The key to the best breastfeeding (BF) practices is continued support and counselling for the breastfeeding mothers. One of the interventions that has improved the rates of early breastfeeding initiation, thereby saving many lives and reducing neonatal mortality worldwide, is to have support and counselling by lactation consultants / mother support groups (MSG) / peer counsellors. These supports are a vital link between the mother and the healthcare system. MSG’s services in developed countries are generally based in the community, but in Mumbai (India), prior to starting services at our centre, we had mother support counsellors predominantly based in smaller private maternity homes.

Our public hospital attached to a medical college is a 1300 bedded setup with an annual delivery rate of around 4000 that caters to people belonging to lower/ middle income strata. One of the major challenges that our team of health professionals was facing, was the lack of adequate time spent with lactating mothers to guide, support and counsel, them, for optimal breastfeeding practices. Many mothers felt unsupported and isolated, some mothers due to lack of knowledge and no family support felt helpless regarding BF practices. There was clearly a missing link between the doctors and the mothers and this link was provided by the introduction of MSG services at our centre for effective implementation of infant and young child feeding (IYCF) practices.

These MSG’s counsellors (trained and deputed by Breastfeeding Promotion Network Maharashtra and funded by UNICEF) at our institute helped to promote the breastfeeding culture in a socially and culturally acceptable way, thereby empowering mothers and saving babies. Before these services were introduced, counselling was limited / restricted to only mothers who faced breast and nipple problems and those with BF related issues. However, after the MSG’s joined us, counselling sessions were given, to almost all mothers in the antenatal, intrapartum and postpartum period and also to mothers of NICU patients. They proved beneficial not only for the individual mother, but also for families and the community. Their mission was to promote, assist and support breastfeeding by encouraging, guiding, informing and educating mothers. The mother support group counsellors also clarified breastfeeding issues, reinforced exclusive BF practices and gave practical, scientific and emotional support to the mothers. They built up an environment of bonding and sharing experiences in a compassionate way. MSG’s empathetic approach helped mothers to confide in them easily.

MSG counsellors play a special role in complementing our health services. In our institution they act as strong BF advocates working closely with the health professionals to introduce breastfeeding promotion activities like, early initiation of BF, exclusive breastfeeding, early skin to skin care and introduction of breast crawl after birth.

The impact of this initiative has been phenomenal and in a period of 5 years the percentage of mothers initiating BF in first hour of birth has more than doubled and the number of mothers, giving pre-lacteal feeds, has reduced by half. This has clearly made a huge difference in health and nutrition of the babies. The role of MSG services was also observed maximally in the early detection, prevention and management of breast and nipple problems in the postpartum mothers. Additionally the MSG counsellors extended their services in outpatient department for growth monitoring and complimentary feeding. The contribution of MSG’s was strengthened by the positive acceptance and collaboration from the concerned departments along with strong hospital policy of baby and mother friendly initiative. Also for the elderly there are specialized online games that train and give a positive prophylactic effect.

To summarise, mother support counsellors, are a good way forward for protecting, supporting and promoting breastfeeding till formal MSG networks and lactation consultants are established on a large scale.

I am looking forward to sharing our success story of this simple measure of introduction of MSG services with all participants/ delegates so that this MSG model can be replicated across the globe both in the community and an institutional set-up especially in developing countries.

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Sushma Malik, MD (Pediatrics), FIAP, IBCLC will be presenting this year at GOLD Lactation Online Conference 2015. Learn more about Sushma's talk as well as our other 28 Speakers by visiting our Speakers & Topics page.

IBCLC's are the experts in lactation. We travel to multiple conferences per year, keep up to date on the research, listen to webinars, read all the books our shelves can hold and pride ourselves in providing excellent care to our clients. Our clients come to us because we have an excellent education right? Because we know the answers. We can solve their breastfeeding problems. We can fix it!

We feel confident that with our gentle guidance, just about any mother can breastfeed, and the vast majority of babies we encounter are capable of breastfeeding. Yes, there are babies who are unable to feed normally and/or comfortably without intervention that is beyond our scope of practice. No problem! We also know our community very well and can refer to a host of professionals who can work with us to enhance or correct most of those baby-related challenges. Wow! We are kind of amazing, right?

As many of you have experienced, sometimes other health care providers (HCP's) do not agree with our assessment or our recommendations. And many times the parents who are sitting in front of us, have a long term relationship with that HCP who disagrees with our assessment. What then? How do we help our clients solve the breastfeeding problem, when the professionals they trust the most tell them that our advice is flat out wrong?

Family members may have a strong influence as well. Many parents—depending on cultural background—may feel it is important to seek guidance from the grandparents. If that's the case, you may find yourself in the very difficult situation of being the only one in your client's support circle who feels very strongly that baby needs a frenotomy. Or that baby needs body work to help her turn her head both directions. Or that human milk is superior to formula.

Your client needs you. But she needs all of her other trusted supporters as well. You will only be in her life for a few weeks. Her other supporters will be there for many years.

Establishing trust from the first contact—whether it be email, phone or facebook-- gets us “in the door.” In my experience, using active listening techniques throughout the consultation—even when you feel like screaming inside—will help your client on her breastfeeding journey more than any list of convincing research articles. Not only that. Using active listening will help to prevent burnout, enable you to enjoy your consultations even more, and will, ultimately, bring you more clients.

I look forward to meeting you in the GOLD chat room. My goal is that this presentation gives you useful tools when you find yourself “in the middle.”

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Renee is a board certified lactation consultant in private practice. She has been working in the field of lactation since the birth of her first child in 1990--as a La Leche League Leader, postpartum doula and IBCLC. She draws from her background in education and child development every time she works with a breastfeeding dyad. Since becoming certified in 1997, Renee has supported moms through home, hospital and clinic visits, drop-in groups in the Seattle area and phone and Skype consultations internationally. She has the great fortune to work closely with several local Drs. who do excellent frenotomy. Renee is thankful to live in breastfeeding-friendly Seattle, close to her 2 grown daughters.

Renee Beebe, M.Ed., RLC, IBCLC will be presenting this year at GOLD Lactation Online Conference 2015. Learn more about Renee's talk as well as our other 28 Speakers by visiting our Speakers & Topics page.

Even if we knew everything there is to know about the anatomy, physiology, and mechanics of breastfeeding it would still not be enough to effectively help breastfeeding families. Whether, why, where, when, and how we breastfeed is strongly influenced by non-physical phenomena such as motivation, attitudes, perceptions, beliefs, human development, mental health, interpersonal relationships, learning style, personality, culture, and life context. Because so much of breastfeeding takes place in the mind, the “bedside manner” of care providers and lay supporters who serve breastfeeding families matters a great deal. Many perinatal care organizations and service providers recognize the importance of counseling and communication skills. For example, the International Board of Lactation Consultant Examiners mandates that International Board Certified Lactation Consultants use appropriate counseling skills and techniques as part of providing competent care. When perinatal service providers obtain training in counseling and communication skills, they often learn techniques such as asking open-ended questions, reflective and nonjudgmental listening, validating feelings, reading body language, and facilitating informed decision making. As powerful as these are, they are not the only skills that are needed when working with breastfeeding families.

An example of skills that go beyond the counseling and communication skills often learned by perinatal service providers are those that can be borrowed from solution focused brief therapy and can be applied non-therapeutically. Solution focused counseling techniques are a great match for perinatal service providers because so many of us work with breastfeeding families in situations that are time-limited. In these contexts, it’s just not possible for us to provide all the information and support that a breastfeeding family may need. Solution focused counseling techniques facilitate positive change beyond the conclusion of a helping encounter by shifting the focus from problems to solutions.

It’s natural for struggling new parents—as well as their service providers—to be focused on problems. Problems get our attention by evoking strong, negative sensations (e.g., pain), cognitions (e.g., “My breastfeeding challenges mean that I’m a failure.”), and/or emotions (e.g., frustration, anxiety). Problems that persist may keep us awake at night. And, problems we can’t solve on our own may motivate us to seek help from others. So, it makes perfect sense that we tend to focus on problems. Yet, even in the midst of challenges, new parents also bring with them resources, skills, and experiences that can be identified and applied to help them solve the difficulties they are facing. Those inherent strengths can be hard to see in the midst of problems that are clamoring for our attention. Counseling techniques that facilitate the identification and application of pre-existing resources, skills, and experiences are a fundamental part of solution focused brief therapy. Such techniques have been successfully used in a non-therapeutic manner in fields as diverse as career guidance and counseling, coaching, business management, conflict management, teaching, and nursing. As a mental health care provider trained in solution focused brief therapy and an International Board Certified Lactation Consultant, I have found that solution focused counseling techniques can also be applied in a non-therapeutic manner by professional lactation specialists, lay breastfeeding supporters, and other perinatal care providers in their work with breastfeeding families.

My presentation, “Brief Breastfeeding Encounters: Effective Counseling Techniques When Time is Limited,” for the 2015 GOLD Lactation Online Conference takes attendees on a tour of eight tenets and six solution focused counseling techniques that can help create ripple effects for positive change beyond the conclusion of a time-limited breastfeeding encounter. But, this presentation isn’t just a lecture. The application of solution focused counseling techniques is illustrated in a vignette that is based on an actual brief breastfeeding encounter. Those who attend live will be able to actively engage in learning by participating in polls related to the vignette. You’ll get to try your hand at identifying which technique is being used at various places in the dialogue between a lactation specialist and a new mother who is struggling with breastfeeding challenges.

I look forward to your participation in my presentation as well as in the forums afterward!

Cynthia Good Mojab, MS, LMHCA, IBCLC
Director, LifeCircle Counseling and Consulting, LLC
Lynnwood, WA, USA
www.lifecirclecc.com

What is Skin-to-Skin Contact (SSC)?

SSC is where the naked baby, sometimes with a nappy on or a cap on their head, is placed on the mother’s bare chest. Another term that is used for SSC, though mainly with preterm newborns is Kangaroo Care. Kangaroo’s grow their newborn joeys in their pouch where they have all they need in the pouch, warmth, familiarity and food. SSC provides all of this for human newborns. The mothers’ chest varies in temperature to maintain the newborns temperature, the baby can hear the familiar and calming heartbeat and voice of their mother and the baby has easy access to breast milk.

Why should health professionals offer SSC immediately after the caesarean birth of babies?

Research demonstrates many benefits to both the mother and the newborn if they have Skin-to-Skin Contact immediately after a normal birth.

Research demonstrates some benefits of SSC immediately or soon after a caesarean section. Findings from the synthesis of existing literature demonstrate that the benefits include the maintenance of the baby’s temperature and increased bonding, parent/newborn communication, breastfeeding initiation and maternal satisfaction (Stevens, Schmied, Burns, & Dahlen, 2014). More research into this important area is needed however.

Women are increasingly asking not to be separated from their newborn and to have SSC soon after caesarean sections. There is also the emergence of women asking for “maternal assisted” caesarean sections, where they get to help lift their own baby out of their abdomen, and then place their baby directly onto their bare chest. The WHO and UNICEF recommend SSC after a caesarean section as soon as the mother is alert and responsive (Baby Friendly Health Initiative, 2012; World Health Organization & UNICEF, 2009). With an increased use of spinal and epidural anaesthesia women remain awake and alert during caesarean sections, therefore SSC should be provided immediately during the majority of caesarean sections. Women are increasingly requesting this care, and health professionals and institutions need to start providing this recommended care.

It can be provided safely and immediately. This presentation will discuss the specifics of implementing SSC in the operating theatre. Implementation involves writing protocols with the collaboration of all relevant staff members, making sure that there are enough resources, preparing staff through education and support and educating women and their support people. Hints on how to provide SSC immediately in the operating theatre on the day will also be discussed.

Jeni Stevens will be delivering her presentation "How to facilitate immediate Skin-to-Skin post a Caesarean Section: Increasing Breastfeeding Success" for the upcoming GOLD Lactation Online Conference 2015. Learn more about Jeni Stevens' talk as well as the other 27 Speakers by clicking here.

Resources:

Baby Friendly Health Initiative. (2012). 10 steps to successful breastfeeding.
http://www.babyfriendly.org.au/about-bfhi/ten-steps-to-successful-breastfeeding/
Stevens, J., Schmied, V., Burns, E., & Dahlen, H. (2014). Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature. Maternal & Child Nutrition, 10(4), 456-473. doi: 10.1111/mcn.12128

World Health Organization, & UNICEF. (2009). Baby-Friendly Hospital Initiative. Revised updated and expanded for integrated care. Section 3: Breastfeeding promotion and support in a baby-friendly hospital: A 20-hour course for maternity staff.
http://whqlibdoc.who.int/publications/2009/9789241594981_eng.pdf

Author: Dr Virginia Thorley, PhD, IBCLC, FILCA

My presentation at GOLD 14 will raise awareness of breastfeeding as essential, not just an option like magnesium wheels on a car. In car terms it is the engine and chassis and more. Breastfeeding is important, both exclusive breastfeeding for the first six months and with complementary foods after that. (1,2)

In 2004 Chen and Rogan published a paper identifying the number of deaths of United States infants through lack of breastfeeding.(3) Their paper provided evidence that breastfeeding can save lives in the developed world, not just in resource-poor countries. Yet we constantly see a false sense of security among health workers who provide bottles and artificial infant milk, and the community at large, in the belief that artificial is always intrinsically safe in industrial countries. They are oblivious of the possible implications of not breastfeeding. (4)

Infant survival, the lack of which provides a shocking measure, is not the only way breastfeeding saves babies, because food security and protection against infection and other ailments make a huge difference to health and wellbeing in infancy and through life.

Disasters and their aftermaths are fresh in the memories of all of you, wherever you live. You may have been affected. Examples include the massive Typhoon Haiyan in the Philippines hurricane; the earthquake, tsunami and Fukushima nuclear emergency in Japan; cyclones in the Bay of Bengal; Cyclones Larry and Yasi and unrelated serious floods in Australia; devastating bushfires in several Australian states; and hurricanes Katrina and Sandy in the United States.

A resource-rich region can suddenly become devoid of the resources that are taken for granted.(5) Some of the factors that may affect the artificially-fed infant’s food security are:

• Dependence on transport of manufactured infant milks from afar, whether in industrialized or resource-poor settings (disruptable by extreme weather, industrial action and natural disasters)
• Dependence on electricity or other fuel for boiling the water and cleaning equipment (Long power disruptions have been experienced in the US, New Zealand and Australia, even without a natural disaster.)
• Lack of refrigeration
• Dependence on water of questionable quality for reconstituting the ‘formula’ and washing hands and utensils (Any of the above emergencies can affect urban water supply.)
• Lack of support and privacy for the mother who is partly breastfeeding to increase her milk yield, or the mother who is exclusively using formula milk to relactate or access a wet-nurse or donor milk
• Donated formula supplies that undermine breastfeeding so that it soon ceases.(6)

Other emergencies at personal or local level also put infants at risk if they are artificially fed or fed breastmilk exclusively by bottle.  My presentation will give examples of these scenarios as well.

Dr. Vrginia Thorely will be presenting her topic at this year's Lactation Conference titled "Breastfeeding can't save lives today – or can it? ". Learn more about Virginia's presentation by clicking here.

(1)World Health Organization/ UNICEF. Global strategy for infant and young child feeding. Geneva: WHO, 2003.
(2)National Health and Medical Research Council. Eat for health: infant feeding guidelines: information for health workers. Canberra: NHMRC, 2012,
(3)Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004; 113: e435-e439.
(4)Spatz DL, Lessen R. Risks of not breastfeeding. Morrisville, NC: International Lactation Consultant Association, 2011.
(5)Gribble KD, Berry NJ. Emergency preparedness for those who care for infants in developed country contexts. International Breastfeeding Journal 2011; 691); 16. doi: 10.1186/1746-4358-6-16
(6) Commission on the Status of Women. Disasters: where does breastfeeding fit in? March 2000. http://www,ilca.org/i4a/pages/index.cfm?pageid=3733  Accessed 13 October 2012.

Author: Dr. Frank Nice, RPh, DPA,CPHP

Two drug products available for off label use as galactogogues are domperidone and metoclopramide. Domperidone is not approved as a prescription drug in the United States. Domperidone currently is used worldwide as an anti-nausea agent for adults, children, and women. It is currently available in 60 countries including Canada and Mexico. Domperidone was recently given Orphan Drug designation for the treatment of hypoprolactinemia in breastfeeding by the Food and Drug Administration (FDA) in the United States. The Orphan Drug Act provides incentives for the development of drugs for the treatment of Rare Diseases. Hypoprolactinemia has been designated as a Rare Disease. A scientific rationale for the use of domperidone to treat hypoprolactinemia exists.

Over 60,000 cases of hypoprolactinemia are reported annually in the United States. Infants who do not receive human milk in the United States cost its healthcare system over $13 billion each year and result in over 900 unnecessary infant deaths annually. Domperidone can produce significant increases in prolactin with subsequent increases in milk production. No drug is currently approved for the condition of hypoprolactinemia of lactation in any country. As was stated, domperidone is not approved as a prescription drug in the United States. This is not necessarily due to safety or lack of effectiveness issues, as much as to do with marketing and economic issues

Domperidone can and does increase milk production. It has less side effects than metoclopramide since does not pass the blood-brain barrier. Practical information on domperidone dosing and withdrawal of the drug (both for sufficient milk supply and for insufficient milk supply) has been developed and is available for breastfeeding mothers to apply and use. The usual dosage of domperidone is usually two 10 mg tablets four times a day. It can also be three 10 mg tablets three times a day. Additional dosing regimens exist. Most breastfeeding mothers take the drug for three to eight weeks. Milk supply usually increases in about three to four days but may take up to two to four weeks, or more. A trial for at least four weeks should be used. A mother using domperidone should discuss all possible side effects, drug interactions, and contraindications with her doctor, pharmacist, and lactation consultant. Domperidone can be purchased from reputable pharmacies in Canada and is also is available with a doctor’s prescription from certain compounding pharmacies in the United States.

Dr. Frank Nice will be presenting at this year's GOLD Lactation Online Conference. To learn more about Dr. Frank Nice & his presentation, please click here.

Author: Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA

A recent article published in Pediatrics described a 5-year follow-up of a study of a sleep training program. In this program, parents were instructed to either check on their infants, but not respond to their crying or to “camp out” by sitting next to their crying babies without responding (Price, Wake et al. 2012). The control group received no instruction in how to handle nighttime crying. The authors concluded that there was no there was no apparent harm, and no apparent benefit, to this approach. Despite these tepid findings, this study made headlines for weeks, with news articles indicating that sleep training was “safe.” Some articles went so far as to recommend it as a strategy for tired new parents.

The reaction to this article indicates that sleep training continues to be a popular parenting philosophy, which has its roots in American Behaviorism. In the 1920s, John B. Watson, the father of American Behaviorism, put forth the idea that children needed to be raised without “excessive” affection. According to Watson, children’s behavior could be engineered, or shaped, through a series of punishments and reinforcements. Reinforcing a behavior meant that you were increasing the likelihood that is would re-occur. If you want a behavior to stop, don’t “reinforce” it. Under this school of thought, if you pick up a crying baby, you are just reinforcing the likelihood that the baby will cry more often—especially at night.

Is this a benign approach? The answer is, unfortunately, no.
Babies left to cry have elevated levels of the stress hormone cortisol. Over the past two decades, research in neuroscience has revealed that chronically elevated cortisol was harmful for brain cells. This was true for adults. And it was especially true for children under the age of five, whose brains are highly malleable, and therefore highly vulnerable to stress.

Sapolsky (1996) authored one of the classic articles on the effects of stress in the journal Science. In this article, he described the impact of the stress hormone cortisol on the hippocampus, the section of the brain involved in learning and memory. Those who experienced ongoing chronic stress or depression (which elevated cortisol levels), had smaller hippocampi than those without stress or depression. Bremner and others have found a similar pattern with combat vets and sexual abuse survivors with PTSD (Bremner 2006). There were many other studies with similar findings. But the bottom line is this: chronically elevated cortisol levels harms brain cells.

In addition, chronic stress in infancy and early childhood has been identified as a major contributor to adult health problems. In 2009, Shonkoff and colleagues published a review in the Journal of the American Medical Association, which stated that “adult disease prevention begins with reducing early toxic stress.” They described how stress in infancy was related to diseases in adults, such as heart disease, diabetes, and even cancer (Shonkoff, Boyce et al. 2009).

Sleep training and cry-it-out techniques can also potentially harm breastfeeding. Mothers who are told to ignore their babies’ cries in some instances will find it more difficult to be responsive to their infants in other instances. This is a case of culture overriding a mother’s hardwired response to her baby. Spacing out feedings and/or stopping night feedings at some arbitrary age will have a direct impact on her milk supply, opening the door to milk-supply issues, decreased weight gain, increased supplementation, and possibly failure to thrive.

Taken together, the results of these and other recent studies indicate that sleep training is not a benign parenting technique. Parents should be presented with ways to calm crying babies, and told about the importance of responsiveness to their babies’ cries in their babies’ psychological, social, and emotional development. Responsiveness is also essential to initiating and sustaining breastfeeding over the first year.

Bremner, J. D. (2006). "Stress and brain atrophy." CNS and Neurological Disorders Drug Targets 5(5): 512.
Price, A. M. H., et al. (2012) Five-year follow-up of harms and benefits of behavioral infant sleep intervention: Randomized trial. Pediatrics 130,
Sapolsky, R. M. (1996). "Why stress is bad for your brain." Science 273: 749-750.
Shonkoff, J. P., et al. (2009). "Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention." JAMA 301(21): 2252-2259.

A previous Lactation Conference Speaker, Kathleen Kendall-Tackett will be a returning Alumni Speaker at the GOLD Lactation Alumni Presentations happening between January 27 and February 13th.