation (DOL) can lead to shorter breastfeeding durations.

MH: Please summarize the results.

DL: Mainly, in all of the groups of labor pain medications and delivery method, we found that mothers who received labor pain medications were 2-3 times more likely to report DOL compared to mothers who did not use labor pain medications and delivered vaginally.

MH: Are there other studies that demonstrate this association?

DL: This information is relatively new. There are 2 other studies, but they are greater than 10 years old. This current study is the most recent data on the topic.

MH: What do you think are the public health implications of these study results?

DL: This research adds to the body of literature on the topic, which can help inform clinicians and women as they make decisions regarding labor and delivery.

More studies need to be done looking at this association to evaluate why this association exists.

Finally, we need to explore if by providing additional lactation support to women who receive labor pain medications, we are able to improve breastfeeding outcomes and prevent the shorter breastfeeding duration that we know exists in women who have DOL.

MH: How can these data be used by pregnant women?

DL: Women can use these data when they are talking to their health care providers about labor pain medications as part of the decision making process. The research can help them make an informed decision with the knowledge that there may be a risk of experiencing breastfeeding difficulties if they use labor pain medications. Women can also be prepared with appropriate community support mechanisms in case they do experience a delay in the onset of lactation after they are discharged from the hospital. Everyone is very excited about the information because it addresses a gap in this field which is great for clinicians who work in labor and delivery and help mothers enhance natural breast feeding.

MH: Studies show it can take up to 17 years to translate research into practice. How do you think we can disseminate this information more quickly to pregnant women and their caregivers?

DL: This study is available online at the Journal of Human Lactation now. We hope to reach as many families and clinicians as possible so that this can go into the clinical decision making process that mothers and their caregivers make.



Help Your U.S. Clients Understand Their Rights in the Workplace

In the United States, Sunday marks Mother’s Day. The United States Breastfeeding Committee (USBC) honors this day through an annual campaign. This year, the USBC is focused on getting the word out about the federal “Break Time for Nursing Mothers” law and what it means for breastfeeding employees, as well as issuing a call to action about the Supporting Working Moms Act, which would expand the law to millions of additional workers. Today, Dr. Kathleen Marinelli of the USBC is guest blogging at Lactation Matters to ensure our community is aware of the U.S. federal requirements and ways to support policy that can improve breastfeeding outcomes for U.S. families.

Help Your Clients Understand Their Rights in the Workplace

With more than half of women with infants employed, simple workplace accommodations are critical for breastfeeding success. By helping moms understand their rights as a breastfeeding employee and plan for their return to work, lactation care providers can support a successful transition so that working moms are supported to reach their personal breastfeeding goals.

The federal “Break Time for Nursing Mothers” law requires employers to provide break time and a private place for hourly paid employees to pump breast milk during the work day. The United States Breastfeeding Committee’s Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law compiles key information to ensure every family and provider has access to accurate and understandable information on this law.

Key Facts about the “Break Time for Nursing Mothers” Law:

  • Who is covered: The law applies to nonexempt (hourly) employees covered by the Fair Labor Standards Act.
  • Space: Employers are required to provide a place that is not a bathroom. It must be completely private so that no one can see inside. Employers are not required to create a permanent dedicated space for breastfeeding employees. As long as the space is available each time the employee needs it, the employer is meeting the space requirements.
  • Time: The law requires employers to provide “reasonable” break time, recognizing that how often and how much time it takes to pump is different for every mother. Employees should consider all the steps necessary to pump, including the time it will take to gather pumping supplies, get to the space, pump, clean up, and return to their workspace. Employers must provide time and space each time the employee needs it throughout her work day.
  • Enforcement: The U.S. Department of Labor’s Wage and Hour Division (WHD) is responsible for enforcing the “Break Time for Nursing Mothers” law. If an employer refuses to comply, employees can file a complaint by calling the toll-free WHD number 1-800-487-9243.
  • Small Businesses: All employers, regardless of their size or number of employees, must comply with the “Break Time for Nursing Mothers” law. Following a complaint from a breastfeeding employee, businesses with fewer than 50 employees may be able to apply for an undue hardship exemption. To receive an exemption for that employee, the employer must prove that providing these accommodations would cause “significant difficulty or expense when considered in relation to the size, financial resources, nature, or structure of the employer’s business.” Until they are granted an exemption by the Department of Labor, they must comply with the law.
  • State laws: Employees who are not covered by the “Break Time” law may be covered be a state law. Contact your state breastfeeding coalition for help understanding the breastfeeding laws where you serve.

The “Break Time for Nursing Mothers” law was an important victory for families, but breastfeeding success shouldn’t depend on a mother’s job type. The Supporting Working Moms Act would expand the existing federal law to cover approximately 12 million additional salaried employees, including elementary and secondary school teachers. We can all help make this happen! Use USBC’s easy action tool to ask your legislators to cosponsor the Supporting Working Moms Act with just a few clicks. Twelve million employees are counting on us! As Surgeon General Regina Benjamin advised us, “Everyone can help make breastfeeding easier.”

We know that workplace lactation support is a “win-win”, benefiting families, employers, and the economy, yet one of the major causes for the drop-off in breastfeeding rates is the lack of effective, reasonable workplace accommodations when mothers return to work. Employers that provide lactation support experience an impressive return on investment, including lower health care costs, absenteeism, and turnover rates, with improved morale, job satisfaction, and productivity. The retention rate for employees of companies with lactation support programs is 94%, while the national average is only 59%!

Breastfeeding and working is not only possible, it’s good for business. Find additional information and resources in USBC’s Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law and help spread the word about this valuable new resource with your clients by sharing this link:

Mothers, babies and employers everywhere will be glad you did!!

Important links and information:

Editor’s note:

This post addresses the need for workplace accommodations for breastfeeding mothers who return to work in the U.S. Workplace accommodations are critical for any breastfeeding parent who has returned to work, regardless of the country of their workplace.

Workplace accommodations are, of course, most critical in countries where paid leave is not readily accessible. A comprehensive comparison of maternity leaves around the globe can be found here and is also discussed in the chapter “Breastfeeding and Maternal Employment” of the Core Curriculum For Lactation Consultant Practice.

How do family leave and workplace accommodations impact breastfeeding rates in your country?

Marinellii-head-shotDr. Kathleen Marinelli is the Chair of the United States Breastfeeding Committee, an independent nonprofit coalition of almost 50 nationally influential professional, educational, and governmental organizations, that share a common mission to improve the Nation’s health by working collaboratively to protect, promote, and support breastfeeding, where she represents the Academy of Breastfeeding Medicine. She is also a Neonatologist and Breastfeeding Medicine Physician at Connecticut Children’s Medical Center, in the Connecticut Human Milk Research Center, and Associate Professor of Pediatrics at the University of Connecticut School of Medicine.


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