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/

Mommy Feeds Baby

I am creating this post in order to receive feedback from individuals who have read Mommy Feeds Baby.  I sent out a link to this blog along with the pre-orders so others can hear what readers think of the new children's breastfeeding book. Please feel free to share opinions, comments and suggestions through this blog.

For those of you who know me, you already are familiar with the journey I have been on to promote breastfeeding, to my newer friends, let me take a minute and share why I wrote a children's book.

I went to college to become a teacher.  I loved writing and children, so the most appropriate goal seemed to be to earn a teaching degree with an emphasis on English.  I taught and administrated for seventeen years and loved every minute of it.  Since I was the head of the English Department, I also got to oversee the Yearbook Class and Journalism Club.  I learned about photography and layout design by attending conferences and training I took my students to.  I was learning skills and techniques right along side of them and didn't know how valuable this information would be years later when I wanted to author a book.

After giving birth to my first child, I continued to work part time.  I was able to work mornings and breastfeed during my prep period and after work.  My second child was born in October, and I began teaching the second semester.  I absolutely hated leaving them with someone else during the day.  My third child was due in May and although I would have the summer off to spend with my kids, I began looking for something else for the fall. Teaching, administrating, coaching, attending Open Houses, field trips and fundraising caused me to be away from home too much.

When my third child was born, I encountered every problem I could in regards to breastfeeding.  Of course, she came the weekend of the La Leche League Conference and LLL was the only breastfeeding resource I had heard of.  I called my doctor, the pediatrician, the lactation consultant--no one was available on the weekend.  My condition turned into full-blown bi-lateral mastitis...then I added in thrush, combine that with a dysfunctional suck and my scenario was complete.   Eventually, I received help from WIC.  Someone recommended the WIC clinic to me and in my ignorance of the program, I replied, "Why go to WIC?  I don't need milk or cheese."  Fortunately, WIC was willing to help me regardless of my ignorance.  I went on to breastfeed for two years and the problems that led me to WIC allowed me to forge a relationsip with the program.  I was offered and accepted a job at WIC helping other moms.  My trials have become my greatest asset in helping others solve their breastfeeding problems.

I continued learning about lactation and after working as a breastfeeding counselor and health educator for seven years, I decided I would follow the steps to become an IBCLC.  I read all I could on the subject, researched the exam and the disciplines I needed to master, worked on my counseling skills, developed prenatal curriculums and studied.  I sat for and passed the exam several years ago and since then have been asked by others how the exam was, what I studied, if I thought they could do it, etc.  That's what prompted the Grow Our Own Program to be conceived.  Laurie Haessly, my supervisor who mentored and encouraged me, found a grant opportunity and asked if I would like to help write a grant to take others down the path of becoming an IBCLC.  Of course I was ecstatic!  We worked on the grant, received the money, and the rest is history.

One of the GOO annual class projects has been to help plan and execute a breastfeeding celebration.  Last year we took on World Breastfeeding Week celebrations at WIC.  When it came time to use the money that had been budgeted for breastfeeding promotion students went to Google to look for items.  I suggested a book.  Since WIC serves pregnant moms and children 0-5, I thought literature would be fitting.  I know how much I enjoyed reading to my children and from my college education and child development classes, I knew the importance of early introduction to books.  The breastfeeding shelves were rather bare.  There were some books of mammals feeding, a few books with a picture or two of well-concealed breasts, some cartoon drawings of moms--but not what I was hoping to find.  I wanted pictures of real moms feeding their babies.  I wanted a book that presented breastfeeding like it really was--unique.  I wanted a book that incorporated moms of different ethnicities, feeding babies of different ages, in different positions and with family members present.  I couldn't find the book I wanted, so I made it.  That is how Mommy Feeds Baby was birthed.

I have been at annual WIC celebrations since 2001 and have often photographed moms breastfeeding their children in order to present them with a keepsake photograph.  I often displayed the pictures to encourage other moms and highlight the beauty of the bond created through the experience.  With this tradition in mind, I decided to make a blank page in the back of Mommy Feeds Baby so a keepsake photograph could be attached, and so moms would remember to take a photo and document this special time.  I only have a breastfeeding picture of myself with one of my children although I breastfed all three--it never occurred to me to photograph the older two.  Now with Facebook, maybe I would have thought of it, but that was fifteen years ago and there were not a lot of breastfeeding pictures circulating.

Well, this is the condensed version (I know it doesn't seem too condensed) of my involvement with breastfeeding and the evolution of the book, but my ultimate goal is to promote breastfeeding as normal and expected.  I hope someday people are surprised or taken back a bit when they see a baby being bottle fed or at least assume that there must be breastmilk in the bottle.  I want children to chant the phrase "Mommy feeds Baby" when asked how an infant eats, I want to change the world!

Hope you have enjoyed reading Mommy Feeds Baby as much as I have enjoyed creating it.
The book is currently available at Jadabug's Baby Boutique or www.birthingandbreastfeeding.com

Thank you, Christy Jo

As a side note:
I wish you knew the moms photographed in the book....  Each picture tells a story.  Some of the moms in the book have overcome great obstacles, some are single moms, some are working moms, some are young, some older, some are professionals, some are feeding their first child, some their fifth --they are you and me and they are breastfeeding!

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

Principles of Lactation Management

I took a break from "regularly scheduled blogs" to say goodbye to my dad.  He was so influential in my life, that if you know me, you know a part of him.  Just another reminder that life is short and we have to love people while we have a chance.  I apologize to those of you who endured my dry spell and thought I had abandoned this project.  I am getting back on track slowly, so let's start with lactation management.


This is a really broad topic and one people will see as an introductory to Lactation.  Often this provides an overview for many aspects of lactation.  One course I looked up on Principles of Lactation Management stated, "Participants will be able to counsel families about the benefits of breastfeeding, assist the mother in managing common breastfeeding problems, make appropriate referrals, teach breastfeeding classes, prepare breastfeeding materials, and support breastfeeding through breastfeeding friendly policies and procedures."  Which confirms my theory that this is almost all-encompassing.


Several of these topics will be handled individually, but let's look at them briefly here and I will give you some resources to get the big picture, then we will get more specific in later blogs.


Counseling on the "benefits of breastfeeding" should really be changed to "risks of formula feeding."  We try to be so positive that we do not accurately portray risks to the infant and mother if we do not do what is natural and veer away from what we were designed to do.  I liken it to Vitamin D.  We need the sun and if we never get sunlight, we will be deficient in Vitamin D...so instead of a casual "benefits of Vitamin D" we talk about the "risks of being deficient"...it sends a different message.  Our language when we counsel is often as important as our words.  Risks can be found everywhere, but keep up with the Academy of Breastfeeding Medicine http://www.bfmed.org/ or the AAP http://www.aap.org/ to get the newest research


"Common breastfeeding problems" would be the problems that fall within lactation educator's scope of knowledge and expertise.  These are the reoccurring issues that we should have a pretty good handle on.  If you need to read up on these, pick up a La Leche League Breastfeeding Answer Book http://store.llli.org/public/profile/92 or Counseling the Nursing Mother  http://www.amazon.com/Counseling-Nursing-Mother-Lactation-Consultants/dp/0763780529/ref=pd_sim_b_1  You are going to read about engorgement, sore nipples, latch, mastitis, thrush, weight gain, feeding patterns; both of these books present this information well and are great resources to have in your library.  You are not going to get too deep into any of these issues as an overview.  Do not try to master every breastfeeding problem right away.  Experience helping moms solve individual problems will be your best education.  Sometimes you find that a "normal" protocol will not work and the confidence and insight you gain by finally coming to a resolution will be exhilarating!


Remember not to practice outside of your scope.  Refer, refer, refer.  Just a couple of referrals we all need to have access to are PPD http://postpartumprogress.typepad.com/weblog/postpartum-depression-support-groups.html (this is the most widely read blog on PPD).  Know local resources for moms as well.  Of course, for medical purposes, refer back to Ob/Gyn or pediatrician.  Support groups are another necessary referral...feel free to add referrals to this blog.  I also have a list on my website http://www.birthingandbreastfeeding.com/; and welcome additions there as well.


It is a good idea to develop breastfeeding classes.  This information can be used for one-on-one teaching, or group education.  Just about every IBCLC I know is also a teacher or has to teach on occasion.  As a Lactation Consultant, you will be the expert in your field and called on to share at conferences, staff meeting, schools, etc.  WIC has some good classes, and I will be adding some outlines to my website later for those of you who need a starting place to help develop a curriculum.  In the meantime, keep notes of things you hear and bookmark websites that you trust as good resources.


Lastly (for this topic), be aware of what "Baby Friendly" is and familiarize yourself with The Who Code of Marketing Breastmilk Substitutes.  If you work in a hospital or clinic...look closely at your policies and protocols, do they promote breastfeeding?


This should give you some things to ponder and organize until my next blog.  Keep me posted on your progress and feel free to share additional advice and recommend this blog to others who may be on the pathway to becoming an IBCLC!

Sit for the Exam in 2011

Okay, there are a couple of posts I should probably be doing right now, but I really feel like I need to put this suggestion out there now.  I saw several people at the Breastfeeding Summit that were looking for a class to take to prepare them to sit for the IBCLC Exam.  As I engaged in conversation and learned about their background and experience, I told them to quit looking and start studying.

My advice is based on the changes coming up in 2012.  If you are experienced in lactation and have sat beside many moms helping them, don't be intimidated by a test.  If you are a competent lactation educator/counselor, you do not need to worry about an evaluation of your skills and knowledge.  I know the Exam can be intimidating and if you haven't had "formal" education, it can cause you to doubt yourself--don't let it!  No instruction can replace experience.  I have also talked students out of taking the exam because they may have met the qualifications, but were not ready to be lactation consultants. If you are ready, go for it, but if you are not--prepare.  Decide where you are personally.

You may be the complete opposite:  loads of experience, but lacking some CEU's or maybe even short a few counseling hours.  I would rather see you grab some CEU's from the web, LLL conference or other conferences and add a day of counseling so you have the requirements in order to be ready to test this year.

Next year, you will be required to take college courses and it could really hinder your progress towards sitting for the exam. Not only the time it will take, but the expense.  Weigh your options.  If you can get your act together by the application deadline--consider this blog a "kick in the pants", if there is no way, consider this a reminder to start looking for college courses or on-line courses so you do not get caught unprepared next year.

Okay, I said it, if you can take the exam this year because you have (or can get) the CEU's and counseling hours--go for it! Purchase the Core Curriculum, Counseling the Nursing Mom and Breastfeeding and Human Lactation.  Read, study, observe and sit with confidence.  If nothing else, it will take the "fear of the unknown" out of sitting in 2012.  You will not loose anything (well, maybe the investment, but you can also still apply for a scholarship until January 31).

One person that stopped by my table at the Summit thought it was funny that I talked her out of taking my class and into sitting for the exam this year.  I guess I haven't made it clear that my goal is to help everyone where they are at.  If you are ready, I will encourage you to take the next step; if you need preparation, I will prepare you; if you need prodding...I can do that too!  Let me know what direction you will be going, and remember--always enjoy the journey!

Resources for LC's

Sorry, I have procrastinated until almost the last day with this blog.  My goal is to take each topic from the Study Schedule and write about it during the week it is highlighted.  I hope my notes in your inbox will be a reminder to keep moving forward and tackle one discipline at a time...July will be here before we know it.  If you haven't downloaded your Study Schedule (or as I like to think of it, your time budget), go to  http://www.birthingandbreastfeeding.com/ and look under "Resources."


There are a lot of really good resources for Lactation Consultants available.  I started the study schedule with this topic since some of the other topics will require you to search articles, read journals, refer moms to others when a problem is outside of your scope of practice.  Anyway, look over these resources, bookmark the ones you think you may need again and add to them for others checking out the blog.


It is always important to be part of your professional organizations, so I want to start with  ILCA (International Lactation Consultant Association).  They have added a new category to their membership this year!  I am very excited since the access to their website is invaluable.  The fee for US members is $165, but this statement now appears on the ILCA website:
     ILCA recognizes that students may benefit from membership in ILCA... ILCA also realizes  
     that many students are not working fulltime and may have difficulty paying for full membership. 
     Therefore, ILCA now offers a STUDENT-level of membership.  This membership will give you 
     all the benefits of ILCA membership EXCEPT you will not receive a print copy of the Journal
     —only online access...this can be used a maximum of 2 years.
The catch is an instructor must sign off that the member is a student in a Lactation Course.  Any GOO Student can print this form out and fax it to me, other students need to have their professors sign the form prior to sending it in.  This is a savings of up to $200 over a two-year period.  You can find the Student Application at http://www.ilca.org/files/membership/join_ilca/2011_STUDENTAFFIRMATION.pdf.   For more information about ILCA and the membership benefits, visit www.ilca.org.


If you are a practicing LC or student earning hours and are looking into professional insurance, the United States Lactation Consultants Association has liability insurance available to members.  You can join ILCA and USLCA together for one rate. http://www.uslca.org/.


Another must-have resource is Dr. Hale's medication website.  This site explains medications and how they relate to lactation and pregnancy.  This is great to refer moms to or to keep yourself aware of new drugs and their interactions during pregnancy and lactation.  Dr. Hale has a brand-new website at http://www.infantrisk.org/.  It is worth checking out.


Looking for another resource and Jack Newman's articles?  Those will be found at http://www.breastfeedingonline.com/meds.shtml.  This site also takes pride in adhering to the WHO Code.  Additional information about the WHO Code can be found at the WHO page http://www.who.int, which also has breastfeeding information and fact sheets.


Remember the national and local branches of LLLI http://www.llli.org/ which offers a wealth of information and local resources.


The last one I will mention is WIC/USDA  http://www.fns.usda.gov. and one of my favorites, http://lovingsupport.org/ (this site is still under construction to some degree, but soon Riverside County residents will have a wealth of information, including local clinics and support groups, available to them.  There is also a toll-free, 24-hour, bilingual number for Riverside County residents.


I have given you some food for thought.  Each one of these sites have several links and you could be kept busy navigating around the web for months.  Pick a few trusted sites, and add to your list as your studies and research leads you to reputable locations.  I know this is a very small sample.  I have not included a lot of government programs, blogs, and some of the well-known sites like Kellymom or breastfeeding.com...these are all good sites and resources, but the study topic this week is "Resources for Lactation Consultants" and I just wanted to give you a sampling.  Your job is to search and document which ones you like and feel would be most beneficial.  Also, additional links are on my website, http://www.birthingandbreastfeeding.com/, and I welcome additional submissions there, and as comments here.


These are exciting times for lactation.  Breastfeeding and the demand for lactation help is on the rise.  Keep focused on your journey and I will be back nest week with "Lactation Management"