IBLCE Exam

I have thoroughly enjoyed every class with my lactation students, but the "Exam" loomed in the heads and hearts of everyone throughout the course, well, the test is over.  Everyone can breathe easily, well, maybe not until October, but at least this step in the process is complete.  I don't remember the buzz on Facebook last year, I must not have been too active on the site, but I can say that none of the comments following the day-long Exam surprised me.  A sampling of posts on my site included:

"I'm not sure what I would have studied more. The questions were very confusing. I felt I did better with the pictures."

"I thought the picture questions were more difficult/challenging. There seem to be 2 correct anwers and/or no correct answer…."

"I was surprised by how much there was about viruses, and seemed like there was a lot of coverage in the photo section of low milk supply, risk of low milk supply, and pics of FTT babies. Maybe a little harder than I expected."

"nothing in test that hadn't been presented in our GOO class.....I also thought pic part was easier than the first part. the first part had alot with 2 right answers IMO and picking the BEST is always subjective with no background info. I just kept thinking World Wide exam!!! 

It was very different from what I expected. It was my first one though, so I have nothing to compare it to. The Health-e-learning courses and prep exam were great. I thought the photo paper was much harder (amazed that some found it easier! Go girls!) and some of the questions were just down-right confusing. But hey, it's done, and I just want to pass...100% would be great, but in the greater scheme of things, I can always try again next year if I fail, and I doubt anyone has ever scored 100%! Hoping for 70%!!!lol

I kept insisting to my class that the exam does not define them.  What defines them in this profession is how they problem solve by reaching down into their vast knowledge base, rely on case studies, summon help from colleagues,  research articles and books for a possible solutions--all in an attempt to help the mother/baby breastfeeding relationship.  

We all are too familiar with the scenario of someone passing the Exam only to fail at giving good advice and support to a dyad.  I had a pretty good idea of what the test would be like from my personal experience, but my goal was never to teach to the test.  I fulfilled my role as an instructor and IBCLC by preparing individuals to help mothers reach their breastfeeding goals.  Although I understood that Monday would come, I was more interested in the Tuesday-Sunday help my students would be giving following Monday!

The GOO Class has always been passionate about helping others and serving their communities and they brought that zeal into the classroom.  Many students were regularly seeing moms in clinics, hospitals, support groups or La Leche League and wanted to build on their experience and gain lactation specific education to better serve their local groups. What an incredible starting point.  We entered the semester with a passion and ended with conviction. Students learned about anatomy, nutrition, counseling, pathology, development, biochemistry, and the other suggested disciplines.  They participated in role playing, conference planning, research assignments and promotional productions--all as a means to understand the many roles of the LC. In order to relate to the communities in which they serve, they attended Moms Groups, La Leche League meetings, Coalition meetings, shadowed nurses in hospitals and visited their local WIC Clinics. The GOO Students received a well-rounded, thought out lactation education.  We celebrated their amazing accomplishments during a graduation ceremony that was attended by over 240 supporters--that was on Friday, then came Monday.

Why do Mondays ever have to come?  It was not a "reality check" there isn't anything "real" about the Exam.  In all my years as an IBCLC I have never assessed a mom by a picture she carried in her purse.  I have never had only "A, B, C, or D" to choose from as possible solutions to a breastfeeding problem, that would be much too easy.  I understand the assessment and the need for a certification process, but I do not want qualified individuals to be disheartened or labeled by this annual exam. I believe with all my heart that my students all did well, because they were all more than qualified to pass an "entry level" lactation test, but none the less I think the test has too much credibility at times.

Take another all-too-familiar scenario.  An individual works 9-5 in an arena where she sees moms...she charts those hours and qualifies to sit for the exam.  Her test taking strategies affords her the ability to eliminate distractors in the multiple choice answers and she narrows the correct answer down to two possible choices.  She "guesses" correctly half of the time and passes with a 75%!  Is it possible to become a Lactation Consultant without the skill to assist moms?  Yes.  Is it possible to work as an IBCLC and do damage to the profession by the service given? Yes.  Is it possible to add "RLC" after a name with little to back up the claim?  Yes.  Is it possible to be passionate, educated, prepared and eager to learn more in the field, yet fail an entry level exam due to its structure?  Unfortunately, yes...the system needs an overhaul, but until that happens, I applaud all the people who took the IBLCE Exam in an effort to support the profession and help mothers.  I am somewhat glad that the results are not available until October.  By then you will all be back at your posts helping moms and serving your communities and no one will pay much attention to how people fared as the results come in.  If you are not among the list of newly certified LC's rest assured, the test will be administered again next July and you will be all the wiser.  Until then, you are still my respected colleagues and friends. Moms are helped by people, not by letters after a person's name!
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Positioning and Latch-on

We spend an awful lot of time discussing latch-on and positioning. I recently looked at the wording in a pamphlet that was explaining how to "properly position" an infant for breastfeeding...the standard cradle, cross-cradle, football and side lying positions were explained along with all the directions, "elevate feet to ensure legs are level and turn infant tummy to tummy...place baby in crux of arm...hand must be placed behind head...etc, etc..."Really?! I was exhausted after reading all the rules and regulations of breastfeeding. I am also not surprised when the formula companies patiently describe the above scenario and take great satisfaction at using directions from lactation experts in their written material. We supply many of the information used by the companies trying to paint breastfeeding as difficult and exhausting.

When infants and moms are left skin-to-skin following birth, often spontaneous breastfeeding occurs within and hour to 90 minutes. No panic, no readjusting, no mandatory pillows...just baby and breast in proximity. Remind mom to stay in her comfortable, "laid back" position and place baby vertically on her body. We see a "baby crawl" and latch. http://www.youtube.com/watch?v=B2p6T8ewu9I. Yet, when well-meaning attendees attempt to "position" the baby, they often interfere with the natural progression and bonding time. Reclined breastfeeding is not anything new. Lactation books explained this years ago, but somehow we lost contact with our instincts and tried to control the experience, or perhaps the medications administered during labor inhibited instincts. More about the laid back position and biological nurturing can be found at http://www.biologicalnurturing.com/

With that said, there are situations and scenarios when assistance is necessary and imperative. A baby with Down Syndrome will definitely benefit from the Dancer Hold.

If poor muscle tone makes it difficult for your baby to latch on well, try supporting your baby's chin and jaw while nursing using the "Dancer Hold." (The name of this position was coined by Sarah Coulter Danner, RN, CPNP, CNM, IBCLC and Ed Cerutti, MD. "Dancer" comes from the first letters of their last names (Dan + Cer).) Hold your baby with the arm opposite the breast you'll be offering. Using the hand on the same side as the breast you are offering, cup your breast with your thumb on one side of the breast, palm beneath, index finger pointing outward, and the other three fingers on the other side of the breast. Use your index finger to support your baby's lower jaw while nursing. As your baby's muscle tone improves through breastfeeding and maturity, he will become able to support himself and breastfeed more effectively.http://www.llli.org/faq/down.html

Although laid-back is effectively used with cesarean births, some moms are concerned about the feet touching the incision. If a mom wants the baby on her side, there is nothing wrong with instructing on the "football hold." Remember, as lactation consultants, we desire to protect the breastfeeding relationship and construct a plan that is agreed upon with the mother. She is autonomous and we must respect that.

As the baby ages, there is little talk about positioning and latch. Babies will eat in any position and adjust well to change. The initial information we give mom should include the point that breastfeeding is natural and babies know how to do it...place baby skin-to-skin following delivery and enjoy the bonding time...position the baby vertically and use your hands to guide and direct as he begins to crawl to the breast. Also, timing is not that crucial. Babies have spent the hours leading up to birth at the "all-you-can-eat buffet." They do not come out starving. Allow the baby time to adjust to the new surroundings and relax.

Moms do need to know that breastfeeding should not be painful. Latch is an issue if no milk transfer is occurring or if mom is experiencing pain. Lactation Consultants can help by observing a feed. Observe a complete feed. Watch mom's breast, the position of the areola in the infant's mouth, the rhythm of the feed, listen for swallows, check to make sure the infants lips are flanged and then observe mom's nipple following the feed (it should be round and symmetrical and not pinched or wedged).

Observation is a lactation consultant's best tool. Look for clues to the mystery of pain like where the nipple is damaged, how severe the damage is, the length of the feeding, the baby's demeanor following the feed--all of these are clues.  Lactation Consultants are detectives. Watch, look and listen--a phrase we all learned in kindergarten--is the best advice I can offer anyone in or entering the field of lactation.

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Christy Jo Hendricks, IBCLC Doula

Birthing, Bonding & Breastfeeding

Infant Physiology and Milk Transfer

This topic is too broad to be thoroughly addressed in a blog, but I can definitely comment on the area and encourage those in the learning mode to continue to examine this very important discipline.  

Ascertaining that the infant actually breast feeds is very crucial to the role of the Lactation Consultant.  It sounds pretty elementary, but it is amazing how many infants wind up with jaundice or failure to thrive due to mismanagement of breastfeeding.  It's not actually breastfeeding that is the problem in most of these cases, but starvation.

When a mom delivers, she has a wonderful synergy of hormones that are adjusted perfectly for bonding and breastfeeding.  The two hormones that are present for only a short time are oxytocin and estrogen--a combination that assists in bonding (Uvnas-Moberg, The Oxytocin Factor, 2005).  While pregnant, the mother has progesterone which inhibited milk production, but with delivery, a  radical withdraw of progesterone and estrogen gave way to high levels of prolactin which enabled milk production (this is another reason to have a mom examined for retained placenta if she does not enter lactogenesis II and has heavy bleeding beyond the 3-4 day).  

The prolactin is the milk producing hormone, but nipple stimulation releases oxytocin which is the milk ejection hormone.  Oxytocin is often referred to as the "love hormone" since it is elicited through stimulation.  Initially, stimulation is necessary to release the milk, but over time, stimulation is less relied on.   If we allow Baby to turn oxytocin on (baby led attachment)  The following timeline is observed: (Matthiesen, Birth, 2001)

Minutes:

  6:  Baby opens eyes

11:  Massages breast

12:  Hand to mouth

21:  Rooting

25:  Moistened hand to breast

        Nipple becomes erect

27:  Tongue stretches & licks nipple

80:  Breastfeeding

Other hormones necessary for the production of breast milk include: insulin, cortisol, thyroid hormone, parathyroid hormone, parathyroid hormone-related protein, and human growth hormone.

Once the hormonal process is well underway, we must turn our attention to the act of breastfeeding. Milk transfer is necessary to feed the baby and to ensure mom continues to make milk. If baby is unable to empty the breast, mom should be encouraged to hand express to finish the process. If the breast is not emptied, it is in jeopardy of slowing production. A full breast not only will not make more milk, it can even inhibit milk production (this is a good time to refresh your memory on the FIL or feedback inhibitors of lactation). 

Often babies will self-latch and feed within a few hours after delivery. Medications and interventions can alter the schedule, but ideally a mom and infant left together to bond will have a successful time breastfeeding (remember the laid-back technique for easy and biological breastfeeding).

Measuring milk transfer can be as easy as noting the babies behavior. Is baby having 1 wet diaper on day 1 (24-hour period), 2 on day 2, 3 on day 3...6-8 on day 6 and beyond? That is one indicator of milk transfer.
The scale is also a good tool to use (especially for the premature infant). Pre and post test weights can assure milk transfer has occurred.

The infant test-weighing procedure should be performed using an electronic digital infant scale with accuracy to at least 2 grams. The infant is weighed clothed pre- and postfeeding without changing the diaper between weight measurements. The prefeed weight is subtracted from the postfeed weight, and the difference represents the volume of milk consumed, where 1 gram of weight is equivalent to 1 mL of milk intake. Milk is slightly denser than water, so in theory this calculation overestimates the test weight results, which is countered by insensible water loss during feeding.

Milk transfer is an area of concern and we must make sure early on that the infant is being fed. Know signs and symptoms of dehydration and make sure early follow-up appointments are kept. Unfortunately, I have to say, many lactation consultants, including myself, have witnessed mismanagement of feeding to a point of readmission to the hospital. Let's educate parents and keep our eyes open to possible warning signs.

For more detailed description of oxytocin and prolactin visit http://www.breastfeedingbasics.org/cgi-bin/deliver.cgi/content/Anatomy/physiology.html

For visible cues of milk transfer, visit http://www.letsbreastfeed.com/research/visible-cues-of-poor-milk-transfer/

Breast Anatomy and Physiology

Breast anatomy should be very familiar to anyone sitting for the Exam.  Not only is it crucial to understanding lactation, but it is also good testing ground for the IBLCE board since anatomy is the same internationally.  Although breastfeeding requires breasts and they have been used throughout the ages, breast anatomy is remarkably understudied (well, by the scientific audience, I should say).  I am amazed at the history of how we originally learned, evaluated and understood the mammary gland.  In case some of you haven't heard the lecture on the breast anatomy's history, I'll give a quick synopsis.  Medical professionals, biology students, lactation experts--all based all their information, decisions and future studies based on breast anatomy research that occurred over 160 years ago.  


Sir Astley Paston Cooper, M.D., FRCS, Bart., (1768-1841) published his findings in On the Anatomy of the Breast in 1840, just before his death.  This publication demonstrated Cooper's mastery of breast anatomy through outstanding illustrations. His findings were never collaborated or even verified by additional trials.  His pictures were widely circulated.  Unfortunately, these early illustrations showed some findings that were later proven false.  The discrepancies were created by the procedure Cooper used to trace the ducts that terminated at the nipple.  He laid out the breast from a cadaver in a asymmetrical way to best suit his study (one reason it is not accurate). Next, he injected dye into each nipple opening to better understand the labyrinth of ducts in the breast.  The initial injection caused a bubble to form when the pressure first entered the breast.  The best way for me to describe this is when a long balloon for making animals is blown up, the first big breath creates a bubble at the front of the balloon before filling the rest of it with air.  A similar phenomenon occurred with the dye in the breast. A bolus of dye created a "bubble" which were named "lactiferous sinuses."  


Finally, in 2006, Peter Hartman began anatomy studies that used ultrasound to trace milk ducts.  From this recent study the earlier depictions of breast anatomy were proven inaccurate.  
The point needs to be made that anyone who has had their anatomy training between 1840 and 2006 needs a refresher course.  A link to a journal of the breast's history and current research is http://www.breastbabyproducts.com/pdf/11_inside_lactating_breast.pdf . This journal article can be printed and shared.  Medela also has free illustrations of the old and new anatomy on their website http://www.medelabreastfeedingus.com/for-professionals/cbe-information/106/breast-anatomy-research.  


There still needs to be much more research on lactation, physiology of lactation and anatomy of the breast.  I am constantly amazed that so little has been done to study the number one way to sustain the life of a child...hope someone gets motivated to tackle this huge project.  In the meantime, take this quick study module as a refresher on anatomy http://www.breastfeedingbasics.org/cgi-bin/deliver.cgi/content/Anatomy/index.html.  The site has some other beneficial modules as well.  Hope this quick blog gets the mind thinking.  I know this is just a jumping off point.  I would also recommend reviewing the hormones that aid in lactation and do a "Google search" on "the lactating breast."  Just check the date on your research...prior to 2006, the research may have been based on faulty findings.


Lactation information, theories and protocols are changing all the time...keep "abreast" of what's new in the field!

Excellent Resource

I received this resource from a friend in lactation and it fit so well with my earlier blog and my class on Cultural Diversity, I had to share it right away.  GOO students, check out the case studies on Cultural Diversity.http://www.aap.org/breastfeeding/curriculum/tools.html