Progress materializes in time. Without devotion and determination, change is not possible.

For Children’s Hospital of Philadelphia (CHOP), an institutional culture shift to promote and support human milk and breastfeeding took nearly two decades and undeniable effort.

In the mid 90s, CHOP established a lactation program under the direction of the hospital’s board certified lactation consultants.

Several years later,  leading breastfeeding educator, researcher and supporter Diane Spatz, PhD, RN-BC, FAAN joined the team. Through a collaborative approach including the work of  nurses, physicians, researchers, administrators and other health care professionals, the program expanded to include comprehensive lactation support for both families and patients as well as the hospital’s employees.

Arguably the best children’s hospital in the nation, CHOP has made important changes to the way they look at breastmilk which has resulted in national and international recognition of their lactation services, especially those in the Newborn/Infant Intensive Care Unit (N/IICU).

Froh tells me it took someone passionate and well-educated like Dr. Spatz to implement a successful system that supports breastfeeding in the hospital. Froh adds that teamwork was an essential part of the process.

“You have to start from the ground up,” she says.

The pathway

CHOP’s lactation programs are inspired by a nurse-driven model.

Transition to Breast Pathway, created by Spatz and co-author Taryn M. Edwards, BSN, RN-BC, is one example led by N/IICU nurses. Infants in the N/IICU face very unique feeding challenges. For instance,  very rarely are they able to enjoy immediate skin to skin contact with their mothers.

The pathway is a systematic guide to help mothers breastfeed their sick infants even in the most extreme and challenging situations.

Step one of the pathway serves to initiate and maintain mother’s milk supply while she is separated from her baby.

Step two is called Human Milk Oral Care. Family members are encouraged to take fresh human milk on a sterile Q-tip and rub it into baby’s oral mucosa. Froh says this allows baby to absorb all of the milk’s critical components. It also aids in gut preparation.

As soon as the medical and surgical teams grant clearance, babies progress to step three where he or she is held skin to skin with mother.

Step four involves non-nutritive sucking at the breast after mother has pumped. Froh calls it Dry Run Breastfeeding. Babies are fed through a supplemental device while practicing at the breast so that a full feeding experience is replicated.

Eventually, baby and mother engage in breastfeeding as possible.

Prenatal consultations

While CHOP provides extensive lactation services after birth, the hospital also includes Prenatal Lactation Consultations for all of their patients.

“We value a model of informed decision when it comes to infant feeding,” Froh says.

Each consultation lasts one hour and allows a lactation professional and family members to discuss infant feeding options. Consults are tailored to family’s specific needs. For instance, if a mother has breastfed several babies before but has never used a pump for a sick baby, the lactation professional focuses on pump use and safety.

Froh tells me about a study that shows that girls form their opinions about breastfeeding between 13 and 14 years of age. While this study shows that high school age girls may be receptive to breastfeeding promotion, when needed, CHOP’s prenatal consultations serve as gentle intervention for the mothers who may have never questioned their predetermined infant feeding choice. To read more about young peoples’ attitudes about breastfeeding, click here.

Froh says many families express positive feelings about breastfeeding.

However, “This is a high stress situation and goals and intentions can change,” she says of families dealing with congenital anomalies.

While exclusive breastfeeding between biological mother and baby is the ideal, it is not always possible.

“We love breastfeeding and we would love to see all of our moms directly breastfeed,” Froh explains. But exclusive human milk provision is an equally important goal at CHOP.

The hospital now has a donor milk program which allows for more families to provide human milk for their babies. Expenses are consumed by the hospital so human milk provision is a very real option.

Integrated care

Among the many reasons CHOP is successful with its breastfeeding support, Froh ranks its integrated care very important. A consistent team of providers offer multidisciplinary care and services all within one building, so help is physically convenient.

While replicating CHOP’s facility layout probably isn’t feasible for most hospitals, Froh offers different, more attainable advice.

“Start considering training your nursing staff,” Froh says. While we know for a fact that we don’t have enough lactation professionals to serve all of the mothers in need, we do have a population of three million plus nurses, she explains.

CHOP N/IICU nurses are required to take additional breastfeeding education throughout their careers. Courses are offered through the hospital, count for continuing education credits and don’t require extra hours at work.

“This really separates our staff from others,” Froh says. “We value our nursing staff as the front line for protecting breastfeeding.”

In fact, CHOP values all of its staff.

Its employee lactation support program offers free prenatal classes, free lactation support, discounted breast pumps and private pumping rooms. The hospital was named by Maternity Care Coalition one of three winners of the 2010 Breastfeeding-Friendly Business Award.

Froh says the hospital is currently collecting employee  breastfeeding initiation and duration rates to quantitatively measure the program’s success.

CHOP recently finished filming The Power of Pumping, an informational video for parents and medical professionals alike. Moms of patients in the N/IICU relate why they made the decision to pump milk for their medically fragile children. Reserve your copy of the full version here.

For information about CHOP’s lactation services in the N/IICU visit: http://www.chop.edu/service/neonatology/resources-for-families/breastfeeding-lactation-services.html. Additional information can be found here: http://www.chop.edu/service/fetal-diagnosis-and-treatment/special-delivery-unit/lactation-breastfeeding.html.

Froh’s dissertation, a qualitative descriptive study titled, “Breastfeeding the Infant Born with Congenital Diaphragmatic Hernia,”  is currently going through the final process of board review at University of Pennsylvania School of Nursing Science.

She recently spoke at Healthy Children’s International Breastfeeding Conference about her findings and her work alongside Dr. Spatz.

This ad and others are part of an anti co-sleeping campaign in Milwaukee, Wis. launched in Fall 2011. The campaign responds to Milwaukee’s staggeringly high infant mortality rates and aims to reduce those numbers by 2017.

The city suffers from some of the worst infant mortality rates in the world. Milwaukee ranks seventh worst among 53 of the largest cities in the U.S.

The disparities between African American and white infant mortality rates are even more startling. African American infant death is nearly three times that of the white community’s. [Retrieved from: http://www.jsonline.com/news/milwaukee/milwaukee-infant-mortality-rate-drops-overall-but-disparity-worsens-sp54t7f-148680905.html]

Angela Lang, RN, IBCLC, ANLC and co-chair of the Milwaukee County Breastfeeding Coalition (MCBC) serves on the Fetal Infant Mortality Review (FIMR) through the Racine Public Health Department.

FIMR is designed to learn what can be done to prevent fetal and infant deaths from occurring. FIMR is part of the National Infant Mortality Review.

“If we knew why Milwaukee’s infant mortality rates are so high, we would have solved the problem,” Lang explains.

But it isn’t a coincidence that all of Milwaukee’s infant deaths in 2009 and into 2010 shared one common factor: all of the babies were formula-fed, as reported by Fox 6 News Milwaukee.

Co-existence

In Wenda Trevathan, Euclid O. Smith and James McKenna’s Evolutionary Medicine,  we learn that “Infants and mothers sleeping within arms reach (co-sleeping) with nighttime breast-feeding represents the evolutionary stable sleeping arrangement…”

In fact, “Co-sleeping may facilitate a unique sensory bridge within the mother-infant dyad that maximizes the chances of optimal development…” [Trevathan, Wenda, Euclid O. Smith, and James McKenna.Evolutionary Medicine. New York: Oxford University Press, 1999. 54. Print.]

As a mother who safely bed shares and breastfeeds, I find Milwaukee’s anti co-sleeping ads insulting. But insulting already breastfeeding and bed sharing families is the least of our worries.

Lang says denouncing co-sleeping altogether does a disservice to mothers in general and the way we naturally feed our babies. She agrees it’s part of our physiology to fall asleep while breastfeeding.

Instead of respecting biology, the anti co-sleeping campaign instills a sense of fear in mothers.

“Because women are so afraid of falling asleep with their babies, they fall asleep in rocking chairs or other places that are far more dangerous to sleep with your baby,” Lang explains.

In its Guideline on Co-Sleeping and Breastfeeding, The Academy of Breastfeeding Medicine concludes, “There is currently not enough evidence to support routine recommendations against co-sleeping.”

The American Academy of Pediatrics suggests room sharing but not bed sharing in SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment technical report.

And in Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position the AAP offers suggestions on how to safely co-sleep and bed share with an infant.

Instead of denouncing co-sleeping or bed-sharing, Milwaukee should focus its efforts on breastfeeding support and safe co-sleeping education.

Breastfeeding itself is protective against Sudden Infant Death Syndrome (SIDS).

However, it is important to note that breastfeeding alone will not protect infants from co-sleeping related deaths. Parents under the influence of alcohol or other drugs should never sleep with an infant. No one should smoke around children. Siblings should not sleep with infants. For other safe co-sleeping guidelines visit: http://kellymom.com/parenting/nighttime/familybed/.

In the article Bedsharing Promotes Breastfeeding, James J. McKenna, Sarah S. Mosko and Christopher A. Richard state that “routinely bed sharing infants breastfed approximately three times longer during the night than infants who routinely slept separately.”

If breastfeeding and bed sharing interlace, can one exist without the other?

Intervention

Lang highlights MCBC’s important collaboration with the African American Breastfeeding Network which serves to address breastfeeding disparities, increase breastfeeding awareness, build community allies and de-normalize formula use.

Lang says the African American population has around a 30 percent breastfeeding initiation rate compared to an overall 75 percent breastfeeding initiation rate. These dramatically low breastfeeding rates are linked to high infant mortality.

The numbers call for increased breastfeeding awareness and support within the community.

In 2011, Lang started working at Wheaton Franciscan Healthcare St. Francis, a Baby-Friendly designated hospital in Wisconsin.

Studies have found that implementation of the Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding is an effective strategy to increase breastfeeding initiation rates in the US hospital setting.

Lang says the biggest contrast between Baby-Friendly facilities and other hospitals is that Baby-Friendly designated hospitals support women in their choice to breastfeed.

“There is a misconception that we try to force everyone to breastfeed,” she says.

In Wisconsin, over 80 percent of mothers initiate breastfeeding but that number plummets to about 16 percent exclusively breastfeeding at six months because too often, mothers are faced with Institutional and Cultural Booby Traps.

When Lang’s first son was born, she experienced pressure from medical staff to feed her baby formula.

“I needed to be an advocate for him against the medical professionals,” she explains.

Wheaton Franciscan recently completed their audit and Lang says that the hospital’s staff does a good job of implementing Baby-Friendly guidelines.

But Wheaton operates under different challenges.

“We don’t own our doctors,” Lang says. “So we can’t enforce trainings for pediatricians, obstetricians and neonatologists.”

That becomes a struggle especially when physicians practice at other locations not Baby-Friendly designated. Inconsistency and unfamiliarity with breastfeeding protocols means trouble for medical staff and ultimately mom and baby.

Public health concern

The AAP released a policy statement last year stating that “infant nutrition should be considered a public health issue and not only a lifestyle choice.”

Over one third of adult Americans are obese but
breastfeeding offers a 30 percent decrease in obesity over a lifetime, Lang says.“If you stop and think about that number, it is unbelievable,” she says.

The United States Lactation Consultant Association (USLCA) recently released a statement for Healthy Weight Week stating that “for the first time in years… obesity and extreme obesity among low-income preschoolers decreased slightly between 2003 and 2010.”

USLCA attributes the lower obesity rates to increased breastfeeding rates.

“…During the study period, the number of low-income mothers breastfeeding their babies increased by more than 10 percent,” the statement includes.

Like the AAP states, breastfeeding is clearly a public health issue; it affects all aspects of the community.

As MCBC and other advocacy groups and individuals continue their mission to normalize breastfeeding, our communities will gradually improve general health outcomes.

Lang was recently chosen by the Wisconsin Association of Lactation Consultants to extend her public health service. This summer, she will travel to Uganda to assist Josephine, an ILCA partner, with breastfeeding trainings.

Lang is also a recent graduate of the Union Institute and University/Health Children Maternal Child Health: Lactation Consulting Program.

Corrections made 3-25: Lang serves on the Fetal Infant Mortality Review (FIMR) through the Racine Public Health Department, not the Milwaukee Public Health Department. She also works at Wheaton Franciscan Hospital St. Francis, not Elmbrook. 

I’d be willing to bet you’ve never thought to compare a circus clown to a nursing mother and her infant. I certainly hadn’t until I had the pleasure of speaking with Healthy Children faculty Kristin Stewart, BS, CLC.

“With circus clowning, you can’t speak,” Kristin explains to me. “Someone in the top row of the arena isn’t going to hear you.”

Instead, circus clowns resort to non-verbal communication.

“If you’re good at what you do, the people in the back will know exactly what you’re doing and why it’s funny.”

Somewhat recently, the stars aligned in such a way that Kristin ran into childhood friend and Healthy Children faculty Kajsa Brimdyr. Shortly after, Kristin began working with HCP.

Having nursed both of her children, Kristin tells me that she has always been interested in lactation on a personal level.

“But once you start really learning, you become more and more passionate,” she says. Kristin is inspired by the idea that something so personal has sweeping influences on “the big picture.”

Since working with HCP, Kristin has also become fascinated by the unspoken communication between the breastfeeding pair, similar to clown and audience.

“There are all sorts of unspoken language,” Kristin explains.

For instance, infants display a wealth of feeding cues other than crying. For more information about infant feeding cues visit: http://www.amazon.com/Pocket-Guide-For-Lactation-Management/dp/1449687784/ref=sr_1_1?ie=UTF8&qid=1360015618&sr=8-1&keywords=pocket+guide+lactation and http://www.nal.usda.gov/wicworks/WIC_Learning_Online/support/job_aids/cues.pdf.

The more time a mother spends with her child, the better she will understand those cues. Kristin explains that this learning of infant body language is not a conscious process. She refers to it as a “subconscious soaking in.”

Health care providers’ disinterest

Kristin describes another non-verbal, subconscious experience.

“I’m sure it’s happened to you,” she tells me. And she’s right.

“You go in to see your [healthcare] provider and you are clearly not what they are thinking about,” she describes the familiar situation. “It’s a subconscious feeling that ‘I’m not important to this person.’”

Because of this scenario she offers this advice to lactation professionals: Really listen, listen to mom and listen to baby.

Kristin knows lactation care workers face unique challenges. She asks us to remember that we’re not alone and to seek support when needed. Getting the support you need will only enhance your ability to encourage mom and baby.

Not your average herstory

After graduating with an Ivy League liberal arts degree, Kristin decided to attend Ringling Bros. and Barnum & Bailey®’s Clown College in the early 90s.

Kristin married her husband and fellow clown, Jay, a few years after graduation. Two years later, they welcomed their first born Karen into the world.

When Karen was just eight months old, the Stewarts made a brave choice to leave their vinyl flooring jobs behind and journey to Japan where Jay had been offered a clown position.

“It was terrifying and exciting and all of those things,” Kristin says.

After spending about a year in Japan, the Stewarts were offered a place in the Ringling’s Red Unit where Jay served as Boss Clown.

Currently, Jay performs with Big Apple Circus’ Clown Care a signature community outreach program that offers classical circus entertainment to hospitalized children at 16 leading pediatric facilities across the United States. [Retrived from: http://bigapplecircus.org/clown-care]

Togetherness

Circus life, a life defined by its commitment to family and community, allowed Kristin time to develop the delicate, non-verbal relationship she’s fascinated by with her second born, Nicholas.

He was only three weeks old when Kristin hit the road with the circus again. She wasn’t performing at that time, but she worked in the circus’ nursery. This allowed Kristin and Nicholas to be with one another very often.

“The time that the circus gave me as a mother was hugely instrumental in my breastfeeding success,” Kristin says. “There was never any pressure to go back to [performing.]”

Kristin’s nursing experience with Karen was more of a struggle.

She tells me Karen was born in a huge facility in Atlanta where locating a lactation consultant was a chore.

Lack of and inconvenient lactation care access remains a huge barrier to mothers’ breastfeeding success everywhere. Measurable steps have been taken by the Affordable Care Act to make services more reasonable for mothers.

Not only did Karen face insufficient access to lactation care, she was afraid to ask for help. Why is it that many women feel like they have to do everything alone? Is it the pressure society puts on us to be flawless in every aspect? Is it because we don’t know where to ask for help? Is it because we’ve lost a sense of sisterly community?

“It’s such a cliche but the circus is such a family-centered place to be,” Kristin says comparing her nursing experiences. “Babies in the circus are everyone’s babies.”

Kristin says she felt embraced by this sense of togetherness while nursing Nicholas.

“There are so many great people,” she says.

The Stewarts became especially close to the 12 to 16 performing clowns.

“They became our extended family,” says Kristin.

When Karen was about 20 months old, Lisa, a family friend came to visit the Stewarts on the road. While Lisa carried Karen around backstage during Kristin and Jay’s performance, she recalls at least six people stopping her wondering, “What are you doing with the Stewart baby?”

“She was so happy to know that we were so safe with the circus,” Kristin says.

Consistent prenatal care

The stories of the Stewart family adventures only get wilder.

A typical week looked like this: Arrive in a given city on Tuesday or Wednesday, load in, perform Wednesday and Thursday night, perform two shows on Friday, three on Saturday and two on Sunday. Sunday night the crew hit the road for the next city which could be anywhere between six and 20 hours away.

Imagine going on an extended road trip for the duration of your pregnancy!

Kristin explains that obstetricians many times refused to see her for prenatal care only once while she passed through the city. Luckily, Kristin’s theatrical talent served her well.

“Often I would have to call and say ‘I’m moving to the area…’”

Kristin simply carried her medical records with her. As a second-time pregnant mom, she says she was confident about her pregnancy even without traditional prenatal care.

“The circus provides outstanding health insurance,” she adds.

Several weeks before Nicholas was due, Kristin traveled to her home on the Cape.

“I wasn’t willing to just go to any hospital,” she explains. “It wasn’t a comfortable option for me.”

Once again, the stars aligned in such a way that Jay happened to be performing only a few hours away when she went into labor. He attended the birth.

“The timing was unbelievable,” Kristin laughs.

To read more about responsive parenting and infant self-regulation click here, here, and here.

Please note: it is vital for moms to have access to all lactation care workers. CLCs, advocate for your services by contacting insurance companies and let them know what a difference you make for moms, babies, families and communities.