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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Communicating & Counseling Skills

I cannot stress the importance of good communication.  Lactation Consultants must be able to effectively communicate and counsel moms, dads, couples, families, pediatricians, obstetricians, communities, neighbors, etc...We have an agenda, like so many other professionals do, and how we communicate it will often cause others to accept or reject our message.

I recently listened to the speech "Love Wins" at the CAPPA Conference and agree with the philosophy in all areas of life...raising children, maintaining a good marriage, sharing faith, promoting lactation...  My husband always says, "the one who gets angry loses--the argument and their reputation."  There is never a good reason to use fear or intimidation to manipulate individuals or convince them to breastfeed.  We must apply the "Love Wins" principle when giving breastfeeding advice.  Put yourself in the mom's shoes.  Often postpartum moms are exhausted, confused, sad, weepy, in pain and lonely.  Be compassionate.  Be gentle.  Be reassuring.  Be comforting.  Be kind.  Behave!  I have heard statements made by LC's that make me cringe.  Of course these statements come from LC's that also have terrible bed-side manners.  Let's decide now to improve the reputation of the profession by always being gracious.  Remember, "people to not care how much you know until they know how much you care."

Besides being kind and using common sense, there are some effective tools to use in communication.  I want to share the 3 Step Counseling Model because it is easy to remember and it works!

Climbing the steps to communication success

Three Steps to Communication Success: 

1. Ask OPEN-ENDED Questions (I don't necessarily like the connotation of the word, but because it rhymes with the other two steps, I remember this step by associating it with the word "interrogate").

Open-ended questions are questions that cannot be easily answered with a "yes" or "no" or other one-word answers.  My favorite open-ended question is "How do you feel about breastfeeding?"  That can really open communication up and help get to the root of the problem.  Remember, our goal is to meet the mother's needs and this is one way to pinpoint what direction you will need to go with your counseling.


While asking open-ended questions, help the dialogue by using the following four probing methods to confirm understanding:


1. Extending
Get the rest of the story; example: “Can you tell me a little more about how you feel about what your mother said?”
2. Clarifying
Make sure you understand what the client means; example: “When you say that breastfeeding may be embarrassing, are you saying you may be embarrassed, or those around you?"
3. Reflecting
Let the patient know you have heard what she has said; example: “So, you think your mother would disapprove?"
4. Re-directing

Move the patient to explore a different related subject; example: “Besides milk supply, what other concerns do you have about breastfeeding?”
Now that communication is flowing...remember to constantly use the second step
   

     2.  VALIDATE CONCERNS

This step encourages mom to continue opening up to you....it says, "you are not alone in your feelings." Get used to (genuinely) sharing that "a lot of moms feel the same way" or "I have heard several moms say this exact thing."  another way to validate is to share personal experience by stating, "I thought that very thing not too long ago..."  This step will become more comfortable with practice.  It is probably the most forgotten step, and the most necessary...never go on to the third step without first camping on this one!  A mom may confide that she doesn't feel like she is making enough milk for her child, and our first response may be to educate (the third and final step).  We may want to dive right in with "if baby is getting enough wet diapers..." if baby is gaining weight...baby looks health...etc.  By jumping right to educating, the mom is made to feel insignificant and shouts the message that her feelings are NOT valid.  It will kill a conversation and close doors to further counseling.  Take time to validate.

Okay, the step we are all so very good at...the last step in the sequence...
     

     3. EDUCATE

Here is where we get the opportunity to answer specific questions.  It is not the time to share everything we know about the topic.  We are not trying to overload the mom, but rather simplify her life by giving her specific advice.  Share in a loving-compassionate way the correct, accurate answer.  Once we have identified the real problem and have isolated the concern, we may address it and help the client get over this hurdle.  Also, a relationship has been established and the next time a problem arises, it will be much easier to get to the root of things since the client will feel comfortable sharing with you.  The client will know you really listened and she will feel like a person worthy of your time.  It is amazing the results that can come from being a good listener and by asking the right questions.  Counseling from the heart reaches the heart of the matter.

We also have to keep in mind when talking to adults to use methods that appeal to the adult learner.  The history and principles of teaching adult learners can be found on the web.  I have included a few to peruse at your convenience.

Principles of Adult Learners

On-line education for adult learners

Websites and books about Adult Learners

Communication is as much of our job as assessment and intervention; in fact, we may never get to the other aspects of our profession without proper communication.  This may not be a large portion of the IBCLC Exam, but it is a large portion of your vocation.  Practice.  Smile.  Be inviting in your personality.  Love others.  Be yourself. 

Looking forward to hearing about your successes,

Christy Jo Hendricks, IBCLC, Doula

For counseling the grieving mother, please be aware of local resources for your families

As you locate excellent resources, please advise so I can add them to my website under "resources"

Christy Jo's website, Birthing, Bonding & Breastfeeding

Normal Growth and Development for the Breastfed Infant

As I discuss the "normal" growth and development I have to remind everyone that every child and circumstance must be independently evaluated and guidelines are just that...guides, not concrete walls that determine absolutes...

Although there are facts and figures along with possible complications and interventions that are specifically related to a preemie, I am not going to address the preterm or near-term infant at this time.  This post will relate to full-term, healthy, breastfed infants.

I have to say one of my pet peeves is the CDC Growth Charts, their development and how they have become the final authority on growth for so many medical professionals.  In fact, many doctors use the charts to provide "scripted counsel" and inevitably recommend or require a baby be supplemented with formula. I am curious to know how many doctors or other professionals actually consider how the Growth Charts were developed and the margin of error that accompanies this type of data comparison.  The empirical data (data charted by experience or observation) and "convenient" smooth pattern created from the charted data vary extensively.

To paraphrase how the research was conducted, babies were measured at different increments and the empirical data was charted. Next, babies (not necessarily the same babies) were charted at different ages, points began forming a pattern, and that pattern clearly signified that over time, babies gain weight (not a difficult hypothesis to have to prove).  The problem I have with the charts is the smooth pattern that the researchers defined based on the empirical data...the points do NOT fall symmetrically on the curve, but vary greatly.  Knowing this, a doctor may inform a parent that their child is below weight, but when looking at the original data, the subject used to create the chart may not have fallen on the smooth curve either!

I really cannot do the report justice, but I implore everyone who works with infants and children to become familiar with the CDC Growth Charts Methods of Development.  It is astonishing to know how many people believe these weights and measurements are absolutes and not guides.

One step that I applaud is the transfer of confidence in the CDC Growth Chart to the WHO Growth Charts.  At least this data compares breastfed infants' growth patterns and establishes the child being breastfed as the baseline for a "normal" growth pattern.  WHO Growth Charts should be available for a base comparison, but more importantly, like previously mentioned, individual history and observation is more important.

Recently, I spoke to a mom that was experiencing regular "check-ups" for her breastfed infant because he was considered to be at "high risk."  The mom felt that her breastmilk was not adequate since the pediatrician questioned her son's weight gain and insisted on regular monitoring.  My frustration was compounded by the mom's emotional state.  She felt inadequate, scared, vulnerable, guilty--all emotions I try to alleviate in parents.

I asked her some basic questions.  Was your infant born early?  How much did he weigh at birth? How is breastfeeding going?  How many wet/soiled diapers in 24 hours?  How much did his dad weigh?  Describe his dad's stature.  How much weight has he gained?...etc.  The answers I received verified my hypothesis...the doctor had not taken a history...dad and mom were both small in stature...baby was gaining weight regularly, having plenty of output and was reaching milestones.  I also observed a feed and milk transfer.   

After counseling the parents and suggesting they speak to their pediatrician about their concerns and requesting "medical reasons why the baby needs supplementation" I was assured that the mom had been empowered and restored to her confident self.

Although no child has the same growth pattern, healthy babies do gain weight and grow.  I do not want to give the impression that failure to gain weight or thrive is in any way acceptable.  Monitoring the slow weight gain is also crucial.  Follow up is mandatory.

What patterns are common in most infants?  Here I will be brief, since these facts and figures can be memorized and retained for future use.  Newborns often loose weight after delivery.  I don't like the phrase "7-10% is acceptable"  it may or may not be...is the baby gaining weight now?  Is the baby alert and responsive?  We must be careful to not make blanket statements.  Babies do typically lose weight due to many circumstances following delivery...did the baby have a bowel movement?  Were meds and fluids administered during labor?  Has baby eaten?  Was the baby weighed on the same scale under the same circumstances...these scenarios allow for variation in weight.  We must remember that  babies are born "full".  they have a direct line to the all-you-can-eat buffet.  They are born with extra fat stores to help them during the transition from colostrum to mature milk, and allowing them time to stimulate the breast and cause Lactogenesis II to occur.  Babies are not born starving and in need of an immediate meal.  So, with that being said, panic should not set in when an infant displays some initial weight loss.

I created a reference chart for the common 10% weight loss and kilogram conversion from pounds.  Feel free to download a reference copy from my website under "Resources".

Other noted patterns of the breastfed infant include:

• Babies regain their birth weight by 10-14 days
• Birth to 1 month weight gain is .5 to 1 oz. per day
• 2-6 month weight gain is 3-5 oz. per week
• Birth weight typically doubles by 4-6 months and triples by a year
• Head circumference increases by 3 inches in a year
• Birth to 6 mo. infants gain about 1 in. each month
• 6-12 months infants gain 1/2 inch each month
• Infant's length increases by 50% at 1 year

Remember each baby is unique and should not be compared to other babies...the best comparison is made between the same baby the previous time you observed him.


Also, if you are sitting for the exam this year, dedicate some personal time studying age groups and milestones in regard to child development.  My students were surprised at how many of the IBLCE questions related to age group and photo recognition based on "typical" growth in the newborn.

Pharmacology and Breastfeeding

Medications, drugs, herbs--all can affect breastfeeding and some are contraindicative to breastfeeding.  The good news is, very few demand cessation of breastfeeding and information about drugs is readily available on a number of reputable websites.

I want to offer some general guidelines since those sitting for the exam will not be able to "Google" medications during the course of answering the multiple choice questions.

As a general rule, many medications are compatible with breastfeeding, but selecting the "safest" medications is advisable.  The aveolar epithelium of the breast is a lipid barrier that is most permeable in the first few days of lactation (when colostrum is produced). The transfer of water-soluble drugs and ions is inhibited by the hydorphobic barrier.  Water-soluble materials pass through pores in the basement membrane and para cellular spaces.  Drugs that have low lipid solubility and are non ionized will diminish its excretion into milk.
Medications should also be avoided the first 5-7 weeks postpartum, if possible.  During the early postpartum period the free fraction of some drugs increases and more readily crosses into the milk.(Lawrence & Lawrence, Breastfeeding a Guide for the Medical Profession, 6th Edition)

Some basic considerations for drug interaction with breastmilk includes:

• Route of administration

The route of administration (your baby is always exposed through the GI tract, but drugs can enter your system several different ways: orally, intravenously, intramuscularly, topically, or through inhalation - topical medications (skin creams) and medications inhaled or applied to the eyes or nose reach the milk in lesser amounts and more slowly than other routes and are almost always safe for nursing mothers; oral medications take longer to get into the milk than IV and IM routes (the drug must first go through the mother's GI tract before it enters the bloodstream, and the milk supply)-with IV drugs, the medications bypasses the barriers in the GI tract to enter the milk quickly and at higher levels, and with IM injections, drugs transfer quickly into the milk because the muscles have so many blood vessels, so the drug enters the bloodstream quickly. http://www.breastfeedingbasics.com/html/drugs_and_bf.shtml

• Absorption rate
• Half-life (choose medications with short half-lives and take immediately after nursing)
• Molecular weight (choose medications with high molecular weights)
• Maternal plasma level (higher maternal plasma levels result in higher milk levels)
• Ionization (choose medications that are ion trapped)
• Dosage (higher dosage has a greater chance transferring into the milk)
• pKa (choose drugs with a lower pKa)
• Solubility (high liquid solubility penetrate the milk in higher concentrations)
• Protein binding (desire high protein binding)

A good reference including reputable links is http://www.aap.org/breastfeeding/files/pdf/Lactmed.pdf
Medications listed as safe (categorized by lactation risk L1-L5) http://www.kellymom.com/health/meds/aap-approved-meds.html
For a list of medications contraindicative to breastfeeding visit http://www.breastfeeding-magazine.com/Unsafe-Drugs-and-Medications.html

Galactagogues, lactagogues and herbs must also must be closely monitored and dosage must be carefully calculated.  Just because they are not classified as drugs and FDA approved does not mean they are safe.  Many moms will try to self-medicate and they must be warned of the danger of the over-use of such herbs.

Birth control with progesterone only is a better option for mothers desiring to use a pill.  Barrier methods are compatible with breastfeeding and the LAM method is also effective if used correctly.

I highly recommend having a copy of Dr. Thomas Hale's Mother's Milk and Medications in your personal library.  Reading the preface of the newest edition will shed a lot of light on medications and how they interact and pass into the baby's blood stream.  Never give advice or perscribe any medication, this blog is for information only and should be used to form some basic understanding of drugs and how they are categorized.

When a mom contacts me about a medication, I initially look it up, see if there is a safer alternative and then suggest she ask her doctor if the other medication would be a plausible alternative to treat her condition and if it would be compatible with breastfeeding.  I also photocopy or print the information about the drug or direct her to the appropriate website.  I never recommend any medication or advise a mom not to take a medication that has been prescribed, that is outside of my scope as an IBCLC

This blog is for informational purposes only.  For medical advice, consult a medical professional.

Biochemistry of Human Milk

Biochemistry is the study of the structure, composition, and chemical reactions of substances in living systems. Biochemistry emerged as a separate discipline when scientists combined biology with organic, inorganic, or physical chemistry and began to study such topics as how living things obtain energy from food, the chemical basis of heredity, and what fundamental changes occur in disease. Biochemistry includes the sciences of molecular biology; immunochemistry; neurochemistry; and bioinorganic, bioorganic, and biophysical chemistry.

With the broad definition of biochemistry, it is obvious that a blog cannot do human milk justice, but I do have some points to share. I have been fascinated with this topic since I began my work in lactation.  In fact, one of my early projects was creating a visual that would allow parents to see in a snap shot how unique breastmilk is. I had seen a list of basic ingredients found in breastmilk compared to those in artificial human milk (formula).  I commenced to build a 3D image of my understanding and the "Lego Stack or Brick Building Block" emerged from my work.  I invented this tool back in 2001 and it has traveled across the US and is used in California WIC instructional material.  I am including a picture of the handout that accompanies the curriculum here, but the idea is to use a set of large building blocks (or duplo legos) and place one "ingredient" on top of the other as the properties of the ingredients are discussed.  At the end of the demo, the breastmilk stack dwarfs the formula stack.  It leaves quite the impression.

Since I created this simple illustration, I have learned so much more about breastmilk's composition.  I wish I could share my entire PowerPoint on Human Milk for Human Babies, but I will do my best to highlight some of the information.  One main  point is that human milk is species-specific.  Just a comparison of different mammals and their milk composition verifies this statement.  If we were to be fair and pick the mammal whose milk has many of the same ingredient percentages as humans, we would most likely be giving our infants donkey or cat milk.  I can't imagine having cat farms of lactating felines to feed our infants, but really, what's the difference between that and cattle farms?  Just a little regression to point out the humor in our loyalty to cow's milk formula.  


Breastmilk, unlike formula is a living organism.  When one looks at breastmilk under a microscope there is plenty of movement.  Contrast that with formula, where the petri dish reveals a stagnant state.  Formula is dead.  It cannot change to meet the needs of a particular infant.  It does not change during a feed.  In fact, the first drop given to an infant at day one is mirrored in the last drop he receives at one year.  Formula companies are now trying to market this change by creating "stage formulas", another gimmick for marketing. (I recently saw a formula ad that stated, "now, one step closer to breastmilk."  Here is a way to put that claim in perspective, stand at attention, move one step to the right and then declare, "I am now one step closer to China"--not anywhere near China, mind you, but able to make an honest statement, providing your geography is correct.  We have to all be aware of the claims marketing experts are making and be ready to expose the propaganda being used).


There are many articles that are well cited available for purchase.  These are the scholarly articles that appeal to the medical professionals and are written in journal language.  A few such articles are found at
http://www.ajcn.org/content/42/6/1299.abstract
http://www.springerlink.com/content/q33725u6p1530587/
http://www.ncbi.nlm.nih.gov/pubmed/6475139
http://www.askdrsears.com/html/2/t020800.asp


No study on milk composition is complete without mention of Marsha Walker's "Just One Bottle" paper  http://www.massbfc.org/formula/bottle.html
For those wanting some basic information on the biochemistry of human milk in order to be prepared for possible questions on the IBCLC Exam, every candidate should be familiar with the following facts:

• Colostrum is high in protein, fat-soluble vitamins (A and E), minerals, and immunoglobulins. (antibodies that pass from the mother to the baby and provide passive immunity for the baby. Passive immunity protects the baby from a wide variety of bacterial and viral illnesses). 
• Two to four days after birth, colostrum will be replaced by transitional milk in the full-term infant.
• Colostrum's primary function is protective due to high immunological factors
• Colostrum coats the sterile gut and protects from pathogens
• Colostrum is lower in fat than mature milk
• Secretory immunoglobulin A (SIgA) is highest in colostrum
• Colostrum creates a laxative effect aiding in the elimination of bilirubin (reducing jaundice)
• Transitional milk occurs after colostrum and lasts for approximately two weeks. The content of transitional milk includes high levels of fat, lactose, water-soluble vitamins, and contains more calories than colostrum.
• Mature milk is the final milk that is produced. 85-90% is water, which is necessary to maintain hydration of the infant. The other 10-15% is comprised of carbohydrates, proteins, and fats which are necessary for both growth and energy. There are two types of mature milk: foremilk and hind-milk.
• Human milk is higher in whey protein (cow's milk is higher in casein)
• Human milk has the lowest total protein 
• Human milk has 19 amino acids (for development)
• Human milk has over 40 identified enzymes (aid in digestion)
• Human milk is highest in lactose (carbohydrate) of all mammals (humans have the largest brain of all mammals at birth)
• There is not much iron in human milk, but infants are born with a large physiologic stores (enough to last 6 months).  These stores are laid down the last trimester, so if an infant went to term, there is likely enough iron to avoid any supplements.  Also, infants absorb 50% of the iron found in breastmilk, but only 4% of the iron in formula and cereals, so it is misleading to point out that formula has more iron since it is not readily available to the infant.  

Obviously, I could go on and on.  In fact, more ingredients are discovered in breastmilk annually. As money is put into lactation research, this list will most definitely be expounded on.  I liken it to our space explorations and discoveries.  I remember in elementary school learning about the Milky Way as the only galaxy and now as I study with my children I am reminded that new planets, stars, other galaxies--have all recently been discovered and what we thought was an exhaustive list of space was actually very anemic compared to recent finding through exploration.  Stay tuned in to research and attend conferences where newly published information is presented.  This is fascinating stuff!  

Humans are obviously made to breastfeed.  Mom's milk is perfect for her individual infant(s).  My new tagline is, "designed to breastfeed." Isn't it nice when we do what we are designed to do?  I recently tried to hammer a nail with a heel of my shoe--it worked, but when I used a small hammer, it was much more effective.

Christy Jo Hendricks, IBCLC, Doula

http://www.birthingandbreastfeeding.com/

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/