No Rules in Relationship

By July Guest Blogger:


Nikki Lee: Mother of 2

(Ed. Note: Our Milk Way blogger Jess Fedenia is on parental leave for the months of July, August, and September, 2016 to welcome a third child into the family. During Jess’s leave, members of the Healthy Children Project, Inc. circle are taking up the blogger role. We extend our gratitude to Nikki for stepping up with such grace and panache!)


Yesterday, I saw a lovely mother and her 5-month-old baby. The mother requested a consultation because her baby wasn’t happy. Part of their history was that the baby would breastfeed very well at night, in bed with mamma, but wouldn’t feed more than twice during the day.

During a lovely long hike through a nearby park, through the woods, and along the stream, with the baby alert and interested in the baby carrier, the mother and I talked about everything: her work, her marriage, her labor and delivery, and her life.  I have found that conducting part of a consultation outdoors is very helpful. It relaxes the mother, and makes her feel safe to tell her story. This easy dialogue creates a connection between us. Working outdoors often dissipates tension; mothers benefit from a reminder that they are part of a bigger world.

After nearly 2 hours of chatty strolling, we got back to my office. The baby was ready to breastfeed. The mother got ready, opening her bra, holding her breast and her baby in a cross-cradle hold. The baby got fussy and the mother got worried; the baby didn’t attach, and they started a subtle battle with each other. The mother was insisting on a particular position and the baby wanted to do it herself.

At that point, it became obvious that the mother’s expectations and understanding were the barrier to easy, fun breastfeeding. She was working to breastfeed the way she had learned in the hospital, every 2 hours whether the baby wanted to feed or not, by holding her breast, pulling it into midline and guiding her baby’s head onto the nipple.

The daytime breastfeeding relationship for this dyad had been a battle for 5 months. She was tired of the struggles, and now was eager for new ideas. She was ready to let the baby teach her how to breastfeed.

When the baby found her own position on her mother’s lap, she showed just how well she could dive at the breast, attach herself, feed, let go and look around or smile at mamma, and then dive back and feed some more. The mother had no idea that her baby had any ability to feed on her own, and was delighted and surprised to see her baby’s skills.  This sweet baby played at the breast, sucking her thumb and mother’s nipple at the same time while resting her foot on the other nipple. The mother didn’t know that this was normal behavior for a 5-month old.

Their interaction was charming to watch. Breasts are babies’ first toys.

Breastfeeding is a relationship that must evolve to suit the mother and baby. Relationship can’t be taught. What can be taught is how to create the environment where the mother and baby can figure out their own way. The problem for this dyad was that they had never developed their own style of breastfeeding; the mother said that every interaction with her baby was a mission to accomplish something, that they had never hung out and discovered each other. Breastfeeding during the day had been about following rules; breastfeeding at night had been mindless. The baby had made her preference clear.

They left all happy, looking forward to a new chapter in their lives.

I love my work.



[This post originally appeared on Nikki Lee’s blog Morning Thoughts, on April 18, 2016. Thanks to Nikki for permission to repost.]

Celebrating the Breastfeeding Champions of North Philadelphia: An interview with Naima Black, CLC, Coordinator North Philadelphia Breastfeeding & Community Doula Program

By July Guest Blogger: Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI, ANLC, CKC

(Ed. Note: Our Milk Way blogger Jess Fedenia is on parental leave for the months of July, August, and September, 2016 to welcome a third child into the family. During Jess’s leave, members of the Healthy Children Project, Inc. faculty circle are taking up the blogger role.)

In June 1997, the Journal of Human Lactation published a paper; Observations based upon multiple telephone contacts with new breastfeeding mothers based on the work this author had done as the lactation consultant in a grant-funded program serving underserved mothers and babies in West Philadelphia for 6 years.

The paper reported some useful strategies that led to 86% of mothers breastfeeding for at least 1 month, 46% breastfeeding for at least 3 months, and 23% breastfeeding at least 5 months. A major finding in this descriptive paper was that about 94% of mothers would achieve sustained breastfeeding after receiving an average of 9 telephone calls over a period of 12.5 weeks. In other words, only about 6% of mothers would need a home visit for more intensive clinical care.

Today, the Certified Lactation Counselors (CLCs) and the Breastfeeding Champions of Maternity Care Coalition, are providing consistent and timely breastfeeding support to an underserved population in Philadelphia, and finding similar results and successes, with the majority of mothers doing well with basic breastfeeding support and only a few needing more intensive clinical care.

Maternity Care Coalition (MCC) is “a nonprofit organization with the mission to improve maternal and child health and well-being through the collaborative efforts of individuals, families, providers, and communities in Southeastern Pennsylvania”. Its programs serve pregnant women at 9 sites in a variety of programs that are funded by national and international organizations: W.K. Kellogg Foundation and Merck, to name but two.  Most programs use a home visiting model.

Naima Black (right) demonstrates comfort measures with a community doula trainee (left)

Naima Black, CLC, has been the Coordinator of MCC’s North Philadelphia Breastfeeding and Community Doula Program since its very beginning in 2012, when the first Kellogg grant was awarded. Interested women from the community are given a free 20-session training to become doulas, and are matched with women delivering at local hospitals. In the past 4 years more than 680 pregnant mothers have been matched with a community doula and received some level of support. For those who had a community doula support them during labor and childbirth, the rates of cesarean section are 10% lower than the general hospital rates.


MCC has always employed healthcare workers who were passionate about breastfeeding; many took a peer-counseling course offered by the Philadelphia Department of Public Health; when more funding became available, many became CLCs. While the original intent was for all the Breastfeeding Champions to become CLCs, it is now difficult to offer the training to everyone who wants it. One problem is staff turnover. Some staff has left after being trained. While MCC pays for its staff to be trained, the hope is that there will be a commitment to the organization in return. However, the reality is that women move away, or seek higher education or leave to find better paying jobs. Unfortunately, community health workers are paid little as grants are stretched to the maximum to serve the most.  Their workloads include providing support for follow-up care, Safe Sleep, and social issues; breastfeeding has become integrated into their caseloads.

Another problem is that grants have shrunk while the demand for credentialed lactation workers has increased because more women are leaving the hospital breastfeeding. This is because all 7 birthing hospitals in Philadelphia are working to implement best practices to promote and support breastfeeding; 2 hospitals have become Baby Friendly, 1 has become Keystone 10 designated, and 2 more are on the last leg of their Baby Friendly journey. (Keystone 10 is a similar program to the Texas 10 Step program, and is supported by the Pennsylvania Department of Health in partnership with the Pennsylvania Chapter of the AAP.)

DT 8
Practicing comfort measures with Community Doula trainees

Mothers find MCC and breastfeeding support by direct referral from other programs such as Centering Pregnancy (administered at one city hospital, and an outpatient clinic) and the ELECT Program (serving pregnant and/or parenting high school students). Word of mouth is a growing source of referrals, as the community doula model used in the North Philadelphia Breastfeeding and Community Doula Program is popular.

If pregnant mom says she doesn’t plan to breastfeed, the community health worker seeks to keep the door open using counseling techniques. Women are asked to, “Tell me more about that”. This is followed-up at next visit. “Would it be okay if I brought more information?”

The number of visits depends on the program. Some offer weekly visits throughout pregnancy, others offer monthly visits. The same is true for postpartum visits, which can be for 1, 2, or 3 years, depending on the program. Clients are also invited to seminars and trainings in addition to the visits.

Sharing affirmations with one another during Community Doula training

The North Philadelphia Community Breastfeeding and Community Doula Program is the first and only one of its kind to use Microsoft Excel® to track data. In the home visiting programs, everything is tracked: feeding intention, initiation and 3-month duration; every contact (phone, text or visit) is documented, and the referent agency is kept in the loop.

The Breastfeeding Champion/CLC model is effective for most women; more challenging cases are referred to Naima, who will call in a community-based IBCLC with more experience. Not all mothers receive breastfeeding support from a Breastfeeding Champion or CLC; sometimes it is the community doula who provides the help. At other times, it is a community member who comes to a breastfeeding support group and needs a referral. Naima has not had to refer onward very often; only about 20-25 mothers (out of 680 cases) have required more intensive breastfeeding support.

Naima is a source of education and support for her staff, as well as doing the administrative tasks required by a grant-funded program. Senior CLCs are available for supervision and support and resources, with Naima as Coordinator being the clinical overseer to everyone.

Just as in 1997, when mothers were supported to breastfeed with regular contact and only a few needed a home visit for complex care, in 2016, most mothers enrolled in MCC programs are supported to breastfeed with regular contact, and only a few need more complex breastfeeding care. The Breastfeeding Champions/CLCs are doing a wonderful job for the majority of mothers, and the IBCLC is there when needed.

In 2014, the CDC cited both IBCLCs and CLCs as professional lactation supporters. Working together, Breastfeeding Champions, CLCs, and IBCLCs can provide a safety net of breastfeeding education and support to underserved mothers, illustrating how effectively a community of lactation care providers can work together in a successful model of practice.

A Reminder to Broaden the Focus: A comfortable breastfeeding relationship rests on much more than “proper latch”


By July Guest Blogger:

Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI,        ANLC, CKC



(Ed. Note: Our Milk Way blogger Jess Fedenia is on parental leave for the months of July, August, and September, 2016 to welcome a third child into the family. During Jess’s leave, members of the Healthy Children Project, Inc. faculty circle are taking up the blogger role.)

I’ve been working with mothers and babies since 1975; I’ve been in private practice as a lactation therapist since 1989. These years have been full and wonderful and I look forward to many more.

Something is happening today in the language used by breastfeeding helpers that disturbs me and feels like fingernails scratching across a blackboard. This the focus on “the latch” instead of focusing on “breastfeeding.”

I’ve heard hospital colleagues say, “I was just latching a baby on when you called,” or “I latched on 24 babies today.” Current prenatal resources talk about the latch, “Getting your baby to latch”. “Your nurses in the hospital can help you and your baby learn to latch.” “Latch on, the key to successful breastfeeding.” “Breastfeeding: It’s Latching On.”

I’ve had clients tell me, “They told me the latch was perfect in the hospital, but it always hurt.”  These mothers are doubting themselves when the experts have told them something different to their own experience. Simply put, latch isn’t perfect if it always hurts. No one asks the mother if she is having fun with her baby, or if she knows when her baby wants to go to breast. It’s all about the latch. Mothers are calling the warm line or lactation professionals to “have the latch checked.”

I see clients controlling the relationship, focusing on getting the baby to latch, with little awareness of, or attention to, comfort or timing. No one seems to remember that healthy babies are born with all the reflexes and skills they need to breastfeed; certainly the mothers I see are always surprised to see what their baby can do when given the chance!

The focus of our work has become the latch, the narrow area where the baby’s mouth and the areola and nipple intersect. True, this component of breastfeeding has to be comfortable and effective. However, it is not the whole story. The whole story is about feelings and relationship, about observing, and about responding. Breastfeeding includes health, with functional anatomy and physiology. Breastfeeding includes environment, respect and timing. Breastfeeding encompasses fun, love, and pleasure.

Making the latch the focus of breastfeeding is like making penetration the focus of lovemaking. Today, it is as though the relationship has been distilled to directions for assembling a piece of furniture from IKEA. We all know that there is much more to intimacy than Part A accepting Part B comfortably and completely. We know that a baby is much more than the sum of its diapers, feeding frequency, and weight. We want to appreciate the emotional components of relationship that make breastfeeding something for mother and baby to enjoy.

Let’s remember the whole, and do what we can to promote relationship, while supporting all its elements.


[A version of this post appeared on the author’s blog, Morning Thoughts, in May of this year.]