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“Break Time for Nursing Mothers” – It’s the Law!

May 8th, 2014 by avatar

By Kathleen Marinelli, M.D.

In honor of Mother’s Day, which is coming up this weekend, I thought it would be important to talk about a challenge that many mothers face after having a baby.  Returning to work and continuing to breastfeed their baby.  Many countries offer a generous leave for new mothers, but here in the USA, it is not uncommon for a new mother to find herself back at work 6 weeks after giving birth.  So many challenges face these women, and the added pressure of work environment that is unsupportive of the breastfeeding relationship and the mother’s need to have a private, appropriate place to pump and store her  milk while separated from her baby is not only critical, it’s the law.  Today on Science & Sensibility, Kathleen Marinelli, M.D, the Chairwoman of the United States Breastfeeding Committee updates us on the “Break Time for Nursing Mothers” law and shares resources for clients and students who are returning to work and breastfeeding.  While this day seems far away to families sitting in  a childbirth class, making space for this discussion and sharing resources can help women to continue to breastfeeding smoothly after returning to work. – Sharon Muza, Community Manager, Science & Sensibility.

With more than half of women with infants employed, simple workplace accommodations are critical for breastfeeding success. By helping moms understand their rights as a breastfeeding employee and plan for their return to work, childbirth educators, doulas, health care providers and lactation care providers can support a successful transition so that working moms are supported to reach their personal breastfeeding goals.

The federal “Break Time for Nursing Mothers” law requires employers to provide break time and a private place for hourly paid employees to pump breast milk during the work day. The United States Breastfeeding Committee’s Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law compiles key information to ensure every family and provider has access to accurate and understandable information on this law.

Key Facts about the “Break Time for Nursing Mothers” Law:

Who is covered: The law applies to nonexempt (hourly) employees covered by the Fair Labor Standards Act.

Space: Employers are required to provide a place that is not a bathroom. It must be completely private so that no one can see inside. Employers are not required to create a permanent dedicated space for breastfeeding employees. As long as the space is available each time the employee needs it, the employer is meeting the space requirements.

Time: The law requires employers to provide “reasonable” break time, recognizing that how often and how much time it takes to pump is different for every mother. Employees should consider all the steps necessary to pump, including the time it will take to gather pumping supplies, get to the space, pump, clean up, and return to their workspace. Employers must provide time and space each time the employee needs it throughout her work day.

Enforcement: The U.S. Department of Labor’s Wage and Hour Division (WHD) is responsible for enforcing the “Break Time for Nursing Mothers” law. If an employer refuses to comply, employees can file a complaint by calling the toll-free WHD number 1-800-487-9243.

Small Businesses: All employers, regardless of their size or number of employees, must comply with the “Break Time for Nursing Mothers” law. Following a complaint from a breastfeeding employee, businesses with fewer than 50 employees may be able to apply for an undue hardship exemption. To receive an exemption for that employee, the employer must prove that providing these accommodations would cause “significant difficulty or expense when considered in relation to the size, financial resources, nature, or structure of the employer’s business.” Until they are granted an exemption by the Department of Labor, they must comply with the law.

State laws: Employees who are not covered by the “Break Time” law may be covered by a state law. Contact your state breastfeeding coalition for help understanding the breastfeeding laws where you serve.

The “Break Time for Nursing Mothers” law was an important victory for families, but breastfeeding success shouldn’t depend on a mom’s job type. The Supporting Working Moms Act would expand the existing federal law to cover approximately 12 million additional salaried employees, including elementary and secondary school teachers. We can all help make this happen! Use USBC’s easy action tool to ask your legislators to cosponsor the Supporting Working Moms Act with just a few clicks. Twelve million employees are counting on us! As Surgeon General Regina Benjamin advised us, “Everyone can help make breastfeeding easier.”

We know that workplace lactation support is a “win-win”, benefiting families, employers, and the economy, yet one of the major causes for the drop-off in breastfeeding rates is the lack of effective, reasonable workplace accommodations when mothers return to work. Employers that provide lactation support experience an impressive return on investment, including lower healthcare costs, absenteeism, and turnover rates, with improved morale, job satisfaction, and productivity. The retention rate for employees of companies with lactation support programs is 94%, while the national average is only 59%!

Breastfeeding and working is not only possible, it’s good for business. Find additional information and resources in USBC’s Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law and help spread the word about this valuable new resource with your clients by sharing this link: www.usbreastfeeding.org/workplace-law.

Moms, babies and employers everywhere will be glad you did!!

Important links and information:

Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law
Action Alert: Supporting Working Moms Act
Directory of State, Territorial, and Tribal Breastfeeding Coalitions
United States Department of Labor Employee Rights Card
Wage and Hour Division Break Time for Nursing Mothers Webpage
The Business Case for Breastfeeding

Do you talk to patients, students and clients about tips for successful re-entry into the workforce while still breastfeeding a baby?  What are your favorite resources to offer women so they know their rights and understand the responsibilities of their employer to assist them in continuing to express breastmilk for their baby. If you are not mentioning this to your families, maybe you will consider how important this information is after reading today’s blogpost and consider passing on these resources.  - SM

About Kathleen Marinelli, M.D.

Marinellii-head shotDr. Kathleen Marinelli is the Chair of the United States Breastfeeding Committee, an independent nonprofit coalition of almost 50 nationally influential professional, educational, and governmental organizations, that share a common mission to improve the Nation’s health by working collaboratively to protect, promote, and support breastfeeding, where she represents the Academy of Breastfeeding Medicine. She is also a Neonatologist and Breastfeeding Medicine Physician at Connecticut Children’s Medical Center, in the Connecticut Human Milk Research Center, and Associate Professor of Pediatrics at the University of Connecticut School of Medicine.

 

Babies, Breastfeeding, Childbirth Education, Guest Posts, Infant Attachment, Parenting an Infant , , , ,

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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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.

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Purchased Breastmilk Overflowing with Bacteria? The Facts Behind the Sensationalistic Headlines.

October 22nd, 2013 by avatar

 By Suzanne Barston

Suzanne Barston, author of Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn’t and blogger on topics related to infant feeding discusses the new study that examines bacterial levels found in breastmilk purchased online.  Did you bother to look beyond the headlines to see what the research showed.  How will you respond to clients, patients and students who ask you what you think and wonder how safe it is to feed their babies purchased or donor milk?  Suzanne points us toward some great information and takes a level-headed look at what this study actually tells us.  To learn more about Suzanne, please read Walker Karraa’s interview with Suzanne for Science & Sensibility here.- Sharon Muza, Science & Sensibility Community Manager.

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As someone who supports formula feeding parents, I’m used to sensationalized media coverage of studies that confuses real risk with relative risk. It’s taught me to look at research with a critical eye, rather than accepting what the reporters (or even the study authors, at times) claim is absolute truth. 

This week’s splashy headlines involved breastmilk, not formula, but the end result has been quite familiar: frightened parents, frustrated advocates, and confused bloggers. Everyone’s talking about a new study published this week in Pediatrics, which according to its authors “documents the potential for human milk shared via the Internet to cause infectious disease by estimating the extent of microbial contamination among samples purchased via a leading Internet Web site.” Some took the findings of this study – the discovery that most of the obtained samples contained pathogenic bacteria – to be proof that milk donation is a risky business. Others insinuated that this was a social problem; that puritanical/paternalistic attitudes towards breastfeeding and feminine bodily fluids cast unwarranted suspicion on milk sharing, and provoked a dire dismissal of relative risk (after all, formula is subject to bacterial contamination as well).

The “absolute truth”, I believe, is floating somewhere in the middle. As Alison Stuebe, MD, points out on her Academy of Breastfeeding Medicine blog, this study was limited by its methodology. The breastmilk samples were obtained through an online site where milk was not “shared” but rather sold per ounce. In order to maintain anonymity, the researchers only corresponded with donors via email, and cut off communication if the seller asked too many questions. Stuebe explains:

 “It’s highly plausible that milk sent with no questions asked, via 2 day or longer shipment, and (in 1 and 5 cases) without any cooling whatsoever, was collected with less attention to basic hygienic precautions. The bacterial load in study milk samples therefore doesn’t tell us about the relative safety of milk obtained following a conversation between buyer and seller about the recipient baby and then shipped overnight on dry ice in a laboratory-quality cooler. Indeed, when the authors compared online milk purchases with samples donated to a milk bank after a screening and selection process, they found much lower rates of bacterial contamination…”

The other important factor to consider is that we can’t know if any babies would’ve necessarily become ill after ingesting this milk; all we can be sure of is that milk transported across the country from anonymous encounters online has a good chance of containing nasty bacteria. This was an in vitro study of a biological substance – not a study that involved actual cases of sickness caused by contaminated breastmilk.

And that is what is so beautiful about it. This was an in vitro study of a biological substance. It looked at breastmilk unemotionally, separate from the individual producing the milk or receiving it. No babies were harmed or even affected by this research. We don’t need to have a defensive reaction to the results, any more than a formula feeding mother needs to have a defensive reaction about a formula recall due to bugs in the powder. 

Food preparation, storage and safety don’t need to be a personal or political issue. I doubt the local grocer feels offended when spinach gets recalled, but she probably feels concerned. Unlike guilt or shame, concern is a healthy emotion, because it allows for a solution to be found. That’s why this study should be viewed as useful information rather than an indictment on milk sharing as a practice. From it, we can learn that more stringent practices are needed to ensure safety – parents can be informed that there are some risks involved in anonymous online purchase of human breastmilk.

The real difficulty, here, is that the issue of breastfeeding balances tenuously between the medical, the personal, and the political. It may be hard to make peace with the fact that obtaining breastmilk might need to become a sterile, regulated activity, prone to corporate involvement (because anytime money is involved we run that risk, especially when it comes to infant feeding), when breastfeeding is such an intimate, personal act. Ironically, the only other solution offered in response to this study is to make milk sharing more personal – that we urge parents to get to know donors, discuss how the milk will be pumped, stored, and transported, and share locally whenever possible. This certainly might cut down on the risks, but the fact remains that unless the donor is a close friend or relative, you are still asking parents to implicitly trust someone they don’t know very well. 

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Rather than angrily striking out at this research, or accepting it as the final word on milk sharing safety, we could simply use it to ask more questions. How, exactly, should milk be pumped, stored, and transported? There’s been some interesting research on how the freezing process affects the antioxidant and vitamin content of expressed breastmilk, for example – should babies fed expressed, donated milk only be given vitamin supplements? How does this affect infant health in the long term? What about ensuring that foremilk and hindmilk are balanced, by giving donating moms guidance on the best pumping practices? Does the milk of a mom nursing a toddler provide the best nutrition for a newborn, or should donations partnerships be based on age?

Lastly, rather than assuming other modes of milk sharing are safer (even if we intuitively believe that they are), can we study samples obtained from other types of donation arrangements, to put parents’ minds at rest? Do women who pump and store their own milk need to be concerned about bacterial contamination? (The lead author of the study, Dr. Sarah Keim, actually did offer some concrete suggestions to Medical News Today on improving the safety of pumped milk – things like sanitizing all containers and pump parts and freezing or refrigerating the milk within 6 hours.)

We cannot be scared of research, and we can’t get angry at it. But we can get angry at a media that grabs sensational headlines and runs so fast with them that we can’t catch up; we can be scared of an atmosphere that makes moms feel that their choices are limited to the lesser of two evils if they are unable to breastfeed. It’s our job, as advocates and care providers, to ensure that women aren’t given false ideas about risk in either direction, so that their “informed choices” can truly be informed.

Suzanne Barston is a maternal health advocate and freelance writer specializing in parenting, women’s interest, and science/health topics. She is the author of Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn’t and blogs as her alter ego, the “Fearless Formula Feeder”. She’s currently at work on an initiative to improve the perinatal experiences of women by addressing infant feeding intention and outcomes in an evidence-based, holistic manner.

 

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