Breast engorgement education for lactation professionals and midwives to prevent conflicting information for postnatal mothers

lorettaWhen Mater Health Services midwife and lactation consultant Loretta Anderson, RN, CM, IBCLC had her first son 13 years ago, she developed unilateral mastitis four months postpartum.

She struggled with low milk production on her right side, and ultimately her son refused to nurse on her right breast.

“I was devastated,” Anderson recalls. “I tried pumping and tricking him, but eventually I weaned this side and fed off one breast for another year.”

 

Five years laters, Anderson gave birth to her second son.

“I wanted breastfeeding to be easier.”

Anderson reports that all was well until she developed mastitis once again four months postpartum, and her second son started to refuse the right breast.

Around this time, Anderson met Paul Clinch, a remedial massage therapist for the Australian Olympic swim team.

Clinch developed a chest muscle and breast tissue massage to enhance breathing capacity in swimmers, Loretta explains. He adapted this massage, known in Australia as The Clinch Technique (TCT),  for mothers struggling with breastfeeding and women enduring breast cancer with lymphatic fluid drainage.

“Following one 30 minute treatment [with Clinch] I attempted to breastfeed my son and he went on the right side and drained it completely without stopping,” Anderson reports.  “I did not have a problem with this breast again and fed for two and a half years!”

Anderson trained in TCT and says she now uses it in her practice with excellent results. She plans to undertake a randomized controlled trial to measure the effectiveness of the simple technique.

Anderson will present Implementation of an Education Package on Breast Engorgement aimed at Lactation Consultants and Midwives to prevent conflicting information for postnatal mothers at the 22nd International Breastfeeding Conference.

“I want to bring a new angle on engorgement and how we at the Mater have made it simple to understand and easy to teach new mothers,” Anderson says.

Anderson will cover the lymphatic system and how it affects breastfeeding during her presentation.

“I will also share a few tricks of the trade when teaching mothers breastfeeding and how they can deal with conflicting advice from other health professionals,” she says. “I will discuss how our unique Mater community tackles breast engorgement education.”

Anderson says she is excited to be part of Mater Health Services. As part of the research team, they produce research aimed at increasing breastfeeding continuation rates.

Statistics from the 2010 Australian National Infant Feeding Survey results indicate that 96 percent of mothers in Australia initiate breastfeeding, but 39 percent of babies are still being exclusively breastfed to three months and less than 15 percent to five months. [Retrieved from: https://www.breastfeeding.asn.au/bf-info/general-breastfeeding-information/breastfeeding-rates-australia]

Currently, Anderson is working on a systematic review on breast massage and its effectiveness in treating breastfeeding problems. She says she hopes it will  bring relief to mothers in a simple and effective way.  

Further, Anderson offers easy-to-understand breastfeeding information on her website breastfeedingcafe.com.au.

“I wanted women to be able to search online in the middle of the night and find somewhere to gain information that they can use immediately,” she says.

Anderson ran a free, monthly group in North Brisbane called Northside Bump Boob and Beyond which will resume meet ups in the New Year.

Anderson provides baby scales and tea and addresses mothers’ breastfeeding concerns.  The group has grown to over 130.

You can participate in Anderson’s International Breastfeeding Conference presentation by registering here.

“I am very much looking forward to meeting and learning from a diverse range of breastfeeding professionals,” Anderson says of the conference.  “I am very interested to see how breastfeeding education is managed in the US and how I can learn and take new ways of teaching back to Australia.  I love being surrounded by like-minded professionals and sharing our passion for breastfeeding mothers.”

Note: Post title has been changed since original publish date.

UF Center for Breastfeeding and Newborns helps mothers reach breastfeeding goals

a3ebb694-cc53-4c3f-b756-f6a43526b115With tears in his eyes, a father hugged Mary Ryngaert, ARNP, IBCLC after she clipped his baby’s tongue tie and his wife reported breastfeeding feeling much better. (Note: Releasing tongue-tie is within the scope of practice of a nurse practitioner.)

“Anytime I clip a tongue tie and the mother’s first words after the baby goes to breast are It doesn’t hurt at all, I can’t believe the difference– that makes my day,” Ryngaert says.

Seven years ago, Ryngaert and her colleague Dr. Sandra Sullivan, MD, IBCLC, opened the UF Center for Breastfeeding and Newborns (CBN) outpatient clinic.  

Ryngaert reports that the most common concerns mothers come to the clinic for are painful feedings and low milk production. Other times, mothers come to talk about pumping milk for when they return to work.

“Whatever is an issue for parents, as long as the breastfeeding relationship goes on, that’s our business,” Ryngaert says.  

She recalls helping another family who struggled for months with supply and suck challenges.

“They traveled an hour each time they came to see me in clinic,” Ryngaert reports.

The infant benefited from working with an occupational therapist who understands how to work toward breastfeeding and how to maintain and increase milk production. Previously, the family visited an OT who told the mother that her baby was using too much energy nursing, and recommended she bottle-feed.

“You may be certain that I did some education after the mother reported that!” Ryngaert exclaims.

After working with Ryngaert and her team, Ryngaert recalls how pleased she was that she had help working toward her goals. The baby’s grandmother, who hadn’t breastfed, was equally excited.

The grandmother became invested in the breastfeeding relationship when she realized how important it was to her daughter, Ryngaert explains.

“She made the hour drive with her daughter and granddaughter for all of the visits and sincerely thanked me every single time,” she remembers.  “I was so happy to receive an email a few months later that the baby was fully breastfed at the breast.”

Teaching is an important component to the support system at the UF Center for Breastfeeding and Newborns clinic. Helping parents read their babies’ cues and understanding what is normal and expected in terms of feedings, sleep, diapers is all part of helping moms meet their feeding goals.

“I particularly enjoy hearing parents talk about this brand new baby’s personality as though they’ve known the child forever!” Ryngaert exclaims.  “And I love pointing out the way the baby tracks the parents down from a few feet away.  It’s such a privilege to be a witness to this intensely important time in the life of a family.”

The Center for Breastfeeding and Newborns’ engages in a  community-based effort to increase breastfeeding initiation, duration and exclusivity among all families.

“We have been facilitators for breastfeeding support groups, in particular a very popular group for African American mothers,” Ryngaert says.

Reducing disparities in breastfeeding was a core concern in the Community Practice Training Initiative grant, which was awarded to CBN in 2010 to provide support for an advocacy program to promote breastfeeding as a strategy to reduce pediatric obesity and overweight and the many health problems associated with these.

“We are interested in increasing community-based peer counselors and expanding postpartum breastfeeding support groups sites,” Ryngaert explains.

She, Dr. Kristina Carswell, and Health Education doctoral student Cynthia Sears are currently working together to apply for grant funding to improve breastfeeding support in communities where there is not a tradition of breastfeeding.

As part of the Baby Friendly core team at UF Health, Ryngaert helped develop the prenatal education program that is used in the prenatal and family medicine clinics. The clinic is part of Step 10 for Baby Friendly— a key to continuity of care.

Ryngaert also engages with several Facebook groups to stay visible.

“Education of upcoming providers is a big part of the work,” Ryngaert adds. “The pediatric residents all rotate through the breastfeeding clinic, seeing first hand the history, feeding assessment and advice we give to support and protect feeding.”

Ryngaert is the chair of the Breastfeeding Education Special Interest Group for NAPNAP and serves as a NAPNAP delegate to the United States Breastfeeding Committee (USBC).

At the 22nd Annual International Breastfeeding Conference, Ryngaert will co-present Culture Change in an Academic Medical Center Setting-The Key word is Quality: The Journey to Baby-Friendly.

“I think it will be a fun presentation that will equip others who are trying to work toward Baby Friendly with some tools to assist in the process,” she says.
To register for the conference, click here.

Emotions matter

FlackingEmotions matter when it comes to maternal child health care, says Associate Professor at Dalarna University Dr. Renée Flacking, RN, PhD.

“It may sound really obvious, but it isn’t,” she says. “Our actions, as parents or staff, are to a high extent governed by our emotions.”

Emotions are important for implementing new and hopefully better guidelines or interventions. When staff find new care routines tedious or difficult, they are less likely to work accordingly, Flacking goes on.

“From a parental perspective, the journey they make through their baby’s hospital stay is so influenced by their emotions and how well they are supported emotionally,” she says.

If parents aren’t given the opportunity to share their experiences and emotions with someone they have a trustful bond with, the hospital stay becomes really difficult. Not only this, parents’ experiences are affected after discharge too.  

Even so, Flacking observes that emotions are very rarely discussed, from the parental perspective or the staff’s perspective.

With a background as a pediatric nurse, working in a neonatal care unit for more than 10 years, Flacking says she has witnessed increased parental presence and participation in infant care.  

Although there are still many countries where parents do not have the opportunity to stay with their babies for more than a few hours per day, Flacking says she’s noticed a huge, global change.

For example, a neonatal unit in Drammen, Norway offers parents and babies private rooms.

Staff are better able to serve families in these private spaces, Flacking notices.  

She notes that Kangaroo Mother Care (KMC) is one of the most important activities to increase physical and emotional closeness in neonatal units. But staff are able to offer other areas of support too. Personal trainers are available to mothers, for example,and parents are offered classes on ‘mindfulness.’

“I am amazed by parents’ resilience and their ability to cope in the neonatal environment and I’m even more amazed by how parents interpret their babies and what they can do for the babies – if we let them,” Flacking says.  

Perhaps most importantly, Flacking and Professor Fiona Dykes’ recent ethnographic research,  Being in a womb’ or ‘playing musical chairs’: the impact of place and space on infant feeding in NICUs, has found that design and spatial configuration impacts feeding.

The results from the study state:

The core category of ‘the room as a conveyance for an attuned feeding’ was underpinned by four categories: the level of ‘ownership’ of space and place; the feeling of ‘at-homeness’; the experience of ‘the door or a shield’ against people entering, for privacy, for enabling a focus within, and for regulating socialising and the; ‘window of opportunity’. Findings showed that the construction and design of space and place was strongly influential on the developing parent-infant relationship and for experiencing a sense of connectedness and a shared awareness with the baby during feeding, an attuned feeding.

Together, Flacking and Dykes edited a recently published book Ethnographic Research in Maternal and Child Health. Healthy Children Project’s Kajsa Brimdyr also has a chapter in the ethnographic text.

Flacking will present Closeness and Separation in the NICU and What is happening with breastfeeding in Swedish NICUs at the 22nd Annual International Breastfeeding Conference. Register here!
Next summer, Flacking, along with the center Reproductive, Infant and Child Health (RICH), will host Dalarna University’s 7th international interdisciplinary conference, Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives.

Breastfeeding infants with special needs

 

ragnhildSince beginning her work as a neonatal nurse in 1990, Dr. Ragnhild Maastrup, RN, IBCLC, PhD has witnessed skin-to-skin contact change from “nice-to-do” to “need-to-do.” When Dr. Maastrup began working in the NICU, skin-to-skin contact was implemented for only one or two hours a day for stable preterm infants with Continuous Positive Airway Pressure (CPAP).

“But the day the infant was transferred from the incubator to a cot, the skin-to-skin contact stopped,” Dr. Maastrup says. “Today we facilitate early skin-to-skin contact. We tell the parents that their infant can ‘live on the parents’ chest’ with no time limits, and that skin-to-skin contact should continue at least until breastfeeding is established.”

Dr. Maastrup notes that in Denmark 81 percent of preterm infants in the NICU have initiated skin-to-skin contact within the first 24 hours of life, and 97 percent within the first week of life. Still, she says, daily duration of skin-to-skin contact can be improved; few infants get more than eight hours of daily skin-to-skin.

For the last decade, Dr. Maastrup has worked as a nursing researcher.  She is in charge of the Knowledge Centre for Breastfeeding Infants with Special Needs which gathers, systematizes, and develops knowledge on breastfeeding infants with special needs at Rigshospitalet and in Denmark and internationally. The Knowledge Centre makes the knowledge accessible for health professionals.

Dr. Maastrup explains that because preterm infants, infants with malformations, and infants who are sick for other reasons have special needs in regard to breastfeeding, the Knowledge Centre aims to develop practice and new knowledge in Rigshospitalet and Denmark so that care, treatment and counseling, in relation to breastfeeding infants with special needs, will be uniform, evidence-based and of high quality.


“The most common misconception about breastfeeding infants with special needs is that preterm infants need a certain weight or age to initiate breastfeeding,” Dr. Maastrup explains. “Breastfeeding should be initiated with infant stability as the only criterion.”

“I have supported mothers in placing their 800 grams baby at the breast to lick, taste and suck a little – and the babies did,” she goes on. “If the infants are physically stable with respiratory support, they can also suck while having CPAP.”

When asked to describe some of the most fascinating findings discovered through her main research areas– breastfeeding of preterm infants and skin-to-skin contact between preterm infants and their parents– Dr. Maastrup shares this:

We did a large cohort breastfeeding study in Denmark with participation of 1488 preterm infants, 68 percent were exclusively breastfed at discharge (breastfeeding defined as feeding at and from the breast.) We found that use of nipple shields for preterm infants was associated with a more than double risk of not being exclusively breastfed at discharge, and did not speed up the establishment of exclusive breastfeeding.

 

We also found that minimizing the use of a pacifier when the preterm infant should breastfeed more was positively associated with exclusive breastfeeding and speeded up the establishment of exclusive breastfeeding with one day.

 

Together with the cohort study we did a survey of breastfeeding support in Danish NICUs showing that breastfeeding is supported for example by recommendations of early initiation of breast milk expression and skin-to-skin contact, and that bottles rarely are used in preterm infants when exclusive breastfeeding is the goal.

 

I have also studied skin-to-skin contact in 22 extremely preterm infants with an average weight of 700 grams, and found that they tolerated the skin-to-skin contact without significant changes in skin temperature or physical stability. 

 

Dr. Maastrup’s thesis, Breastfeeding of preterm infants. Associated factors in infants, mothers and clinical practice, can be found at Lund University’s website: http://lup.lub.lu.se/luur/download?func=downloadFile&recordOId=4431661&fileOId=4431668

A member of the Nordic and Quebec Working Group, Dr. Maastrup attended the First International Neo-BFHI Conference and Workshop, held in 2011 where participants from 24 nations gathered. The Second International Neo-BFHI Conference was held just this year with participants from 32 nations.

The aim of the Nordic and Quebec Working Group was to expand WHO/UNICEF’s BFHI Ten Steps to neonatal care by examining the evidence in relation to breastfeeding promotion, protection and support in neonatal wards; develop and adapt the BFHI’s standards and criteria; and develop and pilot test an assessment tool to evaluate neonatal units compliance with the criteria, Dr. Maastrup explains.

“To remain consistent with the WHO/UNICEF 2009 update of the BFHI standards, the expansion to neonatal wards closely follows the original Ten Steps to Successful Breastfeeding,” Dr. Maastrup says.  “Furthermore, to ensure that recommended practices focus on respect to mothers, a family-centered approach and continuity of care, the working group formulated three Guiding Principles meant to be basic tenets in all of the Ten Steps.”

The guiding principles cover all infants and families in the NICU regardless of breastfeeding or not, she adds.

“After the first conference many BFHI Country Coordinators and international experts from 20 countries have given their invaluable feedback to the Neo-BFHI Core document and performed pilot tests of the confidential Neo-BFHI External Assessment Tool,” Dr. Maastrup shares.

At the second conference, Dr. Maastrup and colleagues presented the final Neo-BFHI package which includes:

  • The Core document with recommended standards and criteria for Three Guiding Principles and Ten Steps to protect, promote and support breastfeeding in neonatal wards
  • A Self-Appraisal Tool to assess standards and criteria
  • Educational material for decision-makers and staff.
  • An External Assessment Tool (confidential, sent to the BFHI country coordinators.)

The Neo-BFHI package helps implement strategies in the neonatal intensive care units that will facilitate breastfeeding. The Neo-BFHI package can be found here.

At the 2016 International Breastfeeding Conference in Orlando, Fla., Dr, Maastrup will present Breastfeeding of Preterm Infants: Associated factors in infants, mothers, and clinical practice as well as co-present Neo BFHI: A Worldwide Expansion Project.

Dr. Maastrup says she is looking forward to sharing knowledge, being inspired, and becoming wiser at the International Breastfeeding Conference.
Register here for the opportunity to network and learn from Dr. Maastrup herself!

The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth

kajsa2There’s no doubt about it; Dr. Kajsa Brimdyr, PhD, CLC loves babies.

“Babies are just so incredible!” Brimdyr exclaims. “Immediately after they’re born they can do such complicated things. We have this idea that you have to be careful when you hold a baby because their heads might fall off, but when you watch what a newborn baby can do when they are skin- to- skin, it’s breathtaking and complicated.”

Babies touch the breast and bring the flavors of the montgomery glands to their mouths. They can watch one breast and scoot back and latch to a breast they haven’t yet seen. They lift their heads. They crawl. Brimdyr notes just a few of the miraculous, often unnoticed talents of the just-born human baby.

Ann-Marie Widström, RN, MTD, Doctor of Medical Science began studying babies’ instinctual dance in the first hour after birth when placed skin-to-skin with their mothers in 1985.

Twenty years later, Brimdyr began working internationally with Widström and Kristin Svensson, PhD, RN helping hospitals implement skin-to-skin contact.

One of Brimdyr’s favorite stories to tell is from when she and her colleagues first visited Egypt. She and her team showed Egyptian medical providers videos of Swedish babies going through the nine instinctive stages in the first hour after birth.

After completion of the video a pediatrician replied, “Well, we have Egyptian babies, and Egyptian babies don’t do this.”  So, Dr. Brimdyr and her team helped the team implement skin to skin in their own hospital, and filmed an Egyptian baby going through the nine stages. The pediatricians were flabbergasted but not convinced.

“Well, we have a very high Nubian population,” they replied.

“So then we had to show them a Nubian baby doing this!” Dr. Brimdyr exclaims.

On their next stop, Texan medical teams were equally skeptical, because “Texan babies are different.” As you may have guessed, the Texan babies proved to be just as amazing as the Egyptian and Nubian babies, dancing through the nine stages.

Brimdyr reflects: “What is it about this behavior that we are so skeptical about?”

While Brimdyr and colleagues are confident in babies’ abilities, Brimdyr does note that they started to see babies who weren’t going through the nine stages even when placed skin-to-skin immediately after birth. Some cried continuously. Some just laid there. Others only exhibited a few of the nine stages.

“How could it be that a perfectly lovely baby from a perfectly lovely mother would not behave in an instinctual  manner?” she wonders.

Brimdyr and an international team recently published The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth.

 

This groundbreaking research makes the invisible visible. It offers insight into what is affecting babies’ instincts right after birth, and it may offer insight into why our breastfeeding goals don’t match our outcomes, Brimdyr says.

Eighty percent of mothers intend to breastfeed, but only about 20 percent are exclusively breastfeeding at six months as recommended by the American Academy of Pediatrics (AAP), the World Health Organization and others.

The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth found that the more pitocin infants were exposed to, the fewer infants suckled. Similarly, it found that the more fentanyl infants were exposed to, the fewer infants suckled.

“I was heartbroken by the results,” Brimdyr confesses. “But…it’s something we have to recognize and acknowledge and do something about.”

When presented with this new information, practitioners wonder, “So what should we be using, because we know our mothers want to have epidurals.”

What would be a concoction that would be safe and effective for mothers’ pain level and for the baby? We don’t have that answer yet.

However, this research grants mothers more power to make informed decisions.

“And it’s about moving the idea away from blame,” Brimdyr explains.

Mothers (like myself) are being told that these drugs do not have an influence on their babies or ourselves. All of the sudden when baby is not breastfeeding, the easy person to blame is the mother, Brimdyr continues.

Of course, there are things we can do to salvage a breastfeeding relationship when it doesn’t get off to a good start.

“But now we are in the realm of heroics helping moms succeed at something that doesn’t seem to be working,” Brimdyr explains. “That’s a much more difficult place to be– much different than when breastfeeding seems easy to her.”

Throughout the study, Brimdyr watched breastfeeding come easily to some of the mother-infant dyads, and she watched other dyads struggle. To watch the struggling dyad was disheartening, she says, so overwhelmingly that she started a whole new study at the same time.   

It’s called Happy Birth Day. Happy Birth Day— based off “House Hunters’” (who doesn’t love House Hunters?) format– chronicles natural childbirth at a Baby Friendly Hospital.  The series aims to combat “Screaming Birth” portrayals in the media.  

“If mothers don’t know what birth could actually be like, and are believing the dramatic media, of course they think it is too scary to try,” Brimdyr comments.


Happy Birth Day is scheduled to premiere at the 22nd Annual International Breastfeeding Conference in Orlando, Fla. You are not going to want to miss this. Register here.