 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.
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 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  I am sitting down today to write about a serious issue intimately related to breastfeeding. There is an enormous amount of pressure placed on new parents to breastfeed. I acknowledge that the known science supports breastfeeding as the ideal feeding choice for newborns. Breastfeeding provides more than nutrition and medical benefits to the lactating parent and infant. It also is a powerful bond between a parent and their baby.
That bond is also formed when bottle feeding in many different forms. There are many reasons why a parent may not breastfeed. It may be a personal choice. Breastfeeding can include struggles which make the journey difficult. I have a full time job assisting parents in their goals so I understand the hurdles that can and do exist. The bottom line is this. If a parent is bottle feeding it is not my place to judge or place guilt on that parent. Society should not place guilt on them either. If they desire assistance in reaching breastfeeding goals, I am there! Our country is a paradox when it comes to messages to new parents and breastfeeding. The initial message is, "Breastfeed, it's the best for baby". Some parents are shamed for not breastfeeding. At the same time the support for breastfeeding in the US is seriously lacking. There is still no paid leave for lactating parents in the US. Many people struggle with adequate time to pump, clean areas to pump and harassment during pumping. Insurance companies are required to cover Lactation counseling but they still often find loopholes around this. Parents have to wait until they deliver their baby to request their electric breast pump from their insurance companies. This leaves them without a pump for a week or more after discharge from the hospital. People continue to face harassment when breastfeeding in public. Lack of knowledge about normal breastfeeding leads to misinformation flowing from many sources. This can lead to early cessation of breastfeeding. Our culture is one of isolation for many new parents. Many people have no family support nearby or limited support. Many have never seen anyone breastfeed before. This produces a larger learning curve when initiating nursing. Support groups, friends, IBCLC's and other support professionals are needed in greater amount and accessibility. If a parent is struggling due to these issues, we need to rally behind them and support them in their breastfeeding goals. We know this is sometimes difficult and parents are left to struggle alone often. This needs to change. Choosing a feeding method for your baby is an emotional and complicated decision which may evolve and change over time. And honestly it is none of my business why a parent chooses one method over another. I am there to provide education and support for all parents on their journey. A new parent's emotional health is paramount in the post partum period and beyond. We have to discuss choices, challenges and feelings openly. No one has the right to judge a person's individual decision to breastfeed, bottle feed or formula feed. We must support our new parents in their decisions and celebrate their strength in knowing themselves and their goals. This is a call to action to improve breastfeeding support, and new parent support and education. We can do better together. Let's talk about Triple Feeding. Triple feeding is when a Lactating parent breastfeeds, pumps and bottle-feeds at every feeding. Does that sound exhausting? It is! It is necessary sometimes but it is something I recommend only when truly needed. There are very important points to keep in mind if you are on this care path. First let's review some reasons why this may have been recommended.
1. Excessive newborn weight loss 2. Jaundice 3. Sleepy at breast 4. Late pre-term challenges (babies born between 34-37 weeks) 5. Ineffective suck pattern at breast 6. Difficulty latching (This list is not exhaustive) The first important point is timing: Newborns eat every 1-3 hours so Triple Feeding often can feel like parents have no break at all. I recommend keeping the whole cycle or process of the feeding to 40 minutes or less. This means, breastfeeding, pumping and bottle-feeding all in 40 minutes. This becomes a challenge when the baby is actually improving and nursing better and longer. In this scenario, we don't limit their time on the breast. But if your baby is simply asleep despite adequate waking techniques, trying to wake them for an hour is counterproductive. Give the nursing a good attempt but if its been 10 minutes, and your baby is still not latching well, you can move on to the bottle portion of the feeding. There will be many times to breastfeed in the future. Luckily babies reflexes to suck and find the breast are present for months. The second point concerns duration: This is a Short Term Care Plan! I educate my clients that they can proceed with Triple feeding for 48-72 hours. At that point, a re-evaluation by your (IBCLC) Lactation Consultant is necessary. The goal of Triple Feeding is to build and maintain your milk supply while addressing your baby's latch issues and keeping the baby fed and energized to learn to nurse. Milk supply will increase over 3 days with adequate stimulation and the baby has also potentially changed in that time. A Lactation Consultant (IBCLC) can re-assess your individual situation and recommend a more sustainable long term plan based on your needs. It is not wrong to continue this method for longer than 3 days. But it is a lot of work. Working with a knowledgeable IBCLC who can support you throughout this process is essential. Triple feeding has a place in reaching lactation goals but it can also be discouraging as it is a lot of work. Enlisting partners to complete the bottle portion of the feeding is helpful. Family members can also clean pump parts and prepare bottles. Reaching out for help and support is necessary! |
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May 2020
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