Experts-in-Lactation Lectures

Loss and grief permeates every part of the life cycle extending to the lactating mother. This talk will dismiss the myth of the ‘stages’ of grief, discuss what is 'normal' grief and give some practical and gentle strategies on how to assist and support women in their grief and loss.

This talk will give important information on the general principles of grief and loss acknowledging that for a new mother grief and loss can co-exist with great joy and happiness.

Read more: XL38: Cry Baby - Grief And Loss And The Lactating Mother

When it comes to breastfeeding behaviour, international evidence demonstrates that many women struggle to find the personal motivation to persist in the early weeks; as a result they fail to achieve their breastfeeding goal.

Applying three basic principles of optimally-motivated behaviour (Mastery, Autonomy and Purpose), an illustration from a motivationally designed instructional program “Designer Breastfeeding” demonstrates how health professionals can facilitate women in achieving their personal breastfeeding goal.

Read more: XL37: MAP-ing Women's Motivation And Succeed To Sustaining Breastfeeding

Until 2006 the growth of breastfed children was assessed by growth references based on predominantly formula fed infants. A study on the growth of breastfed children living under favourable conditions found that their growth deviated significantly from the NCHS-WHO reference.

The WHO Growth Standards are based on an intensive multi-country study and provide a better tool to manage breastfeeding and for early identification of children at risk of both under- and over-nutrition.

Read more: XL36: Breastfed Infant As The Standard Of Growth - WHO Child Growth Standards

Exclusive breastfeeding is achievable for most premature babies. An understanding of the physiology of breastmilk production and maintenance of supply, premature infant breastfeeding behaviour, and the unique feeding challenges posed by prematurity are essential to feeding success.

This talk covers unique benefits of breastmilk for premature infants, establishing and maintaining the breastmilk supply, development of effective feeding behaviours and transition to breastfeeding, including problems commonly encountered by premature babies.

Read more: XL35: Breastfeeding Premature Infants

There has been much research on the various causes of nipple and breast pain in the lactating mother. In recent years, evidence has been brought to light to suggest that some of the more common causes of pain, may not actually be involved or as involved as previously thought.

Our research has suggested that much breast and nipple pain is either: referred from traumatised nipples, vasospasm that radiates, or is a result of muscle tension in the pectoralis area - now identified as Mammary Constriction Syndrome.

Read more: XL34: Mammary Constriction Syndrome And PEC Massage

Failure to produce adequate milk supply meant almost certain death, so throughout history a number of strategies were developed to help mothers make plenty of milk. Methods work on the side of stimulating the rate of milk production, or involve the process of milk release.

While certain ideas may sound exotic or challenge the sensibilities of westerners, they may actually be considered mainstream in their originating cultures.This session will discuss several alternative therapies, including what part of lactation they may work upon, what level of evidence exists to support their validity, and when they might be appropriate.

Read more: XL33: Thinking Outside The Box: Alternative therapies for milk supply issues

“Our study found significantly lower illness rates among breastfed infants.” “Breastmilk is the ideal infant food.” “It’s wonderful that you’re still nursing your baby.” “There was a 20 percent lower risk with breastfeeding.” How can any of these statements be counterproductive? Because breastfeeding is our biological norm, and should be the control group in any study of infant feeding. Surprising things happen when we use formula as the study norm instead.

We’ll look at the effect of inaccurately framed research on the media, health care professionals, mothers, and the general public, and discuss who should be promoting breastfeeding and who should protect and support it, and how.

Read more: XL32: Watch Your Language

Most breastfeeding instruction includes strategies to prevent baby’s hands from ‘getting in the way’ during positioning and latch. Careful observation reveals that infants use their hands in predictable ways that help them find, shape, and move the breast to assist attachment.

This presentation focuses on these predictable behaviors and ways to work with them and when necessary modify them to assist breastfeeding dyads. The longer version includes the research base for these observations.

Read more: XL31: Facilitating Infant Competence: Hand Use During Latch

The majority of advocacy and health promotion efforts to increase breastfeeding in developed countries since the 1980s have emphasized its scientifically verified physical and psychological benefits. The slogan ‘breast is best’ has been successful in terms of awareness, if not application, on a wide scale, even while there are challenges to the relative health benefits and risks of breastmilk and formula.

Knowledge is one of the necessary ingredients in any social change recipe, together with self-efficacy, opportunity, and economic and cultural support; but it has not been sufficient in enabling the initiation and continuance of breastfeeding for most mothers, evidenced by the stagnation of breastfeeding rates in the past 10 years.

This paper considers the ways in which the focus on scientific knowledge, while beneficial, has left a gap in representations of breastfeeding, particularly relating to the potential for breastfeeding to be pleasurable. I argue that we need to promote breastfeeding not only through science but also through reference to experiential and relational advantages. By appealing to mothers through recognition of their maternal sexuality, breastfeeding can be promoted as physically and psychologically pleasurable in addition to (or regardless of) providing health benefits.

Read more: XL30: Breastfeeding for Fun and Pleasure

Good quality evidence demonstrates that breastfeeding is probably the single most effective intervention to promote child health, development and wellbeing in the short, medium and long term, and that it also has a significant positive impact on women’s health. If there was a drug that reduced mortality rates in small and sick babies; prevented acute gastroenteritis, lower respiratory tract infection, otitis media, Sudden Infant Death Syndrome, childhood obesity and diabetes; lowered serum cholesterol and reduced cardiovascular disease in adults; significantly improved cognitive development in children, and reduced breast cancer in women, all with only beneficial side effects, drug companies would compete to produce it and families would pay large amounts of money to buy it. Paradoxically, the product that companies compete to produce and that families pay for is formula. Evidence demonstrates that formula results in none of these positive outcomes.

At the same time it is well known that the knowledge and skills to enable women to breastfeed are not routinely taught to health professionals, and that inaccurate and inconsistent information is standard throughout many health services. This has a major impact on women and babies – many women start to breastfeed but stop in the first few weeks, before they want to and as a result of distressing problems including pain and concern for their baby’s health and wellbeing. Again paradoxically, the rates of breastfeeding are lowest among low income families, who can least afford the cost of formula, bottles and sterilising equipment when a much better alternative is available free of charge.

Breastfeeding is such a contentious issue in some communities that a study in England found that pregnant teenagers considered it to be ‘immoral’ to breastfeed. Perhaps most troubling are the very low rates of breastfeeding and breastmilk feeding of babies in neonatal units; the most vulnerable and the most in need of care and nourishment from their mothers. This paper will examine the factors that underlie this problem, including socio-cultural factors and health professional education and training. It will propose a range of solutions, focussing on those over which paediatricians, neonatal nurses, midwives, health visitors and community nurses have most influence.

Using evidence based on recent research, a pathway to enable women to breastfeed will be proposed. This will include the need to face up to formula and to identify ways of talking with health professionals, the public, the media, and with women themselves, about the important differences between breast and formula feeding.

Read more: XL29: The breastfeeding challenge: Why is breastfeeding a contentious topic?

Our medical culture behaves as if the brain and the gut are disconnected. The autonomic and enteric nervous systems regulate the gut, and the main sensory inputs are olfactory and tactile, provided in skin-to-skin contact. It is usually assumed that the anatomy and physiology of newborns is immature, but given the right context even the preterm gut behaves competently. In terms of available evidence on feeding frequency, there is none. Feeding frequency is however an inverse function of stomach capacity.

There is evidence on fetal stomach capacity from ultrasound, on newborn gastric aspirates, and some evidence on post-mortem studies. Corroborating these, a study on volumes and pressures is interpreted as supporting a newborn stomach maximum capacity of 20 milliliters.

The proposal therefore is that the feeding frequency should be approximately hourly, but adjusted to the actual sleep cycle with associated enteric cephalic phase which averages one hourly. This has implications for reflux and hypoglycemia, two very common feeding related problems; it may even address early epigenetic programming of obesity. While such frequent feedings may seem too much work, closer scrutiny shows it results in a major time saving.

Read more: XL28: Infant feeding frequency: proposal based on available evidence and neuroscience

A comprehensive discussion of breast augmentation and reduction surgeries and their impact upon lactation; discussion of incidence, motivations, surgical techniques, implications for lactation, psychological factors, breastfeeding management, and resources.

Read more: XL27: Breastfeeding after Cosmetic Breast Surgery

Normal human variation can sometimes be difficult to distinguish from minor anomalies that can impact feeding ability. This presentation uses clinical photographs to illustrate a systematic assessment of infant anatomy for optimal breastfeeding.

Minor oral anomalies that may affect breastfeeding are highlighted, including tongue-tie, mandibular asymmetry due to torticollis, natal teeth, hemangioma, and palatal problems.

Minor conditions are differentiated from those that might put infants at risk for significant feeding difficulties.

Read more: XL26: Infant Oral Assessment for Breastfeeding Helpers

Is the doctor right? Is the mother right? Does anyone have a clue? While some situations are quite straight forward, others can be ambiguous and confusing.

Low milk supply can be a matter of misperception only, or it may be very real. Mother’s milk may have come in well in the beginning only to apparently drop off, or it may simply never have come in well at all. The process of determining if there is a problem and where the problem/s may lie can require the skills of a detective, but are necessary in order to form the best prognosis and strategy for the mother-baby dyad.

This session will follow a process of elimination, including how to go about screening for hormonal causes and enlisting health care provider help.

Read more: XL25: Playing Detective: Assessing for insufficient milk supply.

This presentation will teach you how to present breastfeeding from a male perspective and give you the tools you can use to draw dad into the breastfeeding relationship.

During this session we will discuss the traditional role of men in obstetric and childbearing, and how we can use their talents to encourage breastfeeding success.

Read more: XL24: The Role of the Father in Breastfeeding

WHO/UNICEF recently revised the interpretation of Step 4 of the 10 Steps to Successful Breastfeeding to read "Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed." (BFHI, Section 1, 2009, p. 34). Since as early as 2000, international, national and professional organizations have recommended placing all newborns in skin-to-skin contact (Birth Kangaroo Care, BKC) starting immediately after birth and leaving them there until after the first breastfeeding is completed.

Thus, it is necessary for birth practices to change so BKC with breastfeeding is routine care. However, such a change in care is not easy as it means changing culture within birthing units and changing well-established behaviors and habits of health care providers. The evidence is compelling as to the benefits of both BKC and breastfeeding, now BKC with breastfeeding needs to be translated into practice.

Steps to translate BKC with breastfeeding into practice will be presented through examples of implementation projects in the United States, followed by discussion of BKC implementation in other countries.

Read more: XL23: Translating Evidence into Practice: Birth kangaroo care

Some of these misconceptions include that sustained breastfeeding is unnatural, that mothers continue for their own purposes, or that children are developmentally harmed by the practice, fathers are negatively affected, or even that breastfeeding an older child is sexual.

In her presentation Ann Sinnott will address each of these issues citing available research and survey data and examining from where the misconceptions have arisen.

Other questions she'll answer include: Is the urge to sustain breastfeeding into middle childhood, and sometimes beyond, linked to the maturation of the immune system? What could we learn from differences in breastfed and non-breastfed toddler behaviour? How do the reported effects of long-term breastfeeding square up with Attachment Theory and the findings of neuroscience? Ann also explores the familial and social pressures on long-term breastfeeding mothers and the impact the practice can have on fathers and the couple relationship.

Read more: XL22: Breastfeeding Older Children: myths and prejudices

Human infants are the most neurologically immature of all primates at birth, yet infant care practices in many Western industrialised societies fail to acknowledge the implications of this immaturity, especially at night. Babies sleep very differently from their parents: they don’t sleep exclusively at night; they don’t sleep all night; they fall asleep differently, have shorter sleep cycles and experience much more REM.

However, most paediatric knowledge and popular beliefs about babies’ sleep maturation and regulation is based upon studies of formula-fed infants sleeping alone.
In this session the Euro-American preoccupation with infant sleep independence is traced historically and compared with infant care practices across cultures. We will examine the prevalence and nature of parent-infant sleep contact, parental reasons for choosing to sleep with their infant, and the intricate association between breastfeeding and bed-sharing.

We will critically evaluate the complex relationship between infant sleep location and sudden infant death syndrome (SIDS) and argue that there is no single simple message about bed-sharing that is appropriate for all families and all situations.

The case for informed parental choice will be made, and sources of useful guidance will be shared.

Read more: XL21: Infant Sleep, Breastfeeding and Bedsharing: The good, the bad and the practical.

Delayed onset (after 72 hours postpartum) of lactogenesis II is surprisingly common among women in the United States. For example, we found the prevalence of delayed lactogenesis II to be 44% among a diverse cohort of first-time mothers in northern California.

By contrast, the prevalence of delayed lactogenesis II is reported to be 3 to 8 times lower among first-time mothers in Central America, South America and Africa.

Why do U.S. mothers not experience their “second milk” coming in until day 4, 5, or 6, or even later, when women in other settings experience onset on day 1 or 2? How do we optimize lactation support during this temporary challenge? I will present the current evidence regarding.

1. the short and long-term consequences associated with delayed lactogenesis II
2. individual, institutional, and behavioral risk factors associated with delayed lactogenesis II
3. potentially effective interventions to hasten the onset of lactogenesis II, and
4. the importance of in-person post-discharge follow-up support in ensuring that delayed lactogenesis II does not interfere with meeting breastfeeding goals.

Read more: XL20: Delayed Onset of Lactogenesis: Causes, consequences, lactation support

Early supplementation of the breastfed infant with infant formula has significant effects on the recipient infant’s gut flora, can provoke sensitivity and allergy to cow’s milk protein and has been identified as an environmental triggering event in the development of diabetes in susceptible families.

In a recent survey in the United States conducted by the Centers for Disease Control and Prevention, 24% of hospitals supplemented more than 50% of their breastfed infants. Supplementation should be undertaken with specific therapeutic goals in mind. However, the vast majority of supplementation in the hospital is done by maternal request based on infant behavior, cultural influences, or due to clinicians’ use of formula to solve breastfeeding problems. Formula supplementation is generally associated with a shorter duration of breastfeeding. Exclusive breastfeeding at hospital discharge is a vanishing entity.

This presentation will explore reasons for supplementation, look at true medical indications for supplementation, discuss what to supplement, when to supplement, how to deliver the supplement, how much supplement to give, and how to stem the flow of supplements in the hospital. Some hospitals have successfully helped staff reduce inappropriate supplementation by placing infant formula in a medication distribution system such as Pyxix. Others require infant formula to be logged out to help identify usage and where additional staff education and skill areas need improvement.

Read more: XL19: Stemming the Tide of Supplementation: What, When, How, and Why

Recent research has revealed that depression is associated with systemic inflammation, specifically, the increase in proinflammatory cytokines. Puerperal women are especially vulnerable because proinflammatory cytokines significantly increase during the last trimester of pregnancy.

In addition, common experiences of new motherhood, such as sleep deprivation, postpartum pain, and psychological trauma, also cause inflammation levels to rise.

This session will describe the inflammatory response and its relation to physical and psychological stress. This session will also show why breastfeeding and anti-inflammatory treatments, such as Omega-3s, cognitive therapy and antidepressants, protect maternal mental health.

Read more: XL18: A New Paradigm for Depression in New Mothers

For years, it has been the official position of the American Academy of Pediatric Dentistry (AAPD), that “Ad libitum nocturnal breast-feeding should be avoided after the first primary tooth begins to erupt”. The first primary tooth usually starts to erupt around 5 - 6 months of age. The implied purpose of this recommendation is to reduce the risk of infant caries (tooth decay) caused by human breastmilk.

The AAPD also recommends that ‘At-Will’ breastfeeding be discouraged for the same reason. It appears that these recommendations have been interpreted by many pedodontists around the world, that breastfeeding / breastmilk causes tooth decay. For this reason, many pedodontists and some general dentists who treat children, tell mothers to stop breastfeeding altogether if their child has any tooth decay. Some pedodontists have even told mothers it is a form of ‘child abuse’ if they continue to breastfeed if their child has any decay.

Because of harsh statements like this from the dental professionals, many mothers are made to feel guilty for their infant’s decay, and stop breastfeeding. For this reason, many children are denied the many benefits of breastfeeding. In his presentation, Dr. Palmer discusses these issues. In 2005, the American Academy of Pediatricians (AAP) developed a policy which recommended that all infants be given pacifiers when placed down to sleep as a possible way to reduce the risk of SIDS. During his presentation, Dr. Palmer discusses the principles on which this policy is based and his research on the consequences of pacifiers on the proper growth and development of the oral cavity, airway and facial form.

Read more: XL17: Breastfeeding/Infant Caries and the Pacifier/SIDS Issues

From over two decades of research, we have a much better understanding of the physiology of blood glucose, and other fuels such as lactate and ketones, in the newborn baby; but we still have few randomised trials to guide us towards the best strategies either for the prevention or the management of hypoglycaemia. Therefore if we are to manage babies properly, we need to base our clinical guidelines on an understanding of the physiology until we have empirical studies to guide us. We need to understand that babies potentially face two successive nutritional crises: the loss of the placenta at birth, and the delayed arrival of breast milk, especially when the mother is primiparous.

Most babies are robust enough to deal with these two difficulties, but we need to identify, and help where necessary, those babies who are not coping successfully, and are becoming fuel deficient. This presentation therefore focuses on normal physiology in the context of term and preterm delivery; the concept of ‘safe’ blood glucose values in relation to alternative fuels; the hormonal control of blood glucose in the newborn; situations of abnormalities of supply and demand for glucose; and some of the influences of intrapartum care on newborn metabolism.

Read more: XL16: Neonatal Hypoglycaemia - Evidence and Recommendations

Although neonatal jaundice is a common occurrence in both breastfed and artificially-fed infants, there are some special relationships between breastfeeding and jaundice in newborns. These will be explored by first examining the question of why and how jaundice or hyperbilirubinemia is a risk for newborns. The brain disorder known as "kernicterus" will be defined. The scenario of a badly managed case which resulted in development of kernicterus will be presented. Bilirubin metabolism will be examined with diagrams to understand how the newborn differs from the older child and adult in the six specific steps of this process: 1) synthesis; 2) transport; 3) hepatic uptake; 4) hepatic conjugation; 5) hepatic excretion; 6) intestinal reabsorption.

The additonal differences in bilirubin metabolism between the breastfed and the artificially-fed infant will then be explored to understand why breastfed infants normally have a prolonged period of jaundice and hyperbilirubinemia and why some breastfed infants have abnormal exaggerations of jaundice and hyperbilirubinemia. The entities of "Breastmilk Jaundice" and "Starvation Jaundice of the Newborn" will be defined. Using guidelines from the American Academy of Pediatrics, the talk will explore how to identify the infant at increased risk for exaggerated neonatal jaundice and how to assure good follow-up of the high risk infant. Methods for optimizing breastfeeding while controlling hyperbilirubinemia will be explored in detail.

The ultimate goal of the talk is to enable the health practitioner to assist in maintaining breastfeeding while protecting the infant from the rare, but very real, risk of developing bilirubin-related brain damage.

Read more: XL15: Bilirubin Management and Implications for Breastfeeding

Around the world, private practice lactation consultants (PPLCs) fill a gap: providing skilled lactation care for the mother who has left the hospital or birthing center, but now has issues that go beyond those a peer counselor can address. Lactation problems today are complex: rising C-section rates; babies being born (and discharged) earlier; mothers (with NICU babies) who are exclusively pumping; babies with anatomical variations; short maternity leaves; maternal history of infertility and low-supply.

And most PPLCs operate alone. This session will address the professional challenges common to all PPLCs, whatever their work or cultural setting. Legal and ethical issues will be addressed -- and practice tips will be offered that can be implemented immediately.

Read more: XL14: Legal and Ethical Challenges for Lactation Consultants

Mothers of pre term infants may not produce adequate volumes of breastmik to sustain the growing baby's needs.

Dr Morton's research describes expressing techniques which combine early hand expressing plus ongoing Hands-on Pumping. Results show a 48% increase in milk production at 7 weeks.

Read more: XL12: Making Enough Milk for the Preterm

Dr Cregan describes breastmilk as a functional food – that is all components of breastmilk are present to serve a specific function towards the development of every organ and system of the baby.

The provision of breastmilk programs the parameters for normal optimal metabolism, optimal assimilation of amino acids and protection by immunological components which are specific to human species.

Read more: XL11: Composition of Human Breastmilk and Infant Development

Dr Cregan describes breastmilk as a functional food – that is all components of breastmilk are present to serve a specific function towards the development of every organ and system of the baby.

The provision of breastmilk programs the parameters for normal optimal metabolism, optimal assimilation of amino acids and protection by immunological components which are specific to human species.

Read more: XL10: Physiology of Human Lactation: From Pregnancy to Weaning