Liz Westwater, MSM, CLC joins Healthy Children Project faculty

Healthy Children Project has gained yet another brilliant faculty member! Liz Westwater, MSM, CLC joined the team in May 2016.mail

Westwater’s maternal child health journey began at a family planning clinic where she volunteered right out of college.

“I felt very passionate about women’s health,” Westwater says.

She worked her way through the ranks at the clinic: volunteer to clerk to counselor to educator. From here, she moved on to working as a WIC program director. At this time, her focus shifted from a women’s health perspective to maternal child health; especially after reading Gabrielle Palmer’s The Politics of Breastfeeding: When Breasts are Bad for Business.  Palmer’s book helped her to realize that breastfeeding is a feminist issue.

“I had always been an activist– boycotting Nestlé ,” Westwater beings. “I knew that what the formula industry was doing was pretty heinous, but it never dawned on me that breastfeeding could empower women.”

For over three decades, Westwater’s work has empowered women, families and communities alike.

In the mid 70s, she served refugees from Vietnam, Laos, and Cambodia while working at the U.S. Public Health Service Hospital in Boston.

“I feel so fortunate to have worked with these people,” she says. Westwater remembers the transformation from when they first arrived in the states as refugees, struggling with English to when they integrated into the community, opening restaurants and other businesses.

While working at WIC in the late 80s, she and Cindy Turner-Maffei, MA, ALC, IBCLC started a breastfeeding peer counseling program with grant money from the Massachusetts Department of Public Health. Westwater calls the peer counseling program a “ladder up” for WIC participants.

Today, some of the women Westwater and Turner-Maffei originally trained are still WIC peer counselors, turned grandmothers.

“It’s really cool because one of the things we see as a problem with moms who want to breastfeed is their mothers not having a full understanding of breastfeeding,” Westwater explains. It has been found that grandmothers have the power to influence breastfeeding success.

During her time working as the accreditation director of Baby-Friendly USA, Westwater worked on the Best Fed Beginnings project and Communities Putting Prevention to Work, two CDC funded grants to improve breastfeeding outcomes.

In a 2013 interview with Our Milky Way, Westwater said in regard to the growth of the Baby-Friendly Hospital Initiative (BFHI): “These are really exciting times. For many, many years I’ve been involved in promoting breastfeeding and I never thought I’d see this day.”

Today, Westwater says she is most impressed by the amount of people who understand the importance of getting breastfeeding off to a good start.

“When I first started Baby-Friendly in 2005… the biggest struggle was rooming-in,” Westwater explains. “There were so many hospitals that just couldn’t move forward because they were unable to inform their staff and patients about the true importance of rooming-in.”

Toward the end of her work with Baby-Friendly, Westwater says she noticed that hospitals rarely failed to get rooming-in to work.

Westwater also notes that more and more, people understand the importance of skin to skin.

“People are beginning to realize that it can be done, and it should be done, and that families love it!” she says.

Westwater retells the story of a New Hampshire hospital that haphazardly encountered a huge spike in exclusive breastfeeding rates over a two to three month period. The staff realized that a reduction in visiting hours because of the H1N1 pandemic was the reason behind the increase in exclusive breastfeeding rates: mothers and babies were given the opportunity to learn about one another rather than entertain visitors in the early days postpartum.

This fall, JAMA published an editorial called Interventions Intended to Support Breastfeeding, a critique on individual versus system-level breastfeeding interventions, like BFHI.

“I read the article with dismay,” Westwater comments.

She goes on: “I understand we need to be evidence-based; I can’t downplay the importance of evidence…but in looking to the science for guidance, we can’t overlook the ‘duh,’ the common sense. We can’t overlook the natural. I always think about when we were giving birth in caves. Did the midwife or medicine woman take the baby away from the mother? What was the best and safest place for that baby? When I watch a baby [who’s] just been born crawl up a mother’s belly, there is something primal about that. There’s something that goes back to our most ancient survival mechanisms, so I don’t really feel like I need evidence to show that that works.”

Westwater comments further.

“What [the authors are] saying is having an institution support maternity care practice changes isn’t as important as individual interventions; however if the hospital is not making a commitment on an institutional level to improve outcomes, they’re not going to train lactational professionals. They’re not going to give staff time to do the intervention. It does have to be on an institutional level or the institution will not [direct] its resources in a way that is supportive of individual breastfeeding interventions.”

Since working with HCP, Westwater has been struck by the diversity of our country’s landscapes and people. She says has gained perspective on the common ground maternal child health advocates share.

“The folks that we deal with, regardless of their religious background or political beliefs,  all want to improve breastfeeding outcomes,” Westwater observes.  “It saddens me when I look at how polarized we are in this country. And yet when I travel around and teach classes wherever it may be, there is a sense of  comradery, sameness and a passion for healthcare and improving maternity care practices. What I see is that we do have common ground in this country. Maybe something like breastfeeding is the way for us to come together and move forward.”

Ushering in ‘a new season of harmony, justice, and peace’

Smolinski nurses her youngest son in Luxembourg, 2015. He recently turned 4 and still breastfeeds.
Smolinski nurses her youngest son in Luxembourg, 2015. He recently turned 4 and still breastfeeds.

Not surprisingly, this year’s International Breastfeeding Conference presenters are no less inspirational than in years past. We didn’t have a chance to feature everyone before the conference, so this week we’ll continue showcasing their fantastic work.

Amy Smolinski, MA, ALC, CLC co-presented “The Ethics of Breastfeeding Support: Issues Through the Screen” and “United States WBTi Report: Where We Are Now” at the conference this year. She also presented “When Tears Flow and Milk Doesn’t” which was inspired by case studies from her personal experience as a lactation professional.

“In particular, one week last year, I found myself utterly exhausted, drinking a glass of wine and eating an entire bar of chocolate, and I thought, ‘Why do I feel this way?’” Smolinski reflects. “I realized that I had been doing grief work with three clients in a week whose breastfeeding experiences had not turned out the way they wanted.”

Smolinski learned about grief processing and support from her mother who developed and ran the hospice program in their county.

“I realized that I was using the support techniques from the hospice philosophy and model in my lactation counseling,” she says.

The creation and accomplishments of Mom2Mom Global

Mom2Mom Global Executive Director Amy Barron Smolinski (L) and Administrative Assistant Sharen Lee (R) with Theresa Hart from Defense Health Agency, Aug 2016
Mom2Mom Global Executive Director Amy Barron Smolinski (L) and Administrative Assistant Sharen Lee (R) with Theresa Hart from Defense Health Agency, Aug 2016

Smolinski is a former Our Milky Way participant. In 2013, she shared with us her work with Mom2Mom of Kaiserslautern Military Community (M2M of KMC) in Germany,  a network of breastfeeding families that helps new mothers overcome the difficulties of living far from family support to reach their personal breastfeeding goals.

M2M of KMC has matured a great deal in just four years. In fact, in 2015 the organization expanded to support new chapters at other military communities; Smolinski created Mom2Mom Global, now a national nonprofit 501(c)3 organization with chapters in place or forming at more than a dozen military installations throughout the U.S. and Europe.

Smolinski details that in 18 months, M2M Global has:

Mom2Mom Ft. Bragg Board of Directors, World Breastfeeding Week 2016
Mom2Mom Ft. Bragg Board of Directors, World Breastfeeding Week 2016

In regard to becoming an MSC organization, Smolinski explains that M2M chapter directors and ambassadors are already required to obtain accredited lactation credentials in order to provide accurate, evidence-based support and education. Additionally though, she says that many military spouses wish to pursue the IBCLC credential.

“One of the acknowledged barriers to equity in the lactation field is the IBCLE’s hours requirement, and the fact that many people are unable to pursue any of the pathways because they don’t have access to a clinical setting or IBCLC mentor to complete them,” Smolinski explains.  “For military spouses, geographical locations, the demands of single-parenting during deployments or other family separations, and the frequency of moves are all huge barriers to completing the hours requirement.”

What’s more, most MSC organizations are structured to be maintained by the same person over many years. But with a transient military community, these groups sometimes dissolve, she goes on.

“Mom2Mom Global chapters are designed specifically to be sustainable through frequent turnover rates, which means that our chapters will continue,” Smolinski explains.

‘Adapt and overcome’  

Back in 2013, Landstuhl Regional Medical Center (LRMC)– the largest military hospital outside of the continental United States– was working toward Baby-Friendly designation but “because of budget cuts due to sequestration, LRMC could not continue on its journey.

“However, in what is a great example of the Army’s motto, ‘adapt and overcome,’ the Army has developed an internal designation for its military treatment facilities (MTFs), based on the Ten Steps,” Smolinski comments.

The staff of the LRMC Division of Women’s Health and Newborn Care is working diligently on implementing the initiative.

“We’ve seen some amazing progress in the past two years,” says Smolinski.

LRMC accomplishments include:

  • Three designated spaces for breastfeeding/pumping, including the first-ever Mamava pod in an overseas location
  • A required twenty hours of breastfeeding education for staff
  • Skin to skin for an hour after birth offered to most mothers
  • Delayed newborn baths for at least six hours
  • Local breastfeeding support information included in each hospital discharge packet
  • Collaboration with Mom2Mom KMC to cover inpatient lactation counseling services on weekends and holidays

“I was just on shift this past weekend, and we had 100 percent breastfeeding initiation!” Smolinski exclaims.

Reclaiming sacred feminine values

Mom2Mom Holloman Big Latch On 2015
Mom2Mom Holloman Big Latch On 2015

Smolinski holds an MA from Union Institute and University, where her thesis explored re-emerging Sacred Feminine manifestations in the lives of contemporary women. Smolinski incorporates her graduate work with the work she does today, especially with millennial parents.

“Now with today’s millennial parents, I think we are really seeing a new level of the reclamation of sacred feminine values as part of a shift to a more balanced societal paradigm,” she says.  “Millennial mothers are incredibly resourceful, and they are driven by a determination to give the best to their children.  Millennial fathers are eager and willing partners in parenting, equally motivated by what’s best for their children.”

This devotion manifests in positive and negative ways.

“I see so much anxiety in new parents these days,” Smolinski explains.  “They put so much pressure on themselves to be ‘perfect’ parents, and they are constantly inundated with conflicting advice from friends, family, and the digital world of online parenting.  At times, they are paralyzed with fear that every decision they make will somehow damage their children if they don’t get it ‘right.’”  

Perinatal anxiety is rising at alarming rates, and Smolinski thinks this might be the cause. Even so, she attributes millennial parents with great potential.  

“Infant feeding is a great metaphor for life in this case,” she begins.  “When I work with a millennial mother, and she goes from being anxious and terrified through the experience of learning that she can feed her child—figuring out what is the best answer for herself, her baby, and her family—to gaining understanding and confidence in her ability to nourish and nurture her child, something happens.  A fire is lit.  All of the power of that initial anxiety is forged into a new confidence that goes beyond herself and her baby.  She becomes determined to make the world better, to share this newfound power with others.”

And where the media portray millennials as entitled, Smolinski sees a generation with “steadfast rejection of the status quo.”

“Millennials believe in and expect racial, sexual, gender, and economic equality,” she explains further.  “Because they are digital natives, they expect change to happen rapidly, and they know how to utilize the tools of technology and social networking to make it so.”

Mom2Mom Mountain Home Big Latch On, 2015
Mom2Mom Mountain Home Big Latch On, 2015

During work on her thesis, Smolinski connected the image of the world-wide-web with the ancient Native American mythology of the Spider-Woman, the revered creator of life and weaver of connections between people, animals, and the earth.  

“…Our digital world is a new creation… and once millennials gain the confidence and skills to leverage the tools of our time, the connections being forged among us will ultimately usher in a new season of harmony, justice, and peace.”


WBTi involvement

Smolinski’s impressive part in bettering maternal child health keeps going. She took part in the “humbling experience” as a member of the United State’s World Breastfeeding Trends Initiative (WBTi) assessment workshop team.

“It was a fascinating challenge to compile data to see how our perspectives and experiences measured up against the national statistics,” she says.  “When we saw the whole picture, I think one of the biggest surprises was that the U.S. is doing better than expected in several of the indicators, although we clearly have a long way to go to meet goals for optimal public health.”

Smolinski reports being intrigued to see how the United Kingdom is using their WBTi assessment to drive policy development.

“I think we can learn from them how to leverage this data to protect, promote, and support breastfeeding in the U.S.,” she explains.

Smolinski sums up her passion for the work that she does:

…What excites me the most personally is the opportunity to work with so many passionate, dedicated women who are determined to normalize breastfeeding.  I am so privileged to work with women from all walks of life who all share the vision of a military and a world where breastfeeding is commonplace and supported.  I work with Active Duty service members who are warrior mamas, constantly working to bring their commands into compliance with the breastfeeding policies and regulations, because they know that every battle they win makes it easier for every future breastfeeding service member.  I work with military spouses who are able to quickly organize into a powerful force in their local communities to raise awareness and support for breastfeeding, often while their spouses are deployed.  When I’m interviewing someone who wants to start a Mom2Mom chapter, and I ask them why, the response is almost always, ‘I want to make the world a better place.’  And that’s what we do.  Last, but certainly not least, I work with the most amazing group of women on the Mom2Mom Global board of directors!  This leadership team is dynamic, powerful, smart, and cohesive.  We work amazingly well together.  Even though (maybe because) we are all military spouses and mothers.  We currently have an opening for our Chapter Director position, so if anyone out there is reading this and has a DOD ID-card and wants to make the world a better place, we’re waiting for you!

Memories from the International Breastfeeding Conference

15965498_10154762528572211_8086113142961603408_nThank you all for helping make this year’s conference such a smashing success! Here is what you shared as your favorite memory/most fascinating thing you learned/best part of the conference.

Don’t call women “guys.” –Linda J. Smith, Dayton, OH

Being serenaded by Ric. –Cindy Turner-Maffei, Sandwich, MA

Learning about the MTHFR gene. -David, MA

Learning how language can impact our audience, what does the listener want. -Barb, Atlanta, GA

15941522_10154757760157211_5381890504426057103_nLoved the love in the room for Lois. -Betsy, Wellington, FL

Being in a well informed, welcoming, educational fire hose! -E.A. Tailer, Burl., VT

Duck race was such a fun idea! Can’t wait for next year! -S. Lavrere, RN, CLC

I was so impressed with the study of effective skin to skin. It’s a problem I’ve identified at my hospital and will address. -Lisa A.

I loved that my mom’s duck #70 won the duck race. She was crowned Duck Queen, therefore making me Duck Princess! Also I love the microbiome. Any info is good info! -Rachael, Cape Cod, MA

There’s H2O2 in breastmilk!? No Way! -D.J., MA

15941128_10154762669217211_374832778684157534_nListening to all the brilliant speakers. Dr. Ric singing. -Cindy, NE

Value the mothering, return the right for humanization of birth to all women, loved Dr. Jones’ passion and commitment. -Sylvia

It’s nearly impossible to pick one highlight. I’m always fascinated and entertained by Dr. Jones’s presentations. I learned so much about swaddling from Linda Smith. I have a lot to process and reflect on after listening to presentations about race and maternal child health from Black breastfeeding advocates and lactation professionals. I appreciated Sylvia’s props in her autoimmunity presentation. Dr. Gupta shared such vital information. The list goes on and on. Most of all, George and I felt all of your love! – Yours truly, Jess, Hartland, WI

“Autoimmunity and Breastmilk as Epigenetic Medium”

unnamed-6Sylvia Metzger, MPH, MSN, RN, CNL, IBCLC, LCCE is a clinical instructor for maternal-child health nursing at the University of Colorado Colorado Springs. Metzger will present “Autoimmunity and Breastmilk as Epigenetic Medium” at the upcoming International Breastfeeding Conference in Orlando, Fla. This week on Our Milky Way, she joins us for a Q&A. Prepare to be amazed!

Q: How did you become interested in maternal child health?

A: It began with lots of love.  I am truly blessed to have very caring Slovak parents who endowed me with unconditional love throughout my life, and through their consistent nurturing and support lasting into adulthood, showed me how wonderful it feels to have that emotional stability.  I wanted to share some of it; I got plenty extra and I wanted to pass on this imprinted fortune hoping it may one day make a  difference in someone else’s life.  Maternal-child health provides myriads of opportunities to nurture: to me, this field is all about nurturing.  I call it epigenetic nurturing.  I don‘t think that it is a proper scientific term, but I like it.  I believe that compassionate care rooted in the client-nurse connection can truly nurture our DNA.  It’s not that we can change the sequence of our DNA (how our genetic ladder was initially built based on the parental blueprint), but we can modify the environment, which among many factors includes the nurturing of a mother and her infant. So, there are mechanisms beyond our DNA powerful enough to turn on or off certain genes.  Epigenetics can steer the wheel of our health trajectory in both a positive and negative way.  I feel that in this field, I can make the most difference.  So, maternal-child health was just a natural fit.  It never feels like a job. I love caring for babies, moms and dads.  It’s the best field ever, and a true privilege to work in!

 I was actually a biology teacher in Slovakia, and then became a childbirth educator for many years before choosing nursing as my second career. Although biology gave me a comfortable foundation to navigate through basic sciences, I think the real catalyst of my desire to become a maternal child health nurse came with my own motherhood.  Becoming a parent changes every fiber of your being, I think for the better. Everything you do, every decision you make, is suddenly dependently intertwined with your instinct for putting the child’s needs first.  Not that it’s always easy, but it is absolutely worth every bit of self-sacrifice.  And it also somehow makes you stronger and more able to see what actually matters the most in life.

I have two children and had diametrically opposite birth experiences — the first in a intervention-focused military hospital in the US, and the second in a midwifery-led low-key hospital in Germany.  I was initially disheartened with how my birth plans, or better birth dreams, went out  the window in the military setting, but I grew to appreciate the experience.  Holding my daughter erased any remnants of disappointment with the lack of birth options.  Plus, it gave me just the right impulse to become a childbirth educator.  I wanted to not only empower women to help them believe in the wisdom of their own body, but also include future dads in the childbirth preparation.  Once you are in this field, you are hooked for a lifetime, and it is only reinforced when you get a chance to meet and hear some of the most inspiring pioneers in the field: Dr. Cadwell, Dr. Brimdyr, Penni Simkin, and Henci Goer, to mention a few.  They continue to be my inspiration, and I only wish I could express my gratitude for their commitment and contributions in the field.   

Q: You’re in the home stretch of your family nurse practitioner training! That’s wonderful. How has this experience added to your maternal child health advocacy? 

A: It’s hard to believe I am done, and it’s wonderful to have more time for my family and get more sleep, but secretly I think I will miss being a student.  There is so much to learn in family practice, and I am just at the beginning.  But I do believe that the rigorous training has helped me become a stronger maternal child health advocate.  The clinical setting is its own natural laboratory.  Even as a novice, one begins to notice the pattern of complaints patients come in with. You cannot help but wonder about the origins of certain diseases, especially when seeing them in transgenerational patterns- but even more, you want to know what can be done to prevent them or modify their course.

    When parents hold their infant, they are not just looking into the mirror image of their own DNAs.  Certainly, genes play a huge role in an infant’s future health, but fortunately and sometimes unfortunately, the infant’s DNA does not completely inform his or her destiny.  Many diseases cannot be explained by genetic variation alone, and twin concordant studies show fascinating discrepancies in disease development reflecting the power of the environment. Every baby’s destiny can actually begin before conception, reflecting both the paternal and maternal health status.  Dad’s lifestyle and health before conception actually matter, and can also pre-program a baby’s health trajectory.  It is not just the mom’s intrauterine environment.  Paternal obesity prior to conception, for example, can increase the incidence of obesity and metabolic disorders in offspring, independently from the maternal status.  But how much do we focus on fathers during preventative care visits? I would love to change that. Epigenetic effects can also be passed on from grandparents to grandchildren.  PTSD, for example, seems to have a transgenerational effect, with parental stress exposure prior to conception influencing stress reactivity of offspring, and increasing the risk of PTSD in future generations.  I feel that the translational research from epigenetics has such a great potential to help clinicians refocus priorities from treatment to prevention.  I would love to be a part of that.    

Q: Your work with military families helped mitigate the risk of child abuse. Do you have any favorite memories you’d be willing to share of your work in Germany?

A: I feel so blessed having had the privilege to care for military families living overseas. It’s hard to be in another country without close family when you have a new baby, and at the same time adjust to a new culture, often parenting alone while your spouse is deployed.  Transitioning to parenthood is like stepping into a foreign land….there is that excitement but also a bit of fear of the unknown, and of being scrutinized by others.  You try to sort through well meant and sometimes unwanted advice, constantly struggling with the worry that you aren’t doing everything you can for your baby.  The military recognizes these challenges, and offers home visiting services to support new parents prenatally and until the age of four.

You asked about my favorite memories, there are so many.  I had a hard time leaving when our tour ended.  It was the most rewarding job because it allowed me to really connect with families.  My clients taught me so much more than I could have ever given them in return. They showed admirable resilience and a willingness to grow from their past, often traumatic, experiences.

Best moments? Talking young soldiers into wearing a pregnancy empathy belly to better understand their wives (of course, with a few push ups and pull ups), but also to more appreciate their wife’s changing body.  Waking up to an early morning phone call and reassuring a soon-to-be-dad that what he just described are early contractions, and all will be ok.  Having the privilege to be at my client’s birth after hours and hours of walking outside in the dusk and dawn to get the labor started.  Sharing the first moments of tears and joy.  Seeing a tough military dad confidently place a baby skin-to-skin when mom had an emergency C section.   Hearing a dad who attended every breastfeeding class proudly encouraging his wife, “Honey, it’s ok, you are supposed to have just a few drops of colostrum, that’s plenty for him!“  Witnessing the transformation of young pregnant teens to amazingly caring moms.  Receiving a recent email from a mom who had a difficult childhood, who overcame breastfeeding difficulties, and shared that she wants to become a lactation consultant and support new moms.  A 10 pm phone call with lots of crying – both mom and her 6 week old newborn — who just needed  reassurance that this is the normal peak of crying.  Jogging with postpartum moms while carrying at least 2 babies to make it easier on the moms, and seeing the moms‘ glow through the sweat of accomplishment.

Q: Please tell us a bit about your work with Baby-Friendly Hospital Initiative (BFHI.)

A: I absolutely love being in the midst of a major change at our hospital and embracing its natural ups and downs. Our lactation team and maternal child management have so far received encouraging feedback from our families, and this is really why we are all here – for moms, babies and dads.  When you hear, “ I never had anybody spend this much time teaching me about breastfeeding…“, or,“I cannot believe that this time it doesn’t hurt. Thank you for staying with me for so long to help with the latch“, or, “I wasn‘t sure if I can breastfeed twins, but the laid back position you showed me made me believe I can…and I did!“  The effort is more than worth it.  As with any significant change, the initial waves of resistance among staff, who are required to complete quite an intensive program of theoretical and skill-based training, can be understandable.  As we began to teach BFHI to our mother/baby, labor/delivery, and NICU staff, however, we learned that listening and validating nurses‘ concerns went a long way.  I consistently tweaked the curriculum based on the reaction of the previous class.  For example, one of our NICU nurses voiced concern about the safety of donor milk because of legalization of marijuana in Colorado, and felt more comfortable with formula supplementation.  All it took was a bit of a research and a phone call to a manager of the Mother’s Milk Bank, who kindly explained the strict screening criteria, which includes THC, for donor milk.   My only disappointment is not having had the opportunity for our lactation team to provide such face-to-face BFHI training for our obstetricians, anesthesiologists, pediatricians and neonatologists. They have to complete online training only, and although I understand the hardship of time and commitment of their professions, I think it is a missed opportunity to hear their concerns and brainstorm ways to overcome their resistance.  I was fascinated with the talk of Dr. Flacking from Sweden – their neonatologist was involved in the actual environmental design and redesign of the NICU which helped promote skin-to-skin contact and thus subsequently led to much earlier exclusive breastfeeding outcomes of their neonates.  We are lucky to have many supportive physicians, especially neonatologists, and are very close to getting our designation, which is so exciting!   

Q: What is your response to the recent JAMA editorial that criticizes system-level intervention like BFHI?

A: The commentary “Unintended Consequences of Current Breastfeeding Initiatives“ in JAMA Pediatrics is a hot topic making headlines.  It focuses on Step 4 of the BFHI– Help mothers initiate breastfeeding within one hour of birth.  Although this step promotes uninterrupted and continuous skin-to-skin contact immediately after birth and until the first feeding is complete, it clearly leaves room to utilize clinical judgement.  It specifically states, “….unless there are documented medically justifiable reasons for delayed contact or interruption.“ It encourages, but does not mindlessly mandate skin-to-skin contact throughout the hospital stay, no matter what the situation.  

Guideline 4.2 states:“After cesarean birth, mothers and their infants should be placed in continuous, uninterrupted skin-to-skin contact as soon as the mother is responsive and alert, with the same staff support identified above regarding feeding cues, unless separation is medically indicated.“  This step also leaves significant room for decisions based on clinical judgment, and thus should not be interpreted rigidly.  I do not interpret this rigidly as black and white, but rather as an effort to promote what mother nature intended for us in the first place.  And here is where I think the authors agree with the BFHI – rigid adherence to the Ten Steps may inadvertently promote potentially hazardous practices.  So, it is not the 10 Steps that are faulty, but rather incorrect interpretation or lack of compliance with the guidelines.  But if the public reads the subheadlines such as, “Doctors write commentary saying an initiative designed to make hospitals safe for newborns might actually be endangering them,” they may think – run away! Don’t have your baby in the Baby Friendly Hospital!

The authors write, “Unfortunately, there is now emerging evidence that full compliance with the 10 steps of the initiative may inadvertently be promoting potentially hazardous practices and/or having counterproductive outcomes.” Here, I must disagree.   I actually think that FULL compliance would minimize the risk of adverse outcomes.  Full compliance with the BFHI steps respects critical thinking and sound clinical judgment.

So, if a mom is absolutely exhausted after a medicated birth, and is perhaps on magnesium sulfate, it would likely not be safe to keep the baby skin-to-skin if there is no continuous supervision available, but this is accounted for, in my opinion, in this BFHI step.

I think we have to be careful about how we interpret not only available data, research articles and editorials, but how we can be subconsciously selective, and naturally read what fits our belief system.  Yes, clinicians cannot ignore case study reports, no matter how rare, because one loss of a baby’s life is too many.  I believe that we have to remain humble about the fact that we do not have all the answers and are deciphering complex issues in small increments, and may never find the answer to all the questions.  But the issue has to be placed in a broader context, with the focus on prevention.  Herlenius and Kuhn in 2013 (Translational Stroke Research), for example, reviewed published reports regarding the sudden unexpected postnatal collapse in infants who appeared absolutely healthy.  They found that SUPC, although rare can result in death, with 1/3 of the events occurring in the first 2 hrs after birth, and the remainder in the first week of life during skin-to-skin contact in the prone position. But does this mean we should undermine the importance of BFHI, or should we place serious focus on increased clinical supervision of the mother/baby dyad during the first hours of skin-to-skin contact?  Could this be more of an issue of understaffing rather than a flaw in the BFHI design, which clearly outlines, “direct continuous observation by medical staff during skin-to-skin contact“?  Even if unobtrusive continuous monitoring was available, were the SUPC events really preventable? Infection, cardiac disorders, and metabolic defects were listed as the most common possible etiology for the SUPC.

As for Step 9 (24 hr rooming in) – I think that the key word the authors are using is again “rigid.”  In my opinion, being rigid is never good.  The concerns of bed falls, hospital liability, and role-modeling unsafe sleep practices, are justified.

In regards to concerns of sudden unexpected postnatal collapse, the focus might shift towards maximum compliance with one of the key concepts of direct continuous observation by medical staff during skin-to-skin contact, as well as reinforcing safe sleep practices in the breastfeeding mom-baby dyad, rather than questioning the efficacy of the entire initiative.

We have to see the bigger picture, and that is that any systemic effort to promote feeding breastmilk, ideally exclusively, far outweighs the risks on an epigenetic level.

Q: You’ll be presenting “Autoimmunity and Breastmilk as Epigenetic Medium” at the upcoming International Breastfeeding Conference. Could you please share a few teasers from your presentation?

A: I think that a majority of new parents do not receive adequate and clear information about how breastmilk affects health outcomes.  It may also seem daunting to try to present complex findings from the field of molecular biology to a parent with minimal background or interest in basic sciences.  But I want to try because I think we should.  I am actually finding that the majority of my patients are fascinated with and open to this concept, and I am trying to overcome scientific jargon with lots of fun visual teaching aids.  I hope to help them view breastmilk as a live biological system directly capable of modulating gene expression (meaning having the ability to turn the genes on or off).  They typically do not expect to see live moving cells (and yes, I am a geek, I do have a picture), and they certainly are not thinking of some strange epigenetic mechanisms that can boss our DNA around, commanding specific genes (say those predisposing the child to autoimmune diabetes) to activate or not.  Yet, breastmilk is capable of sending dynamic epigenetic messages to our DNA during critical periods of an infant’s development, and contributes greatly to long-term health outcomes.

I also introduce my patients to the breastmilk microbiome with my pink stuffed model of Lactobacillus. These friendly types of bacteria (there are a great variety), exert their own gene-modulating capability which can affect our immune, endocrine and metabolic systems, and even our neuro-behavioral development.  We now have some amazing research showing how breastmilk  might influence the initial bacterial colonization of the infant’s gut through epigenetic mechanisms, which is unique when compared to formula.. Many autoimmune conditions such as Crohn’s disease, Lupus or Celiac disease, show dysregulation of our healthy microbiome as one of many complex etiologic factors, and share similar epigenetic alterations.  Breastfeeding, for example, has been shown to decrease the risk of autoimmune Diabetes type I, among many other benefits, and epigenetics may help explain how.  

I am excited to share some bits and pieces of new information that can hopefully shed new light on the incredible design of human breastmilk, and maybe appreciate The Creator‘s masterpiece at a new level.

Q: Epigenetics has brought to light that some things seemingly irrelevant, have a profound impact on babies. Will this information add to the stress of mothers? How do we present this information to parents without totally freaking them out?

A: An excellent and valid point.  I can certainly see how some concepts of epigenetics, especially when presented as isolated concepts, can increase parental anxiety.  Emerging evidence on the developmental origins of health and disease implies that what happens in the uterine environment matters.  Intrauterine signals can “program”, just like in a computer, the pathways of fetal growth and neurodevelopment through epigenetic mechanisms, increasing the risk of developing a disease later in life.  So, yes, parental anxiety is a valid concern, but epigenetics is not an all or nothing phenomenon; it’s more like a sliding scale.  Many chronic diseases, including autoimmune ones, take many years to develop, and although often familiar in origin, they are also multifactorial.  This can be good news, because at least some risk factors can be modified or avoided all together.  So, I actually think that we can embrace new findings of prolific research as opportunities to modify what we are capable of.   There is a myriad of opportunities to care for our genes, and counteract some of the unavoidable adverse effects a growing baby inadvertently may encounter, so luckily it’s not all gloom and doom.  We can, to a great degree, override some of our DNA‘s destiny.

Q: How do we market this information to health care providers?

A: I believe that a major shift needs to take place at both the micro and macro system level.  In my studies I saw how much a clinician is expected to accomplish in 20 minute increments with patients and between patients. The documentation is insane, and takes so much time away from patient interaction and teaching, which I believe is the  foundation to connect with the patient and increase therapeutic success. So, unless the primary healthcare focus shifts more towards prevention rather than disease management, and more time is allotted for patient education, I think providers cannot be held wholly responsible.  I see, however, several avenues where epigenetic concepts could be integrated into our healthcare.  My goal is to keep learning about the emerging epigenetic research applicable to clinical practice, and incorporate key concepts of epigenetics into maternal-child health curriculum for every nursing and medical student.   

Q: It has been estimated that it takes 17 years for science to be applied to practice. Because epigenetics is an emerging science, do you worry about this phenomenon?

A: I think we are already applying some concepts in clinical practice, so I want to say no, but in reality, I think that there is still a long road ahead.  As clinicians and educators, we need more training to understand the current translational research in epigenetics with practical applications to direct patient care.  We need to understand the meanings and the limitations of the available epigenetic tests which, from my experience, are not yet generally available at a primary care level. The reimbursement for these services, of course, will also be a challenge, as the healthcare focus would truly have to shift towards preventative care.  Although such changes inevitably face some initial skepticism and resistance, I believe that we have enough evidence-based knowledge to take the first bold steps, especially in the field of maternal-child health.  I believe that there are critical windows of opportunity to influence an infant’s health outcomes without expensive new tests.  Why not begin with what’s doable?  Let’s start by shifting our focus to health promotion and prevention of non-genetic diseases, such as preconception health counseling (and not leaving out fathers), promoting maternal wellbeing and resiliency during pregnancy, advocating healthy birth practices, encouraging parental skin-to-skin contact, and providing timely and ongoing breastfeeding and nutritional support to new families. That we can do today!   

Q: What are you most looking forward to at the conference?

A: There is so much! You can literally feel the shared enthusiasm and passion for breastfeeding support from every corner of the world.  Yet, nobody is pushy and judgmental when breastfeeding is not the parental choice.  The room is full of loving oxytocin, energizing exchanges of ideas, and opportunities to gain eye-opening perspective through the lens of international experts.  Last year, for example, helped me so much to prepare training for the hospital staff, especially for NICU.  Even though the healthcare infrastructure and cultural norms in Scandinavian countries may be different from ours, I believe that we actually can, in small increments, adapt some of their successful strategies to promote earlier breastfeeding success.  These concepts, for me, are often born right here.  When I first shared the Scandinavian NICU successes from the last year’s conference with our NICU nurses, some were initially skeptical, but it planted the right seed.  The 24/7 skin-to-skin contact, or the environmental adaptations of the NICU layout to send a message to parents: “Please stay here with your baby all you can, you are welcome and this is your bed, your chair…,“  were energizing and endlessly inspiring, but above all doable in our setting.  

Now, had you asked me about the pre-conference, I can barely wait to go to Sea World again to soak in every bit of information about lactation strategies of aquatic mammals, behind-the-scene, up close and personal!  Slovakia is beautiful but has no ocean, so forgive me for behaving like an Alice in Wonderland.  Last year, I was glued to the display glass, mesmerized with the beauty of beluga whales, and the innate wisdom of our mammalian sisters.  Cetaceans, such as dolphins, have shown remarkable similarities with humans.  They can provide milk on average from 12 to 18 months (up to 3 yrs), even though young dolphins are ready to eat “solids“ (fish) just about the same time as human babies – about 6 months!  Yet mom and calf often maintain close proximity until 4-5 years. And, just in case you are wondering, you will not find visible “breasts“ but rather mammary slits.  A baby dolphin can roll its tongue like a straw and the sides of its tongue have little finger-like projections that help keep the thick milkshake-like milk in the calf’s mouth, but salt water out.  The nursing only takes 5-10 seconds, so they snack many times during the day, no schedule! Isn’t that an accomplishment?  

Q: Any current projects you’d like to highlight?

A: Definitely The Human Microbiome Project! It’s a National Institute of Health initiative with the goal to study our microbiota (we have plenty, almost 5 pounds of our body weight), and its emerging and shockingly significant impact on human health and disease.  We will hear more about the acquisition of the early infant microbiome and its impact on neonatal health, such as prematurity, which is fascinating!  Our gut microbiota work for us really hard.  They are slaving away, affecting our immunity, metabolism, endocrine system, and even our neural pathways.  I had no idea that an obese patient can have very different gut bacteria than a lean counterpart, and that these microbiota can epigenetically influence the patient’s metabolism.  The wrong bacteria can literally reprogram our metabolism towards obesity.  I look forward to learning more about how to feed our microbiota right – for now, my understanding is that they love to munch on prebiotics, which is why I would like to touch on this topic during the conference.  Breastmilk serves as an excellent prebiotic and is full of human milk oligosaccharides, which can, for example, decrease the risk of necrotizing enterocolitis, a devastating condition affecting predominantly premature infants.  The therapeutic potential in treating illness with underlying dysbiosis through manipulation of the enteric microbiome, which would also include autoimmune conditions (Crohn’s, diabetes type I) may be tremendous.
Please join us at the International Breastfeeding Conference! More info here.

Encouraging culture change through the Baby-Friendly Hospital Initiative

Source: United States Breastfeeding Committee.
Source: United States Breastfeeding Committee.

Before birthing and breastfeeding her children, before beginning her career as a lactation professional, Laura Corsig, BA, BS IBCLC, LCCE was captivated by anthropology and women’s studies during her undergraduate program.

The territory felt “deeply innate,” Corsig explains.

Corsig now serves as Novant Health’s (North Carolina) lead lactation consultant where she led a multidisciplinary team to Baby-Friendly designation in 2012.

She will present Perceived Barriers and Facilitators of Healthcare Providers Regarding Implementation of the BFHI at the upcoming International Breastfeeding Conference in Orlando, Fla.

Corsig says that in the beginning of Novant Health’s journey to Baby-Friendly, it “seemed almost impossible without ‘making’ people change.”

“However, in the end, using evidence, influence, and persistence, I didn’t have to ‘make’ anyone change,” she goes on. “It became everyone’s idea in their own time and then we reached a tipping point.  My biggest challenge became my biggest asset.”

Encouragement from hospital administration and other leadership roles made the process surmountable.

“Their support gave me courage to ask questions and challenge old paradigms,” Corsig says.  

Finally, Corsig found comfort in friends she made along the way, like Liz Westwater who currently serves as Healthy Children Project’s newest faculty member.

In light of a recent JAMA editorial that criticizes system-level breastfeeding interventions like BFHI, Corsig says that the author’s comments are not reflective of the Baby-Friendly experience she’s had.

Corsig explains:

We live in a time where complex ideas are whittled down to soundbites and tweets and depth of understanding is lost.  To me, I need to engage both my left and right side brain when reading the BFHI Guidelines and Criteria for Evaluation.  I have learned that I need to read the words and understand the process, goals, percentages of attainment, etc.  That’s my left brain.  I also need to use my right brain to ask myself what is Baby-Friendly’s intent here?  That usually gets me to the crux of the issue.  To me, the article focused on “left brain” standards and ignored “right brain” thinking.  It’s not either/or.  It’s both/and.  Baby-Friendly guidelines are a target to hit and a culture to change. Those have to be attained together and in harmony.  That isn’t easy.  It pushes the healthcare setting to be better.

Over the course of her career, Corsig has welcomed over 10,000 expecting parents in breastfeeding classes.

Source: United States Breastfeeding Committee.
Source: United States Breastfeeding Committee.

“…Teaching breastfeeding class is an honor,” she says. “I feel tremendous responsibility to get breastfeeding class right.”

In a climate where most are asked to do more with fewer resources, teaching a roomful of parents is good time management for lactation professionals, she explains. Group perinatal classes such as the CenteringPregnancy model have also shown improved health outcomes for patients and cost savings for health systems.

Breastfeeding class can also set the tone for what parents might expect with hospital lactation services.

“It’s our opportunity to provide knowledge, confidence and reassurance so they feel in good hands when they arrive and after discharge,” Corsig says. “We want that to be affirming, warm, open, non-judgmental and supportive.”

Corsig considers several factors when coordinating an effective breastfeeding class. For instance, the time classes are offered.

“I am a morning person and I wouldn’t be nearly as good at teaching at the end of a work day,” she explains.

Teaching methods are equally important, especially during Corsig’s classes which total two-and-a-half hours.

“I interject with videos and play music before, after and at break,” she says.  

Corsig envisions teaching her own husband in a breastfeeding class to better reach fathers present.

When constructing breastfeeding classes, it’s important to know that adults learn differently than children; information needs to be relevant.

Linda J. Smith, MPH, FACCE, IBCLC, FILCA offers a wide variety of games and activities for teaching breastfeeding and human lactation in her book Coach’s Notebook: Games and Strategies for Lactation Education.

Corsig has observed that this generation of parents seems to understand preventative health.

“That gives me a lot of hope for our future,” she comments.

Register for the International Breastfeeding Conference here.