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Preparing Mothers for Breastfeeding after a Cesarean – The Educator’s Role

April 22nd, 2014 by avatar

By Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE

© Sharon Muza

© Sharon Muza

April is Cesarean Awareness Month (CAM).  In a post earlier this month, I shared my favorite websites for birth professionals to learn and share with students and clients about cesarean prevention, recovery, vaginal birth after cesarean along with a fun quiz to test your knowledge about cesarean and VBAC information.  Today, as Lamaze International continues to recognize CAM, LCCE and IBCLC Tamara Hawkins shares information on how professionals can help prepare women who will be breastfeeding after a cesarean to get off on the right track for a successful breastfeeding relationship. – Sharon Muza, Science & Sensibility Community Manager.

Working in New York City,  I see many women who have given birth to their babies via cesarean section. Most hospitals in my area have a cesarean rate close to 40% and 30% of those births are primary cesareans.  April is Cesarean Awareness Month and I wanted to discuss cesarean birth and breastfeeding.  As both a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant, I work with women both before and after a cesarean birth.  I meet mothers who could have prevented many lactation issues if equipped with a few practices to get breastfeeding off to a good start after a cesarean birth. I want to share some practical teaching tips on preparing a mother to successfully breastfeed after having a cesarean birth. In a childbirth class,  it is important to give anticipatory guidance to mothers in class who are preparing to birth about the realities of breastfeeding after a cesarean.

I recommend discussing breastfeeding after cesarean births in all portions of your childbirth class; labor and birth, newborn care and breastfeeding classes, in order to cover different aspects of breastfeeding initiation.  During the labor and birth variations class, discuss how cesarean births affect baby and mother physically and emotionally. Provide tips on how to get through the first days in the hospital such as skin to skin, rooming in, explain the normalcy of cluster feeding and give breastfeeding support resources for the mother to use once she returns home. I find giving a wealth of well researched information in class will not help a mother who may be having breastfeeding trouble several weeks later after the baby has arrived. In newborn care and/or breastfeeding class, provide additional details: latch, positioning, signs of hunger, feeding length and times, cluster feedings, care for engorgement and sore nipples. Supplement with your list of resources.

Many birth professionals report cesarean births as a common reason for delayed Lactogenesis I. I like to lay out solutions for common concerns and problems that arise for mothers when breastfeeding after a cesarean. These solutions include care for the areola/nipple complex, swelling, positioning and latch techniques, anticipating frequent feedings, feeding a sleepy baby, and caring for engorged breasts.

Solutions and Teaching Points

Insufficient glandular tissue and low milk supply

I have seen an explosion of mothers who have insufficient glandular tissue and low milk supply. During class discussions about baby’s first feeding, explain normal breast changes to expect during pregnancy such as prominent veining, dark areola/nipple complex, growth of about one cup size in breast tissue, and tenderness. These changes indicate the process of Lactogenesis Stage I – when the epithelial cells of the breasts begin to convert to milk secreting cells under the influence of the hormone prolactin. When mothers have no or very little breast growth during pregnancy this indicates a deficiency in stage I of lactogenesis. Often, this is why a mother may have trouble with milk supply and not just because she had a cesarean. It is important we make a distinction in this for the mother because if the mother is blaming herself for an unplanned cesarean and then believes the cesarean birth caused the low milk supply it can cause undue distress. I typically just present the expected breast growth information and state, “If you have not had any changes, feel free to reach out to me or speak with your health care provider about your concerns.” When a mother is empowered with anticipatory guidance, it can help her make solutions to adequately feed her baby at birth, build her milk supply and find appropriate breastfeeding support. Even if she has a cesarean, she should not expect low milk supply unless she has the markers of IGT.

Creative positioning and latch techniques

© http://flic.kr/p/5f29EK

© http://flic.kr/p/5f29EK

We cannot expect a mother to sit straight up in a chair to nurse after a cesarean and we have to model positions to help mothers understand how to nurse laying back, in football positions and cross cradle. The side lying position for mothers who gave birth by cesarean can be hard as the mother can experience pulling on her incision as she is trying to roll on to her side.  Additionally, as she is laying in the side lying position, there can be pain, and some babies’ legs are long and can kick the incision. Depending on the available space where I teach, I can get on the floor and demonstrate how to hold the baby in multiple positions simulating being in a bed. I also discourage the use of “breastfeeding pillows.” They tend to not fit well around a mother in bed. If a mother is in a chair she’s liable to lean too far over to reach the baby who is resting on the pillow. It’s best to teach good posture in classes to prevent maternal back and neck discomfort and demonstrate having the baby up close to mother’s abdomen and breast to affect a deep latch.

Frequent feeding

Parents will receive many “tips” about breastfeeding after a cesarean delivery. Every nurse, health care provider, lactation consultant/counselor, mother, sister and friend will tell her something different about when to feed her baby. It is the role of the childbirth educator to prepare them for frequent feeds and give rationales as to why feeding a baby frequently is important.  Rather than stating a set “frequency” such as feed every 2-3 hours, I want them to understand the newborn’s normal pattern of sleep and wakefulness and how this influences their feeding behaviors. Mothers may be drowsy after a cesarean birth, particularly if the surgery followed a long labor.  They may also be in pain. Pain medication, while necessary for good pain management after surgery, can also contribute to a mother feeling sleepy. Holding her baby skin to skin will help the mother connect with her baby and relax. Both mother and baby need to be relaxed to get breastfeeding off to a good start. Explain to mothers during class that babies may want to nurse within the first hour and to wait for those cues: rooting, hands to mouth and suckling. Babies are often sleepy after cesarean births, especially if mother was pushing, had been treated with magnesium for pre-eclampsia or had been through a long induction. When a baby does not feed as often as anticipated, this will of course upset the mother and can lead to delayed Lactogenesis II.

Educators have to set expectations properly. Working on a time line, I discuss, breastfeeding in the operating room during the cesarean repair and in the recovery room. When partners are in class, teach them how to place the baby skin to skin with mom and support the baby if the mother’s arms or hands are restricted with blood pressure cuffs and IV lines. Discuss hand expression for those sleepy babies who are not rooting within 45 minutes of birth. Dr Jane Morton has a fantastic video illustrating how to express colostrum by hand. This is especially important for babies born to a mother with gestational diabetes, as these babies tend to be at risk for low blood sugar and formula supplementation.

If the baby has to go to the nursery before breastfeeding has been established, we discuss delaying the newborn bath and the rationale. When babies get a bath, not only is the vernix and amniotic fluid (which is a familiar taste to the baby) washed off, the baby will most likely cry, a lot, and fall into a deep sleep making it harder to wake for a feeding. Also, many babies are kept for a longer time in the nursery to warm up after the bath delaying skin to skin and breastfeeding. If the baby has not breastfed in the operating or recovery room, suggest the parents ask for the bath to be delayed until the next day and expect the baby to be on contact precautions. That means there may be a sign on the bassinet alerting care providers to wear gloves when caring for the baby.

Moving along the timeline, we move right into newborn sleep-wake patterns and cluster feedings. I tell them the baby is not born knowing there is a clock on the wall. There is no magic formula that says the baby should be fed 8x/day or every 3 hours or even for 15 minutes on the breast. Expect the baby to nurse 45 minutes every hour for four to five hours straight. That’s when you will really get their attention and can again discuss normal baby routines, colostrum volumes and the size of the newborn stomach.

Dealing with a sleepy baby

Babies born via cesarean can be sleepy for many reasons; exposure to magnesium sulfate and analgesia, long labors, and long second stage to name a few reasons. These babies need to be fed one way or another. Teach clients how to hand express and feed their baby at the breast. Holding the baby close to the breast, hand express 20 drops from each breast and rotate twice between each breast. Approximately 80 drops equal a teaspoon. This is the estimated amount the baby will take in during breastfeedings on day one and two of life. The mother can hand express directly into the baby’s mouth or into a spoon. I prefer a soft baby spoon as a plastic spoon can be sharp on the edges. Hand expression can prevent serious engorgement and increase likelihood of normal Lactogenesis II by stimulating release of prolactin.

Dealing with engorgement

Mothers that get engorged after a cesarean sometimes are dealing with breasts that are extremely edematous. It is important to discuss the difference of being engorged with milk versus engorged with interstitial fluid or swelling. At the time I cover the topic of cesareans in the childbirth class, I differentiate the two by describing how the breasts feel under both circumstances. I describe the breasts as feeling like a bag of marbles when it is full of breast milk and like an overfilled water balloon when it is just interstitial fluid. The care plan for each type of engorgement is a bit different. To start, emphasize on demand feedings to prevent buildup of fluid and discuss the use of Reverse Pressure Softening to remove local swelling in the areolar/nipple complex to affect a deep latch.

Breasts that appear swollen and feel soft like a water balloon need hand expression to get the milk flowing and to keep the areola soft. No application of heat is warranted with this type of swelling. Warm compresses can cause blood and lymphatic vessels in the breast to dilate and release more fluid. The goal is to reduce the swelling. After every feeding, application of cool compresses to the breasts is best. Cold therapy slows circulation, reducing inflammation, muscle spasm, and pain. The goal here is to keep the areola soft to prevent pressure building up around the milk ducts and prevention of milk flow.

Breasts that are hard with palpable alveoli are full of milk. The mother can once again use hand expression to get the milk flowing and will benefit from warm compresses to the breast for about 5-10 minutes before feeding. If her milk begins to leak, than the warmth is a good tool. If the milk does not begin to leak out, that is an indication that interstitial swelling is present and heat should not be used. Only cool compresses after feeding and/or pumping should be used in this situation.

Mothers that have cesarean births are very vulnerable to the hardships that come along 3-4 days after the birth including sore and swollen breasts, possible low milk supply and general recovery complaints that are associated with major abdominal surgery. Giving anticipatory guidance to succeed with breastfeeding amongst these possible issues and challenges are important to help mothers gain the confidence to succeed in making breastfeeding work.

After birth, a mother may have less support in her postpartum room and at home. She may even be alone most of the time during breastfeeding. After her labor and birth, it is likely she will not be able to access information stored in the left side of her brain if she is having breastfeeding difficulties coupled with fatigue and pain from birth. She will still reach out and ask questions. Very likely her first sources will be an online chat room, on a Facebook page or on a website somewhere. Childbirth educators should provide specific resources to find breastfeeding information. Share local breastfeeding and cesarean birth support groups along with the contact information for breastfeeding professionals during your childbirth classes.

I recognize that there is a lot of work to do in the birth world to bring down the cesarean birth from the current 32.8%. We can inform our students and clients with information to keep breastfeeding as normal as possible if a cesarean birth should occurred. It is our responsibility in the classroom to give our clients those tools to help them succeed in breastfeeding no matter how they give birth.

What information do you share with your clients about cesarean birth and successful breastfeeding? How do you prepare them for possible breastfeeding hurdles after a cesarean birth?

About Tamara Hawkins

tamara hawkins head shotTamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE is the director of Stork and Cradle, Inc offering Prenatal Education and Breastfeeding Support. She graduated with a BSN from New York University and a MSN from SUNY Downstate Medical Center. She is a Family Nurse Practitioner and has worked with mothers and babies for the past 16 years at various NYC medical centers and the Elizabeth Seton Childbearing Center. Tamara has been certified to teach childbirth classes since 1999 and in 2004 became a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant.  Follow Tamara on Twitter: @TamaraFNP_IBCLC

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Guest Posts, Healthy Care Practices, Infant Attachment, Newborns , , , , , ,

Lamaze Celebrates International Board Certified Lactation Consultants & IBCLC Day with a Fun Quiz

March 5th, 2014 by avatar
© ILCA

© ILCA

Today- Wednesday, March 5th, 2014 is IBCLC Day.  Board certified lactation consultants go through a rigorous training and exam process to become certified.  After certification, they are qualified to help women to feed and nourish their babies and support feeding issues that may occur in the mother-baby dyad.  The International Board of Lactation Consultant Examiners (IBLCE) is the organization that administers the exam worldwide and approves certificants, along with managing the recertification process.  They also maintain a registry that lists all the certified lactation consultants.  The International Lactation Association (ILCA) is the worldwide professional organization for International Board Certified Lactation Consultants (IBCLCs) and other professionals who support breastfeeding.  ILCA’s website maintains a directory of working IBCLCs so that mothers and professionals can locate an IBCLC in their area.

IBCLCs work in a variety of settings and with a diverse population of women and their babies.  They may also work in other capacities; as a physician, childbirth educator, doula, midwife, nurse or other professional along with their lactation consultant skills.

On Science & Sensibility today, we have a quick and fun quiz to test your knowledge of what an International Board Certified Lactation Consultant might do to help mothers and babies and also highlight some of their skills.   By taking the quiz, you can learn more about what an IBCLC does and how they can be a resource for a wide variety of mothers and babies.


Will you join me in recognizing the IBCLCs that work with your patients, your students and your clients with a brief thank you and shout out for all they do to support healthy mothers and babies?  Every childbirth educator or other birth professional surely has a few favorite lactation consultants who have gone the extra mile for your clients and patients?  Why not send them an ecard to honor the work they do?  Select the perfect ecard here and let the men and women working as IBCLCs know how much you appreciate their efforts.  Join Science & Sensibility and Lamaze International in thanking an IBCLC! And let us know how you did on the IBCLC quiz in the comments section.

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Babies, Breastfeeding, Childbirth Education , , , , , , , ,

2014 Confluence – DONA & Lamaze International Want You to Submit an Abstract!

January 3rd, 2014 by avatar

confluence header

You are invited to submit an abstract for the 2014 Confluence – Lamaze & DONA flowing together for safe, healthy, birth and beyond happening in Kansas City, Missouri on September 18-21, 2014.  Abstract submissions are being accepted until January 29th and I know that Science & Sensibility readers are some of the most interesting, engaged and knowledgeable professionals on topics related to pregnancy, birth and postpartum topics that exist anywhere.

confluence definitionThis unique joint conference is breaking new ground in bringing together two long-time leaders in the childbirth professions, DONA International and Lamaze International so that members of both organizations can share learning opportunities, ideas, networking occasions, and collaboration and learn from each other and other experts. Won’t you consider submitting an abstract?

Conference objectives are to:

  • Incorporate the use of technology and innovation in order to meet the needs of childbearing families.
  • Discuss how evidence-based research and best practice guidelines may be incorporated into practice, used to advocate for safe and healthy birth, promote professional collaborations, and support quality initiatives.
  • Implement innovative techniques that support the physical, emotional, cultural and educational needs of childbearing families.
  • Describe current research initiatives and approaches to perinatal care that may impact safe and healthy birth, postpartum, breastfeeding and early parenting.

Abstracts are being solicited that speak to one or more of the following areas:

  • Using Technology and Innovation to Reach Childbearing Women: The Listening to Mothers III Survey indicates that childbearing women are highly connected to social media and widely receive information about childbirth, postpartum, and parenting through social media platforms. How can childbirth professionals connect electronically with new or potential clients and integrate technology into education, support and advocacy? How can we best connect to families with diverse needs? These sessions may consist of case studies, technology tool demos and best practices, or marketing tips for the independent provider, educator and doula.
  • Evidence Based Teaching and Practice: The use of evidence based information is at the heart of childbirth education and labor and postpartum support. Recently developed quality initiatives and professional guidelines can be used to advocate for safe and healthy birth, breastfeeding support, VBAC, parent-infant attachment, and other topics important to parents and to those who provide childbirth support. How can evidence-based practices be combined with awareness and sensitivity to the range of cultural and religious traditions and preferences to promote safe and satisfying births? These sessions will provide information about how to incorporate evidence-based information into support, education, quality initiatives and advocacy efforts.
  • Supporting the Needs of Childbirth Professionals: Doulas, childbirth educators, nurses, midwives, and others are continually searching for creative ways to understand and meet the physical, emotional, religious, cultural and educational needs and preferences of childbearing families. Topics that sometimes generate strong political, cultural and social opinions (for example circumcision, vaccination, and co-sleeping) may be addressed. Presenters will share innovative techniques for supporting and sharing information with pregnant and parenting families. In these sessions the attendees will act as the learning audience and presenters will share with peers unique learning tips and support techniques.
  • New and Emerging Research in the Field of Childbearing: These sessions are for the presentation of new research, practice guidelines and collaborative efforts (published in the last three to five years) that are relevant to childbearing families and those who serve those families. Topics may range from holistic approaches to perinatal care, nutritional recommendations, effects of stress and toxic environmental exposures on pregnancy, the life course approach to healthy birth, preconception health and other subjects. These abstracts may be submitted for a live session or a poster presentation.

The deadline for abstract submission is January 29th, 2014 and I am confident that many of you have expertise, knowledge and skills that need to be shared with this gathering of professionals. What a great opportunity for you to present on your passion and for all the birth professionals; childbirth educators, doulas, lactation consultants, midwives, physicians, l&d nurses, counselors, authors and more to learn from YOU! Receive a generous honorarium and conference discount if your abstract is accepted.

Please consider sharing your wisdom!  Start working on your confluence abstract now.  You can find more information on submitting an abstract and access to the the online abstract submission tool here.  See you in Kansas City!  Let us know in the comments section if you are planning to submit!  I look forward to all of your great ideas!

2014 Confluence, Babies, Breastfeeding, Childbirth Education, Conference Calendar, Conference Schedule, Continuing Education, Uncategorized , , , , , , , ,

Research Review: Are There Any Benefits to Performing an Early Frenotomy on Newborns?

December 10th, 2013 by avatar

By Elias Kass, ND, LM, CPM

Breastfeeding is often considered the next big challenge after childbirth. New mothers and babies work together to establish a successful breastfeeding relationship. Sometimes, there are complications that can make things harder than they should be.  Tongue tie is one of the circumstances that can interfere with getting the breastfeeding relationship off to a good start. Please welcome Dr. Elias Kass, to Science & Sensibility as he reviews a recent study on early frenotomy (tongue tie clipping) in newborns and shares his thoughts on the study results. – Sharon Muza, Community Manager

With tongue tie seemingly on the rise, it’s always nice to see new literature approach the issue. “Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie” (Emond et al) compares releasing the tongue tie (frenotomy) immediately versus waiting and providing standard breastfeeding support.

What is tongue tie?

Tongue tie describes the presence of a frenulum that restricts the tongue’s ability to reach out and grasp the breast for successful breastfeeding.

Anterior tongue tie Image Source: Melissa Cole, IBCLC, RLC

Anterior tongue tie
Image Source: Melissa Cole, IBCLC, RLC

The most profound anterior tongue tie is one that connects the tip of the tongue to the edge of the gum. These babies have a V- or heart-shaped tongue when they cry, cannot extend their tongue at all, cannot follow a finger tracing along their bottom gum, and cannot generally latch well. Tongue ties can occur all along the spectrum of the tongue and the floor of the mouth, and some are hidden under the surface layer of skin, which we call “posterior tongue tie.”

The role of the tongue in breastfeeding

The tongue is incredibly important in breastfeeding. The baby must reach out with his tongue and grasp the breast. The tongue forms the primary seal, preventing milk loss and air intake. The movement is intrinsic to the tongue. Rather than sawing the tongue in and out, the muscular impulse starts at the tip of the tongue and moves inward, moving milk from the breast into the mouth. The middle of the tongue acts to form the milk into a ball, and the back of the tongue is responsible for coordinating swallowing, raising the larynx so that milk is directed down the esophagus and not down the trachea into the lungs.

What happens when a baby is tongue tied?

Tongue tie interferes with this intricate coordination in many ways. Some babies cannot extend their tongue. Those babies will have difficulty finding and attaching to the breast, but they may be able to nurse if the nipple is placed in their mouth just right. These babies come off the breast easily and become frustrated because they cannot adjust the position of the nipple in the mouth. The babies who are so tied they cannot extend their tongue over their bottom gum will reflexively clamp their gums. To the nursing parent, this pressure can feel like biting, and can damage nipples incredibly quickly, causing cracking, bleeding, pain, and because the skin is now broken, infection. 

Some babies can extend their tongue against the “rubber band” of the tongue tie, but their tongues “snap back” frequently. This can feel like a sawing against the underside of the nipple, and that friction can also damage nipples. These babies tire easily, because their feeding is made more difficult by the resistance of the rubber band. Snap back can sound like clicking. Clicking can also be caused by loss of suction from the underside of the breast. The tongue should stay mostly in the middle of the mouth when breastfeeding, with the jaw opening to create suction in the middle and back of the mouth. If, when baby opens her jaw, the tongue is tied to the bottom of the mouth, her tongue will snap away from the breast, losing suction.

Some babies can extend but not cup their tongues. These babies generally mash the nipple against the roof of the mouth, causing flattened, ridged nipples. Others thrust their tongue against the nipple instead of reaching under it, which leaves the nipple looking like a lipstick applicator.

What is a frenotomy?

Frenotomy refers to the procedure where this tongue tie is released (or in some places, “revised”). Though not all providers perform this procedure, providers from many different specialties have been known to offer it: pediatricians, family practice doctors, ear nose and throat specialists, dentists, and some midwives. For most, it is a simple, in-office procedure.

What did this study look at?

The researchers determined which babies were tongue tied based on the Hazelbaker Assessment Tool for Lingual Frenulum Function and the LATCH score (Latch, Audible swallowing, nipple Type, Comfort, Hold ). Those who had mild-moderate tongue tie according to the Hazelbaker score, as well as a LATCH score less than 8 out of 10 were eligible for the study. Those babies with severe tongue tie according to the Hazelbaker score were not randomized, and were instead offered immediate frenotomy; their outcomes were not considered as part of the study. Some parents of babies who otherwise qualified for the study refused to be randomized because they felt strongly about receiving frenotomy upon diagnosis.

When considering whether to intervene for tongue tie, it’s important to consider appearance as well as functionality. Some tongue ties are not readily visible but interfere greatly with functionality. Some tongue ties appear dramatic, but breastfeeding is not affected. (There are other long-term considerations, like speech and oral health, in deciding whether or not to release a tongue tie that is not affecting breastfeeding.) The Hazelbaker score is a good way to evaluate functionality because it takes into account whether baby can extend her tongue, cup it into the appropriate shape, moved it appropriately, and maintain suction, as well as the severity in appearance. The Hazelbaker score has good inter-scorer correlation, meaning that different professionals using the tool will arrive at the same conclusion (whether or not the baby should have a frenotomy) nearly 90% of the time. Using a consistent tool can help the individual provider get a better sense of who needs the procedure, but it can also help us as readers to know whether the study population was appropriate, and whether the study’s conclusions can inform our own practice.

V-shaped tongue Image Source: Osama Moshet, MD, FAAP

V-shaped tongue
Image Source: Osama Moshet, MD, FAAP

The LATCH score is a very broad evaluation of how breastfeeding is going, and despite its name, only barely addresses latch itself. Using such a general assessment in conjunction with the Hazelbaker score may have helped the researchers isolate the babies who were both tongue tied and having difficulties breastfeeding, as opposed to those who were tongue tied but doing okay.

In measuring outcomes, they used these two measures again, and added several more measures concerning breastfeeding behavior of newborns, breastfeeding self-efficacy (how confident mom felt in her ability to feed her baby, as well as an observer’s evaluation of breastfeeding effectiveness), and pain.

Conclusion

The primary outcome was LATCH score at 5 days. Secondary outcomes were LATCH score at 8 weeks, and the other measures listed above at 5 days and 8 weeks. The Hazelbaker score was another “outcome of interest” at 5 days, as was infant weight at 8 weeks. At 5 days, parents could choose to have frenotomy regardless of whether they had been randomized to the control arm or the intervention arm.

The researchers concluded “Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.”

Discussion

Though the study is structured fairly soundly, it doesn’t really answer its own question of whether frenotomy helps improve breastfeeding, largely because of the outcomes they chose to study. The LATCH score is not an indication of tongue functionality, success of frenotomy, or long-term breastfeeding success. Five days is also probably too soon to pass final judgement on whether the frenotomy helped; babies and nipples are still healing. The study also excluded those with severe tongue tie, and it’s safe to assume these babies would have significant improvement when their tongue ties were corrected.

Mothers did feel significantly more effective in their feeding when their babies had received frenotomy (which is correlated with duration of breastfeeding), and more of those who didn’t receive frenotomy were feeding by bottle. It’s unclear whether this bottle feeding was because of the pain associated with breastfeeding or because of inadequate milk transfer or nutrition, but it’s possible that some of those parents have been helped by immediate frenotomy. Indeed, some of the mothers who had been randomized to the control group requested early frenotomy because their feeding was so painful. There were statistically significant improvements in the Hazelbaker score, representing improvement in both appearance and functionality.

Very thick  submucosal/posterior tongue tie. {link url="http://www.bayareabreastfeeding.net"}Bay Area Breastfeeding & Education, LLC{/link} Image Source: Bay Area Breastfeeding & Education, LLC

Very thick submucosal/posterior tongue tie.
Image Source: Bay Area Breastfeeding & Education, LLC www.bayareabreastfeeding.net

Many features of this study mirror how I treat tongue tie in my practice. Almost all babies are referred by lactation consultants or their own pediatricians because they are having difficulty breastfeeding, or because their tongue ties are so profound that we can anticipate speech and oral health problems if it’s not corrected. I use both the Hazelbaker score and the scoring tool in the appendix of RL Martinelli’s “Lingual frenulum protocol with scores for infants” to capture the infant’s feeding history, anatomy, and functionality on both the gloved finger and at the breast. These scores help support a systematic approach to these infants, and helps communicate back to their referring provider what I’m looking for when I decide whether or not to recommend frenotomy. Though most babies referred do need frenotomy, some need other kinds of support instead, and some just need reassurance around normal feeding patterns.

The article didn’t go into much detail about the aftercare. Aftercare is a crucial variable in improving breastfeeding and maximizing success of the procedure. Seattle area practices who perform significant numbers of frenotomy have collaborated to create a list of exercises we ask parents to do with their babies 5 times daily for a week to keep the area open, reduce reattachment, and help baby learn to maximize their new freedom of movement. We also generally recommend craniosacral therapy to help release tight muscles and retrain movement patterns. Many families have incorporated other feeding tools or accessories into their regimens, whether that’s nipple shields, bottles, supplemental nursing systems, or formula. With frenotomy, most will be able to start to move away from those tools, and need continued support from a lactation consultant to relearn how to nurse at the breast. Though most mothers feel that baby nurses differently immediately, some babies take longer to change their approach, and some do not benefit at all.

Releasing tongue ties is a very satisfying part of my practice. I love when breastfeeding parents nurse immediately after the procedure and their faces light up because for the first time it doesn’t hurt to feed. These parents have been working very, very hard to breastfeed, and I feel strongly that this procedure removes a significant obstacle. The more I work with breastfeeding families, the more in awe I am of the complexity of breastfeeding, and importance of excellent breastfeeding support.

Childbirth  and breastfeeding educators should be sharing that painful breastfeeding sessions are not normal and should be evaluated by a lactation consultant.  Educators should provide resources for qualified LCs in their communities to families in need.  For those that work with breastfeeding dyads, what are you seeing in terms of tongue tie and treatment success? Please share your experiences.- SM

References

Ballard, J. L., Auer, C. E., & Khoury, J. C. (2002). Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.Pediatrics, 110(5), e63-e63.

Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., & Sutcliffe, A. (2013). Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Archives of Disease in Childhood-Fetal and Neonatal Edition, fetalneonatal-2013.

Martinelli RL de C, Marchesan IQ, Berretin-Felix G. Lingual frenulum protocol with scores for infants. Int J Orofacial Myology. 2012;38:104–112.

About Dr. Elias Kass

elias kass head shot

Elias Kass, ND, LM, CPM

Elias Kass, ND, LM, CPM, is a naturopathic physician and licensed midwife practicing as part of One Sky Family Medicine in Seattle, Washington. He provides integrative family primary care for children and their parents, including prenatal, birth and pediatric care. He loves working with babies! Practice information and Dr Kass’s contact info is available at One Sky Family Medicine.

Babies, Breastfeeding, Guest Posts, New Research, Newborns, Parenting an Infant, Research , , , , , ,

Insta-gram or Insta-gasp? The Ethics of Sharing on Social Media for Birth Professionals

October 24th, 2013 by avatar

Attorney and Lactation Consultant Liz Brooks, President of the International Lactation Consultant Association, takes a look at the issues that childbirth professionals might want to consider before sharing information on a social media platform like Facebook, Twitter, Instagram, Pinterest or others.  Do you follow the HIPAA guidelines, even if you are not bound to do so?  What has been your experience?  Please share your thoughts and experiences in our comments section. – Sharon Muza, Science & Sensibility Community Manager.

By Liz Brooks, JD IBCLC FILCA

Is it ever ethical for a healthcare provider (HCP) to post a photograph or video of a patient on a website or Facebook page? My first reaction is “Heck No!,” but the question deserves a deeper look, especially since social media platforms serve as a predominant means of communication, marketing and information-sharing. It is the way we can speak to today’s mothers, and it is the way they insist on reaching us. 

Privacy and confidentiality are hallmarks of the traditional healthcare professions. I am an International Board Certified Lactation Consultant (IBCLC), and right there, in my ethical code (called the IBLCE Code of Professional Conduct for IBCLCs, or CPC), it says at Principle 3 “Preserve the confidentiality of clients.” Further, I am required under the CPC (a mandatory practice-guiding document) to “Refrain from photographing, recording or taping (audio or video) a mother or her child for any purpose unless the mother has given advance written consent on her behalf and that of her child.” 2011 IBLCE CPC, 3.2. Translation: If I want to take a picture of a mother for any reason at all (to document healing of a damaged nipple, perhaps), even if I drop it into a patient folder only I will ever see, and which I lock away in a file cabinet, I had better get the mother’s written consent first. 

But what about a doula or childbirth educator? Are doulas or educators considered “healthcare providers” in the way a doctor, nurse, midwife or IBCLC would be? Or are they removed from the rules in healthcare?

The Childbirth and Postpartum Professional Association (CAPPA) describes the doula as an important informational and emotional link between the pregnant/laboring woman and her healthcare providers … a part of the birth team. DONA International, another doula organization, describes the role as “a knowledgeable, experienced companion who stays with [the mother] through labor, birth and beyond.”

This is what else we learn from CAPPA and DONA International: It is clear that privacy of the mother is paramount. Any person who is certified through CAPPA is expected to follow a Code of Conduct that is quite plain in its requirement to protect privacy: “CAPPA certified professionals will not divulge confidential information received in a professional capacity from their clients, nor compromise clients’ confidentiality either directly or through the use of internet media such as Facebook or blogs.” (Page 1, Bullet 4, CAPPA Code of Conduct.) The Code of Ethics from DONA International echoes this requirement: “Confidentiality and Privacy. The doula should respect the privacy of clients and hold in confidence all information obtained in the course of professional service.” (DONA Int’l Code of Ethics Birth Doula, 2008.)

Childbirth educators are held to a similar standard. Lamaze International, which offers an international certification for those who are working with pregnant women and their families, has a Code of Ethics for its Certified Childbirth Educators. That Code indicates “Childbirth educators should respect clients’ right to privacy. Childbirth educators should not solicit private information from clients unless it is essential to providing services. Once a client shares private information with the childbirth educator standards of confidentiality apply.” (Standard 1.07, 2006 Code of Ethics, Lamaze International.)

So it seems that healthcare providers, childbirth educators and doulas alike should NOT be posting pictures of their clients/patients on the Internet. So why are we seeing so many of them?

Because if the mother agrees to have her picture or personal information shared, her informed consent changes everything. The notion of protecting privacy is that the patient or client ought to be in control of whatever information gets shared with the outside world. Anyone who has attended a conference, and benefited from education that included clinical photographs, knows that some clients/patients are willing to allow their images to be seen by others. They may require conditions of use (i.e. do not show the face), but they willingly agree.

“So all I have to do is just ask the mother?” you wonder. Well … not so fast. Some other considerations may (dare I say it?) cloud the picture:

  1. Some healthcare providers, hospitals or birth facilities may have rules of their own affecting whether or not images may be taken, by you or even the family. You will need understandings and consent up front, often signed on forms as proof, before you can whip out the smart phone. 
  2. If the doula or childbirth educator has a professional, business relationship with other healthcare providers, or healthcare facilities, she may well be considered a “business associate” for purposes of the privacy-protecting sections of the Health Insurance Portability and Accountability Act (HIPAA), and its first cousin in enforcement, the Health Information Technology for Economic and Clinical Health Act (HITECH). Under HIPAA/HITECH “business associates” who have ANY kind of access to patient information (like: name and address) are held to the same standard for privacy as the healthcare provider. And if there are breaches of privacy, both the business associate AND the HCP are held liable. Enforcement actions recently have included actions against small practices, including the levying of some hefty fines. The person working with the family, who has a professional relationship with a covered entity under HIPAA, should be certain that her own business associate agreement is up-to-date and signed. It is important that she respect the requirements set by her (probably skittish) business partner, before she seeks the mother’s consent.
  3. Make sure you and the mother are very clear in your understanding of what her “consent” really means. Many a mother has been disappointed that her great and wonderful news announcing her baby came from someone else first … even if the plan all along was to have everyone share the great news once mom revealed it.

Discuss all the possibilities with the patient/client. Who can publicly discuss the pregnancy/birth/sonogram? Who can take and post pictures? What and who can be included in the pictures (faces, body parts, location-identifying background all matter). Who can text? Who can tweet? Is a link back to a website or Facebook page by the mother required? When can all of this take place?

As a savvy advocate for the mother, you may want to suggest that she have these same discussions with her own circle of family and friends. While they will not be held to the legal and ethical standards required of a doula or HCP, the disappointment will be no less acute for the mother if the glorious news of her pregnancy or birth is spilled by a friend, first. 

As doulas, childbirth educators, IBCLCs and HCPs who work in maternal-child health, we are privileged to be willingly called into the intensely personal and life-changing events that pregnancy, birth and early parenting represent. Our need to respect the wishes, dignity and privacy of the family are not diminished because modern technology makes news-sharing so easy.

About Liz Brooks

Liz Brooks, JD, IBCLC, FILCA, is a lawyer (since 1983) and earned her International Board Certified Lactation Consultant credential in 1997 after several years as a lay breastfeeding counselor.  Before she left the practice of law, Liz worked as a criminal prosecutor, a lobbyist and a litigator, with a focus on ethics and administrative law.  That expertise followed her to lactation:  She wrote the 2013 book, “Legal and Ethical Issues for the IBCLC,” and was lead author for one ethics chapter in each of three other books.

Liz is on the ILCA Board of Directors (President 2012-2014).  She was designated Fellow of the International Lactation Consultant Association (FILCA) in 2008. She currently is the United States Lactation Consultant Association Alternate to the United States Breastfeeding Committee and is an Elected Representative on their Board of Directors (2012-14).  Liz can be reached through her website.

 

 

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