 Hi everyone! I’m back to talk tongue-ties again. I see this problem a lot because I’m a lactation consultant. People usually call me when something isn’t going well. Lots of times it is Not a tongue-tie! Phew. But sometimes it is. I know it can be an exhausting and frustrating topic. Let’s get to the bottom of what you really need to know as a parent facing this issue. Let’s get some myths out of the way… MYTH: Tongue-ties are a fad Nope. They are being recognized more often due to increased breastfeeding initiation rates in our country and better training. MYTH: My baby can stick their tongue out of their mouth so they don’t have a tongue-tie. Maybe. But the extension of the tongue is only one motion of the tongue that is evaluated and elevation is critical to many functions especially breastfeeding. MYTH: My baby’s doctor said my baby does not have a tongue-tie. Maybe. Has your doctor had extensive training in identifying a tongue-tie? What screening tools did they use to evaluate your baby’s tongue? Did they watch a whole breastfeeding session and take a full feeding history? Were their suggestions helpful in resolving your concerns? If not, seeking out an IBCLC can be key.  Now onto the good stuff. If you suspect that your baby has a tongue-tie, please consult an IBCLC (International Board Certified Lactation Consultant). We do not diagnose conditions but many of us are trained to assess for these issues and know when to refer to a trained MD. Also please find out if your IBCLC is experienced with tethered oral tissues. (TOTS)(tongue-tie, lip-tie) Common Symptoms of Infant Tongue and Lip Tie Poor Latch/inability to latch Sliding off the nipple Fatigue during feeds >12 feeds in 24hr-endless feeding <8 feeds in 24hr Sleepy feeds Poor weight gain Clicking during a feed Maternal nipple pain and damage(compressing, chewing, gumming, pinching, scraping the nipple) Increased maternal nipple/breast infections Low milk supply Milk oversupply Dribbling milk at the breast/bottle Digestive issues (gassiness, ‘reflux’ due to extra air being swallowed and poor control of the milk during swallowing) Various other feeding challenges *Keep in mind that you can experience some of the above symptoms for other reasons as well. Your IBCLC will be able to figure out the cause with your help. Your IBCLC is your Quarterback on this journey. An IBCLC trained in TOTS will be invaluable for you and your baby’s journey to better health. Since tongue-ties can potentially lead to challenges with other issues throughout the lifespan it is worth having this addressed even if you elect not to directly breastfeed. And yes, we help with bottle skills, pumping, and safe formula preparation too! Imagine that you have a limp and discover that you need some surgery on your knee. You go to the orthopedist and they repair your knee. They hand you a prescription for physical therapy and say, “you must complete 20 sessions of physical therapy to ensure proper healing, maintain range of motion and return to full function”. After having undergone the procedure you dutifully report to PT and slowly improve. What would happen if you skipped PT? You might experience stiffness, difficulty walking, continued pain and it’s possible you would not improve at all or end up feeling worse. This is similar to a tongue-tie release which is called a Frenectomy. The tongue is connected to the floor of the mouth and the muscles and fascia of the body. The tongue has not been lifting in a natural way due to the restriction. Therapy to address the overall body tension or compensations is critical to a good release and recovery afterward. Specific tongue exercises are necessary to gain the best function and results after the release. Manual therapy is recommended in a sandwiched approach. This may be done by a chiropractor, osteopath, craniosacral therapist, or physical therapist who is specially trained in very gentle approaches for infants and newborns. It is best to do this before and after the release. The tongue exercises are often handled by your IBCLC. Sometimes an SLP (Speech and Language Pathologist) or MFT (Myofunctional Therapist) will be recommended. Your IBCLC will have observed a feeding or several and examined your baby. They will be able to guide you on the timing of these appointments and what professionals may or may not be necessary in your specific case. IBCLC’s help you manage the breastfeeding and milk supply throughout this process, carefully adjusting your care plan as needed. We monitor you and your baby’s progress through these steps. We partner with the Doctor who performed your baby’s Frenectomy. We partner with any additional professionals you consult to ensure more informed and wraparound care. The takeaway? There are a few needed steps for good results from a tongue tie release. This process does not need to be stressful or full of mystery. If you have an IBCLC on your team, you can focus on enjoying your baby! Isn’t that what it is all about?
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 Photo by Dahlak Tarekegn from Pexels I’m going to share my favorite simple tips for a great start! I understand that looking for straightforward answers can drag you down the ‘google’ rabbit hole. Speaking to friends and family can be dizzying with varying advice. And even professionals will sometimes offer different approaches. I often hear, “I keep hearing different answers to my questions!”. Yup! It’s not you! There can be more than one ‘right’ answer. Finding the best answer for you requires an individualized approach. If it’s a breastfeeding question of any complexity, ask an IBCLC! Others are well meaning and may or may not have the right answer. And what worked for their baby may not be right for yours. International Board Certified Lactation Consultants (IBCLC’s) are trained in current evidence based information in Lactation and take continuing education regularly. I happen to always be in the midst of a webinar or headed to a conference (Pre-covid). We also happen to be a tight knit group of practitioners. We pool our collective wisdom and bring it to you. The other reality of lactating (and parenting) is that the ‘right’ answer or advice for a one day old baby is different for a three day old baby and certainly different for a one week old and so on. Then there are specific details unique to your situation that may alter these answers. When seeking your answers, an IBCLC can support you in areas of basic education and complex situations. My personal motto is “Knowledge is Power”. (credit-Thomas Jefferson) I have noticed that the more I know, the less I worry. I can also act sooner to prevent a real problem. This is absolutely essential in breastfeeding. Basic education on the normal expectations for the first few weeks (and beyond) helps us immensely as parents. We show more resilience during those middle of the night cluster feeding sessions when we have learned about them ahead of time. We can reach out for skilled support at the first sign of an issue. This can prevent problems from compounding and worsening and brings us to a resolution much faster. If you are familiar with some basic warning signs, you can reach out and prevent such issues as slow weight gain and low milk supply. See my blogs on “What’s all this about Tongue Tie?” and “How do I know if my baby is getting enough milk” https://www.lactationconsultantathome.com/blog/previous/2. So how do I start off strong in my journey?? I highly recommend a breastfeeding class prenatally or a prenatal consultation with an IBCLC to prepare for birth. Ask for help often in those early days when you may have access to help. Hit the call button and ask for the nurse or lactation consultant especially if nursing is challenging or painful. Don’t let anyone tell you that nursing is supposed to hurt in the beginning. It’s not!! Keep your baby in your room at the hospital and at home. You will see and hear their early feeding cues and be able to respond to them faster. Breastfeeding more often will result in a higher milk supply sooner assuming other factors are normal. This strategy also results in easier latches when your baby is less frantic Limit those visitors! You can end up ‘entertaining’ them when you are exhausted, uncomfortable and really wanting to bond and nurse your baby. Sleep anytime you can fall asleep between feedings! Stock your pantry with high protein, higher fat healthy snacks to munch on during nursing sessions. Remember your baby will often need to be held by you or your partner/family between feedings. They crave closeness and this is normal! Skin to skin contact is best. Schedule an in-person or virtual consultation with an IBCLC postpartum if you are still having challenges. IBCLC’s are specialists in Human lactation. We are trained specifically to work with the lactating parent and baby as a couplet and assess and create a care plan. If you are concerned about your journey and not getting answers from your providers, seek guidance from the experts. Get off Google!!!! Most of the answers you will get are wrong and upsetting! Most of the time, when I do this myself, I come away thinking I’m dying of some terrible disease. Here are two reliable resources for basic information: www.kellymom.com and https://www.llli.org/ I can’t overstate how helpful a breastfeeding class is for expectant parents. I always observe that those who have taken one are more relaxed and flexible facing their nursing journey no matter what the circumstances. They feel empowered and more able to accept the truly unpredictable nature of having a new human being in their lives. A prenatal consultation with an IBCLC will cover all of these basics plus individual concerns. Knowledge is power!! Congratulations on your new journey!  Photo by Nicole De Khors from Burst  What is an IBCLC? IBCLC’s are the gold standard in Lactation Care. IBCLC’s are certified by the International Board of Lactation Consultant Examiners (IBLCE), which requires re-certification every five years. To become an IBCLC we complete 90 hours of lactation specific education, hold a degree in a health sciences field and have 1000 hours of lactation specific clinical experience. To achieve the re-certification we must take 75 hours of continuing education. IBCLC’s collaborate with health care providers. When should you consult an IBCLC? Endless Feedings (usually this is more than 12 feeds in 24hr repeatedly) You are not sure if your baby is getting enough to eat Pain while nursing Breast or nipple pain Nipple damage (sore, cracked, blistered or bleeding) Low milk supply Oversupply Plugged ducts/ Mastitis Overactive letdown Baby is not latching or not able to maintain the latch Baby is sleepy at the breast, not nursing actively Tongue Tie/Lip Tie/Buccal Tie Baby weight gain issues Concerns about potential reflux Pre-maturity Twins/Triplets Positioning Pumping/Flange fit Transition to solids Back to work planning Special health care needs Breastfeeding and Lactation Education Weaning/Milk Suppression This list is not meant to cover every reason to consult an IBCLC IBCLC's can help in numerous ways in common, and complex feeding issues. We are uniquely positioned to assess and create a workable care plan with your feedback that keeps your specific goals in mind.  What am I supposed to feel when I’m nursing? Is it supposed to hurt? My friend told me my nipples would hurt for the first month. I heard that bleeding is normal in the beginning. I was told my nipples would toughen up after a few weeks. Was I supposed to prepare my nipples before delivery? Is it normal that I have damaged and painful nipples? These are just some of the common statements and questions I hear often. I’m going to break down the common reasons for nipple pain and what you can do to get back on track. First, let’s discuss what normal feels like in the first 1-2 weeks. In the first 10-20 seconds of a good latch, you may feel discomfort or even slight pain. After 20 seconds, that discomfort should diminish and it should feel like a tug and pull sensation and no pain. If you feel pain after the initial latch, this is a signal your baby is latched in a shallow manner. No preparation is needed for your nipples prior to delivery! They are ready to nurse! Breastfeeding is not supposed to hurt even right after delivery. Bleeding is never normal. The initial discomfort you may feel in the first 10-20 of the latch usually fades after a week or two. In the first week after birth as the parent and baby are learning positioning and latch, there can be some imperfect latch attempts. It only takes 1 or 2 minutes of an improper latch for a blister or crack to occur. Minor damage that occurs minimally in this way is common but not normal. What do I mean by that? This damage signifies a shallow latch and the need to work to correct it, but is fairly common in the first several days to have a few missteps. If you are struggling with repeated damage into the second day of life for your baby, please reach out for skilled Lactation help. Improper latch is one of the most common reasons for sore nipples. If your nipple is not deep enough in your baby’s mouth and resting on the soft palate junction in his/her mouth, your nipple may become compressed (flattened like pancake), or appear pointy like a new lipstick shape. This can progress to blisters, cracks, and bleeding. Non intact skin is more likely to become infected as well. It is also important to realize that the baby gets much less milk when latched in a shallow manner. Their weight and growth is at risk and your milk supply will not be properly stimulated. The number one fix for this issue is adjusting positioning and latch to attain an improved latch. If you have done this well, your nipple will heal fairly quickly and you should not see a return to damaged nipples. Minor damage should heal in 2-3 days with a corrected latch. (There are many reasons that babies have difficulty latching deeply. This blog is addressing nipple pain and care. If you need assistance attaining and maintain a proper latch, seek out the help of an IBCLC (International Board Certified Lactation Consultant)) There are many other reasons for your nipples to be in pain. It is important to work with an IBCLC to discover to reason you are in pain to recommend the best treatment. Other issues that can cause nipple pain are:
Let’s discuss nipple care. Your nipples took a beating. Now what? Applying your own colostrum or breast milk is the best treatment. It has the power to prevent infection, speed healing and is safe for the baby.
This treatment is not an exhaustive list of all the effective remedies available. Your Lactation Consultant is uniquely qualified to help you identify the source of your nipple pain and the best tailored treatment for your needs. Consulting an IBCLC in the setting of continued nipple pain is essential to successful breastfeeding. Pain is one of the number one reasons parents stop nursing. References: Berens, P., Eglash, A., Malloy, M., Steube, A., and The Academy of Breastfeeding Medicine. (2016) ABM Clinical Protocol #26: Persistent Pain With Breastfeeding. Breastfeeding Medicine.11(2). 1-8. DOI: 10.1089/bfm.2016.29002.pjb Bonyata, K. (2018, January 16) Healing Tips For Nipple Cracks Or Abrasions. KellyMom. https://kellymom.com/bf/concerns/mother/nipplehealing/ Walker, M. (2013). Are There Any Cures For Sore Nipples? Clinical Lactation. 4 (3). 106-115. Witkowska-Zimny, M., Kamińska-El-Hassan, E., & Wróbel, E. (2019). Milk Therapy: Unexpected Uses for Human Breast Milk. Nutrients, 11(5), 944. https://doi.org/10.3390/nu11050944 This blog is not intended to substitute for medical advice and is of a general nature. Please consult an IBCLC, or MD to address your specific concerns.  Today I am writing about Telehealth Lactation Consults. You may also hear the term Virtual Consults. This method of support has been a part of many IBCLC’s (International Board-Certified Lactation Consultant’s) repertoire for years before the current health crisis. Recently many IBCLC’s have added this service and sought training on making this successful for our clients and families. What is a Telehealth Consult? A Telehealth or Virtual Consult is a consult that is conducted through HIPAA compliant, secure live video. This means I am still adhering to regulations to safeguard your privacy and medical information. A consult through video has limitations and does not replace an in-person consult and examination. This is also true if you have a Telemedicine visit with your MD. What can I do to support you and your family through Telehealth?
What is different in a Telehealth Consult?
Please have a person available to help position the camera/computer during the consult (For those with scheduling issues, I can arrange evening consults) Please have sufficient lighting in the room and a separate portable light/lamp that can be directly aimed at a subject Have your camera available to take pictures/videos for later review Telehealth consults, due to their nature, may require more follow up messaging (this is included) IBCLC’s are a creative group of professionals. We have always utilized videos, gesticulating with our hands and using props like dolls and knitted breasts to aid us in teaching! We have adapted to Virtual Lactation. Let us be there for you and your family during this time! Let’s keep the milk flowing, prevent problems and keep the babies/children and parents smiling on this journey! Join us online!  During this current health crisis, babies are still being born and more families may need the support of a Lactation Consultant. As a Registered Nurse and IBCLC (International Board Certified Lactation Consultant) I routinely work with babies in the NICU (Neonatal Intensive Care Unit) and the Newborn Nursery. These babies are fragile and I take my responsibility to protect their health and your families' health very seriously. These are the precautions I take. Excepting the added pre-screen questionnaire, these are the same precautions I take on a regular basis. Prior to your consult: 1. I screen all clients and their family for signs of an illness via a questionnaire prior to the consult. I offer a Telehealth consult for those who report symptoms and still desire a consult. 2. I will notify you of any illness in myself or my family and cancel the consult. I will either reschedule or assist you to find another IBCLC in a timely manner 3. I thoroughly clean all my supplies with approved disinfectants, including my iphone/ipad and pen before and after each consult During your consult: 1. I wash my hands with soap and water thoroughly for a minimum of 20 seconds and use clean paper towels to dry them 2. I sanitize my scale with an approved disinfectant and use one of your receiving blankets on my scale for weight measurements 3. I use disposable gloves when examining your baby's mouth and any time I touch you I am now proud to offer Telehealth Consults through a HIPAA compliant Secure Video I continue to enjoy my passion for supporting families on their breastfeeding and lactation journeys!  Lactation Consultants as a group talk a lot about Hand Expression. There are so many reasons why we stress this technique. Let's talk about how this technique can help boost milk supply and be your best friend throughout Lactation.
What is hand expression? This is a technique to use your hands to effectively remove milk. It is an alternative to an electric or manual pump. (Link below for a great video on how to do this) So why hand express? 1. Boost milk production (more on this in a minute) 2. Get some drops to entice your baby onto the breast 3. Feed your baby those liquid gold drops via a spoon when they are not latching well or sleepy 4. Soften the breast during engorgement to aid in latching the baby 5. Get some drops to apply milk to sore nipples. This helps prevent infection and speed healing. (see an IBCLC for persistent sore nipples or nipple damage) 6. Drain the breast instead of using an electric or manual breast pump (This is critical if one loses electricity and your pump does not have a battery) 7. Hand expression is a key part of managing plugged ducts Let's talk again about milk production. There are many circumstances in which the baby is not nursing in the early days. It is then important to stimulate your milk production in other ways. In the first 3-5 days after birth the breast milk is very thick. When nursing effectively babies are very good at removing this early milk called colostrum. Babies create a vacuum and massage the ducts. An electric pump uses only suction. It is much less effective at removing the thick milk. Think of placing an electric pump flange on the end of a toothpaste tube. It would have trouble removing the toothpaste. (the nipple stimulation still triggers the oxytocin and prolactin to produce milk so this is why pumping is also recommended). But hand expression is able to remove many more drops of milk than the electric pump in these early days. The more milk removed, the more your body makes! Combining hand expression with an electric pump is the ideal regimen to initiate a large supply if the baby is not going to the breast effectively 8-12 times every 24hr. In one study, it was shown that adding hand expression in addition to traditional pumping resulted in a large milk supply. "Mothers who used hand expression more than 5 times a day in the first 3 days yet pumped with the same frequency as other study mothers, expressed an average of 955 mls, about a quart a day by 8 weeks. This is more than a term 4 month old would need." (Morton et al., 2009) An additional study demonstrated a higher milk yield with hand expression. "Net milk yield per woman was 2 mL manually (median; range: 0–12.6 mL) and 0.6 mL (0–7.2 mL) by electric expression (P < 0.05)." (Ohyama, M., Watabe, H., Hayasaka, Y., 2010) Milk supply is determined by how much milk is removed from the breast. Early and frequent effective removal is the best way to achieve a healthy milk supply. Hand expression is an essential part of boosting supply in those early days and a useful technique for the duration of lactation. This technique takes a little practice but comes easily quickly. Hand Expression Video https://med.stanford.edu/newborns/professional-education/breastfeeding/hand-expressing-milk.html (Morton, 2006) References Morton, J., Hall, J., Wong, R. et al. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 29, 757–764 (2009). https://doi.org/10.1038/jp.2009.87 Morton, J., Newborn Nursery https://med.stanford.edu/newborns/professional-education/breastfeeding/hand-expressing-milk.html, 2006 Ohyama, M., Watabe, H., Hayasaka, Y., (2010). Manual expression and electric breast pumping in the first 48h after delivery. Pediatrics International. Volume 52, Issue 1. Pages 39-43.  As an International Board Certified Lactation Consultant (IBCLC), I receive many questions about breast care during lactation. These questions and concerns increase around the holidays especially. Parents have less time for self care and this can result in pain and sometimes infection.
 Let's talk about milk supply. I often hear from clients that they are eating Lactation cookies or drinking Mother's Milk Tea to increase their milk supply. These are just two examples of items that are touted to increase supply. Some herbs and food can increase supply legitimately for some people in certain circumstances. Evidence based advice from an International Board Certified Lactation Consultant (IBCLC) and your MD is advised when taking additional supplements of any kind.
Lactation cookies will increase your waistline but not your milk supply. Let's talk about how the milk is made. The process is demand and supply. The more the baby eats, the more milk your body makes. If your baby is nursing effectively 8 to 12 times (sometimes more) every 24hr, you will most likely make a full milk supply. If your baby removes 2 ounces (as an example), your body is triggered to make 2 ounces again. If your baby is not nursing at the breast, you can build this supply with effective pumping. It's recommended you pump 8-10 times every 24hr to make a full milk supply. It is more effective to pump every 15 minutes every 2 1/2 hours than 30 minutes every 4hr. In other words, more frequent is better. It may be recommended to rent a multi-user pump with a stronger motor in the first month after birth. A common herb called Fenugreek is traditionally been utilized to increase milk supply. It is available in capsules and in tea at the store. This herb is contraindicated (unsafe) for those with Diabetes. It can lower your glucose. It can lower milk supply in those with Hypothyroidism. Many women have undiagnosed Hypothyroidism or become Hypothyroid for the first time in the post partum period. It is from a legume and can cause an allergic reaction for those with legume and nut allergies. This is an example of when an herb is not a one size fits all. The bottom line is that if you want to take an herb or supplement, please consult an International Board Certified Lactation Consultant. There are numerous herbs and supplements that can increase supply. They all have cautions and each one must be chosen individually for the mother. There is an important point to remember when considering herbs, supplements and foods that boost supply: If you are not adequately removing your milk with the baby nursing well or pumping 8-10X (plus) every 24hr, the herbs or supplements will not work. Most of the time, a low milk supply is due to inadequate milk removal. It is important to work with an IBCLC to identify the cause and create a plan to increase your supply. What is the takeaway? Enjoy those cookies if you like them! But consult an IBCLC if you have milk supply issues!  Historically it was common place for hospital staff to bathe the newborn within 2 hours of birth or even sooner years ago. Bathing the newborn separates the baby from the mother in this critical time period. The baby also has more difficulty maintaining their temperature this soon after birth. This can lead to longer time periods under the warmer. Even twenty four hours later, babies can tolerate a quick bath with fewer temperature drops. But enough background. On to the evidence!
Multiple studies have been conducted on delayed bathing comparing multiple variables important in the newborn period. They studied temperature regulation, glucose levels, breastfeeding rates, skin to skin, bonding and parent participation in newborn care. Here are just some of the amazing results: One study compared babies that received a bath at two hours of age versus a bath at twenty-four hours old. The study found that breastfeeding rates improved by 10 percent and formula supplementation decreased by 10 percent. There was a decrease in incidence of low glucose(hypoglycemia) and lowered temperature(hypothermia). They found increased bonding and increases parent participation in infant care. (LiVolsi, 2018) A another study found benefits of the vernix which provides nutrients and protection the baby's skin. Vernix is the coating on the baby's skin at birth. This study also found significant beneficial impacts on increased breastfeeding rates, and a lowered incidence of low glucose (hypoglycemia) and hypothermia. They also found increased skin to skin care and bonding! So many benefits from one action. (Liberth, Fontana, 2018) The World Health Organization states: "Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps. The mother and baby should not be separated and should stay in the same room 24 hours a day." (2012) Note: Clothing is needed if skin to skin is not being performed. A blanket draped over the back of the baby and a hat is required in the early hours with skin to skin. Hospital staff will instruct you on safe skin to skin positioning. The baby has been bathed in the amniotic fluid for months. A woman's montgomery glands, located on the areola, secrete a substance that is similar in taste and smell to the amniotic fluid. This assists the baby in finding the nipple to begin nursing. Delaying the bath preserves the familiar scents for the baby. This is one of the many reasons that delaying the bath can help with breastfeeding. Keeping the parents and the baby together for more hours and especially during the critical early hours is very important. By minimizing incidences of hypothermia and lowered hypoglycemia, this powerful time period is protected more successfully. Simple but powerful practices have immense positive effects on outcomes for babies and parents. Ask for a delayed newborn bath! References LIBERTH, M.; FONTANA, J. Benefits of Delayed Bathing. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, [s. l.], v. 47, p. S30–S31, 2018. Disponível em:<https://search-ebscohost-com.libdb.fairfield.edu:8443/login.aspx?direct=true&db=rzh&AN=130486177&site=ehost-live&scope=site>. Acesso em: 6 maio. 2019. LiVolsi, K. (2018). Improving Neonatal Outcomes through the Implementation of a Delayed Bathing Program. Improving Neonatal Outcomes Through The Implementation Of A Delayed Bathing Program, 1. Retrieved from https://search-ebscohost-com.libdb.fairfield.edu:8443/login.aspx?direct=true&db=rzh&AN=131799073&site=ehost-live&scope=site WHO (2012), WHO recommendation on bathing and other immediate postnatal care of the newborn. retrieved on 5/6/2019 https://extranet.who.int/rhl/topics/newborn-health/care-newborn-infant/who-recommendation-bathing-and-other-immediate-postnatal-care-newborn |
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