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Providing private care in a clinical setting

I am very excited to share that I have been asked to provide services out of the Pasqua South Medical Clinic (PSMC) in Regina. This clinic maintains a really unique atmosphere, one I have never experienced in a medical clinic, ever. Think bright colours, up beat staff, and health and wellness to the core, with a holistic approach. 

As many of you know, I provide breastfeeding workshops to doulas so they are better prepared to help moms with breastfeeding right after birth and in the early hours. One of the PSMC staff members happens to be a doula and she attended my last workshop. She was pretty intrigued by a lot of the info I was presenting early on in the workshop, and looked at me, eyes wide, and said, "You should be working in a doctor's office". Of course, I giggled, and said something along the lines of, "Well, of course, I agree, but we seem to be a long ways from that in our current model of care."  

As the weekend progressed, this attendee was making notes and getting wide eyed and just digesting and processing the info I had to share. She was so excited to have new info to help moms and babies and support breastfeeding. That excitement and eagerness was carried over to the PSMC owner, a family physican. By the end of the weekend the physician and myself were in discussion trying to figure out how to make this idea work. 

The awesome thing about this clinic is that it is already a collaborative centre. Having someone like myself join was not a new idea; there was already a massage therapist, a speech language pathologist, physiotherapist, and more will be coming along as the space grows (there is an addition being build as we speak to open this summer). 

Within a few weeks of talking we arrived to this: 

Now, here is the number one question I get asked at this point: Why if you are working with a physician's office do mothers' have to pay to access your care? The answer is simple; physicians can bill for services they provide. They cannot bill for services they do not provide or oversee. Lactation is not often a medical issue and few cases of healthy breast-feeding babies would need to see a physician. While I was doing research about what this set up could and should look like, I looked at other relationships with physicians and IBCLC's. There are not many in Canada and they all operate differently from one another and differently than what we are envisioning here. When I looked at breastfeeding clinics that we have in Canada, there were not many that would be close to this relationship, aside from The International Breastfeeding Clinic (IBC) in Toronto and the Goldfarb Clinic in Montreal. What is notable in these clinics is despite the names and "hype" around them, they are not free for mothers. Seeing a physician is free, but appointments with the lactation consultants are not or at least until recently they were not always free. At the IBC the IBCLC's are fee for service and just recently the hospital gave funding to the Goldfard clinic for their lactation consultants. Until then there was no funding. The Goldfarb clinic is a specialized clinic, however, the wait list a few weeks long, so mothers often have steps in between. This idea of "fee for service" for lactation/health care is a "new" idea in Saskatchewan, but it really is not a new idea in Canada. If Saskatchewan families want access to good, specialized services then sometimes we have to accept the costs associated with that specialized care. I am hopeful in the future we will have more insurance companies on board and funding will come. That is going to be a big task and I am doing my part in that, but there will be many parts to get to that outcome. 

I look forward to seeing many families at the clinic and working as part of a bigger team.    

Effectiveness of breastfeeding peer support

In 2012, Finish researchers published a study in the Journal of Clinical Nursing reviewing past studies that had “focused on breastfeeding, breastfeeding support interventions, and education of healthy mothers and infants”.

The researchers combed through 34 studies published between 2000 and 2008 that were focused in Europe, North America, Australia, and New Zealand. At the time they began the study, the researchers pointed out that peer breastfeeding support was rising in popularity, particularly in the UK. Even so, very little research had been done up to that point on peer support, its cost effectiveness, and its impact on breastfeeding rates.

Researchers outlined 4 elements that are necessary for peer support interventions to be effective:

1. Well-planned peer education
Mothers were generally dissatisfied with the support of their peers if they had received no training.

2. Continuance of support from pregnancy to the postpartum period
If new mothers receive no support during pregnancy or at the hospital, any postnatal support would likely be ineffective.

3. Working together with professionals
Professional support is critical while the mother is at the hospital and if she experiences serious difficulties while breastfeeding. On the other hand, peer support can better offer advice related to breastfeeding and everyday life.

4. Variety of means to give support
This includes such things as individual support, support groups, educational classes at the hospital, hospital-based breastfeeding drop-in centres, pictures, and breast pump loans.

The most important requirement for ensuring a successful breastfeeding experience is that the mother feels supported and empowered. Because support must happen over a period of several months, having a variety of trained support persons is integral. It’s unreasonable to expect that a friend, mother, or even a doctor will be able to provide continual support for such a long period. Having a team—no matter how loosely based—can help spread out the burden of supporting a struggling mother. In addition, hiring a lactation consultant can be an ideal combination of peer and professional support.

Lactation consultants are educated and trained; they are available for prenatal, natal, and postnatal support in a comfortable and approachable manner; they work with professionals, and they have access to a variety of support methods.

Contact me if you’d like to know how I can provide the best support you can receive.

Breastfeeding and the Birth Professional

I am excited to be doing this workshop! I will be presenting information about breastfeeding and how the birth professional can make an impact on their clients future breastfeeding goals prenatally, at birth, immediate postpartum and the early days following delivery. Topics will include: promoting breastfeeding during pregnancy breastfeeding as the norm risks of not breastfeeding components and nutrients in breastmilk skin-to-skin first contact at breast first hour and early days new guidelines to determine efficient feeding when to help, when to observe positioning how to assist reluctant feeders breast/nipple concerns birth practice and impacts on breastfeeding practices that enhance breastfeeding dangers of supplements common clinical concerns special needs neurological concerns if baby cannot feed at the breast red flags woman who need extra attention when to refer BFI: what it is and what it means for clients case studies We will have a variety of information sharing formats including videos & discussions to take part in plus the much needed reflections about our work as birth professionals and observations and scenarios we have been part of. January 18 & 19, 2014 2 full days 8am-5pm Lunch will be potluck or bring your own to keep fees down Fees: Early bird (before January 5th)  $290 Regular $ 325 Non-refundable deposit of $75 to hold a space. Space will be limited. Payment Options Deposit $75.00 CAD Early Bird (before Jan 5th, 2014) $290.00 CAD After Early Bird (Jan 6th, 2014) $325.00 CAD Early Bird Balance $215.00 CAD After Early Bird Balance $250.00 CAD   If needed we can arrange payment plans. My proposed plan is the $325. $75 deposit to registration and then 4 separate payments of $62.50 to follow (either bi-weekly or monthly). Post-dated cheques will be collected. Please email kasmith@accesscomm.ca to request this option. Testimonial from a past workshop: Recently I was a participant in Kim Smith's Breastfeeding Workshop for Doulas. My reason for taking the course was to add to my helping skills in the initial breastfeeding realm, as well as talking to moms after they have experienced birth trauma and may have had breastfeeding difficulties as a consequence. I thought that the workshop was very comprehensive and raised many key issues. Kim addressed a wide variety of topics, and reinforced what is normal to see and what key tools a doula can use to assist her client. It also covered elements, like the WHO code of breastmilk and breastmilk substitutes, BFI, and societal issues which affect our clients. We had lots of opportunity for discussion, videos which were informative and relevant, and Kim did a great job keeping us on task and facilitating the workshop. She came prepared with technology but it was very well balanced and well used to teach the workshop. My feedback to Kim was that every birth professional should review this information. Even though I am a health care professional and have a degree, I found that the information Kim provided was cutting edge, evidence based, and would absolutely apply to any professional working with lactation. As a labour doula, I have seen the benefit to having additional breastfeeding support on board with my own clients. Not all clients are able to access feeding advice, and it has been inconsistent. I think Kim's workshop would absolutely apply to our professional development as health care workers and definitely to doulas, midwives, and anyone else working with mother and child. Congrats Kim on getting your workshop together and looking forward to even more!

What is a Lactation Consultant, LC, IBCLC?

The term lactation consultant or LC has become the title for someone with expert knowledge in breastfeeding. They may work with moms and babies to address breastfeeding issues and concerns. They may also teach classes, assist with establishing breastfeeding, and promote and protect breastfeeding.


Origin of the term “Lactation Consultant

The term “LC” originated as a short form of “IBCLC” or International Board Certified Lactation Consultant because, as you can see, that term is a mouthful.

“LC” is not trademarked and does not hold a professional standard like “IBCLC” does, so one will occasionally find a practicing LC who is not an IBCLC. Consumers (mothers and families) and other professionals (doulas and doctors) need to be aware of this.

As well, not all those who work as “lactation consultants” in health centres or breastfeeding support centres are IBCLCs. Some employers encourage employees to pursue the credential but don’t mandate it for employment.  Many times, nurses with some breastfeeding education fill these jobs.

Why is this IBC part so important?

The International Board of Lactation Consultant Examiners (IBCLE) awards the title of International Board Certified Lactation Consultant to only the candidates who meet the comprehensive pathway and pass an international exam. This allows IBLCE to establish the highest standards in lactation and breastfeeding care worldwide and to certify only the individuals who meet these standards.

Breastfeeding alphabet soup

I’d like to explain some of the breastfeeding alphabet soup by using the birthing support alphabet soup, as people seem to relate to that.

 

BIRTH	ROLE/RESPONSIBILITY	BREASTFEEDING
Childbirth Educator (CBE)	EDUCATION	Lactation Educator (LE)
Doula	SUPPORT	La Leche Leader
Midwife	CLINICIAN/MANAGEMENT	IBCLC

All the roles are important, but they provide their own distinct scope, responsibilities, and abilities. They can all work together to provide comprehensive support.

Primary roles of caregivers

As you can see, I’ve broken this down into three primary roles.

1.      Education

2.      Support

3.      Clinical management

Education

Educators teach you about the normal and expected processes of childbirth and breastfeeding. They typically call themselves childbirth educators and lactation educators. 

They teach the normal process of birth and what you can expect when having a baby, as well as encourage and promote breastfeeding.

This information helps you make decisions, helps you know if you are on track, gives you references for getting the birth and breastfeeding relationships you want, and helps answer your questions.

Educators typically teach community classes in group settings.

Support

Support people are typically those who have additional training in supporting mother, baby, and family during crucial times: birth and breastfeeding.

They’re typically doulas and La Leche League (LLL) leaders. Doulas are usually paid professionals, and LLL is a mother-to-mother peer support group. These roles offer the encouragement and motivation you need to get through the processes of birth and breastfeeding.

They’re well versed in normal and expected outcomes. They know to watch for red flags to ensure they can guide you further if you have come outside the normal, expected process.

Their job is to provide physical and emotional support, encouraging you to ask questions of your caregivers to make sure you’re well informed about what occurs. They have resources and guidelines to reassure you that you’re indeed in the realm of normal, and if things deviate from normal, they can point you in the direction of more resources.

Clinical management

Lastly, we have the clinical management professionals.

These are the folks responsible for the clinical and medical bits of the scenario. They look at the facts and figures, big picture, and red flags to rule in or out the things that are not in the normal and expected category and making a plan from there. They have the clinical experience of things that fall outside normal and how to manage them.

Working together

All of these people have a place in the realm of support and caregiving; what’s important is they know their role and responsibility and respect the others’. Where it becomes problematic is when the client receives something different from what she expected. Sometimes, this occurs because the roles of each provider isn’t clear to her, and she might conclude that one person isn’t performing a role properly. Let’s look at how this might apply to IBCLCs specifically.

In our example, a mother assumes that a lactation educator* is an IBCLC. She notices that despite consulting with the LE, her breastfeeding issue remains unresolved. She decides to seek more help through a La Leche League leader, who determines that the issue is outside her scope and recommends an IBCLC. The mother insists that she already saw an IBCLC, but received no help.

*this person could also be staff at a breastfeeding clinic or nurse who comes to her home

This example is typical, and it hurts all support people. The educator gets a bad rep because she didn’t help. The LLL leader is helpless because the needs were outside her scope. The IBCLC profession gets a bad rep because the client misunderstood the different roles and expectations.

Moms need to know clearly what their expectations are and who can best meet those expectations based on role, scope, and experience. All breastfeeding and lactation professionals have a responsibility to work together to ensure mothers have accurate information, so they can receive the support and encouragement they need as efficiently and as quickly as possible.

Is pumping being used as a new "magic fix" for breastfeeding concerns?

If I asked myself if pumping was being used as a magic fix for common, yet easily managed, breastfeeding concerns I would have to say yes, it is. The idea to pump instead of, or in conjunction with, breastfeeding is often suggested to mothers by their support people. These support people include other new mothers and experienced mothers at places like Mommy and Baby Yoga, Mommy and Me time, Kinder Music, Baby Signs, the museum, StarBucks, any place mom's and babies hang out together; you all know where mommy's go. Other support people are their mothers and mother-in-laws, sisters, sisters-in-laws, aunts, grandma's, that old family friend; again, you know who these people are. Of course, other new mother's support people include Health Care Providers like doctors, nurses, midwives and the complementary support people like doula's and childbirth educators. And, in case you are not aware, these people include many that did not breastfeed themselves or were not successful in their attempts to breastfeed.

Most moms new moms have the intention of breastfeeding, as so as expected, it comes up in conversation. People feel the need to ask new moms how breastfeeding is going, new moms feel compelled to seek out support in these early weeks or health care providers are following up mom and baby. When moms are asked about breastfeeding they share the concerns they have with breastfeeding in hopes that someone can help them. Here is the list of common complaints and one likely answer they will receive to alleviate that concern.

Sore Nipples -> Pump and bottle feed
Baby not effectively sucking -> Pump and bottle feed
Thrush -> Pump and bottle feed
Engorged -> Pump between feeds
Plugged Duct -> Pump between feeds or pump and bottle feed
Needing to feed in public -> Pump and bottle feed
Over Active Let Down -> Pump before feeding
Low supply -> Pump between feeds or after feeds
Baby not sleeping -> Pump and bottle feed or have someone else feed
Colic -> Pump and have someone else feed
Foremilk/Hindmilk concerns -> Pump before feeding

It appears that pumping can be a common suggestion to alleviate the most probable breastfeeding issues. We need to be aware it is not a magic fix, it is most likely to be a band-aid, and it does not "fix" anything. We also need to be aware that pumping can create more issues.

These are just a few ways this pumping band-aid could create more issues for mom and baby.

With sore nipples, generally the most common concern, generally easy to fix, pumping only results in double the work. Why would a new mother want to add in all the extra work of pumping and bottle feeding when getting some assistance with position and latch could make the problem go away, in even the very next feed? Often long term pumping is not going to sustain a babies needs and milk supply like breastfeeding directly from the breast would. Often breastfeeding relationships end far sooner than mother's intended due to supply issues because it leads to supplementation or another feeding method all together. This might not be the case all the time, as some mothers, do exclusively pump, but there is unique difference between a mother who makes the decision to exclusively pump compared to one who is trying to get baby nursing pain free at the breast and needing to pump in addition to. 

How about that baby that just is not sucking effectively or will not latch? Let's see, how do people learn? We learn by doing. If we take baby away from the breast, how does he learn? Again, we need to support moms and babies in positioning and latch and innate instincts that babies have to feed and let them learn together. If habitual placement is still not getting baby latching and sucking, we need to further evaluate what might be going on with that baby. Ignoring the difficulty baby is having and turning solely to the pump does not make the original issue baby was having go away.

Thrush is no reason to stop feeding at the breast. The reality with pumping with thrush is that mothers now have more parts and equipment to treat or throw away. Thrush can sometimes take time to clear up but it spreads so easily, we need to restrict what comes into contact with the thrush to stop the spread of it, not add more to it. There are medication and alternatives that we can use to treat thrush and the discomfort of thrush as we are trying to eliminate the nasty little bug it is.

Milk supply works on supply and demand so as well as pumping to relieve engorgement seems like a good idea right now, later on the fullness comes back and generally more full then the previous time, as a mother's body thinks that is milk that baby needed. If moms are engorged because a baby is not eating, then the answer is to get the baby eating, not pumping. The more baby is at the breast the less engorged mother's will be, assuming baby is eating well. Again, back up to latch and sucking. If baby is not waking to feed and mom is starting to fill up, mom can put baby to breast and encourage that baby to eat, to play his role in this breastfeeding relationship. Another concern with engorgement is that as much as it may seem logical that when mothers are engorged, it means they have a good, healthy milk supply, in fact the opposite can occur. The more often a women is engorged, the faster her milk supply will start to decreased. When breasts are full it sends a signal to the part of moms brain responsible for milk supply to slow production down and milk making cells start to shut down, resulting in less milk in the days ahead. Pumping when engorged can also pull more fluid, and not just milk, into the breast, resulting in edema. Often that fullness is confused for milk and "good supply".

Plugged ducts are uncomfortable, in fact down right painful, and yes moms want them out, but pumping is not the most effective way to unplug a plugged duct. In fact it can lead mom right back to the engorgement stage and create the spiral onwards from there, when the easiest way to get rid of that plug is by using baby, again.

I am starting to see a larger amount of women pumping so they can feed their baby while out and about. First, people that want to go out in public just need to accept that mothers and babies go out in public, too, and mothers and babies use breasts to feed. Secondly, mothers need to be informed about how this "solution" really is only one that is feasible for a small time. Each feed mom misses at the breast impacts that supply and demand mechanism again. If mom is out and is not feeding baby or replacing a feeding session without pumping again her body and brain communicate this to each other and the process of milk supply slows down. This again goes back to what I mention early about keeping up supply, supplementing and ending the relationship early than expected.


Over Active Let Down is a problem that some moms struggle with but again pumping can just aggravate this problem. It is an easy problem to aggravate as it can lead to the engorgement issue and when baby is ready to feed, mom is ready to burst with milk and when the let down occurs it is like opening up a dam. Baby gets flooded with milk, has trouble managing flow, staying latched, becomes upset and this all causes frustration in mom and baby. Positioning, latch and frequent feeds are the easy fix here. On the other side of it, some babies have a hard time handling a normal let down, but it mimics and over-active let down. We need to be sure that we know if we have a baby that is struggling with a normal flow or a true over active let down.

For the healthy, full-term infant pumping for primary low supply should be the last resort. Babies truly are the best solution here again; baby to breast = more milk in breast. Secondary low milk supply is a different issue and does not fall into the category of common yet easily managed breastfeeding concerns., which is what I am addressing here.

Pumping to top up or to force more milk into that non-sleeping baby:. Fuller tummy does not equal more sleep in babies. Babies have very small tummies, breastmilk is readily absorbed and digested so babies feed frequently. The issue here is not the amount of milk the baby takes, but rather unrealistic expectations and misunderstandings babies. If babies are really struggling with sleep, it is worthwhile seeking out a feeding assessment to ensure all the things above are not an issue.

Colicky babies are much better soothed at the breast than any other way, pumping to feed another way removes that comfort source from this already high needs baby and can make the baby even more upset. There is no real understanding behind colic and why some babies are colicky and some are not but there is good understanding that skin-to-skin and mothering at the breast calms these babies best. Again, all things above should be ruled out before we just assume we have a colicky baby.

Foremilk/hindmilk imbalance or what is being perceived as such seems to be rampant these days. It seems like a viral condition that has spread. So many moms seem to feel they have this issue, when in fact it is very rare. However, if a mother thinks this is an issue she has and pumps to get to the hindmilk, we go back to the engorgement cycle where mom has too much milk, can have a forceful let-down and then babies do get more foremilk than hindmilk, they are upset by the flow of milk and we end up in a vicious cycle. Worst case scenario, in fact, this could create that colicky baby we all fear. Foremilk/ hindmilk is best controlled by frequent feeds and proper positioning.

I am pleased to see fewer mom's grabbing for a formula can when breastfeeding challenges arise but I am not thrilled to see more mom's grabbing for the pumps.

Mom's please seek out appropriate, knowledgeable, support when you encounter these easily managed breastfeeding concerns.

Foremilk! Hindmilk! Baby MUST feed for 20 minutes a side.

“You need to nurse for 20 minutes on the first side and then move baby to the other side for twenty minutes.” Did anyone ever tell you this? What if your baby only nursed for ten minutes? Did you ask what would happen? I suspect you may have been told that is not long enough for your baby to get the hindmilk (higher fat milk). Is 20 minutes that magic “long enough” time frame? What if baby wanted to be there for 25 minutes? What happens then? Do you have no more milk?  

Have you ever expressed breastmilk? What does it look like? Have you expressed more than one time? Did your milk look the same each time? I suspect it varied from thin, watery and blue, to yellow and thick. Did you notice a difference with the time of the day you pumped? How about before a feed or after a feed?

What does the research say?  In point form the basics are:

·   As the baby feeds the content of the milk the baby receives is higher in fat

·   Each feeding can vary in fat content

·  The fattiest part of one feed might actually contain the same fat content of the start of another feed

·  Milk is milk; no real need to differentiate foremilk and hindmilk. Some is more concentrated, some less so, but your baby needs it all.

·   Babies all stay at the breast for different lengths of time and what satisfies them varies

·   The breast is not a reservoir. It is never “out” of milk. If babe hangs out nursing more milk will “let down”. It will flow faster if you switched breast, perhaps, but there is no rule to have to take a baby off one side to put him on the other

 

Is there a time when we might pay more attention to foremilk and hindmilk?

·  Is there an issue with baby sleeping at the breast?

·  Is there an issue with baby being fussy at the breast?

·  Is there an issue with babes weight?

·  Is baby swallowing at breast?

·  Is baby relaxed, with wide open hands and content at the end of feeds or no?

If there are any of these types of concerns, seek out an IBCLC to address the concerns. It may be somewhat related to the so called foremilk/hindmilk. It can sometimes be ONE factor to take into account for the whole picture when some of the above issues are seen. But it would not solely be a foremilk/hindmilk issue.