Celebrating Infant Mental Health Awareness Week

This summer, we are revisiting some of our previous publications as they relate to various national celebrations. 

This week is Infant Mental Health Awareness Week, so we are re-sharing “Breastfeeding is…” a 2014 piece. Based on an interview with Barb O’Connor, this piece describes how breastfeeding is so much more than nutrition, including establishing secure attachments which are fundamental to infant mental health. 

——

With a gentle pulsing of the sand, a baby sea turtle emerges from her hatching place. She breathes the salty ocean air and immediately begins her race to the rushing tide. She dodges stealthy crabs and gulls, mounts beach debris and endures what seems like an endless journey. Programmed for survival, she plunges into the abounding ocean, her lifeline.

Worldwide, there are over 70 conservation laws and regulations that protect sea turtles.

Not far from the briny ocean breeze, a mother hears her infant cry as she enters the world outside of the womb for the first time. Placed on her mother’s abdomen, the baby relaxes for several minutes until she begins to awaken. Soon, she makes mouthing and sucking movements signaling her interest in her mother’s breast. She leaps and crawls upward with intermittent periods of rest. When she reaches the breast, her hands become increasingly active and she familiarizes herself with her mother’s nipple. She suckles enjoying her first few sips of thick colostrum. After the first feed, she will rest again in the arms of her mother, her lifeline. [For more information about the 9 Stages visit: http://www.magicalhour.com/aboutus.html]

When a newborn is given the opportunity to practice early survival skills, amazing things happen.

But all too often, the newborn’s programming is interfered with by well-meaning health care professionals and popular, although non evidence-based health care practices.

“Our culture really discredits the importance of early beginnings,” Healthy Children faculty Barb O’Connor, RN, BSN, IBCLC, ANLC says. “If we protect and nurture mothers and infants, that’s going to impact future outcomes.”

Barb O’Connor (back left) pictured with colleagues from HCP and ALPP.

She goes on,  “Mothers and infants really have a synergistic recuperation from birth and if breastfeeding is supported and not interfered with, both parties are able to develop in a manner that leads to positive health outcomes.”

O’Connor discusses several cultural components that make establishing normal, healthy beginnings nearly impossible for families.

Our culture urges independence. Mother and baby are expected to properly function away from one another immediately after birth. Most birthing facilities don’t encourage or appropriately support the important practices of skin to skin contact or even rooming in.

Moreover, mothers are often expected to return to work or school while they are still bleeding from childbirth.

“There are other cultures that really value moms and babies and you can see it in the legislation,” O’Connor says.

Differently, our country provides mothers with zero paid maternity leave.

To be fair, there have been strides made in terms of promoting, protecting and supporting breastfeeding families in our nation. The Baby-Friendly Initiative (BFI) offers more and more families the opportunity to successfully breastfeed for instance. Particularly, BFI advocates for babies by requiring the facilities to provide the healthiest practices for mom and baby. O’Connor calls skin to skin contact and rooming in essential practices for all babies regardless of feeding method.

Still we have a lot to grasp, especially when it comes to older breastfeeding babies and children.

“Because we focus so much on breastfeeding being nutrition, our culture doesn’t really understand what breastfeeding really is for infants over one,” O’Connor says.  “We don’t understand as a population that nursing becomes a source of joy and communication and a way of life that should only be discontinued as mother and child mutually desire.”

O’Connor is particularly interested in the value of breastfeeding beyond nutrition.

“The delight I witness in the eyes of a baby who is nursing is indescribable; it is pure, unadulterated joy,” she says. “Every baby deserves the right to experience this loveliness.”

And skin to skin and breastfeeding are lovely in so many ways.

Breastfeeding is a stabilizer.

When a mother holds her baby skin to skin to breastfeed, she regulates her baby’s body temperature, heart and breathing rates, stress and glucose levels just to name a few. [For more information see these publications on skin to skin contact.]

O’Connor is fascinated by the findings of Dr. Nils Bergman and KH Nyqvist. Bergman, Nyqvist and colleagues have discovered that if the mothers of low birth weight babies practice Kangaroo Mother Care (KMC), they learn to breastfeed at incredibly young gestational ages. KMC also supports increased brain development and decreased mortality for low birth weight babies.

O’Connor’s daughter Brandy, mother and full-time caregiver of a special needs son who, born at 25 weeks gestation (now 5 years old), spent 110 days in the NICU, will speak at Healthy Children’s upcoming International Breastfeeding Conference about her experience with KMC and breastfeeding. She will share her perspective of the emotional turmoil, hospital practices, and challenges experienced by mothers of infants in the NICU.

“It has taken her a long time to come to a place where she could talk about this,” O’Connor says of Brandy’s experience. “I am extremely excited for my colleagues who work in the NICU to hear her perspective on how the experience affects new mothers”.

Breastfeeding is empowering.

The symbiotic relationship between breastfeeding mother and child and the infant’s programming for survival has a profound impact on the mother’s physical and mental well-being, O’Connor explains.

She continues that a child’s desire to breastfeed for comfort can be empowering. No one else but the mother has the capacity to console an upset child the way she does.

In Breastfeeding: A Feminist Issue, author Penny Van Esterik explains the many other ways breastfeeding is empowering including:  “breastfeeding confirms a woman’s power to control her own body, and challenges the male-dominated medical model and business interests that promote bottle feeding” and ”breastfeeding requires a new definition of women’s work – one that more realistically integrates women’s productive activities.”

Breastfeeding is immunity.

Maternal body flora and milk prime an infant’s immune system in a way that cannot currently be replicated and offers beneficial lifelong effects. O’Connor cites Lars Hanson’s immunology of breast milk research.

“A fully breast-fed infant receives as much as 0.5-1 g of secretory immunoglobulin A (SIgA) antibodies daily, the predominant antibody of human milk,” authors of Breast feeding: Overview and breast milk immunology write. “This can be compared to the production of some 2.5 g of SIgA per day for a 60 kg adult. These SIgA antibodies have been shown to protect against Vibrio cholerae, ETEC, Campylobacter, Shigella and Giardia.”

Breastfeeding is communication.

“If I see a baby who looks anxious or isn’t taking the breast well, it’s an immediate sign that something isn’t right in baby’s life,” O’Connor says.

As stated babies seek the breast for survival, so if baby refuses to breastfeed, they are communicating in a non-verbal way, she continues. Perhaps baby is ill or injured. When circumstances like these arise, it is important that the dyad receive help from a lactation professional who can assist with investigating the problem.

O’Connor reminds lactation professionals that it is always important to practice from a current, evidence-based perspective and to possess appropriate counseling skills.

“Most moms want to breastfeed,” she says. “It’s a matter of figuring out how to fit it in her life.”

Breastfeeding is regulatory.

A breastfed baby is offered control over the amount of milk she ingests whereas a bottle-fed infant’s intake is usually dictated by the amount of milk in its artificial container.

Consequently bottle feeding, regardless of the type of milk, may have future implications on obesity.

“Infants who are bottle-fed in early infancy are more likely to empty the bottle or cup in late infancy than those who are fed directly at the breast,” authors of Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? conclude.

Breastfeeding is survival.

O’Connor suggests we reevaluate our definition of survival. Survival goes beyond the performance of simple body functions.

“We have to look beyond that at a more encompassing definition,” she says. “Babies who are breastfed have a different potential for intellectual and interpersonal relationships.”

In fact, authors of Breast feeding and intergenerational social mobility: what are the mechanisms? conclude that “Breast feeding increased the odds of upward social mobility and decreased the odds of downward mobility.”

The effect was mediated in part due to stress mechanisms,” O’Connor comments.  “This is really fascinating.”

Breastfeeding has become of international concern because it offers protection against infant mortality. The World Health Organization’s Millenium Development Goals include breastfeeding as a strategy to combat child malnutrition and reduce child mortality.

In “Breastfeeding and Infant-Parent Co-Sleeping as Adaptive Strategies: Are They Protective against SIDS?” included in Breastfeeding: Biocultural Perspectives, James J. McKenna and Nicole J. Bernshaw explore the epidemiological studies that suggest that breastfeeding may be protective against SIDS.

What does breastfeeding mean to you? How else is breastfeeding more than nutrition? Please share your thoughts in the thread below.

 

Other relevant pieces

Field of lactation gains child psychologist

Cheap medicine: laughter

Implications of mother baby separation

Continuing the conversation about language use in perinatal health

What is ‘appropriate’ language? What one might consider distasteful, hurtful, impactful, another may consider harmless or meaningless.

Photo by Miguel Á. Padriñán

Take this exchange offered by Ravae Sinclair, JD, CD (DONA), LCCE at the early 2020 International Breastfeeding Conference for example:

A white-presenting lactation professional working with a black mother and her baby shortly after birth exclaimed something along the lines of, “Awww, look at him, he looks just like a little thug!” commenting on the slight sag in his newborn hospital cap.

“Little thug”– a heavily loaded term generally carrying negative connotations– was understandably a trigger for the mother. She shut down no longer feeling safe in the space and asked to be discharged early. Most likely, the lactation professional did not intend to offend, but the impact of this short exchange has much further reaching consequences than the intention itself.

We have explored the impact of language to a relatively great extent here on Our Milky Way. You can check out these pieces for examples:

In a recent exchange, Nikki Lee added to this ongoing conversation about language in maternal child health. She shared an observation about how “the media rarely misses a chance to plant negative seeds in the public’s mind about breastfeeding”.

Citing an example from a PubMed alert that morning– Sudden Death in a Breastfeeding Woman with Arrhythmogenic Mitral Valve Prolapse— Lee commented “I ask you, how in the world does the infant feeding method have to do with the death of this mother? She had some kind of cardiac defect; pregnancy and labor place huge stresses on the cardiovascular system. What would you think and how would you feel if you saw a headline ‘Sudden death in a formula feeding woman with arrhythmogenic mitral valve prolapse’?”

Julie Smith’s, et al 2008 paper Voldemortand health professional knowledge of breastfeeding – do journal titles and abstracts accurately convey findings on differential health outcomes for formula fed infants?  “showed a surprising ‘Voldemort effect’ in the studies examined; formula feeding was rarely named as an exposure increasing health risk in publication titles or abstracts.” The authors conclude that “ If widespread, this skew in communication of research findings may reduce health professionals’ knowledge and support for breastfeeding.”

In her own reflection on the use of language in perinatal support, Donna Walls, RN, BSN, ANLC shares her guest post Our words need to send a supportive message- how can we do it? this week on Our Milky Way.

——

As a child I often repeated “sticks and stones can break my bones, but words can never hurt me”. As an adult, I know this is not true. Words are powerful. In our breastfeeding advocacy world, words can be used to build a new mother’s confidence, or they can be used to undermine it. Below, I offer you some of my pet peeves,  words and phrases we commonly use without  thinking about their impact.

Source: United States Breastfeeding Committee

First, maybe the most common and certainly one of the most harmful is talking about “milk coming in”. We know that the number one fear of new moms, especially first-time moms, is not having enough milk. In the first days after birth,  there aren’t often  visible signs of milk production. New parents have often heard about engorgement and how breasts get so full, they look like they are ready to explode. But, they see no signs of exploding breasts in the first one to two days after birth. They may be able to express drops which is encouraging but no big reassurance that there is plenty for their baby.

We often see at about two days of age the occurrence of “cluster feeding” when their quiet, precious newborn seems ravenous and so, so hungry. Many moms think, or unfortunately are told, that this is a sign of not having enough milk. This is not even slightly, vaguely true but rather a normal newborn feeding pattern. We dutifully tell this anxious mother not to worry; her “milk will come in” in a day or two. The not-so-subtle message is that there is no need to worry about not having milk now, that  it soon will come in.

What has happened is that we have reinforced her biggest worry about not being able to adequately feed her baby. I don’t believe for a minute that this is intentional on our part, really just one of those things we have always said and never really examined the consequences.

I sometimes feel sorry for underappreciated, often ignored colostrum. Maybe it’s time we change the language. So instead of saying “your milk will come in”, might I suggest we instead say “the milk you’ve been making for your baby while you were pregnant is there for the first feeds. It is newborn milk, sometimes called colostrum, and this small volume is all your baby needs in the first hours and days. When you nurse frequently in these first days the newborn milk will change over to mature milk and you will see an increase in the amount as your breasts will become fuller, firmer and heavier.” You can of course  come up with your own wording just as long as new parents get the message that there is milk NOW- not “coming in” later!

Source: United States Breastfeeding Committee

My second pet peeve is judgey diagnoses of flat nipples. Way too often when prenatal breast assessments are done, there is a diagnosis of flat nipples, usually based only on the appearance with no regard to assessing function. Once these misunderstood nipples are labeled, the mother is deemed not quite right for feeding. Silly exercises and gadgets are recommended to make already elastic skin behave appropriately. First point: nipples are erectile by nature, some stand up a lot, some a little. Sadly most new mothers have seen artificial nipples and think they should look like these, not ever recognizing that we have the real nipples so why aren’t bottle nipples more like ours?! When counseling mothers, ask the mom if she notices her nipple erecting in cold weather or with sexual/manual stimulation.

As a clinical lactation care provider for many years, I would often be saddened by the words used to make a mother feel her nipples weren’t quite right, not good enough. I have seen too often women struggling with breastfeeding because they were told even before the baby’s birth that the chances were slim for successful breastfeeding; bad nipples would certainly cause problems.

I am quite sure males are not discouraged about the abilities of their erectile tissue at the onset of sexual activity. This is not to say that there may not be challenges  with inverted nipples; they may cause challenges  when they are retracted enough to not ever be stimulated or stretched for hormonal release, but flat nipples will evert. They just want to do it their way. We need to remind moms that the nipple their baby will prefer is attached to their favorite person.

Third, let’s talk about the term engorgement. By definition, engorgement  is not normal. It is a state brought on by interruptions in the expected initiation of lactation [Source]. Unfortunately, the term is used by professionals and families to mean a fullness in the breasts. Signs of engorgement include hot, reddened, uncomfortably swollen breasts which can be hard for a newborn to correctly latch to the breast. This needs to be distinguished from normal signs of lactation when breasts become rounder, fuller, firmer and heavier. Too often a mother may complain about her breast “engorgement” and interventions are recommended to help reduce the discomfort and swelling when in reality she just needs to be reassured that what she is feeling is normal and actually a good sign that she is producing milk. So, my request is that when a mother talks about her concerns about engorgement, our response needs to be to ask something along the lines of “what exactly are you feeling?” as well as the usual questions of frequency of feedings, adequate output and signs of comfortable  latch.

Source: United States Breastfeeding Committee

Our words can have a profound effect on the success or failure of breastfeeding. A huge part of our job, our responsibility to our patients and their families is to build confidence in their ability to nourish and nurture their newborns. Be aware of the message that is being sent and choose words that will build confidence, be generous with realistic praise and couch our intervention suggestions with success in mind. Ask for parents’ input; we want them to know their thoughts are important to the process!

Reference Cadwell, K. and Turner-Maffei, C.  Pocket Guide for Lactation Management. 2022. Jones and Bartlett. Burlington, MA.

Changing the culture of mother baby separation in one Northeastern hospital

“I got to touch him once and they took him right away from me,” Northern Light Eastern Maine Medical Center labor and delivery nurse Jennifer Wickett says, remembering the birth of her first child 19 years ago.

Wickett desired non-medicated births, but her three children ended up being born via cesarean sections for various reasons. Wickett’s personal birth experiences coincided with her early professional life, working at a hospital in Massachusetts as a labor and delivery nurse.

At the time, she explains, the process was this: the baby was born,  taken to the warmer, vitals and weight were recorded. The baby was wrapped in a blanket and held next to mom’s face for five to ten minutes and then taken to the newborn nursery.

Skin-to-skin in the OR, Healthy Children Project

“I hated that for my patients and I hated that for me,” Wickett says.

So Wickett singularly started changing that culture of mother baby separation.
Now, at Northern Light Eastern Maine Medical Center, Wickett attends about 95 percent of the c-sections, and she says she was able to “take control.”

“[Initially] I wasn’t tucking baby in skin-to-skin, but I was putting baby on top of mom with the support person helping hold the baby,” Wickett explains.
She deemed it the Wickett hold: baby placed chest down on mom with knees tucked under the left breast and baby’s head on the right breast.

Attending a Kangaroo Mother Care Conference in Cleveland galvanized her efforts: the evidence clearly supported skin-to-skin contact immediately after birth and beyond.  Fellow nurses, anesthesiologists and other team members were resistant, but Wickett and a few other fellow nurses who created the Kangaroo Care Committee kept at it, always leading with kindness and communication. Rather than approaching the process with an “I have to do this” agenda, Wickett involves and acknowledges all of the participants in the room.

For instance, to the mother, she asks permission while also explaining the importance of skin-to-skin contact.

“They’re in hook line and sinker when I explain that their body regulates their baby’s temperature,” Wickett explains. “They don’t want to give that baby up; they are not letting that baby go.”

To the anesthesiologist, she facilitates open communication. Wickett lets them know that she assumes responsibility for the baby. “Are you good?” she often checks in with the anesthesiologist, while minding their space to work safely and efficiently.

Wickett  makes certain to involve the partner in their baby’s care, asking them to keep a watchful eye over mom and baby.

Photo by Jonathan Borba

Just about half of the babies she sees begin breastfeeding in the OR, she reports. From the OR, babies are kept on their mothers’ chests as they’re transferred to the recovery room, continuing the opportunity to breastfeed. All in all, Wickett says that babies born by c-section at her hospital spend more time skin-to-skin than those who are born vaginally.

After a vaginal birth, eager nurses often disturb skin-to-skin contact to complete their screenings and documentation. Excited partners wanting to hold their baby tend to do the same.

In the OR though, Wickett says there are at least 30 minutes without these disruptions.  Once mother and baby are transferred to the PACU, mothers report decreased pain when skin-to-skin is practiced.

What’s more, Wickett reports hearing often “This baby is such a good breastfeeder!” because the babies have an opportunity to initiate breastfeeding within the first two hours of life.

The World Health Organization (WHO) recommends that immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 grams with experienced staff if assistance is needed), after all modes of birth. The recent Skin-to-skin contact after birth: Developing a research and practice guideline synthesizes the evidence. [Read more here.]

Skin-to-skin, Healthy Children Project

Wickett and seven other colleagues had the opportunity to complete the Lactation Counselor Training Course (LCTC) last year.
While she says she would have loved to have been able to take the course in-person, Wickett still found the material and resources “fabulous.”

For the past four years, there’s been a vacancy in the perinatal coordinator position at her hospital, so Wickett hopes that her new credentials will allow her to fill the need.  In the meantime, Northern Light Eastern Maine Medical Center offers outpatient lactation visits. The center’s breastfeeding support groups halted during the height of COVID and have yet to resume; Wickett reports that they are trying to bring those back virtually.

Additionally, Maine residents have access to the CradleME Program which
offers home-based services to anyone pregnant up to one year postpartum.
In partnership with the Mothers’ Milk Bank Northeast , Northern Light Eastern Maine Medical Center became the first milk depot in the Bangor area.

You can read more Our Milky Way coverage on skin-to-skin after cesarean birth in  Skin-to-skin in the operating room after cesarean birth , The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth , and Skin to skin in the OR.

Also check out Skin to Skin in the First Hour After Birth; Practical Advice for Staff after Vaginal and Cesarean Birth Skin to Skin.

Find some beautiful KMC imagery here.