Ramadan Mubarak: Breastfeeding in Islam

“Allah u Akbar,” the adhan resonated from the immaculate minarets of the mosques in Morocco. It’s one of the most profound, sensorial memories I have from my studies abroad; the deep, ethereal song dancing through the bustling streets of the medina inviting believers to prayer.morocs

Islam’s holy month of Ramadan, a time for introspection, purification of the body and strengthening of spiritual bonds marked by the sighting of the new moon, is now well underway.

During the celebration of Ramadan, from sunup to sundown, Muslims worldwide take part in:

  • daily readings of the Quran,

  • charitable efforts,

  • avoidance of smoking and sexual intercourse and

  • fasting with no food or water.

Fasting requires a great deal of self-control and offers Muslims an opportunity “to diminish…dependence on material goods, purify their hearts and establish solidarity with the poor to encourage charitable works during the year.” [Retrieved from: http://www.time.com/time/world/article/0,8599,1919257,00.html#ixzz2YlNq3Hlt]

But as much as fasting during Ramadan is about self-discipline, it also presents communities with a unique chance to come together in support of one another.

“A community that fasts together supports each other,” as Rabbi Robert W. Haas puts it in the film American Ramadan.

Perhaps it is this sense of community, where Muslims fast and partake in iftar together, that grants participants the strength for this religious undertaking.

While there are several interpretations of fasting for pregnant and lactating women amongst Muslim communities, Union Institute and University Maternal Infant Health student and Babies Express founder Alice Byrd RN, IBCLC, ANLC, CBE tells me that the choice to fast during Ramadan is typically up to the mother’s discretion.

Mothers sometimes express concern about fasting while lactating: does fasting during Ramadan affect the quality and quantity of breastmilk?

Bener’s research, Fasting during the holy month of Ramadan does not change the composition of breast milk, concludes that breast milk quality and composition in nursing mothers is unaffected by Ramadan fasting.

Kelly Bonyata, IBCLC of KellyMom also offers research that supports these findings in Religious Fasting and Breastfeeding. She provides information about maternal diet and breastfeeding in How does a mother’s diet affect her milk?

Although studies show that breastfeeding mothers need not worry about milk composition during Ramadan fasting, Byrd recommends lactating mothers reevaluate their choice to fast day by day.

“[Mothers] definitely have to get up to eat in the morning so that their energy level is up, especially early on when the baby is eating about every two hours,” she says.

When and if a breastfeeding mother finds that she is unable to participate in fasting due to the risk of her or her child’s health being harmed, she has other options to take part in the holy celebration.

She may make up the fast at any other point in the year.

She may offer food to the less fortunate, feeding one person for each missed day of fasting.

“For those who cannot do this except with hardship is a ransom: the feeding of one that is indigent…. Allah intends every ease for you; He does not want to put you to difficulties….” (Quran 2:184-1)

Interestingly, according to Lactation in Islam., “…the moral importance of breastfeeding is stressed. The mother receives the reward of a good deed for every single drop she gives her child.”

Byrd cautions that when fasting during Ramadan becomes too trying for a mother, she may resort to bottle feeding, spurring a potentially vicious downfall of her breastfeeding relationship.

However, stressing the religious importance for a Muslim woman to breastfeed her child may preserve and promote breastfeeding, as suggested by Lactation in Islam. Ensuring that she is aware of her religious rights as well as ensuring proper breastfeeding education and support offers mother the confidence to feed her baby and fully participate in her religion.

For example, the Quaranic verse 2:233 recommends breastfeeding for two years which is (potentially) significantly longer than the American Academy of Pediatrics’ breastfeeding recommendations.

Even more, “according to Islam a nursing mother is entitled to receive compensation from the father for nursing the child.” This idea stresses the value of breastmilk and may even serve as a source of empowerment.

Milk kinship, where non-biological mother breastfeeds a non-biological baby also implies the importance of breastmilk in Islam. Historically, milk kinship was practiced to forge loyalty amongst community members, but the custom persists in modern time.

Byrd tells me she has a friend who nursed her twin sister’s child after her friend’s sister passed away. (Click here and here to learn about the risks associated with informal milk sharing.)

Natural term breastfeeding isn’t always easy to achieve especially when a mother must return to work, Byrd reminds us.

“Becoming educated about pumping [in the workplace] and their right to breastfeed is hard for some women,” she explains.

Muslim families might also face the challenges associated with English as a second language. This is a particularly important barrier to recognize during prenatal care and labor and delivery as it is documented that birth experience affects breastfeeding outcomes.

Because there are an estimated 50 different dialects of Arabic, language can pose a special challenge when it comes to communicating with Muslim families.

Byrd says she often finds that families don’t quite understand the translated phone lines that she uses with non-native English speaking clients.

If language doesn’t present a barrier to breastfeeding, sometimes cultural misunderstandings do.

Byrd mentions traditional male and female roles within Islam for instance.

She also says that lactation professionals might misinterpret Muslim signs of respect for discourteous behavior.

“If a female [professional] is speaking to a male, he might be turned away from her or he might lower his gaze,” she explains.

Further, it is the mother’s postnatal right to be at a state of rest for 40 days after childbirth.

Byrd explains that family, friends and neighbors cook meals, clean the home and sometimes even feed the mother during this postpartum period. She says that medical professionals often deem Muslim mothers “princesses” or “needy women” instead of accepting this as a part of their upbringing.

How upsetting that we don’t better embrace this practice in America!

The notion of modesty within the Muslim religion may present cultural barriers when not fully understood as well. Female modesty is associated with endless interpretations.

For example, Muslim women may choose to wear no traditional covering, a full body covering called the burqa or any variation in between. (Explore more Middle Eastern veil styles here: http://www.huffingtonpost.com/anne-peterson/know-your-veils_b_812944.html#slide=228734)

No matter her image, all women’s humility must be respected. A woman in a low cut tank top may never nurse her baby in public whereas a woman dressed in hijab may.  Medical and lactation professionals should exercise special cultural sensitivity around nursing Muslim women and remember that things like region and adherence to traditional Islamic beliefs will influence her comfortability to expose any part of her body.

Byrd explains that there are special clothing for nursing Muslim mothers who wish to remain completely covered. I found this website which offers breastfeeding abaya: http://www.modestclothes.com/islamic/dept/muslim-nursing-clothing.html.

The Boston University School of Medicine has compiled a list of general guidelines to respectful interaction with Muslim patients that may be helpful for the lactation professional. This resource can be found here: http://www.bu.edu/bhlp/Resources/Islam/health/guidelines.html.

Lactation professionals working with Muslim families should also consider that culture and medical practice often muddle.

As I explored the Quran’s statements on breastfeeding, I found this narration from Imām as-Sādiq (as): “Oh Mother of Ishāq, don’t feed the child from just one breast, but feed from both, as one is the substitute for food, and the other is a substitute for water.”[359]

The Quran also directs women to eat only pure food because all she ingests affects her nursing child.

With these examples in mind, we’re presented with the dangers of culture dictating improper breastfeeding practice.

It is imperative that lactation professionals practice cultural sensitivity and receptiveness to better influence the success of Muslim families’ breastfeeding relationships.

Especially during the intense celebration of Ramadan, breastfeeding advocates and professionals can preserve a nursing dyad’s breastfeeding relationship through careful consideration of cultural and medical practice.

Advice from mama to physician

It’s obvious that pediatricians have the potential to influence the health and well-being of our children in a huge way. In order to effectively monitor the health of our little ones, it is essential for parents and physicians to establish trusting, respectful relationships with one another.

And because we know that breastfeeding offers unprecedented nutritional value, protection, and bonding and sensory opportunities, it is perhaps most important that pediatricians and parents develop dialogue about infant feeding methods.

Without the creation of open conversation and mutual respect, we risk developing antagonistic relationships between two important caregivers which may put our children in undesirable and unfair positions.

Let me illustrate.

When my daughter Willow was about two months old, I started to notice small amounts of blood and mucus in her stool. I was horrified. Conveniently, I was in the midst of my Certified Lactation Counselor training where I learned about proctocolitis otherwise known as a milk protein allergy. When Willow and I returned home from the CLC training, I took her into urgent care and offered my diagnosis to the pediatrician on call.

“What exactly do you do?” she asked, presumably impressed with my new vocabulary.

“I’m a stay-at-home mom,” I replied. She didn’t respond.

After a fairly thorough physical examination of Willow, the ped handed me several sheets about rotavirus and intussusception along with instructions on how to collect stool samples for further testing.

Aside from the trace amounts of blood in her stool, Willow did not present any other intussusception symptoms. She exhibited not one symptom of rotavirus. Although annoyed and concerned by the pediatrician’s uneducated verdict, I followed her instructions.

The following week, we visited Willow’s regular pediatrician and she was just as baffled by the on call ped’s prognosis as I was. To my relief, Willow was properly diagnosed with a milk protein allergy as I had predicted. Instead of worrying about the risk of severe dehydration or putting my tiny baby through surgery, I was simply instructed to eliminate casein and whey from my diet.

Unfortunately, this is not the only frightful story I have to share about the pediatricians my daughter and I have encountered. Reflecting on these unfortunate events, I have compiled advice for parents and pediatricians alike on how to work as a team to better serve our children.

Whyte,BryonI also spoke with Dr. Byron Whyte, MD a pediatrician currently working at Pediatricare of Northern Virginia. His insight enables a more balanced discussion and has allowed me to appreciate physicians as human beings rather than the all-knowing deities that I wish they were.

The following are recommendations for making health decisions for your child:

  • Interview, interview, interview.

“You should know from the beginning who it is that you are dealing with,” Whyte says of selecting a pediatrician.

What kind of practitioner are you interested in? Does the doctor welcome questions? Does the doctor seem invested in children? Is there something about the doctor that you wish was different?

Whyte reminds us that choosing your obstetrician or midwife is just as important a factor in caring for your baby after birth as choosing a pediatrician.

“I wish we could do more on the OB end,” he says of offering breastfeeding education and support.

That’s because we know that the birth team plays an essential role in helping mothers breastfeed successfully.

“It would be great if there were a study about how much we talk about breastfeeding prenatally and how much that changes breastfeeding outcomes,” Whyte says.

What we do know is that birth experience affects breastfeeding outcome, so starting a conversation about breastfeeding prenatally is invaluable and can have lasting effects on your child’s health.

Whyte says the Baby-Friendly Hospital Initiative is very exciting because its policy to “not stick a bottle in every baby’s mouth” will help to shift breastfeeding back to the infant feeding “default”. BFHI’s model sets moms up for breastfeeding success.

Because we lack continuity of care within our healthcare system, it is often the work of the lactation professional to bridge the gap between parents and other medical professionals. It is in parents’ and children’s best interest to look for practitioners who have established good relationships with lactation professionals.

However, Whyte sheds light on the reality of relationships between pediatricians and lactation professionals within the community.

“When you’re out in the community, it’s harder to communicate,” he explains.

That’s because medical professionals working in the community don’t share the convenience of physicality like lactation specialists and physicians do within a hospital setting.

Whyte explains because they don’t always have the opportunity to talk about their patients together, he sometimes has a hard time trusting the care that patients receive from the lactation specialists.

For example, he says that if he refers ten patients to a specialist and eight of them come back using nipple shields, he doesn’t feel like they have done their job. It’s such a relief to know that there are pediatricians out there like Whyte who aren’t comfortable with overuse of instrumentation!

  • Keep yourself informed.

When Willow was seven months old, I needed my wisdom teeth extracted. I was concerned about the effect of the anesthesia on my breastmilk and milk production, so I asked our pediatrician for advice. She told me that I shouldn’t worry about it “because so many women are anesthetized during birth and they breastfeed just fine.” RED FLAG.

Dr. Thomas W. Hale, RPh, PhD runs the InfantRisk Center an evidence-based medicine and research call center. I consulted the center’s InfantRisk Helpline (806-352-2519) where I learned that two of the three drugs to be used during my procedure were hazardous while breastfeeding.

IMG_0581Luckily, my oral surgeon gladly used the alternative anesthesia recommended by the center and my breastfeeding relationship with Willow continues unharmed.

The Drugs and Lactation Database (LactMed), a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed to, including information on maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider, offers mothers and healthcare professionals a similar resource. [Retrieved from: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT]

While the internet can be a scary place to receive medical advice, it offers parents supplemental information when they have concerns about the information provided by practitioners.

  • Trust your instincts. Trust your child.

 While I do not doubt that pediatricians are highly trained medical professionals, I firmly believe that parental instinct often outshines what practitioners sometimes pull from outdated medical textbooks.

For example, Willow recently had a urinary tract infection misdiagnosed as a yeast infection. Even after explaining how certain I was that she had a UTI judging by her symptoms, the infection went undetected for three days because our pediatrician failed to consider my intense instinct.

Looking back, I wish I would have insisted she reconsider the diagnosis.

Parents: don’t be afraid to stick up for yourself and your keen intuition! Physicians: Do not undermine the power of parental instinct.

  • Find respectful ways to convey your concerns.

I find that I have a difficult time being proactive about the issues I have encountered with physicians. I accept their advice with a quiet nod then return home to vehemently vent to my husband instead of trying to make change.

Don’t do as I do; alternatively, share the resources you find relevant with your child’s practitioner. Maybe it’s a book or a published study you’ve come across.

For instance, our pediatrician had never heard of the alternative vaccine schedule nor had she heard of Baby-Led Weaning until we reported that we would be practicing this infant weaning method. She was uninterested and unsupportive in our desire to do something “different.” Perhaps she would have been more receptive to learn about this alternative method from a professional; Gill Rapley’s books are a great resource for the uninformed.

When you find it difficult to express your feelings, it might also be helpful to bring a support person with you to appointments. Perhaps your partner is more comfortable questioning the physician and together you can better facilitate conversation.

  • Be receptive.

The other day, a girlfriend of mine told me that when she told her four-week-old son’s pediatrician that she and her son bedshare, he recited a laundry list of bedsharing safety concerns and told her that only poor, uneducated people do that. I can barely imagine how I might have reacted to a statement like that. Wrong on so many levels.

While Whyte doesn’t find that bedsharing speaks to a socioeconomic status, he does have his doubts about the safety of bedsharing when not accompanied by a manufactured co-sleeper. He cites increased SIDS risk as one concern.

My research shows that bedsharing can be done safely when mother exclusively breastfeeds. (See Dr. James J. McKenna’s Mother-Baby Behavioral Sleep Laboratory) Actually, bedsharing promotes breastfeeding and might even reduce SIDS.

When your thoughts about parenting practices differ from those of the pediatrician, it’s difficult to be receptive of their counsel. However, we must remember that physicians generally have our children’s best interest in mind and it’s always important to receive and reflect on the information they provide with open ears.

Likewise, physicians must remember that parents generally have their children’s best interest in mind.

  • Remember that physicians are humans too.

Whyte tells me that his experience as a father has influenced his work in a good way.

“It gives you the other side of it,” he says.

“For the most part, I’m speaking as a physician but the dad stuff comes in as well because I’ve been there,” Whyte says of the experiential things like being up all night with an upset baby.

He adds that as a physician and parent, he is better able to advocate for his patients.

“Listen, I know this isn’t my own child but if it were…” he role plays. Parenthood allows him to separate himself from the “sterile point of medicine.”

I am fascinated to hear about Whyte’s experience as a male breastfeeding advocate.

“There is no positive point to it,” he says.

He explains that he often watches people recoil when he talks about breasts, even in a medical context.

“These organs are completely different outside of the bedroom,” he references the intended function of breasts.

As a male breastfeeding supporter, Whyte encounters other challenges.

“[Mothers] are less inclined to nurse with me in the room,” he says. “The worst is if a mom will stop a feed.”

Whyte recalls working in the NICU. When he entered the nursery, nurses closed curtains around breastfeeding mothers to shield them from his presence.

“That really doesn’t send the right message,” he rightfully explains.

Whyte finds himself judged in additional ways too.

“I find that often times there is this sort of assumed barrier between [physicians] and [lactation professionals],” he says. “We end up in this weird tug-of-war where we are fighting for control of the baby. That’s not cool; we are all working together.”

He suggests lactation professionals not make generalized assumptions that pediatricians are automatically anti-breastfeeding.

Unless a physician “says something crazy,” Whyte encourages lactation professionals to assume that we all want the patient to breastfeed.

  • Know that you have options.

Keeping in mind that physicians are humans too, if you’ve encountered down right foolishness (like when I met a pediatrician who likened the female urethra to the vaginal canal) and can’t take it anymore, know that you have every right to change practitioners. If you do choose to leave, be honest about why. It might help the practitioner reconsider his or her practices.

Dr. Whyte starts work at George Washington University’s student health center this month where a Breastfeeding Friendly University Project has been established.

He says he’s most excited about helping people transition from childhood to adulthood.

“As a kid, mom and dad are in charge and they are kind of guiding you,” he says of adolescent health care. “The only way to get good care is to be forthright.”

Excellent advice indeed.  

kmcMom2Mom KMC shared this great resource they created to empower parents in the medical setting:

Breastfeeding empowering language in medical settings 

Goal: Productive dialogue ending in a plan that is best for baby/child

Questions:

What exactly is your recommendation/concern?  (“Maybe you should supplement with formula.”)

Why are you recommending this course of action?  (“Your baby is slipping on the growth curve.  He’s not gaining weight as fast as he should.”  Follow-up questions: “What exactly is your concern?  Is he missing milestones?  Is he losing weight?  How fast ‘should’ he gain weight, and how far behind is he slipping?”  “Are you using the WHO growth charts based on breastfed babies, or the CDC charts based on formula-fed babies?” etc)

What is the desired outcome of this course of action?  (“Formula will make the baby put on weight faster.”)  Follow up: How will that benefit the baby?

What are possible undesired outcomes of this course of action?  (Here’s where you need to be informed.  Dr. might say “none.”  This is your opportunity to state your case for why you are opposed to what is proposed, i.e. “Won’t introducing nutrition other than breastmilk increase my baby’s gassiness/fussiness?  Formula feeding causes me to miss breastfeeding sessions, which will decrease my milk supply and undermine the breastfeeding process.  What if my baby is allergic to formula ingredients?  I really need to be exclusively breastfeeding right now to help my body regulate my hormones.”  etc.)

Are there alternatives to this course of action?  (“Can I supplement with pumped milk instead?  Can I increase nutrients in my diet or take vitamin supplements to pass them on through my breastmilk?  Do I need to try feeding longer or more frequently?  Can I meet with a lactation counselor or consultant to make sure my latch is correct and the baby is getting all of my milk?”)

What if we wait on taking this course of action?  (“Let me try some of these other things first, and let’s see how the baby is doing at his next two checkups.”)

Helpful phrases:

We’re on the same team here.  We both want what’s best for my child.  I just need to understand exactly what you think is best so I can be comfortable with the decision we make together. (Lead into above questions)

I’m not sure I understand.  Can you provide clarification?

Could I please see the policy?

I’m willing to assume that risk, and I’ll sign a waiver of liability if you provide one.

Could I please speak with someone who is more familiar/comfortable with the breastfeeding process?

I’m a parent trying to do what’s best for my {sick, hurting} child.  Please have patience with me as I try to figure this out.

Please check the baby’s notes for the PCM’s orders on breastfeeding.  If there are questions, you’ll have to contact the PCM.*

*Ask your baby’s PCM to write a note ordering that the child will be breastfed through needle sticks, blood draws, IV’s, catheterizations, or any other unpleasant procedures.  No one can override a doctor’s order.

Have you seen the latest research on this?  (Direct to Academy of Breastfeeding Medicine at http://www.bfmed.org, or have research summary printed out in advance.)

I need some time to research this information.  What is the best way to contact you if I have more questions?

Read more about Mom2Mom KMC here. Visit them on Facebook.

[Please note change made 7/15: Dr. Whyte currently works at Pediatricare of Northern Virginia, not Olde Towne Pediatrics.]

OB/GYN sheds light on creating breastfeeding culture

alison_stuebe_abogMaternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine Alison Stuebe, MD, MSc recently wrote Breastfeeding and depression: It’s Complicated,  a fascinating post on the Academy of Breastfeeding Medicine’s blog. Her work is of such value because she recognizes that overstating the “benefits” of breastfeeding sometimes negates the reality of the experience for mother infant dyads.

Particularly intriguing is the story Stuebe tells of a mother who admits experiencing more concern about her milk production and her relationship with the pump than mothering her crying infant.

“When we emphasize breastmilk, we have completely misunderstood the biology of infant feeding,” Dr. Jack Newman replies in the post’s comment thread.

Stuebe fills me in on a theory that explains this woman’s (and other’s) obsession with milk production. Dr. Barbara L. Frederickson, Kenan Distinguished Professor of Psychology and Principal Investigator of the Positive Emotions and Psychophysiology Lab at the University of North Carolina, argues that obsessive passion comes from negative reinforcement.

“When we talk too much about the evil agents in formula, we risk creating obsessive passion,” Stuebe explains.

She describes obsessive passion this way: A fervid runner injures her ankle. Although continuing to run on that injury will decrease her chances of healing, she continues to do so. Her passion triumphs in an obsessive fashion and she ultimately risks destroying her ability to run all together.

On the contrary, a runner who exhibits harmonious passion will nurture her injury so not to risk the chance of never being able to run again.

Stuebe relates this analogy to the breastfeeding mother. If the risks of formula feeding are so ingrained in her mind, she may be motivated to neglect her child’s needs just as long as she never allows that baby to consume “rat poison”, or formula as Stuebe half-jokingly puts it.

Too often, breastfeeding advocates (including myself) become so hung up on the evils of formula that we leave mothers who do not successfully breastfeed in the dust with no other way to connect with their babies; hence the baby left to cry while mother squeezes out her last drop of milk.

Stuebe’s current research on breastfeeding and depression questions conventional thoughts about infant feeding and its relationship to the way mothers and infants connect.

If you look at a population of several hundred three-month-olds, you will find that more of the depressed mothers bottle feed, Stuebe explains.

However when longitudinal studies are considered, it’s hard to argue, “If she would just breastfeed, she wouldn’t be depressed,” Stuebe continues.

The study’s current results about oxytocin and depression are provoking.

“It could be that mothers who have lower oxytocin levels have trouble with breastfeeding and also feel more anxious and depressed,” Stuebe reflects in Breastfeeding and depression: It’s complicated. “Or it could be that, for mothers whose baseline oxytocin is lower, breastfeeding gives them a boost that’s essential for them to feel connected to their babies.”

She concludes, “The nuances of the biology suggest that doctors absolutely need to think about the effect of breastfeeding on a woman’s mood symptoms.”

Tackling a fragmented health care system

In fact, all health professionals caring for the mother infant dyad need to practice with this suggestion in mind.

Because of the nature of fragmented care in our nation, lactation professionals are often the only caregiver assessing the mother and baby as a couple.

“We’re that glue and we need to be watching really carefully,” Stuebe says.

She gives us simple advice and reminds us that the Edinburgh Postnatal Depression Scale or EPDS is a very easy test to administer to measure postpartum depression. It takes about five minutes and is translated into many languages.

Although there is sometimes a harmful disconnect between mother and baby providers, Stuebe says that there are breastfeeding medicine practices that serve to bridge the gap springing up around the country.

For instance, MilkWorks located in Lincoln, Neb. offers support from a variety of lacatation professionals including a medical doctor, lactation counselors and consultants, nurses, breastfeeding educators and dieticians.

In Chapel Hill, N.C., women have access to the Women’s Birth and Wellness Center which also offers lactation care within the community.

For the mother suffering from PPD, these centers offer an alternative to medication that might ultimately require her to stop breastfeeding.

While many communities are developing support centers for mother infant dyads, there is still a lot of scatter within our system. Stuebe says it would be ideal if these services were offered at YMCAs for instance, or if family physicians were able to provide a kind of “one-stop shopping” experience.

Stuebe says that pushing health care to be more woman-centered in general is a huge step in the right direction. To accomplish this, we need innovative ideas, new models, and new approaches.

Considering all of the science

“Those of us involved in breastfeeding advocacy need to be thoughtful about how we talk about the science,” Stuebe explains.

Getting people excited about breastfeeding research is a start, but it only goes so far. For the non-believers, the breastfeeding skeptics, getting a roomful of people fired up about breastfeeding makes them think, “This is a cult,” Stuebe half-heartedly chuckles.

(She makes clear that she is part of the cult, so she says that with love.)

It’s important for breastfeeding advocates to remain open about the research that doesn’t confirm what we already believe. Similarly, we should consider the studies that completely turn what we once believed upside down.

Stuebe explains that it’s too easy to dismiss new research on the grounds that someone involved in the process received money from a formula company. Instead, we should look at the findings critically.

Stuebe’s breastfeeding wisdom doesn’t end here.

Saving nipples two ears at a time

She suggests we remain receptive with clients as well.

“Communication starts with listening,” she says.

Lori B. Feldman-Winter, MD, MPH, Head of the Adolescent Medicine Division at Cooper University Hospital and National Faculty Chair of the Best Fed Beginnings project once offered Stuebe this analogy to consider: A doctor asks a pregnant woman if she plans to breastfeed. The woman replies that she’s apprehensive because she’s uncertain she wants to have her nipples pierced. The doctor explains that the holes for breastfeeding are already in place. “Well in that case, of course I’ll breastfeed,” the woman responds.

Feldman-Winter suggests always starting conversation with a parent by asking what he or she has heard about breastfeeding. Listening saves nipples!

Creating conversation in the workplace

Conversation is crucial among lactation professionals’ colleagues as well. Fittingly, Stuebe tells me about a book called Crucial Conversations: Tools for Talking When Stakes are High which discusses how to establish mutual purpose and mutual respect.

Establishing collaborative relationships within the workplace can be especially valuable in the hierarchical field of medicine.

Perhaps a misinformed doctor gives a patient incorrect breastfeeding advice. Stuebe suggests lactation professionals respectfully question the physician’s information privately. She advises resisting the urge to shout, “You stupid fool!”

“Feeling stupid in front of the patient doesn’t feel particularly good,” she explains.

When physicians are the least knowledgeable about breastfeeding, it can either motivate them to learn, or it can turn them off completely; they may decide that breastfeeding isn’t their problem, Stuebe tells me.

She adds that unfortunately there is no culture in place that dictates offering proper breastfeeding support is the physician’s responsibility.

Considering the breastfeeding OB/GYN

As a mother of three boys, Stuebe is able to speak not only to the physician’s experience but also to that of the breastfeeding OB/GYN.

The training process is generally unfriendly to nursing mothers, she tells me. Demanding schedules often don’t allow time for pumping. And when there is time, co-residents sometimes see a mother’s need to pump as an excuse to dump her work on someone else.

Sadly, when nursing OB/GYNS aren’t supported in their breastfeeding journeys, their guilt and anger can sublimates into their general perception of breastfeeding. The same might happen if an OB/GYN’s partner had a difficult time nursing.

Fortunately, Stuebe reports being blessed with a supply that withstood extended spans between pumping.

She started her internship the first day her son turned three months old and recalls “walking down Brookline Avenue to Brigham and Women’s Hospital with a Pump-in-Style slung on [her] back and a vague determination to breastfeed.” [Retrieved from: https://bfmed.wordpress.com/2012/11/16/building-a-breastfeeding-culture/]

Her decision to breastfeed was hardly influenced by medical school as breastfeeding was “not really in the mix at all.” Most of her initial breastfeeding education as a mother was self-sought; reading So That’s What They’re For and observing her sisters’ breastfeeding adventures. Stuebe says that breastfeeding eventually defined her as a mother.

“Breastfeeding became the one thing they couldn’t take from me,” she says of her time interning. “They could take my soul, sanity and sleep, but they would not keep me from nursing my baby.”

In Building a breastfeeding culture, Stuebe further explains what motivated her to nurse her children.

Sharing her stories

Perhaps it is Stuebe’s willingness to share her personal experience that makes her contributions to the field of lactation so extraordinary. She is so human, so humble yet so outstanding.

Take her Twitter description for example: High risk obstetrician, aspiring midwife, Breastfeeding researcher and advocate, mom of three. Aspiring midwife catches my eye.

“I love low risk birth,” she explains. “I believe in physiology, but I think that even in the sickest patients I’ve taken care of, I try to remember that this is still a life event for them.”

She recalls a mother with severe cardiac arrhythmia who birthed her baby in “low lights and lovely ambiance” with the cardiac intensive care unit outside the door. Her baby went skin to skin immediately after birth and latched within the first four minutes! Stuebe remembers the image of the baby’s small hand resting on its mother’s defibrillator pad.

Stuebe has worked closely with the Massachusetts Breastfeeding Coalition, helping with web design and a variety of educational initiatives. She’s currently involved with the Carolina Global Breastfeeding Institute at UNC where she serves as an institute-associated faculty member.

In her pre-medical life, Stuebe worked as a journalist which she says has significantly influenced her ability to communicate with the public and her patients.

To read more about Stuebe’s work, visit the Breastfeeding Medicine blog here and her compilation of articles at the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM) here.

Take chances, make mistakes, get messy

kathy_2012I was thrilled to have the opportunity to speak with health psychologist and lactation professional Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA a few weeks ago. I was equally thrilled when she mentioned The Magic School Bus during our interview. (For those of you unfamiliar with it, The Magic School Bus is a series of children’s books about Ms. Frizzle, a sprightly grade school teacher, and her class’ journeys aboard an anthropomorphic school bus to places like outer space, the past and my favorite, the human body.)

Kendall-Tackett tells me the best piece of professional advice she’s received is to allow yourself to make mistakes. She quotes Ms. Frizzle, “Take chances, make mistakes, get messy.”

While I failed to ask her if she drives a school bus or wears funky science-themed dresses, Kendall-Tackett is a bit of a Ms. Frizzle herself. As founder of UppityScienceChick.com, she shares Ms. Frizzle’s fascination with science and offers a forum for sharing current and noteworthy research on the mind-body connection.

Because of the career path she chose, Kendall-Tackett says she knew she wasn’t going to fit into a traditional mold.

“I had to find a way to make it work for myself,” she says.

Her entrepreneurial spirit allowed her to create a brand for herself but calls it a “weird balance” between her academic background and self-marketing. She claims five main job titles: author, editor, publisher, speaker and science chick.

“It’s been an interesting process, something I’ve kind of had to learn along the way,” she says of entrepreneurship.

One of Kendall-Tackett’s newest and most exciting ventures is the launch of Praeclarus Press, a small press that focuses on women’s health. It offers e-books, webinars, and uplifting art, uses new, eco-friendly publishing technologies, donates a portion of sales to worthy organizations that support women and children in the U.S. and abroad, and offers low cost products to provide information to the widest possible audience. [Retrieved from: http://www.praeclaruspress.com/About-Us.html]

In her Shift Happens: How Scientific Paradigms Change and Why These Shifts Should Matter to Lactation Consultants editorial, Kendall-Tackett discusses Thomas Kuhn’s work exploring how scientific revolution occurs. Relating his findings to the work of the lactation professional, she explains that it is not in our best interest to accept all new ideas, but that it can be equally detrimental if we shut ourselves off from all new ideas.

In a sense, Preclarus Press’s mission stands in line with this notion.

“If we can put new information out there, we do our best to promote change,” Kendall-Tackett explains.

For instance, she calls The Virtual Breastfeeding Culture: Seeking Mother-to-Mother Support in the Digital Age  by Lara Audelo, CLEC a “game-changer.” It offers lactation professionals advice on how and why they should connect with their clients through various social media platforms in a world of expanding digital communication.

Kendall-Tackett admits, “I haven’t even scratched the surface with what you can do with social media.”

Still, she’s active on Facebook. Even more, she offers mothers and health professionals innovative, evidence-based breastfeeding information on a variety of web-based platforms.

Of her many accomplishments, she and co- investigator Tom Hale received the John Kennell and Marshall Klaus Award for Excellence in Research in 2011 for the Survey of Mothers’ Sleep and Fatigue.

Kendall-Tackett tells me she finds inspiration for her research from concerns mothers express. Like when a mother sparked Kendall-Tackett’s interest to begin the Survey of Mothers’ Sleep and Fatigue after the mother admitted to co-sleeping on couches and sofas with her infant.

“My reaction was we need to find a way to document this,” Kendall-Tackett says.

Her research exploring normal maternal infant sleep behavior contributes to safe and realistic sleep recommendations for mothers and infants. Watch her short video Safe Sleep with Your Baby here.

Kendall-Tackett expresses hope that her research will counter standard policy. She has made her slides and much of her other work readily available to the public so that lactation and health care professionals have the evidence they need to push policy change within their communities. Kendall-Tackett calls it a grassroots effort.

Along with policy change, Kendall-Tackett emphasizes the importance for lactation professionals to build a relationship with a mentor.

“Having good teachers makes a tremendous difference,” she says.

And mentorship can be a two-way street. Upcoming lactation professionals possess digital skills that the older generation lacks.

A combined effort of all maternal infant health advocates have led to amazing strides in the protection, promotion and support of breastfeeding.

“I’ve really seen a lot of forces come together in an unprecedented way,” Kendall-Tackett says.

Kendall-Tackett and I agree that the general public is still missing an important angle when it comes to breastfeeding.

“If people can get breastfeeding right, a lot of other things take care of themselves,” she says.

While it doesn’t eradicate all of the problems, it has a significant positive influence on many of them like infant mortality, maternal depression and fatigue and child abuse.

Still, Kendall-Tackett would like to see more work done around childhood abuse and its effects on the breastfeeding experience. She has previously published work on this topic: http://jhl.sagepub.com/content/14/2/125.short.

Kendall-Tackett puts the notion of change into perspective when she explains that we don’t have to wait for sweeping societal changes. If we help one mom at a time, we’re getting there. Helping one mom can be just as significant as helping a community of them.

While Kendall-Tackett advocates for breastfeeding in the highest regard, she reminds us that overly generalized messages can be harmful.

Recalling watching a baby placed skin to skin on a new mother for the first time, she advises caution when promoting skin to skin for every new mother. Instead of experiencing the expected cascade of love hormones, as a sexual abuse survivor,  this mother recoiled in horror.

Lactation caregivers should always be cognizant of the fact that while we have the potential to positively influence a mother’s breastfeeding experience,  we also have the potential to make a mother’s experience worse if support is not offered in a cautious, sensitive and nonjudgmental manner.

Kendall-Tackett has spoken twice at Healthy Children Project’s International Breastfeeding conference in recent years; once sharing her knowledge on postpartum depression and another on sexual abuse and breastfeeding.

Visit her websites at http://www.BreastfeedingMadeSimple.com/, http://www.uppitysciencechick.com/, http://www.kathleenkendall-tackett.com/ and http://www.praeclaruspress.com/.

Lactation professional contributes to New Hampshire’s breastfeeding success

lisa picI started the interview like this: Congratulations on being ranked number one for perinatal care for the fifth year in a row. I know a lot of the work you do contributes to great outcomes for moms and babies in New Hampshire.

She replied so seriously: How do you know that?

Not at all expecting that response, I stuttered; the words stumbled out of my mouth: Well, all the work you do with breastfeeding. That’s what really matters.

Lisa Lamadriz, RNC, IBCLC is one humble woman. Before our interview, I read and heard a lot about her, leading me to believe that she indeed does have a lot to do with NH’s great perinatal care.

Lamadriz works at Dartmouth Hitchcock Medical Center (DHMC), a Baby-Friendly tertiary care center where she heads the Baby-Friendly team. In 2007, she created lactation support programs for families with infants at Children’s Hospital at Dartmouth’s (CHaD) Intensive Care Nursery (ICN). She created a nutrition group that provides staff education. [Retrieved from: http://chad.dartmouth-hitchcock.org/documents/pdf/chad_matters_winter_2007.pdf] She serves as New Hampshire Breastfeeding Taskforce’s co-chair. She contributes to CHaD’s breastfeeding episodes. And the list goes on.

During our chat, Lamadriz continued to prove that she and the collaboratives she’s a part of have a lot to do NH’s breastfeeding success.

As stated, back in April, the 2011 Maternity Practices in Infant Nutrition and Care (mPINC) Survey results from the Center for Disease Control and Prevention (CDC) showed New Hampshire as number one for the fifth straight year in perinatal care practices associated with breastfeeding success. The New Hampshire Department of Health and Human Services (DHHS) says the survey results are due largely to the efforts of the New Hampshire Ten Steps to Successful Breastfeeding Program, headed by Dartmouth-Hitchcock’s Bonny Whalen, MD. [Retrieved from: http://www.dhhs.nh.gov/media/pr/2013/04-apr/04032013survey.htm]

The Ten Steps program began as a hospital-based project but has grown into a state-wide initiative. DHMC’s journey to Baby-Friendly began about 15 years ago, but the facility recently revamped their efforts in 2009. The hospital was awarded designation in 2012. Read more about their efforts here: http://www.dartmouth-hitchcock.org/news/newsdetail/61662/.

Lamadriz tells me families have often told her they chose DHMC for their birthing experience specifically because of its Baby-Friendly designation; a great marketing tool as Baby-Friendly USA project manager Liz Westwater explains in Baby Friendly Hospitals decrease traumatic birth experiences, increase breastfeeding rates.

Getting DHMC staff excited about Baby-Friendly designation started with a large skin to skin campaign. Before the implementation of the Ten Steps began at the facility, Lamadriz admits that while they thought they were doing a great job getting babies skin to skin, they realized they could do a lot better (even with about a 30 percent population of high risk deliveries).

So bulletin boards showing evidence of the effectiveness of BFHI went up throughout the hospital. Staff champions mingled with resistant staff members.  Physician champions spread the word about breastfeeding.

Lamadriz names Dr. Whalen one of those physician champions. As a pediatrician, medical director of the Newborn Nursery and a certified lactation consultant, her positive influence on breastfeeding spreads far and wide. Even more, Lamadriz tells me she’s passionate about integrating breastfeeding education and support into young physicians’ curriculum.

Neonatologist Juliette Madan, MD, MS is equally encouraging about breastfeeding and breastmilk feeding. Her efforts allowed for an update of the ICN’s feeding guidelines. Mothers are now encouraged to provide colostrum for baby before any kind of supplementation is offered. Lamadriz says babies are never just automatically started on artificial baby milk.

“The gut is so fragile,” she explains. “It really needs that colostrum before we put anything else on it.”

The ICN’s support and patience with breastmilk feeding low birth weight babies has played a part in allowing the facility to significantly decrease the use of non-medically indicated formula supplementation. In fact, Lamadriz says their breastfeeding initiation rates are close to 98 percent. Any breastmilk feeding at time of discharge varies between 45 and 60 percent.

Because of the size of the facility, Lamadriz says it’s often difficult to engage everyone in the Baby-Friendly process, a common challenge facilities face when working toward designation.

However like many other successful Baby-Friendly facilities, DHMC formed a multidisciplinary quality improvement team comprised of clinicians including those from CHaD, the Prenatal Clinic, Birthing Pavilion, Newborn Nursery, INC, Pediatrics, Food and Nutrition Services, Finances and Purchasing to ensure every care provider a mother comes in contact with supports her breastfeeding goals. [Retrieved from: http://www.dartmouth-hitchcock.org/news/newsdetail/61662/]

“Our biggest improvement was in the area of prenatal breastfeeding education in the clinic,” Lamadriz says in a DHMC news release. “We updated our patient education materials, and created a process with the staff in the prenatal clinic to provide small amounts of breastfeeding education at each prenatal visit.”

While DHMC excels in its prenatal breastfeeding education, it still struggles with sustaining Baby-Friendly’s rooming-in model.

“Nurses feel like they are doing mom a favor if they take baby out for sleeping,” Lamadriz tells me, yet another common but not unconquerable challenge.

By improving prenatal education, Lamadriz says parents are better able to advocate for their families.

“They actually drive the practice,” she says. “They really take the initiative of keeping their baby with them.”

Postnatally, DHMC offers lactation support services including a Lactation Clinic and referrals to support groups like the Women’s Health Resource Center.  We know that continuity of care is essential when supporting moms’ breastfeeding goals, so DHMC lactation professionals make sure to communicate with mom and babys’ other health care providers.

Lamadriz says she and her co-workers connect with other maternal child health programs in NH through the state’s breastfeeding taskforce. Representatives from different organizations including WIC, universities, La Leche League and the Department of Health and Human Services (which heads the obesity prevention program) work toward a common goal to support breastfeeding throughout the community.

Members of the 10 Steps Collaborative including Lamadriz, Whalen, Joyce Kelly, RN, MPH and  Dr. Alison Holmes of Concord Hospital and Dartmouth-Hitchcock have educated staff at six  of the 20 birthing hospitals in NH about the 10 Steps program.

Through a survey, Lamadriz says they learned that one of hospitals’ biggest barriers to become Baby-Friendly is the cost of educating their staff. Lamadriz provides education and skills days to facilities in need.

“Hospitals are really working on the ten steps and trying to improve,” Lamadriz says. “I’m hoping that will increase our [breastfeeding] duration rates.”

According to the CDC’s 2012 breastfeeding report card, NH’s exclusive breastfeeding rates at six months came in just under 25 percent, about ten percentage points higher than the national average. While NH’s duration rate is one of the highest in the nation, 25 percent of babies breastfeeding at six months is still arguably a very dismal number.

The 10 Steps Collaborative provides education across the border to Maine’s Let’s Go! program, an initiative to reduce obesity that includes a breastfeeding component. Maine’s exclusive breastfeeding rates at six months come in just above 15 percent.

Despite the somewhat gloomy numbers, Lamadriz says she is very optimistic about future birth and breastfeeding outcomes in our country.

“I think we have a lot of work to do and I sometimes worry about the hightechness of everything,” she says. “But I am optimistic because I do see the younger mothers reading about breastfeeding and knowing a lot when they show up for their appointments.”

Lamadriz says it’s sometimes difficult to get people to slow down and recognize the importance of the biological and anthropological connection between mom and baby.

“It’s my generation’s responsibility to make sure young women are aware of how important this special time is.”

Lamadriz will take her responsibility to the next level this fall when she attends Boston University’s Master of Public Health: Maternal Child Health program. As a graduate of Union Institute and University’s Bachelor program in Maternal Child Health: Lactation Consulting, she says she gained a more global perspective on maternal child health issues. (The Healthy Children Project collaborates with UI&U to provide the lactation content of this degree program.)

“I became keenly aware of the horrible things happening to women and girls,” she says. “It flipped me upside down. Something inside of me said, ‘OK, now you know this so what are you going to do?’”