When I first became a doula, I didn't know about many online resources for doulas; I don't know if they were even very common at that point. In terms of my continuing education as a doula, I learned from books, talking with doulas, midwives, and nurses, and of course hands-on from attending births! After taking a couple years' break from serious doula-ing, though, I was getting back into it, looking for more resources, and found a number of doula-related sites and listservs. Then I started reading blogs and discovered an even bigger world of blogs and resources.
In-person networking and sharing are still important, but I have learned so much from online resources that I almost think joining a single doula forum or listserv, at the very least, should be a requirement for being a doula. I am often surprised, in fact, by how little some doulas know about topics that I have seen extensively discussed in various online settings. We have a responsibility to ourselves and our clients to stay current with changes in maternity care practices, new research, and current events in the birth-o-sphere. So much of that is easily available online. And practicing solo, sometimes in hostile or isolated settings, can make it very difficult to generate the kind of community and collegial settings where doulas can share information and learn from each other. I have learned so much, and deepened my thinking, from reading information and debates on testing, interventions, informed consent, the doula's role, and more by participating in listservs and through the many great blogs by doulas, midwives, nurses, and other people interested in and passionate about birth.
That isn't to say every doula should become a blog junkie like me, though! Simply joining your local doula listserv often sends news items and discussion through your inbox, as well as connecting you to the local birth network. Usually those listservs will have "digest" settings so you can get all the messages sent each day packaged together in one e-mail. (I am already drowning in e-mail, so I set all listservs to arrive as digests or my inbox would be out of control!) If you don't have a good local listserv, I recommend Alldoulas.com where you can both connect with local people and interact with doulas from all over the world. I don't go on there very often, but the forums have been friendly, helpful, and a great resource for me when I needed them.
If you DO want to become a blog junkie like me (or just find a few good blogs to follow), I've created a "bundle" of my favorite blogs for those of you who use Google Reader. Click here to easily see and subscribe to all or some.
I should also say that I have also benefited hugely from the online resources available for communication among IBCLCs, specifically Lactnet. Reading about puzzling or complicated cases, the different takes of LCs from around the world on those cases or on issues of ethics and professional responsibility, and learning new tips and tricks has been fantastic and so educational. I sometimes see advice or techniques for situations I've encountered, and I print out them out and keep them on my clipboard at work in case I need them. (For example, I recently had great success with advice for how best to use reverse pressure softening with a very edematous mother.) As a new IBCLC, I know I have a huge amount left to learn and reading Lactnet is like getting to peer over the shoulder of more experienced LCs as they think and work with moms/babies.
What are your favorite doula/birthworker online supports or resources?
Showing posts with label lc work. Show all posts
Showing posts with label lc work. Show all posts
Thursday, June 9, 2011
Thursday, June 2, 2011
The breastfeeding police, or how what you don't know can hurt breastfeeding mothers
Anne at Dou-la-la has a guest post up on The Leaky Boob and it is a gem. Here's a few excerpts:
I am a brand spankin' new IBCLC (just got my exam pass in October 2010). Before that I was trained as a breastfeeding educator (think peer counselor-type level) and as a doula, and I wrote my senior thesis on breastfeeding. I knew a fair amount about this whole feeding-babies-with-your-breast thing, I really did. But once I started training as an IBCLC, I suddenly realized how much I DIDN'T know...and when I started actually working as an IBCLC, I realized how much I STILL didn't know all OVER again. In fact, the more I learn the more I stop answering questions confidently, and instead turn to my mentor LCs (with their 5-20+ years of experience) and reference books to double- and triple-check what I THOUGHT I knew, before I give any answers. And in the meantime I hear loads of unhelpful or clueless "advice" being doled out left and right. (If I hear one more NICU nurse suggest "drinking lots of water" as a solution for low supply...)
As Anne says, this isn't a "leave it to the experts, ladies" kind of situation - there absolutely is a setting for educated, compassionate peer support and it it SO important. But let's have it be educated and compassionate - not rife with statements like "everyone can make enough milk" (I saw 2 women in the hospital this past week with classic signs of insufficient glandular tissue, and if they don't reach a full supply even with optimal milk removal, there will be a pretty darn good physiological reason that they CAN'T).
When they hear that I'm a lactation consultant a lot of people share their difficulties with breastfeeding with me (same goes for doula and birth!) I sometimes hear it as a defensive explanation, sometimes as a way of continuing to grieve/process the experience, sometimes as a simple "oh, you'll be interested in this" conversational topic. No matter what, it's hard to find a way to respond, but even when I hear something in their story that doesn't sound accurate or misguided, I try to focus on what I can simply validate and acknowledge. "Exclusively pumping is so hard, I'm impressed you stuck with it as long as you did", or "That sounds so painful, I'm sorry that happened to you". (One of my LC colleagues says, "I'm sorry things didn't work out; often people find breastfeeding is easier with the next baby" to help leave the door open for trying again in the future.)
What I don't do is ask questions or try to learn more about the situation. If a mother thinks things could have gone differently or wants to know how to change things with the next baby, she will ask me! In the meantime, support, empower, offer resources to help the mother learn more and get more advanced help - but let's stop assuming we know everything about a woman's situation, particularly after the fact. It doesn't do her any favors and it sets breastfeeding back as well.
Please read Anne's post for a thought-provoking discussion on this topic! And please share your thoughts - what do you say when a mother shares her difficult breastfeeding story? If you had challenges breastfeeding, what were helpful/unhelpful things that people said to you?
YES, I do think that women who feel they ‘can’t’ produce enough milk have often been sabotaged (i.e. booby-trapped) in ways they are unaware of. And one of the things that most often thwarts them is misinformation.
HOWEVER. Statements that imply that really, everyone can breastfeed and if they didn’t succeed, they just didn’t try hard enough, mind over matter? EVERY BIT as misinformed as the bad advice that might have led a mom to undermine her supply or her belief in her supply. I know it’s highly unorthodox for a breastfeeding advocate to call other breastfeeding advocates out when their intentions really were good, but I see so much poor advice online that it’s really starting to get to me. ...
This does NOT mean that there is not a place for peer support. There so absolutely is is – La Leche League turned the tide on breastfeeding half a century ago and its very foundation was peer support. But part of being a trustworthy resource is knowing when something is beyond your knowledge – even for professionals, certain things are beyond one’s scope of practice, and it is crucial to have the honesty and humility to know when to refer.
I am a brand spankin' new IBCLC (just got my exam pass in October 2010). Before that I was trained as a breastfeeding educator (think peer counselor-type level) and as a doula, and I wrote my senior thesis on breastfeeding. I knew a fair amount about this whole feeding-babies-with-your-breast thing, I really did. But once I started training as an IBCLC, I suddenly realized how much I DIDN'T know...and when I started actually working as an IBCLC, I realized how much I STILL didn't know all OVER again. In fact, the more I learn the more I stop answering questions confidently, and instead turn to my mentor LCs (with their 5-20+ years of experience) and reference books to double- and triple-check what I THOUGHT I knew, before I give any answers. And in the meantime I hear loads of unhelpful or clueless "advice" being doled out left and right. (If I hear one more NICU nurse suggest "drinking lots of water" as a solution for low supply...)
As Anne says, this isn't a "leave it to the experts, ladies" kind of situation - there absolutely is a setting for educated, compassionate peer support and it it SO important. But let's have it be educated and compassionate - not rife with statements like "everyone can make enough milk" (I saw 2 women in the hospital this past week with classic signs of insufficient glandular tissue, and if they don't reach a full supply even with optimal milk removal, there will be a pretty darn good physiological reason that they CAN'T).
When they hear that I'm a lactation consultant a lot of people share their difficulties with breastfeeding with me (same goes for doula and birth!) I sometimes hear it as a defensive explanation, sometimes as a way of continuing to grieve/process the experience, sometimes as a simple "oh, you'll be interested in this" conversational topic. No matter what, it's hard to find a way to respond, but even when I hear something in their story that doesn't sound accurate or misguided, I try to focus on what I can simply validate and acknowledge. "Exclusively pumping is so hard, I'm impressed you stuck with it as long as you did", or "That sounds so painful, I'm sorry that happened to you". (One of my LC colleagues says, "I'm sorry things didn't work out; often people find breastfeeding is easier with the next baby" to help leave the door open for trying again in the future.)
What I don't do is ask questions or try to learn more about the situation. If a mother thinks things could have gone differently or wants to know how to change things with the next baby, she will ask me! In the meantime, support, empower, offer resources to help the mother learn more and get more advanced help - but let's stop assuming we know everything about a woman's situation, particularly after the fact. It doesn't do her any favors and it sets breastfeeding back as well.
Please read Anne's post for a thought-provoking discussion on this topic! And please share your thoughts - what do you say when a mother shares her difficult breastfeeding story? If you had challenges breastfeeding, what were helpful/unhelpful things that people said to you?
Friday, April 1, 2011
Thoughts on IBCLC training, reimbursement, and where the profession is headed
I don't remember when I first realized that the profession of "lactation consultant" existed. I must have encountered it at some point doing research for my undergrad senior thesis, which was (to make it very brief) a literature review and mixed-methods study on infant feeding decisions. The following year, when I did AmeriCorps, was my real introduction to the world of breastfeeding support: I did a 3-day training to become a Certified Breastfeeding Educator (taught by an IBCLC), began doing breastfeeding support in the clinics, and did some shadowing with in-hospital IBCLCs. That experience made me realize that I wanted to be an LC. One of my absolute favorite parts of the job was doing breastfeeding support, and I liked what I saw the LCs that I worked with getting to do. I enjoyed the one-on-one interaction, the clinical problem-solving, the feeling that you were working to help the mother achieve something that was important to her, and the satisfaction when something you suggested worked and - click! - for the first time, mom and baby had a successful feeding.
At the time, though, I looked into becoming an LC and couldn't imagine a way to get enough hours. At the time, IBLCE (the certifying organization for LCs) required thousands of hours of clinical practice to be eligible to sit the exam (for an interesting historical overview of IBCLC eligibility requirements, check out this presentation - opens as a PDF). When I was looking, the requirement was 2500 hours of clinical practice, which I would have to find a way to get independently (since apart from my one-year AmeriCorps term which was already over, I didn't have a job where I could get hours that would count towards my eligibility).
And I really considered how to make it happen. For years, I wanted to become an LC, and I would investigate ways to do it, and then I would give up again. And in this post I'm going to talk about why.
I've been putting off, mulling over, composing and revising this post for a long time. The seeds were sown when I first heard about the new requirements to sit the IBCLC exam, and when I read debates on Lactnet and other listservs; I've gotten e-mails and read other people's posts about this issue; but it's taken a while for me to figure out my thoughts about it.
The impetus to finally put this out there was sparked by some conversations I had at the Breastfeeding & Feminism conference with IBCLCs and IBCLC-wanna-bes. The wanna-bes talked with me about the difficulty of finding and funding training, the IBCLCs talked about their awareness of that difficulty, the limitations of the LC community in addressing the shortage of good training, and the issues with the current pathway system.
This is my current thinking and I'm very curious to hear what others think about it. I apologize for the length - it's quite possible it could be shorter and more succinct, but if I spend too much more time revising it will never get posted!
To start off, a little background about how you become an IBCLC: historically, there have been different pathways to qualifying to sit the exam. They have changed names and requirements more than once, but in my understanding they've all fallen under more or less two different routes:
1) Becoming an IBCLC already having some kind of medical/nursing/clinical degree. To qualify to sit the exam, these people have to have some lactation-specific education (although it is not standardized - hours from a vast array of providers and topics can count), and they also have to meet a minimum number of hours spent working with breastfeeding dyads. Importantly, these hours do not need to be under the direct supervision of an experienced IBCLC and can happen as part of the professional's regular work. So a nurse on a postpartum floor, a pediatrician, a dietitian at a WIC office - all of these people may be able to get their minimum hours through their work. (Pathway 1 in the current system.)
2) Becoming an IBCLC without having any kind of clinical degree. To qualify to sit the exam, these people have to also have lactation-specific education, and they need to meet a minimum hours requirement. However, their minimum hours need to be completed under the mentorship of one or more IBCLCs who have recertified at least once. (Pathway 3 in the current system.) These people can also do an educational program approved by IBLCE (Pathway 2), which provides the mentoring, hours, etc. all in one package, and requires somewhat fewer minimum hours, but those programs are few and far between.
Starting with those who will sit the exam in 2012, IBLCE is changing the requirements. From their information page on the upcoming changes:
The discussions I've seen online have covered a range of reactions. A lot of people are very upset about the new requirements. They argue that requiring all this essentially requires you to become an RN if you want to become an IBCLC (almost all of these are either required in nursing school or required prerequisites for nursing school). Some individuals from other countries have noted that there simply is no way for them to take these courses - they don't have community colleges or schools where you can just take a few credits here and there - unless they actually do enroll in a full-time academic program to become a nurse. Additionally, some people feel that lactation consulting is already becoming overmedicalized and is moving away from its unique roots in peer counseling, focus on empowering the mother, and in helping mothers find their own solutions vs. prescriptive "treatment", and this is accelerating that trend.
Other people are very supportive of the new requirements - even some people who came up through old, non-clinical pathways. They argue that if IBCLCs want to become respected as a clinical practice specialty, they need to have requirements that parallel other clinical degrees. MDs, RNs, OTs, PTs, etc. etc. - none of them begin practice, and most don't even begin their training, without taking basic courses in biology and anatomy, nor should they. An IBCLC who doesn't understand fundamentals of nutrition shouldn't be counseling a mother about appropriate complementary foods, and an IBCLC who can't read and communicate in medical terminology and documentation won't be respected by other clinical professionals that s/he is expected to work with.
IBLCE addressed some of these concerns directly in their FAQs page about the new requirements:
I see both ways on the new requirements piece. Unfortunately there are a lot of LCs out there who don't know what they're doing. And unfortunately I don't think it has very much to do with their educational backgrounds.
The way I see it, there are bad LCs out there who have medical backgrounds and never bothered to do more than count up their contact hours with mothers/babies and study for the exam, without doing any training with other LCs to improve their skills/knowledge base. There are also bad LCs out there who don't have medical backgrounds and did their training without understanding important basics of anatomy, physiology, how to read research, etc. and who have never pushed themselves to improve their skills/knowledge. (There are also bad LCs out there who have great education/experience through whatever pathway and are just bad. There are also bad doctors, nurses, etc. etc. - being able to get through a rigorous educational program and pass a test does not, unfortunately, necessarily make you good at your profession. Sigh.)
But I believe that all the challenges these new requirements pose for IBCLCs-in-training - in the U.S. at least - have less to do with the requirements themselves, and more to do with the educational pathways available. And in the end, it all comes inevitably back to licensure and reimbursement. How? Let me explain:
It may be standard and reasonable for RNs, MDs, PTs, etc. etc. to have these courses as prerequisites or as part of their professional education. However, they are generally not expected to come up with the entirety of their professional education on their own. They have educational programs which provide at least some of their educational requirements, along with things like student loans, work-study positions, fellowships, or other structured financial assistance that helps students get through their education without having to pay for it all up-front, out-of-pocket.
This is not true of IBCLCs-in-training. Along with all of these distribution requirements, they need to pay for 90 hours of IBLCE-certified lactation education (under the old requirements 45 hours). This education - which can be conferences, online courses, in-person workshops, etc. - is not cheap. Finally, they often have to pay private IBCLCs for mentorship (if they can even find one – frequently a very challenging undertaking, one of the main reasons being that the private LC is essentially training her own competition). Understandably, mentor IBCLCs need to be compensated for the extra time and effort they put in for teaching. This is another chunk of change.
When you look at all that, you are looking at a significant amount of $$$ to become an LC. (You are also looking at the exact reason that even though becoming an LC was my dream from the moment I met one, I never did it on my own. We'll get back to this in a moment.)
There are a very small number of IBLCE approved educational courses that provide a really standardized, all-in-one education the way a medical or nursing school does: you get your clinical education and your clinical rotations in a package. If they're through an accredited institution, you might even be able to get student loans to help pay for it.
This type of program was how I managed to finally get IBCLC training, because one happened to get started at my school while I happened to be there. This is why I was so excited and honestly in awe of the fact that I was getting to become an IBCLC. Why was it so amazing to me? Why did I hold off pursuing this dream?
And this is where we get back to licensure and reimbursement. (I know this is U.S.-centric, but the U.S. has a pretty large percentage of LCs and I think that LCs face this issue to varying degrees around the world. It's also one of IBLCE's justifications for changing the requirements.) Many people who look at the new requirements have said something along the lines of "Then I might as well go ahead and become a nurse". Why would they say that if they want to become LCs? Because nurses get paid. Nurses are part of standard care in a hundred different practice settings, they are licensed, and what they do is reimbursable through insurance. This is among the reasons that non-RN IBCLCs are not generally hired by hospitals, pediatric practices, etc. and among the reasons that private practice IBCLCs have trouble making a living. (The US Lactation Consultants Association has an excellent white paper on reimbursement - particularly relevant are pages 14-15).
There was no way I could justify, to myself, sinking thousands of dollars into an education that would take years and lead to a profession that could probably never be my sole source of financial support. I most definitely couldn't justify paying out-of-pocket for all that education or figure out a way to do it without decimating my future financial health and again - for what?
I think that the solution to all of these problems - training, education, experience, or lack thereof - is to have more standardized educational programs available through accredited schools. But I imagine schools, if/when they consider offering IBCLC training programs, will have financial concerns similar to the ones I had when contemplating the certification. Will they really have enough students willing to pay the amount of money needed to sustain those programs, now that these programs are about to get a lot more expensive?
The bottom line to me: you can get people to pay for years of nursing school, med school, etc. because they know they can pay back those loans eventually, and support themselves. The same promise is not there with LC work and until it is, more and more stringent educational requirements make it harder and harder for people to get into the profession without having some other professional credential that will get them reimbursed fairly for their work. An MPH student (not an RN) asked me at the conference whether I would recommend her doing the IBCLC course next year and because the cost of it has risen so much since I took it, I honestly couldn't give her a strong "yes" unless she is willing to commit to a life of private practice. She pointed out that I have a hospital position, but I assured her that I got it basically through sheer luck and those positions are few and far between.
I get that IBLCE is aiming for that eventuality of licensure and reimbursement and that they're hoping that changing the requirements will be a step in that direction. They say as much in the FAQs:
But what’s not really acknowledged here is that a profession that was already fairly inaccessible without great financial privilege will now be almost totally inaccessible. A lot of IBCLCs have said to me, "Oh, we're so glad to see you! We see so much gray hair at LC conferences, we need young people in the profession!" But young people can't afford to go into the profession, to say nothing of other groups that may have greater financial and family struggles. I go to LC conferences and see almost all white faces. IBLCE acknowledges that fewer people may sit the exam under the new requirements, and they promise a future pay-off. But how far into the future?
So that's what I'm thinking right now. And one final slight tangent: the other thing that writing this post has made me realize really bothers me is the current requirement for practice hours for clinical professionals. I think the need for all this RN-like training especially digs at some people because those who come through non-clinical pathways train for hundreds - and, under previous pathways, sometimes thousands - of hours under experienced LCs (and paid for those hours). However, RNs get to count up hours they spend as part of their jobs - no LC supervision necessary - and then take the exam. I’m not saying this experience is not valuable, but we don’t say to nurses “Hey, you do a lot of things that are related to what doctors do – pass the medical boards and you can practice medicine!” And IBCLCs spend a lot of time talking through anxieties and emotions with their clients, but can’t just count up those hours, take an exam, and become licensed as therapists.
Let me clarify here that I am NOT saying that all, or even most, RN IBCLCs are unqualified! I have gotten my training almost exclusively from RN IBCLCs who I respect profoundly and are fantastic LCs. Several of them have, however, told me how lucky I am to be able to mentor with LCs because when they got their certification they had never worked with another LC and had to learn on their own a lot of what they're teaching me now. To my mind, if non-clinical professionals are now being asked to spend time and money getting the coursework that the clinical people already have, the clinical professionals should be required to spend the time and money on finding and using direct LC mentorship. I think that would be at least as big a step towards improving the quality of the profession as these new requirements.
And that's my more-than-two-cents! Other thoughts out there? Especially from prospective IBCLCs?
At the time, though, I looked into becoming an LC and couldn't imagine a way to get enough hours. At the time, IBLCE (the certifying organization for LCs) required thousands of hours of clinical practice to be eligible to sit the exam (for an interesting historical overview of IBCLC eligibility requirements, check out this presentation - opens as a PDF). When I was looking, the requirement was 2500 hours of clinical practice, which I would have to find a way to get independently (since apart from my one-year AmeriCorps term which was already over, I didn't have a job where I could get hours that would count towards my eligibility).
And I really considered how to make it happen. For years, I wanted to become an LC, and I would investigate ways to do it, and then I would give up again. And in this post I'm going to talk about why.
I've been putting off, mulling over, composing and revising this post for a long time. The seeds were sown when I first heard about the new requirements to sit the IBCLC exam, and when I read debates on Lactnet and other listservs; I've gotten e-mails and read other people's posts about this issue; but it's taken a while for me to figure out my thoughts about it.
The impetus to finally put this out there was sparked by some conversations I had at the Breastfeeding & Feminism conference with IBCLCs and IBCLC-wanna-bes. The wanna-bes talked with me about the difficulty of finding and funding training, the IBCLCs talked about their awareness of that difficulty, the limitations of the LC community in addressing the shortage of good training, and the issues with the current pathway system.
This is my current thinking and I'm very curious to hear what others think about it. I apologize for the length - it's quite possible it could be shorter and more succinct, but if I spend too much more time revising it will never get posted!
To start off, a little background about how you become an IBCLC: historically, there have been different pathways to qualifying to sit the exam. They have changed names and requirements more than once, but in my understanding they've all fallen under more or less two different routes:
1) Becoming an IBCLC already having some kind of medical/nursing/clinical degree. To qualify to sit the exam, these people have to have some lactation-specific education (although it is not standardized - hours from a vast array of providers and topics can count), and they also have to meet a minimum number of hours spent working with breastfeeding dyads. Importantly, these hours do not need to be under the direct supervision of an experienced IBCLC and can happen as part of the professional's regular work. So a nurse on a postpartum floor, a pediatrician, a dietitian at a WIC office - all of these people may be able to get their minimum hours through their work. (Pathway 1 in the current system.)
2) Becoming an IBCLC without having any kind of clinical degree. To qualify to sit the exam, these people have to also have lactation-specific education, and they need to meet a minimum hours requirement. However, their minimum hours need to be completed under the mentorship of one or more IBCLCs who have recertified at least once. (Pathway 3 in the current system.) These people can also do an educational program approved by IBLCE (Pathway 2), which provides the mentoring, hours, etc. all in one package, and requires somewhat fewer minimum hours, but those programs are few and far between.
Starting with those who will sit the exam in 2012, IBLCE is changing the requirements. From their information page on the upcoming changes:
IBLCE has identified eight subjects in which all first-time candidates must have completed the equivalent of one semester of higher education. These 8 higher education courses are:
* Biology
* Human Anatomy
* Human Physiology
* Infant and Child Growth and Development
* Nutrition
* Psychology or Counseling or Communication Skills
* Introduction to Research
* Sociology or Cultural Sensitivity or Cultural Anthropology
In addition, all first-time candidates must have completed continuing education in 6 subjects that health professionals typically will have studied as part of their professional training and/or are required for ongoing maintenance of their professional credentials. These 6 additional general education subjects are:
* Basic life support (e.g. CPR)
* Medical documentation
* Medical terminology
* Occupational safety, including security, for health professionals
* Professional ethics for health professionals (e.g. Code of Ethics)
* Universal safety precautions and infection control
The discussions I've seen online have covered a range of reactions. A lot of people are very upset about the new requirements. They argue that requiring all this essentially requires you to become an RN if you want to become an IBCLC (almost all of these are either required in nursing school or required prerequisites for nursing school). Some individuals from other countries have noted that there simply is no way for them to take these courses - they don't have community colleges or schools where you can just take a few credits here and there - unless they actually do enroll in a full-time academic program to become a nurse. Additionally, some people feel that lactation consulting is already becoming overmedicalized and is moving away from its unique roots in peer counseling, focus on empowering the mother, and in helping mothers find their own solutions vs. prescriptive "treatment", and this is accelerating that trend.
Other people are very supportive of the new requirements - even some people who came up through old, non-clinical pathways. They argue that if IBCLCs want to become respected as a clinical practice specialty, they need to have requirements that parallel other clinical degrees. MDs, RNs, OTs, PTs, etc. etc. - none of them begin practice, and most don't even begin their training, without taking basic courses in biology and anatomy, nor should they. An IBCLC who doesn't understand fundamentals of nutrition shouldn't be counseling a mother about appropriate complementary foods, and an IBCLC who can't read and communicate in medical terminology and documentation won't be respected by other clinical professionals that s/he is expected to work with.
IBLCE addressed some of these concerns directly in their FAQs page about the new requirements:
17. With these new requirements, it seems to me that IBLCE is discouraging those of us who are not health professionals from becoming IBCLCs. I know of several IBCLCs in my community who are not health professionals and they are well respected. Why has IBLCE placed so much focus on the new general education requirements?
IBLCE continues to support the long-standing practice of welcoming and encouraging practitioners, who are not health professionals, to prepare and become IBCLCs. The ability to actively listen and take the time to collaborate with mothers in developing an appropriate care plan and the dedication to supporting families beyond the early postpartum period are some of the well-developed competencies of candidates who are not health professionals.
As the lactation consultant profession has matured, it has become clear that it is necessary for all IBCLCs to be well-grounded in those subjects that are typically studied by health professionals. A strong foundation of knowledge in the health disciplines that are typically included in health profession curricula will position all IBCLCs to function as well-respected members of the maternal-child health team. In addition, employers and policy-makers will have increased confidence in the IBCLC credential. With this increased confidence in place, initiatives such as licensure, reimbursement and more jobs for IBCLCs are more likely to be successful.
22. I'm an experienced IBCLC and hold no other credential in the health professions. If I were not already certified, I would not be able to qualify for the 2012 exam without returning to school. This does not seem fair and it appears that IBLCE is discouraging non-health professionals from applying. Did the IBLCE Board take this concern into consideration before making the changes?
Yes. The IBLCE Board gave quite a bit of consideration to your particular concern. In fact, there are a number of Board and staff members who are IBCLCs that hold no other credential in the health professions. The IBLCE Board holds the mother support background in such high esteem that the IBLCE By-laws require that no less than 51% of Board members have experience in mother support leadership. In spite of concerns similar to yours being expressed, the consensus of opinion was that improving the quality of the IBCLC credential was of utmost importance. The Board voted overwhelmingly to support the changes.
I see both ways on the new requirements piece. Unfortunately there are a lot of LCs out there who don't know what they're doing. And unfortunately I don't think it has very much to do with their educational backgrounds.
The way I see it, there are bad LCs out there who have medical backgrounds and never bothered to do more than count up their contact hours with mothers/babies and study for the exam, without doing any training with other LCs to improve their skills/knowledge base. There are also bad LCs out there who don't have medical backgrounds and did their training without understanding important basics of anatomy, physiology, how to read research, etc. and who have never pushed themselves to improve their skills/knowledge. (There are also bad LCs out there who have great education/experience through whatever pathway and are just bad. There are also bad doctors, nurses, etc. etc. - being able to get through a rigorous educational program and pass a test does not, unfortunately, necessarily make you good at your profession. Sigh.)
But I believe that all the challenges these new requirements pose for IBCLCs-in-training - in the U.S. at least - have less to do with the requirements themselves, and more to do with the educational pathways available. And in the end, it all comes inevitably back to licensure and reimbursement. How? Let me explain:
It may be standard and reasonable for RNs, MDs, PTs, etc. etc. to have these courses as prerequisites or as part of their professional education. However, they are generally not expected to come up with the entirety of their professional education on their own. They have educational programs which provide at least some of their educational requirements, along with things like student loans, work-study positions, fellowships, or other structured financial assistance that helps students get through their education without having to pay for it all up-front, out-of-pocket.
This is not true of IBCLCs-in-training. Along with all of these distribution requirements, they need to pay for 90 hours of IBLCE-certified lactation education (under the old requirements 45 hours). This education - which can be conferences, online courses, in-person workshops, etc. - is not cheap. Finally, they often have to pay private IBCLCs for mentorship (if they can even find one – frequently a very challenging undertaking, one of the main reasons being that the private LC is essentially training her own competition). Understandably, mentor IBCLCs need to be compensated for the extra time and effort they put in for teaching. This is another chunk of change.
When you look at all that, you are looking at a significant amount of $$$ to become an LC. (You are also looking at the exact reason that even though becoming an LC was my dream from the moment I met one, I never did it on my own. We'll get back to this in a moment.)
There are a very small number of IBLCE approved educational courses that provide a really standardized, all-in-one education the way a medical or nursing school does: you get your clinical education and your clinical rotations in a package. If they're through an accredited institution, you might even be able to get student loans to help pay for it.
This type of program was how I managed to finally get IBCLC training, because one happened to get started at my school while I happened to be there. This is why I was so excited and honestly in awe of the fact that I was getting to become an IBCLC. Why was it so amazing to me? Why did I hold off pursuing this dream?
And this is where we get back to licensure and reimbursement. (I know this is U.S.-centric, but the U.S. has a pretty large percentage of LCs and I think that LCs face this issue to varying degrees around the world. It's also one of IBLCE's justifications for changing the requirements.) Many people who look at the new requirements have said something along the lines of "Then I might as well go ahead and become a nurse". Why would they say that if they want to become LCs? Because nurses get paid. Nurses are part of standard care in a hundred different practice settings, they are licensed, and what they do is reimbursable through insurance. This is among the reasons that non-RN IBCLCs are not generally hired by hospitals, pediatric practices, etc. and among the reasons that private practice IBCLCs have trouble making a living. (The US Lactation Consultants Association has an excellent white paper on reimbursement - particularly relevant are pages 14-15).
There was no way I could justify, to myself, sinking thousands of dollars into an education that would take years and lead to a profession that could probably never be my sole source of financial support. I most definitely couldn't justify paying out-of-pocket for all that education or figure out a way to do it without decimating my future financial health and again - for what?
I think that the solution to all of these problems - training, education, experience, or lack thereof - is to have more standardized educational programs available through accredited schools. But I imagine schools, if/when they consider offering IBCLC training programs, will have financial concerns similar to the ones I had when contemplating the certification. Will they really have enough students willing to pay the amount of money needed to sustain those programs, now that these programs are about to get a lot more expensive?
The bottom line to me: you can get people to pay for years of nursing school, med school, etc. because they know they can pay back those loans eventually, and support themselves. The same promise is not there with LC work and until it is, more and more stringent educational requirements make it harder and harder for people to get into the profession without having some other professional credential that will get them reimbursed fairly for their work. An MPH student (not an RN) asked me at the conference whether I would recommend her doing the IBCLC course next year and because the cost of it has risen so much since I took it, I honestly couldn't give her a strong "yes" unless she is willing to commit to a life of private practice. She pointed out that I have a hospital position, but I assured her that I got it basically through sheer luck and those positions are few and far between.
I get that IBLCE is aiming for that eventuality of licensure and reimbursement and that they're hoping that changing the requirements will be a step in that direction. They say as much in the FAQs:
15. These new requirements will make becoming an IBCLC even more expensive. Are the IBLCE Board members concerned that the new requirements will reduce the number of applicants who are eligible to become IBCLCs?
The new requirements may result in a decreased number of exam candidates in the short term. However, the reason for making these changes is to increase the value of IBCLC certification. The IBLCE vision for the IBCLC credential is to "increase the number and improve the quality of IBCLCs."
IBLCE is the global authority in lactation consultant certification and raising the educational standards for the lactation consultant profession is crucial to the future growth and value of the IBCLC credential. While there may be a short-term drop in the number of prospective IBCLCs, the increased value of the credential will make IBCLC certification more highly desired by not only first-time candidates but also by recertifying IBCLCs.
But what’s not really acknowledged here is that a profession that was already fairly inaccessible without great financial privilege will now be almost totally inaccessible. A lot of IBCLCs have said to me, "Oh, we're so glad to see you! We see so much gray hair at LC conferences, we need young people in the profession!" But young people can't afford to go into the profession, to say nothing of other groups that may have greater financial and family struggles. I go to LC conferences and see almost all white faces. IBLCE acknowledges that fewer people may sit the exam under the new requirements, and they promise a future pay-off. But how far into the future?
So that's what I'm thinking right now. And one final slight tangent: the other thing that writing this post has made me realize really bothers me is the current requirement for practice hours for clinical professionals. I think the need for all this RN-like training especially digs at some people because those who come through non-clinical pathways train for hundreds - and, under previous pathways, sometimes thousands - of hours under experienced LCs (and paid for those hours). However, RNs get to count up hours they spend as part of their jobs - no LC supervision necessary - and then take the exam. I’m not saying this experience is not valuable, but we don’t say to nurses “Hey, you do a lot of things that are related to what doctors do – pass the medical boards and you can practice medicine!” And IBCLCs spend a lot of time talking through anxieties and emotions with their clients, but can’t just count up those hours, take an exam, and become licensed as therapists.
Let me clarify here that I am NOT saying that all, or even most, RN IBCLCs are unqualified! I have gotten my training almost exclusively from RN IBCLCs who I respect profoundly and are fantastic LCs. Several of them have, however, told me how lucky I am to be able to mentor with LCs because when they got their certification they had never worked with another LC and had to learn on their own a lot of what they're teaching me now. To my mind, if non-clinical professionals are now being asked to spend time and money getting the coursework that the clinical people already have, the clinical professionals should be required to spend the time and money on finding and using direct LC mentorship. I think that would be at least as big a step towards improving the quality of the profession as these new requirements.
And that's my more-than-two-cents! Other thoughts out there? Especially from prospective IBCLCs?
Thursday, November 18, 2010
A breastfeeding support home visit
The last Centering Pregnancy group I co-facilitated, the other co-fac was an experienced LC. Between the two of us, we told the midwife that she should let us know when the moms in the group deliver and we would help them with breastfeeding if they need it. Unfortunately, they deliver at a different hospital in town (not the one where I work) where lactation support is extremely minimal. That hospital also tells moms things like "Just let her cry, she'll figure it out eventually" and "Don't feed your baby more often than every 3 hours" and "Don't let them nurse more than 30 minutes". As you can imagine, a lot of breastfeeding problems result... not to mention jaundice readmits.
One of our Centering moms had help from the midwife at the hospital (including her jaundice readmit), and from the LC once at home. Baby would not latch consistently, and the LC e-mailed me today to say that she thought things had been going better but she had just found out they weren't. She was booked. Could I see this mom today?
It was good timing - I didn't work last night - so I called the mom and headed over. Pulling in to the apartment complex and going into her apartment was a total flashback to my AmeriCorps days* - three immigrant families packed into a single apartment, each with one bedroom of their own. The bedroom was even just like I remembered, cramped with a big TV in the corner.**
We spent a long time working on feeding, pumping, and talking about our plan. She has two problems - getting her baby to latch and maintaining a supply with just a hand pump (which wasn't getting used often enough). This mom told me her goal is "puro pecho" which if you've read my "los dos" post, you know isn't always the case with Hispanic moms! I am so determined to help her reach her goal - she is a committed mom who has been persistent where other people would have given up.
Still, it made me discouraged. A more privileged mom would hopefully have the education and resources to quickly identify breastfeeding problems and feel entitled to help; she would be able to hire a private lactation consultant to make multiple home visits; she would be able to rent a hospital-grade pump to maximize her supply.
This mom happened to do Centering and happened to have for facilitators two LCs with extra time on their hands. What about all the dozens and hundreds of other moms in her situation, who we don't know and can't see? In many other counties, I could refer her to a WIC peer counselor; her county's WIC has none and doesn't seem interested in getting any. At best she might be able to get a better pump from WIC (which she didn't realize - I knew to call and ask.) If not for the very rare happenstance of hands-on support, she'd just be left to struggle on her own, offering a screaming baby the breast 8 times a day and using the hand pump she got in the hospital to get what she can.
This is breastfeeding support in our country, to the most vulnerable moms who need help the most. This is why we need to talk about the public health risks of seeing formula as a perfectly good fall-back. This is totally unfair to mothers who WANT to breastfeed, who are working hard to breastfeed, and who do not have the resources to get the help they deserve.
*Bonus AmeriCorps story: Our supervisor did not love us doing home visits - you wouldn't either, if you were an experienced midwife with strong maternal instincts, in charge of a group of naive but enthusiastic young women. She approved home visits only in very specific circumstances and with lots of warnings. We also had to call when we got there and call when we left safely. Like I said, strong maternal instincts. So one of my teammates and I went to do a home visit one day after lots of dire warnings and promising to call. We are primed to be cautious. We get there and it's just mom and baby home. We start helping her... and her boyfriend walks in just home from work - with a six-pack of beer. Immediately we both get a little anxious. This is what our supervisor was most concerned about - boyfriends/husbands/other men around who would give us a hard time or see us as a target. We're having trouble getting the baby latched (all the while keeping one eye on the guy doing stuff in the kitchen) and we suggest to mom that she pump a little to get the milk flowing. Her boyfriend leaps into action, assembling the breastpump, bringing it to her, and then sits beside her, asking us a lot of concerned questions about how the baby is feeding. So much for our paranoid fantasies!
**For a long time I wondered about that - how could people only have enough money for one bedroom, but still enough to have a huge expensive TV? - until one of my AmeriCorps teammates explained to me that buying expensive electronics was how many people in South American countries keep liquid assets. Think about it - if you don't or can't get a bank account, how can you make sure you can get cash if you need it, without actually keeping all that cash on hand? One way is to buy something that will be easy to re-sell quickly. It's not a great investment, because it will depreciate instead of appreciate, but people only have so many options. I really appreciate the work that community-based organizations and credit unions do to help teach people about banking and make those options more accessible.
One of our Centering moms had help from the midwife at the hospital (including her jaundice readmit), and from the LC once at home. Baby would not latch consistently, and the LC e-mailed me today to say that she thought things had been going better but she had just found out they weren't. She was booked. Could I see this mom today?
It was good timing - I didn't work last night - so I called the mom and headed over. Pulling in to the apartment complex and going into her apartment was a total flashback to my AmeriCorps days* - three immigrant families packed into a single apartment, each with one bedroom of their own. The bedroom was even just like I remembered, cramped with a big TV in the corner.**
We spent a long time working on feeding, pumping, and talking about our plan. She has two problems - getting her baby to latch and maintaining a supply with just a hand pump (which wasn't getting used often enough). This mom told me her goal is "puro pecho" which if you've read my "los dos" post, you know isn't always the case with Hispanic moms! I am so determined to help her reach her goal - she is a committed mom who has been persistent where other people would have given up.
Still, it made me discouraged. A more privileged mom would hopefully have the education and resources to quickly identify breastfeeding problems and feel entitled to help; she would be able to hire a private lactation consultant to make multiple home visits; she would be able to rent a hospital-grade pump to maximize her supply.
This mom happened to do Centering and happened to have for facilitators two LCs with extra time on their hands. What about all the dozens and hundreds of other moms in her situation, who we don't know and can't see? In many other counties, I could refer her to a WIC peer counselor; her county's WIC has none and doesn't seem interested in getting any. At best she might be able to get a better pump from WIC (which she didn't realize - I knew to call and ask.) If not for the very rare happenstance of hands-on support, she'd just be left to struggle on her own, offering a screaming baby the breast 8 times a day and using the hand pump she got in the hospital to get what she can.
This is breastfeeding support in our country, to the most vulnerable moms who need help the most. This is why we need to talk about the public health risks of seeing formula as a perfectly good fall-back. This is totally unfair to mothers who WANT to breastfeed, who are working hard to breastfeed, and who do not have the resources to get the help they deserve.
*Bonus AmeriCorps story: Our supervisor did not love us doing home visits - you wouldn't either, if you were an experienced midwife with strong maternal instincts, in charge of a group of naive but enthusiastic young women. She approved home visits only in very specific circumstances and with lots of warnings. We also had to call when we got there and call when we left safely. Like I said, strong maternal instincts. So one of my teammates and I went to do a home visit one day after lots of dire warnings and promising to call. We are primed to be cautious. We get there and it's just mom and baby home. We start helping her... and her boyfriend walks in just home from work - with a six-pack of beer. Immediately we both get a little anxious. This is what our supervisor was most concerned about - boyfriends/husbands/other men around who would give us a hard time or see us as a target. We're having trouble getting the baby latched (all the while keeping one eye on the guy doing stuff in the kitchen) and we suggest to mom that she pump a little to get the milk flowing. Her boyfriend leaps into action, assembling the breastpump, bringing it to her, and then sits beside her, asking us a lot of concerned questions about how the baby is feeding. So much for our paranoid fantasies!
**For a long time I wondered about that - how could people only have enough money for one bedroom, but still enough to have a huge expensive TV? - until one of my AmeriCorps teammates explained to me that buying expensive electronics was how many people in South American countries keep liquid assets. Think about it - if you don't or can't get a bank account, how can you make sure you can get cash if you need it, without actually keeping all that cash on hand? One way is to buy something that will be easy to re-sell quickly. It's not a great investment, because it will depreciate instead of appreciate, but people only have so many options. I really appreciate the work that community-based organizations and credit unions do to help teach people about banking and make those options more accessible.
Wednesday, August 25, 2010
Volumes: a huge problem
The response to my last post on "los dos" pushed me into finally finishing this one! The volumes given to babies are a huge part of what makes "los dos" so problematic, but are a problem on their own as well. We don't know exactly why breastfeeding is protective against obesity, but a big part of it may be the part with the breast. It's harder (although by no means impossible) to overfeed a baby at the breast. When you're giving a bottle, it's much easier to overfeed a baby and to override their own feelings of satiety/being full by persuading them to just finish what's left in the bottle, or what we think they should be taking.
This problem, unfortunately, frequently starts on the first day of a baby's life. Have you ever seen the belly balls made by Ameda? I think they are a nice way to visualize the size of a newborn's stomach on days 1, 3, and 10. Day 1 is a shooter marble, representing 5-7 milliliters(ml), and Day 3 is a ping-pong ball, representing 22-27 ml. As a frame of reference for those of us not used to metric, 1 fluid ounce = 30 ml, and 1 teaspoon = 5 ml.
These are tiny volumes, as is appropriate for tiny babies with tiny stomachs designed to handle small volumes of colostrum that empty quickly (the gastric emptying time of breastmilk is about half that of formula).
These volumes mean that at one feeding, even on Day 3, a baby should be getting a maximum of 1 ounce.
And yet over and over in the hospital and out of it, I am absolutely boggled (and sometimes horrified) by the volumes that people are able to push to a baby via bottle. I walked into a room the other night and a mom had breastfed her 1-day-old baby on both sides, and THEN given him 40 ml via bottle. All of us routinely see parents who are able to get babies to take 45 ml or more at nearly every feed. Even at day 3, these babies are literally eating double what they're supposed to.
What happens when babies get fed such huge volumes? First of all, they spit up. Give a brand-new baby a 10 ml feed (and remember, this is just 2 teaspoons!) and you may find most of it spilled down her front. It can be scary for the parents and probably doesn't feel that great to the baby.
Second of all, they don't eat. New babies forced to take one huge feed may not eat again for the rest of the day, spitting up constantly with distended abdomens. Babies consistently getting supplemented after breastfeeding, even with smaller volumes, take longer to wait for the next feed -- maybe 4-5 hours instead of 2-3. Physiologically, this isn't sufficient to establish a good milk supply in most women.
Third of all, they get hungry. Forced to take huge volumes over and over again, they start expecting huge volumes. Mom's colostrum can't possibly keep up, which leads to a fussy baby, which leads to more supplements, which leads to less breastfeeding, which leads to lower supply...you see where this is going.
Huge volumes are one of the banes of the hospital LC's existence, as far as I'm concerned. And yet it's so hard to address.
I don't want to be the mean LC who tells the parents they just overfed their baby and doomed breastfeeding, but I do want to educate appropriately on volumes. I want to tell parents that this is too much for a baby's stomach, and that it can create problems with breastfeeding. I want to convince the parents that such huge volumes are a bad idea.
Unfortunately, the babies don't cooperate.
Parents seem to expect a baby who takes a large feed quickly and then sleeps soundly for at least 2 hours and preferably 3 or more, and overfed babies do this very well. "Baby doesn't wake up to feed as often" doesn't really sound like a problem to them. And yet once I cross the line into warning her "You can compromise your milk supply" that risks mom hearing what she probably already believes, which is that she won't produce enough milk. AND I hear the eye-rolling message boards of the Internets in my head. ("The lactation person in the hospital told me if I gave my baby ONE BOTTLE of formula, I would NEVER produce enough milk! Boob nazi!")
Parents also expect that if the baby is hungry, she/he will keep sucking, or will be willing to take a bottle back into his/her mouth. Overfed babies will most certainly keep sucking if they have a constant flow of liquid down their throat (the bottle will flow by itself without any help from them) -- in fact, it's hard for them to stop because then they would choke -- and they have a firm stimulus in the back of their mouths. They will do this regardless of their own feelings of hunger or satiety. You can also often get an unwilling baby to accept a bottle nipple back in if you play around long enough (less frequently true for the breast).
I know that responsiveness to hunger/satiety cues is an issue identified, and under research, by people out there in the infant feeding world. I think a key piece is being able to interpret NORMAL newborn behavior (fussy does not always equal hungry! frequent waking is not pathological!) and respond to a baby's cues instead of overwhelming them.
What do we do at the hospital to solve this? We try so hard to educate everyone at their first hi-I'm-the-LC visit if they are planning to do any supplementation. (Obviously we also try to educate them about exclusively breastfeeding, but this is harm reduction.) This takes different approaches, generally from the "your baby's stomach is only this big!" school of thinking.
I've also started taking a more direct route. If I'm the one bringing the bottle (you can't win every time) I pour out everything but what they baby should take at that feeding. (That a 2 oz bottle is considered the standard for a newborn nursery just shows how insidious the formula industry is). We would not give 4 pain pills to a mom and say "but only take one". Neither should we hand her a 60 ml bottle and say "but only give 10" especially because if baby keeps sucking they interpret that as "still hungry". This also prevents the practice of re-using the same bottle for multiple feedings (this happens all the time even though the bottle clearly says it should be discarded after an hour.)
It also helps to at least ask moms to give supplements via a supplementing tube at the breast (you can rig up a cheap, easy one with a 10 ml syringe and a 5 french feeding tube) or a similarly-sized dental syringe. The 10 ml syringe makes that amount look like a large amount, we have parents push it very slowly, and it at least keeps baby stimulating the breast.
I'm trying to get the nurses to do the same although this is more challenging -- I am winning a few interested parties over to trying it. Unfortunately, not every nurse sees these volumes as an issue, which leads me into my second group of overfeeders: the hospital staff.
Oh man, I wish with all this I could say that it was only the parents. But no, if a partially-breastfeeding (or even exclusively formula feeding) mom has asked baby to get a bottle in the nursery, there are nurses who will give 25 ml on Day 1 just like anyone else. (Or more, to the point of pathological...) One of the nurses who is now an LC told me it used to be a point of pride for her that she could get babies to finish the bottle, and I've heard similar stories elsewhere from nursery nurses -- getting that baby to eat who just wouldn't was (and sometimes still is) a valued skill, and getting them to eat a lot meant full, happy, healthy babies filling your nursery.
I will say, not all nurses do this! They will come to me and say "she asked me to give a bottle so I only gave him 10 ml, why don't you go see if he's hungry again and wants to breastfeed" or "she asked me to give a bottle before she came upstairs from L&D but I just made his bath take an extra long time, maybe you could get her started breastfeeding". They tell parents independently not to give too much and that it interferes with breastfeeding, or set them up with a dental syringe with a tiny amount of formula if they insist on supplementing, and they don't hand them 3 or 4 bottles at a time. Thank you, wonderful nurses!
How to solve this problem in the long-term? I heard the prolific and very smart breastfeeding researcher Kay Dewey speak last year, and she talked about her research trying to teach parents to interpret feeding cues correctly. Unfortunately, that education (done with WIC participants) was found to be ineffective at reducing overfeeding. It sounded like their next step with that research, to expand the education from just feeding cues to teaching parents how to interpret their babies' cues generally, was going much more successfully. I'm looking forward to reading more about it as they complete their research. I think it's the right direction to go in -- I believe a big part of the issue with volumes is the unrealistic expectations for "satisfied" baby behavior. Getting it to parents, however, will be a big step and take a long time.
In the meantime, what do you do to discourage parents from giving big volumes? Did you know how much babies were supposed to take in their early days?
This problem, unfortunately, frequently starts on the first day of a baby's life. Have you ever seen the belly balls made by Ameda? I think they are a nice way to visualize the size of a newborn's stomach on days 1, 3, and 10. Day 1 is a shooter marble, representing 5-7 milliliters(ml), and Day 3 is a ping-pong ball, representing 22-27 ml. As a frame of reference for those of us not used to metric, 1 fluid ounce = 30 ml, and 1 teaspoon = 5 ml.
These are tiny volumes, as is appropriate for tiny babies with tiny stomachs designed to handle small volumes of colostrum that empty quickly (the gastric emptying time of breastmilk is about half that of formula).
These volumes mean that at one feeding, even on Day 3, a baby should be getting a maximum of 1 ounce.
And yet over and over in the hospital and out of it, I am absolutely boggled (and sometimes horrified) by the volumes that people are able to push to a baby via bottle. I walked into a room the other night and a mom had breastfed her 1-day-old baby on both sides, and THEN given him 40 ml via bottle. All of us routinely see parents who are able to get babies to take 45 ml or more at nearly every feed. Even at day 3, these babies are literally eating double what they're supposed to.
What happens when babies get fed such huge volumes? First of all, they spit up. Give a brand-new baby a 10 ml feed (and remember, this is just 2 teaspoons!) and you may find most of it spilled down her front. It can be scary for the parents and probably doesn't feel that great to the baby.
Second of all, they don't eat. New babies forced to take one huge feed may not eat again for the rest of the day, spitting up constantly with distended abdomens. Babies consistently getting supplemented after breastfeeding, even with smaller volumes, take longer to wait for the next feed -- maybe 4-5 hours instead of 2-3. Physiologically, this isn't sufficient to establish a good milk supply in most women.
Third of all, they get hungry. Forced to take huge volumes over and over again, they start expecting huge volumes. Mom's colostrum can't possibly keep up, which leads to a fussy baby, which leads to more supplements, which leads to less breastfeeding, which leads to lower supply...you see where this is going.
Huge volumes are one of the banes of the hospital LC's existence, as far as I'm concerned. And yet it's so hard to address.
I don't want to be the mean LC who tells the parents they just overfed their baby and doomed breastfeeding, but I do want to educate appropriately on volumes. I want to tell parents that this is too much for a baby's stomach, and that it can create problems with breastfeeding. I want to convince the parents that such huge volumes are a bad idea.
Unfortunately, the babies don't cooperate.
Parents seem to expect a baby who takes a large feed quickly and then sleeps soundly for at least 2 hours and preferably 3 or more, and overfed babies do this very well. "Baby doesn't wake up to feed as often" doesn't really sound like a problem to them. And yet once I cross the line into warning her "You can compromise your milk supply" that risks mom hearing what she probably already believes, which is that she won't produce enough milk. AND I hear the eye-rolling message boards of the Internets in my head. ("The lactation person in the hospital told me if I gave my baby ONE BOTTLE of formula, I would NEVER produce enough milk! Boob nazi!")
Parents also expect that if the baby is hungry, she/he will keep sucking, or will be willing to take a bottle back into his/her mouth. Overfed babies will most certainly keep sucking if they have a constant flow of liquid down their throat (the bottle will flow by itself without any help from them) -- in fact, it's hard for them to stop because then they would choke -- and they have a firm stimulus in the back of their mouths. They will do this regardless of their own feelings of hunger or satiety. You can also often get an unwilling baby to accept a bottle nipple back in if you play around long enough (less frequently true for the breast).
I know that responsiveness to hunger/satiety cues is an issue identified, and under research, by people out there in the infant feeding world. I think a key piece is being able to interpret NORMAL newborn behavior (fussy does not always equal hungry! frequent waking is not pathological!) and respond to a baby's cues instead of overwhelming them.
What do we do at the hospital to solve this? We try so hard to educate everyone at their first hi-I'm-the-LC visit if they are planning to do any supplementation. (Obviously we also try to educate them about exclusively breastfeeding, but this is harm reduction.) This takes different approaches, generally from the "your baby's stomach is only this big!" school of thinking.
I've also started taking a more direct route. If I'm the one bringing the bottle (you can't win every time) I pour out everything but what they baby should take at that feeding. (That a 2 oz bottle is considered the standard for a newborn nursery just shows how insidious the formula industry is). We would not give 4 pain pills to a mom and say "but only take one". Neither should we hand her a 60 ml bottle and say "but only give 10" especially because if baby keeps sucking they interpret that as "still hungry". This also prevents the practice of re-using the same bottle for multiple feedings (this happens all the time even though the bottle clearly says it should be discarded after an hour.)
It also helps to at least ask moms to give supplements via a supplementing tube at the breast (you can rig up a cheap, easy one with a 10 ml syringe and a 5 french feeding tube) or a similarly-sized dental syringe. The 10 ml syringe makes that amount look like a large amount, we have parents push it very slowly, and it at least keeps baby stimulating the breast.
I'm trying to get the nurses to do the same although this is more challenging -- I am winning a few interested parties over to trying it. Unfortunately, not every nurse sees these volumes as an issue, which leads me into my second group of overfeeders: the hospital staff.
Oh man, I wish with all this I could say that it was only the parents. But no, if a partially-breastfeeding (or even exclusively formula feeding) mom has asked baby to get a bottle in the nursery, there are nurses who will give 25 ml on Day 1 just like anyone else. (Or more, to the point of pathological...) One of the nurses who is now an LC told me it used to be a point of pride for her that she could get babies to finish the bottle, and I've heard similar stories elsewhere from nursery nurses -- getting that baby to eat who just wouldn't was (and sometimes still is) a valued skill, and getting them to eat a lot meant full, happy, healthy babies filling your nursery.
I will say, not all nurses do this! They will come to me and say "she asked me to give a bottle so I only gave him 10 ml, why don't you go see if he's hungry again and wants to breastfeed" or "she asked me to give a bottle before she came upstairs from L&D but I just made his bath take an extra long time, maybe you could get her started breastfeeding". They tell parents independently not to give too much and that it interferes with breastfeeding, or set them up with a dental syringe with a tiny amount of formula if they insist on supplementing, and they don't hand them 3 or 4 bottles at a time. Thank you, wonderful nurses!
How to solve this problem in the long-term? I heard the prolific and very smart breastfeeding researcher Kay Dewey speak last year, and she talked about her research trying to teach parents to interpret feeding cues correctly. Unfortunately, that education (done with WIC participants) was found to be ineffective at reducing overfeeding. It sounded like their next step with that research, to expand the education from just feeding cues to teaching parents how to interpret their babies' cues generally, was going much more successfully. I'm looking forward to reading more about it as they complete their research. I think it's the right direction to go in -- I believe a big part of the issue with volumes is the unrealistic expectations for "satisfied" baby behavior. Getting it to parents, however, will be a big step and take a long time.
In the meantime, what do you do to discourage parents from giving big volumes? Did you know how much babies were supposed to take in their early days?
Friday, August 6, 2010
Tips for working nights
One of the things slowing down my posting rate, even post-IBCLC exam, is my schedule working nights doing lactation support. I thought it would be so easy going in! After all, I'm a doula and have now lost count of the number of nights I've powered through on a PowerBar and some adrenaline (I don't even do caffeine). Then I'd go home, sleep it off, and be fine. How different could this be?
Color me naive. It is so different to work nights regularly than it is to jump in for a night or two, power through, and then go straight back to your normal schedule. At the end of the first two weeks of nights, I was on the cliff's edge and totally unable to figure out why. Two things helped me realize why this was so hard:
1) To shift from sleeping, say, 11pm-8 am and then start sleeping 8 am-4 pm, then switch back 3 days later, is like having a 9-hour time zone jump twice a week. Hello, jet lag!
2) Apparently, your brain makes melatonin during the day and serotonin at night. When your sleep schedule gets screwed around with and you don't get any "day", you don't get any serotonin. Hello, inexplicable depression!
I was basically a wreck - miserable for no reason, other than of course the reason that I was tired all the time and felt like I could never get enough sleep.
Now, however, things have improved greatly and I attribute this in large part to my new plan for handling nights. I found Rural Doctor's post on working nights very helpful - she has instructions from sleep to eating - but I've made some modifications.
First, I tried to do her method of splitting up sleep - getting up fairly early in the morning and then going back to bed and sleeping in the afternoon. I may try it again, but 1) that means the entire day is shot for me - and this is unfortunately not my only job, so that can make schedules challenging and 2) my body has yet to agree that, for example, 5 + 4 = 9 when it comes to sleep. I can sleep 5 hours, then break, then sleep 4 hours, and feel equally crappy both times I wake up and for many hours afterward. I have to get long consecutive sleep stretches. This has been the #1 most important change from the first 2 weeks, where I was still trying to convince my body to do simple addition.
Also, I don't do caffeine so that part is skipped. I tried it one night when I was really sleep-deprived with a big ol' cup of highly caffeinated tea before work. I still can't definitively pin this on the caffeine, given that I was also so sleep-deprived, but I got a horrific headache at work. Like, when I bent over patient beds to help with latch and positioning, my head would feel like it was going to throb apart when I stood up. One of the lovely nurses dug into her personal stash of ibuprofen for me (and I vowed never to be without it at work again), I was capable of bending over to assist with feedings again, and decided no more caffeine.
So my schedule, with modifications from the original, is more or less this:
Night before first night shift:
Day of first night shift:
For each night shift:
After the last day shift:
The other thing that has been helpful with all this is just time and getting my body used to it. The first time I tried to pull an all-nighter to write a paper, I couldn't function past 3 am. College (and my last-minute paper-writing habits) beat this weakness out of me quickly and while I always rued my procrastination and felt fairly nauseous the next day, I could do an all-nighter when needed. This proved invaluable when I started working as a doula. I spent the first couple weeks of this job feeling queasy and crappy almost constantly, whether I'd worked the night before or not. And then...it just got better. My body figured it out.
So my recommendation to any of you who are dealing with transitioning to a new sleep schedule, or trying to figure out how to do long doula calls and still remain upright, is to give yourself time and patience. I had some panicky moments where I thought I was going to feel like this forever/as long as I had this job (which at that point didn't seem like it could possibly be very long). It passed, and now I feel reasonably functional even on my more sleep-deprived days.
Of course, it messes with posting...I promise I'm working on those, albeit slowly...
Color me naive. It is so different to work nights regularly than it is to jump in for a night or two, power through, and then go straight back to your normal schedule. At the end of the first two weeks of nights, I was on the cliff's edge and totally unable to figure out why. Two things helped me realize why this was so hard:
1) To shift from sleeping, say, 11pm-8 am and then start sleeping 8 am-4 pm, then switch back 3 days later, is like having a 9-hour time zone jump twice a week. Hello, jet lag!
2) Apparently, your brain makes melatonin during the day and serotonin at night. When your sleep schedule gets screwed around with and you don't get any "day", you don't get any serotonin. Hello, inexplicable depression!
I was basically a wreck - miserable for no reason, other than of course the reason that I was tired all the time and felt like I could never get enough sleep.
Now, however, things have improved greatly and I attribute this in large part to my new plan for handling nights. I found Rural Doctor's post on working nights very helpful - she has instructions from sleep to eating - but I've made some modifications.
First, I tried to do her method of splitting up sleep - getting up fairly early in the morning and then going back to bed and sleeping in the afternoon. I may try it again, but 1) that means the entire day is shot for me - and this is unfortunately not my only job, so that can make schedules challenging and 2) my body has yet to agree that, for example, 5 + 4 = 9 when it comes to sleep. I can sleep 5 hours, then break, then sleep 4 hours, and feel equally crappy both times I wake up and for many hours afterward. I have to get long consecutive sleep stretches. This has been the #1 most important change from the first 2 weeks, where I was still trying to convince my body to do simple addition.
Also, I don't do caffeine so that part is skipped. I tried it one night when I was really sleep-deprived with a big ol' cup of highly caffeinated tea before work. I still can't definitively pin this on the caffeine, given that I was also so sleep-deprived, but I got a horrific headache at work. Like, when I bent over patient beds to help with latch and positioning, my head would feel like it was going to throb apart when I stood up. One of the lovely nurses dug into her personal stash of ibuprofen for me (and I vowed never to be without it at work again), I was capable of bending over to assist with feedings again, and decided no more caffeine.
So my schedule, with modifications from the original, is more or less this:
Night before first night shift:
- Stay up as late as possible, generally about 3 am.
Day of first night shift:
- Sleep till 11 am or so. Then have afternoon/evening available for getting other work done (my shift begins at 11 pm, unlike most shifts which start at 7 pm).
- Pack lunch, put together outfit (I don't own many scrubs and tend to go the business casual route the way most of the other LCs at this hospital do.)
For each night shift:
- Packing a lunch: helpful, although the cafeteria at night has a couple reasonably healthy, although not-super-appetizing options (I can't think of much less appetizing than hospital cafeteria packaged sushi at 3 am). But there's not always time to run down there, so it's good to have the food nearby.
- Snacks!: Helpful for staying awake. I also use them to health it up if I caved and brought a frozen entree. So last night I had a frozen burrito but brought cherries and carrot sticks to go with it. (I also rarely go into the nurses' lounge, where lurk the donuts...)
- Hydration: I have learned to skip, for reasons related to sleep. How to put this delicately? Wait, I'm a doula, I don't do delicacy: if I drink all night, it makes it hard to stay asleep during the day because I get up to pee too often and then it's hard to get back to sleep. I try to drink water before or at the beginning of my shift, and then really limit it. I'll chug all I want if it's my last night shift in a set, but the other nights I value sleep over thirst-quenching.
- Get out as soon as you can: One of the best tips I got from the Rural Doctoring post was not to hang around and chit-chat with the oncoming shift. It really does feel like being rescued from Gilligan's Island, or having fresh troops arrive at a beleaguered battlefield. Especially being the only lactation person on overnight, I want to recount complicated cases, tell them something crazy a nurse said, ask about the schedule, chitchat about the weather, etc. etc. Instead I push myself to mention anyone who I think needs more explanation than easily fits on the follow-up list I'm leaving, and then wish them a good day and head out. Again: sleep takes priority.
- Mid-shift slump: I tend to have a slump around 4 am, especially the first night in a set. Those moments of tiredness can feel a little desperate - that "oh my god, if I don't sleep RIGHT NOW I am going to cry" - but it's happened enough times now that I remind myself that it will pass and I'll feel better within an hour. By the time shift change happens, I could probably stay up the rest of the day (not recommended).
- Keeping it dark: I keep forgetting to bring sunglasses with me to wear home at the end of the shift to keep my body thinking it's night. Knock on wood, I've had no trouble falling asleep even without this (fortunately it's a short drive home). However, keeping my room dark has made a HUGE difference in the quality of my sleep. I got Eclipse 0% curtains at Target, and while they don't actually let in 0% of the light, those + a sleep mask make a big difference. I also use two fans (ceiling and box) to stay cool and for white noise. Heaven! (I add the Rural Doc's recommendation of a cat who is a good napper.)
After the last day shift:
- Short nap in the morning, no more than 3 hours. Stay up till a normal bedtime and then go to bed and sleep as much as needed.
The other thing that has been helpful with all this is just time and getting my body used to it. The first time I tried to pull an all-nighter to write a paper, I couldn't function past 3 am. College (and my last-minute paper-writing habits) beat this weakness out of me quickly and while I always rued my procrastination and felt fairly nauseous the next day, I could do an all-nighter when needed. This proved invaluable when I started working as a doula. I spent the first couple weeks of this job feeling queasy and crappy almost constantly, whether I'd worked the night before or not. And then...it just got better. My body figured it out.
So my recommendation to any of you who are dealing with transitioning to a new sleep schedule, or trying to figure out how to do long doula calls and still remain upright, is to give yourself time and patience. I had some panicky moments where I thought I was going to feel like this forever/as long as I had this job (which at that point didn't seem like it could possibly be very long). It passed, and now I feel reasonably functional even on my more sleep-deprived days.
Of course, it messes with posting...I promise I'm working on those, albeit slowly...
Thursday, July 8, 2010
Tip of the day
Calculating weight loss of newborns? You can get reaaaally good at doing it on your own: (Birth weight - Current weight) / Birth weight * 100 = % lost. Or you can find a website to do it for you.
The first way can solidify your admittedly weak arithmetic skills. But the second way is so easy!
And that's your tip of the day, and possibly of the week since I have been too busy with work + Fourth of July + life to be posting much. I promise the next installments of my MPH series are in the works!
The first way can solidify your admittedly weak arithmetic skills. But the second way is so easy!
And that's your tip of the day, and possibly of the week since I have been too busy with work + Fourth of July + life to be posting much. I promise the next installments of my MPH series are in the works!
Saturday, June 19, 2010
Why do babies get supplemented in the hospital? A story from my first week on nights
While I have told myself I was going to try to pick up the posting rate in June, this week was my first doing night shifts (11 pm - 7 am) on lactation support at the hospital where I've been training to be an LC. I feel pretty comfortable there at this point, but it feels so strange to have my own electronic charting ID and not have to wait for anyone else to log me in - before, we were being supervised by the LCs and so I would chart on their accounts under their supervision.
Obviously, I've been a little anxious about whether the night nurses would be welcoming, whether people would be willing to call me - basically whether I'd have any work at all! While all the staff I've talked to so far have been nothing but happy and excited to have lactation support available, the first night was really quiet. I saw a few people in the first couple of hours, then sat around, and then things picked up from 5 am - 7 am when people started to wake up and call for assistance. I told myself that the census was low, and staff were still getting used to me being there, but I wondered if every night would be so quiet. The big hope was that having someone overnight on lactation would help prevent a lot of the bottles and supplementation that happens at night. Was I going to be able to do that?
The following night answered that question for me. I basically never sat down except to chart. I spent at least an hour with in three different rooms. And my big victory was helping keep a hypoglycemic baby from being unnecessarily supplemented. The cut-off for hypoglycemia in the newborns here is 45. The nurse caught me in the nursery and said she had tested twice, baby was just below the cut-off and heading in the "wrong direction". To the nurse, formula seemed like a medical necessity at this point. She asked if maybe I could do it at the breast. When I came into the room, though, mom was crying - she didn't want to supplement. I offered to handle the situation from there and the nurse said that was fine - she left us to it. The mom told me the baby had been hungry and about to feed, right before the nurse had come in and taken him for the blood sugar testing. I said "Well, if he's hungry, he can nurse and if he nurses well, he won't need any formula."
So, we put the baby to breast - and this baby was, indeed, very hungry and nursing fairly well. Still, I was anxious - I did not want to screw this up, I was going to get all the colostrum into that baby that I could. The nurse had brought a couple of dental syringes for the formula. I took one and popped the stopper out, and asked mom if we could hand express into it from the other side and supplement the baby with expressed colostrum. Mom said OK very readily and wow, she had plenty! I was boggled to think this baby could have ended up with formula with so much colostrum available. The mom's sister was spending the night to help her out and happily assisted with hand expression (with mom's agreement, of course) - it was so nice to see such good family support! Who says other family members can't participate in breastfeeding?
Between nursing and supplementing, by the end of the nursing session I was having to take him off and wake him up repeatedly, and he would fall asleep as soon as he got back to the breast. This kid was full. (But I was not going to let him go to sleep without getting every last drop he could!) Finally, I put him skin-to-skin with mom (also good for blood sugar!) and called the nurse to tell her "went great, no formula needed!" And you know what? The nurse was totally fine with that. She gave the baby a full hour before rechecking his sugars and - yay! - baby was back above the cut-off - "heading in the right direction". The nurse was actually very gracious and helpful about all of this, and I realized after talking with one of the other LCs that it's not a "breastfeeding is bad" mentality at all on the nurses' part - this nurse just wanted to fix the blood sugar, and the formula could be the fix, or my help with breastfeeding could be the fix. Of course, since I'm not always there, it would be nice if this experience helps her have more confidence in the future with putting baby to breast as the first line of treatment. But one step at a time!
After all this drama about avoiding what probably would have been just several milliliters of formula, you may be wondering, what's wrong with just a little supplementation? Just to get the baby's blood sugar up - then they could go on breastfeeding, no problem. And I think it's a fair question. It doesn't seem like a single bottle would do that much harm. And yet we know that babies who are supplemented - even a single bottle - in the early days tend to have shorter durations of both exclusive and any breastfeeding. And is that so surprising? After all, we say to mom "You need to supplement with formula because your baby's blood sugar is low", what is the message we are sending? "Your milk has not been feeding your baby adequately, and it will not feed your baby adequately; we cannot trust that it is there in sufficient amounts and/or that your baby can get enough of it." Any wonder that these moms go on to mistrust their ability to nurse their babies? Additionally, even just a little formula affects baby's gut flora for weeks, changing the balance of beneficial flora that exclusive breastfeeding establishes (for more information on all of this, see this article by Marsha Walker, particularly the section "Some Cautionary Words About Supplementing with Formula").
Does all this mean we should not give formula when medically necessary? Of course not! But as you can see, medical necessity in this situation was somewhat blurry. With no breastfeeding support, it's possible that this baby would have needed to be supplemented with formula. But in the end, it turned out not to be necessary at all. Babies get those bottles of formula not necessarily through malice, but because of staffing issues, longstanding habit, and lack of education and lack of trust in breastfeeding. They get formula without the understanding of the risks of "just a little bit".
What can you do to avoid unnecessary supplementation in the hospital? A few things:
1) Prepare yourself for breastfeeding - read, take a class, attend La Leche League meetings - boost both your knowledge and your confidence.
2) Choose a certified baby-friendly birthplace - this won't eliminate the possibility of unnecessary supplements, but it will greatly decrease them!
3) Make sure breastfeeding is going well - let the staff know you are committed to breastfeeding, ask for a lactation consult, and solicit outside help from La Leche League or a lactation professional if you need to. Yes, those people can come visit you in the hospital!
4) Surround yourself with family and friend support. Maybe the sister-in-law who keeps asking whether the baby is "too hungry" is not the person to spend the night with you!
5) Be ready to advocate for yourself if needed, and have all that knowledge, preparation, and support ready. I saw another mom a few months ago who confronted the same night-time pressure to supplement for hypoglycemia. She insisted that she get a chance to breastfeed first and, lo and behold, that baby's sugar came up too. Self-advocacy is not always easy (and unfortunately not always successful), but it is very important!
So that's my first dispatch from nights! I'm currently in recovery from the crazy schedule-shifting and ready to get back to regular sleep patterns for a few days. Any nurses out there have tips on shifting back and forth? I'm used to doula work where you can't plan it - you just power through and then sleep it off over the next couple of days. Tips for actually planning your night shifts would be greatly appreciated!
Obviously, I've been a little anxious about whether the night nurses would be welcoming, whether people would be willing to call me - basically whether I'd have any work at all! While all the staff I've talked to so far have been nothing but happy and excited to have lactation support available, the first night was really quiet. I saw a few people in the first couple of hours, then sat around, and then things picked up from 5 am - 7 am when people started to wake up and call for assistance. I told myself that the census was low, and staff were still getting used to me being there, but I wondered if every night would be so quiet. The big hope was that having someone overnight on lactation would help prevent a lot of the bottles and supplementation that happens at night. Was I going to be able to do that?
The following night answered that question for me. I basically never sat down except to chart. I spent at least an hour with in three different rooms. And my big victory was helping keep a hypoglycemic baby from being unnecessarily supplemented. The cut-off for hypoglycemia in the newborns here is 45. The nurse caught me in the nursery and said she had tested twice, baby was just below the cut-off and heading in the "wrong direction". To the nurse, formula seemed like a medical necessity at this point. She asked if maybe I could do it at the breast. When I came into the room, though, mom was crying - she didn't want to supplement. I offered to handle the situation from there and the nurse said that was fine - she left us to it. The mom told me the baby had been hungry and about to feed, right before the nurse had come in and taken him for the blood sugar testing. I said "Well, if he's hungry, he can nurse and if he nurses well, he won't need any formula."
So, we put the baby to breast - and this baby was, indeed, very hungry and nursing fairly well. Still, I was anxious - I did not want to screw this up, I was going to get all the colostrum into that baby that I could. The nurse had brought a couple of dental syringes for the formula. I took one and popped the stopper out, and asked mom if we could hand express into it from the other side and supplement the baby with expressed colostrum. Mom said OK very readily and wow, she had plenty! I was boggled to think this baby could have ended up with formula with so much colostrum available. The mom's sister was spending the night to help her out and happily assisted with hand expression (with mom's agreement, of course) - it was so nice to see such good family support! Who says other family members can't participate in breastfeeding?
Between nursing and supplementing, by the end of the nursing session I was having to take him off and wake him up repeatedly, and he would fall asleep as soon as he got back to the breast. This kid was full. (But I was not going to let him go to sleep without getting every last drop he could!) Finally, I put him skin-to-skin with mom (also good for blood sugar!) and called the nurse to tell her "went great, no formula needed!" And you know what? The nurse was totally fine with that. She gave the baby a full hour before rechecking his sugars and - yay! - baby was back above the cut-off - "heading in the right direction". The nurse was actually very gracious and helpful about all of this, and I realized after talking with one of the other LCs that it's not a "breastfeeding is bad" mentality at all on the nurses' part - this nurse just wanted to fix the blood sugar, and the formula could be the fix, or my help with breastfeeding could be the fix. Of course, since I'm not always there, it would be nice if this experience helps her have more confidence in the future with putting baby to breast as the first line of treatment. But one step at a time!
After all this drama about avoiding what probably would have been just several milliliters of formula, you may be wondering, what's wrong with just a little supplementation? Just to get the baby's blood sugar up - then they could go on breastfeeding, no problem. And I think it's a fair question. It doesn't seem like a single bottle would do that much harm. And yet we know that babies who are supplemented - even a single bottle - in the early days tend to have shorter durations of both exclusive and any breastfeeding. And is that so surprising? After all, we say to mom "You need to supplement with formula because your baby's blood sugar is low", what is the message we are sending? "Your milk has not been feeding your baby adequately, and it will not feed your baby adequately; we cannot trust that it is there in sufficient amounts and/or that your baby can get enough of it." Any wonder that these moms go on to mistrust their ability to nurse their babies? Additionally, even just a little formula affects baby's gut flora for weeks, changing the balance of beneficial flora that exclusive breastfeeding establishes (for more information on all of this, see this article by Marsha Walker, particularly the section "Some Cautionary Words About Supplementing with Formula").
Does all this mean we should not give formula when medically necessary? Of course not! But as you can see, medical necessity in this situation was somewhat blurry. With no breastfeeding support, it's possible that this baby would have needed to be supplemented with formula. But in the end, it turned out not to be necessary at all. Babies get those bottles of formula not necessarily through malice, but because of staffing issues, longstanding habit, and lack of education and lack of trust in breastfeeding. They get formula without the understanding of the risks of "just a little bit".
What can you do to avoid unnecessary supplementation in the hospital? A few things:
1) Prepare yourself for breastfeeding - read, take a class, attend La Leche League meetings - boost both your knowledge and your confidence.
2) Choose a certified baby-friendly birthplace - this won't eliminate the possibility of unnecessary supplements, but it will greatly decrease them!
3) Make sure breastfeeding is going well - let the staff know you are committed to breastfeeding, ask for a lactation consult, and solicit outside help from La Leche League or a lactation professional if you need to. Yes, those people can come visit you in the hospital!
4) Surround yourself with family and friend support. Maybe the sister-in-law who keeps asking whether the baby is "too hungry" is not the person to spend the night with you!
5) Be ready to advocate for yourself if needed, and have all that knowledge, preparation, and support ready. I saw another mom a few months ago who confronted the same night-time pressure to supplement for hypoglycemia. She insisted that she get a chance to breastfeed first and, lo and behold, that baby's sugar came up too. Self-advocacy is not always easy (and unfortunately not always successful), but it is very important!
So that's my first dispatch from nights! I'm currently in recovery from the crazy schedule-shifting and ready to get back to regular sleep patterns for a few days. Any nurses out there have tips on shifting back and forth? I'm used to doula work where you can't plan it - you just power through and then sleep it off over the next couple of days. Tips for actually planning your night shifts would be greatly appreciated!
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