We all know breastfeeding is critical for both mothers and babies. Most of us are supporters, advocates, counselors, mothers, grandmothers and just generally breastfeeding cheerleaders! We want to help and sometimes it can be hard to know how to help. In a groundbreaking new article, nine unique elements have been identified as modifiable behaviors that can increase breastfeeding success. We always knew there were things we could do! Now we have clear definitions of what those things are. Truly incredible!
The article was recently published in Acta Paediatrica and you can find it here. The research was an observational study conducted in Masaka, Uganda. It looks at 300 newborns in the postpartum unit as well as 166 infants attending the 6-week postpartum clinic. The research team utilized the Lactation Assessment & Comprehensive Intervention Tool (LAT). A tool chosen because it did not aggregate assessment items and has been validated.
What the research found was that there are nine elements that were significantly related to effective breastfeeding: the infant state and feeding cues pre-feeding, four postitioning elements including tummy-to-mummy, infants arms around the mothers breast, the breast not being held or shaped, and the baby’s head being free of restriction, and three latching elements which include the gape, the baby’s head tilt, and the baby’s lower lip reaching the breast first.
I was delighted to speak briefly with Dr. Anna Blair, the lead author on this remarkable paper to ask her few questions on the research and the findings.
Q: What would you say are the key takeaways from the research?
Dr. Blair: There are certain predicable, easily explained things that parents can do to help their baby breastfeeding effectively, before the baby even touches the breast. We found that having the baby tummy to mummy, for example, really matters. It’s best not to hold the breast. Watch that the head is free of restrictions. There’s been a lot of focus on assessing infants already at the breast, but the pre-feeding behaviors and attaching matter.
Q: Was there anything in the results that surprised you?
Dr Blair: Many of these elements we’ve believed for years – written about in numerous texts by experts – but now we have clear findings from research.
I think it was interesting that the baby’s head being free of restrictions mattered more with the infants in post partum than at the 6 week checkup.
Breasts being held have become such a common practice and this research shows it is negatively associated with effective breastfeeding. I was not surprised by that because there has been some previous research on breast shaping having a negative impact on breastfeeding. But look at the images of people breastfeeding and the instructions from hospitals – they largely include breast holding and shaping , which is so unfortunate.
Q: What has you excited about this research?
Dr. Blair: What we found in this study has easy to follow, straightforward ways to improve breastfeeding effectiveness and feeding and I think that is very exciting.
I hope the article sparks as much excitement for you as it did for me and for the research team. I also hope it sparks lots of conversations in your communities and workplaces around these specific, modifiable behaviors and how it might change our practice and the way we help moms and babies.
I was able to sit down with one of the authors of the paper, Dr. Kajsa Brimdyr, to talk about the work and the experiences of the team while in Uganda.
Dr Brimdyr, can you tell us a little about the project?
While the project began in January 2023, planning began a year earlier. We’ve known Scovia Nalugo Mbalinda for many years. She and I worked together in Gulu, Uganda on a skin-to-skin project that resulted in several papers (you can find one here) and the beautiful video Kristin Svensson and I created to educate about skin-to-skin in Gulu. (You can watch it here). Mike was a member of the International Guideline Project workshop that we conducted in Iceland in 2023 (read the guideline here) and it was thrilling to work together again. Our team was interdisciplinary, from the US, Sweden and Uganda, consisting of PhD researchers, an MD, midwives, and breastfeeding specialists along with two Ugandan research assistants. We worked collaboratively with the leadership team at the hospital, including midwives, nursing students and physicians.
When we arrived at the hospital, our team started out by observing births and the newborn behavior. We video recorded newborn behavior starting from birth and continuing for the first hour. This was to get a baseline of what was happening at the facility.
Then, we began to implement the research methodology, PRECESS, which we have used and published about in the past in Egypt (read about it here) and Texas (and here). We began with a training program for staff based on the supplementary material in the International Guideline for Skin to Skin (you can find a copy of the supplementary material here).
True skin-to-skin contact begins immediately after birth and is uninterrupted and continuous, for at least an hour after birth. We also offered guidance for potential challenges. Then, the staff began implementing the guideline: immediate, continuous, uninterrupted skin-to-skin contact for at least an hour after birth for all of the deliveries – every staff member, every shift. It was a change in practice, not just a change for those who were part of the study. The hospital made the decision to change care for all. Then, our research team came back 6 weeks later. Not only were the staff continuing to implement the guideline, but they had also improved their skill with skin to skin.
When staff first see how capable newborns are, as they see the 9 stages for the first time, it’s just so special to me. They can see how much these new babies can do.
There are still challenges ahead. For example, the beds in the labor and delivery are narrow and don’t have side rails, and mothers are worried that the baby might fall off…. and it would be helpful if the unit had beds that are more conducive to skin to skin in the first hour.
What do you think the key take-aways are from the project?
I love that this intervention is quick and easy to implement, and that it is sustainable. It’s possible to make significant change in a short period of time.
Was there anything that surprised you while you were there?
We were not surprised by this, but we were impressed by the collaborative spirit of the team at the hospital. Our research team was at the hospital 24 hours a day and we worked long shifts to cover the time. It was important for us not to just be there for births of only one shift of staff or another, but covering nights, days and weekends. The staff were so warm and welcoming, teaching us their process, and embracing the changes.
Do you have any favorite stories about your time there?
We loved so many parts of our experience doing this research. One thing that was extra fun was the storks. They have these enormous, 5-foot-tall storks, with a wing span of 12 feet! the storks live in that part of Uganda. The maternity hospital had a tree just outside of it filled with these storks. In many parts of the world, storks are a symbol for babies being born. Our team thought it was so special that the storks like to hang out at the maternity unit!
Is there anything else you’d like us to know about your work in Uganda?
There’s more to come! We’ll let you know when the other articles are published!
Let us know what you think or if you have any questions about the newest research paper. And as always, may all your ways be Milky Ways.
Dr. Howard Markel (History of Medicine, University of Michigan) and Ira Flatow discuss in a Science Diction interview the origin of the word cancer citing Hippocrates as “he applied the Greek word karkinos, which means crab.”
Dr. Markel digs deeper: “… if you examine a tumor, if you actually feel a malignant tumor, you’ll note that it’s hard as a rock. And so some have explained that it reminded him of the hard shell of a crab. But others have said it may have reminded him of the pain that a malignant tumor induces. It’s much like the sharp pinch of a crab’s claw. And an even better version is that it suggests the tenacity with which, you know, a crab bites you…And then about 100 years later, another very famous doctor named Galen extended that Hippocratic metaphor even further. He was dissecting a breast tumor. He noticed all the veins and tributaries of malignancy around that mass, and he said it looks just like a crab’s legs extending outward from every part of its body. And so the term really stuck.”
[From the Sarcastic Boob]At any point in the year, cancer will be heavy on many Americans’ minds, because over half of us know someone who’s been diagnosed. Then, during October, we’re bombarded with the color pink, in an apparent breast cancer awareness effort.
The breast cancer awareness industry and our culture at large neglect breastfeeding and the use of human milk in its preventative messaging. Breast cancer research has even been featured on a stamp but never breastfeeding, unlike many other countries over the past several decades. (Check out an amazing collage here.) The St. Louis Breastfeeding Coalition is working to change that through their breastfeeding stamp petition.
Research shows that “not breastfeeding is associated with health risks for both mothers and infants. Epidemiologic data suggest that [not breastfeeding] is associated with an increased incidence of premenopausal breast cancer, ovarian cancer, retained gestational weight gain, type 2 diabetes, and the metabolic syndrome.” [Stuebe, 2009]
Interestingly, an association between breastfeeding and cancer was noted in the late 18th-century by “medical men”.
This TIME article reads: “In 1772, man-midwife William Rowley wrote: ‘When the vessels of the breasts are over-filled and the natural discharge through the nipple not encouraged … it lays the foundation of the cancer.’ Frances Burney – an aristocratic novelist who underwent a mastectomy in 1811 – attributed her disease to her inability to breastfeed properly: ‘They have made me wean my Child! … What that has cost me!’
But as Lee points out, “One has to know what to look for to find a mention of breastfeeding.”
She also argues, “It hasn’t been hard to study; look at the global research.” One study she cites can be found here, and from a quantifiable, preventive aspect, Lee cites Britta Stordal’s work.
“‘Women who had children but did not breast-feed had about 1.5 times the risk for ER/PR-negative breast cancer,’ said Meghan Work, MPH, doctoral student in the Department of Epidemiology and first author. ‘If women breast-fed their children, there was no increased risk for ER/PR-negative cancer. This is particularly important as breast-feeding is a modifiable factor that can be promoted and supported through health policy,’ Work said.”
This message is different from the American Cancer Society’s of course, but it plants skepticism about the possibility of breastfeeding. Read Valerie McClain’s notes on the dubious phrase “if-you-can” here. Also check out our piece Taking ‘if’ out of the equation.
Twenty years ago, Healthy Children Project’s Barbara O’Connor, BSN, ANLC and her local breastfeeding task force attempted to secure a breastfeeding promotion table at a community breast cancer awareness run/walk. She shares about the struggle:
Our local task force decided that this would be very appropriate for us to have a breastfeeding promotion booth; the race was attended by a large number of community participants, and we believed we could reach many people with information about the research regarding the association of decrease in breast cancer with increase in breastfeeding rates. We contacted the race committee only to be told that our booth would be inappropriate at this event. We were very perplexed…
We were not allowed to have a booth the first year. Not disheartened, we requested again the next year. We actually had to have a phone conversation with the race director. Only after much discussion and a great deal of apprehension were we allowed to set up a booth.
[The booth] was incredibly successful. Itwas very tastefully displayed with much information regarding the benefits of breastfeeding emphasizing, of course, the reduction in breast cancer. Many community member stopped to talk and some were very surprised to learn about the research regarding breastfeeding and reduction of breast cancer. The task was pleased to have preserved and then allowed the opportunity to successfully educate the community.
We never did understand why the committee was so hesitant to allow us to participate. There were a host of other booths at this event, the majority being about reconstructive surgery and support after the diagnosis. No booth with the emphasis on prevention. And as soon as the word breastfeeding was mentioned in the conversations with those on the committee, there seemed to be this reluctance to allow the booth. Of course, no members of the committee understood the relationship between breastfeeding and cancer reduction. So, in the end, I suppose it was a good opportunity for education all around.
Acknowledging the cynicism, Lee continues, “One challenge to prevention is that it puts people out of work…The money it costs a woman to treat breast cancer goes to pay for drugs, machines, nurses, doctors and all the other accoutrements of health services.”
That product comes with risks. Author Alison Stuebe writes: “Several studies have examined associations between formula feeding and childhood leukemia based on the hypothesis that immunoreactive factors in breast milk may prevent viral infections implicated in the leukemia pathogenesis.47 Two meta-analyses1,48 found a 1.3-fold higher risk of acute lymphoblastic leukemia (95% CI, 1.1–1.4) among formula-fed children compared with children who were breastfed less than 6 months. Kwan and colleagues48 also found a 1.2-fold higher risk of acute myeloid leukemia (95% CI, 1.0–1.4) among formula-fed infants compared with infants breastfed more than 6 months.” [2009]
Direct breastfeeding is collaborative in a way that bottle-feeding is not, offering another form of awareness and protection. In this case, breastfeeding offered early detection of breast cancer in the mother because of her baby’s refusal to nurse from one side, a phenomenon known as Goldsmith’s Sign.
Source: United States Breastfeeding Committee.
Dr. Kathleen Arcaro’s research “has shown that exfoliated cells in breast milk provide valuable information on breast health and can help predict breast cancer risk,” noted in this article.
There’s research being conducted that suggests human milk might someday be used to treat and cure cancer. Read about that here in a piece by Donna Walls, RN, BSN, IBCLC, ANLC.
Lee– as one of us who knows someone diagnosed with cancer– also suffered from the death of a dear friend at the claws of cancer. In Milk Train Brings Healing to Baby and Mom, Lee recounts her experience providing milk for her friend while she was sick. It’s one of those pieces I keep reading over and over, a gripping account of beauty within tragedy, and a reminder of the power of human milk and mothers that has yet to be recognized in our country.
National Breastfeeding Month is such a dynamic time of year on account of the weekly observances that honor unique cultures and voices within the wider realm of lactation and breastfeeding.
We’re revisiting a previous publication, as we did earlier this summer celebrating various national celebrations, in honor of AANHPI Breastfeeding Week.
Gorgeous content from Asian, Southeast Asian, Pacific Islander (ASAP!) Breastfeeding Taskforce’s Social Media Toolkit 2023
As part of the observance, the U.S. Breastfeeding Committee AANHPI Caucus presented the AANHPI Lactation Community Forum, an open panel discussion where AANHPI community members shared about their journeys to becoming lactation support professionals as well as provided guidance on how we can further build community capacity to support AANHPI families.
The Alameda County’s Asian, Southeast Asian, Pacific Islander (ASAP!) Breastfeeding Taskforce AANHPI Social Media Toolkit produced shareable social media content including messages and captions in the toolkit which have been translated into 11 different AANHPI languages: Chinese (both traditional and simplified), Farsi, Hindi, Hmong, Japanese, Korean, Native Hawaiian, Samoan, Tagalog, and Vietnamese.
In an engaging discussion with Tonya Lang, MPH, CHES, IBCLC and Grace Yee in 2022, they described the diversity that exists under the AANHPI umbrella, shaking away the stereotypical idea that Asian culture is monolithic.
The overgeneralization of the API community has led to some misleading data about breastfeeding rates. On an aggregate level, initiation and duration rates are relatively high, but the statistics don’t account for stark disparities within these population groups. This piece covers this phenomenon in more depth and offers strategies for tailoring infant feeding support in the Chinese American population.
More gorgeous content from Asian, Southeast Asian, Pacific Islander (ASAP!) Breastfeeding Taskforce’s Social Media Toolkit 2023
As Dr. Magda Peck has pointed out, numbers and data are important because they drive decisions and policies, but they also have the potential to sanitize humanity. That’s where stories come in. Not only do they humanize the numbers, they can also help us make sense of the data.
In an effort to demonstrate the complexity and diversity of this population, we have collected several stories by and about those in the AANHPI community.
Joanne Datangel-Gallardo, MD, DPPS of the National Children’s Hospital, Philippines has worked extensively with relactation efforts. Read about Dr. Datangel-Gallardo’s work here.
Also out of the Philippines is a piece by Micaela Papa detailing how breastfeeding saved one baby’s life and helped her mother recover from the stress of Typhoon Odette.
Not far south from this archipelago, is the island nation of Timor Leste. Here, emergency response efforts to protect breastfeeding have saved the lives of many. Community members manage and intercept artificial baby milk and other ultra-processed food product donations among other components of the nurturing care model. Read about these efforts here.
In Indonesia, efforts are also underway to combat commercial milk formula companies. Find a simple model for reporting Code violations here.
Jenny Lei Ravelo writes about the tangle of infant feeding complexities on Indonesia’s remote islands complete with stunning photos in partnership with the 1000 Days Fund.
In India, the Foundation for Mother & Child Health (FMCH) works to empower families from vulnerable communities with actionable information and services, resulting in health seeking behavior and nutritious food choices in order to tackle maternal child malnutrition, ultimately breaking the cycle of poverty. Read about the organization’s impact here.
And another beautiful collection from Asian, Southeast Asian, Pacific Islander (ASAP!) Breastfeeding Taskforce’s Social Media Toolkit 2023
Also exemplifying culture centered in health, is the Hmong Breastfeeding Initiative (HBI). With funding from Reducing Disparities in Breastfeeding through Continuity of Care Identifying Care Gaps grant from National Association of County and City Health Officials (NACCHO), the Hmong Breastfeeding Coalition (HBC) conducted an environmental scan of the Twin Cities (Minneapolis and Saint Paul, Minn.) on breastfeeding promotion and support for child-bearing age Hmong women and families. Read more here.
Tiffany Pao Yang has played a crucial role in this work. The daughter of Hmong refugees, she is especially invested in helping change the narrative around infant feeding in the Hmong population. Read part of her story here.
MORE TO EXPLORE
Professionals who identify as AANHPI or work PRIMARILY with AANHPI communities in birthing or lactation, are invited to complete a 10 minute nationwide survey and share it with colleagues.
The AANHPI Lactation Collaborative seeks to compile and create a resource directory to share publicly on their website. Your answers will also help inform future projects focused on increasing access to lactation support and resources for AANHPI birthing people.
If you have completed this survey in the past, please only retake it if you need to update your responses.
Responses are confidential other than information voluntarily provided for the AANHPI resource directory.
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’?”
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.
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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.
