Sunday, July 31, 2011

What every doula should know about breastfeeding: Tip #2: When to refer, how to refer

Preface: Often as a doula, before I became an LC, I would encounter situations in the hours after the baby was born, or at postpartum visits, where I wasn't quite sure what to suggest; or looking back, I realize I could have done something differently. I've decided to share some tips with other doulas about things that I wish I had known long ago! Today is Tip #2: Referring to advanced support.

Knowing when to refer and how to refer mothers to advanced breastfeeding support is a vital part of a doula's role in supporting breastfeeding.

WHY to refer:

As doulas, we spend hours, sometimes days with our clients through one of the most intense experiences of their lives. You often end up very bonded and very invested, and when breastfeeding issues arise you're ready to jump in and do everything to make it work.

Resist the temptation to solve everything for your client!

On doula listservs I sometimes see questions like, "My client's baby's weight is down 12% and she's having to supplement with formula. What can I do to help her?" or "My client's baby just won't latch, should I suggest she do a lot of skin-to-skin?" You can give so much to a client in this situation: compassion, practical support, a listening ear at 2 a.m.; but the most important thing you can give her is a referral to a lactation consultant and the encouragement to call ASAP. She has a problem that needs quick professional help; it will probably not be helpful to her for you to come back in a couple days with tips from people who have never met her.

A 3-5 day CLC/CLE/CBE etc. course is wonderful (as is years of experience breastfeeding your own babies, helping friends, etc.) but KNOW YOUR SCOPE and be careful about venturing slowly into deeper and deeper waters where suddenly you discover you're in way over your head. It is so easy to get drawn into helping beyond your expertise. I speak from experience! I have written about how the more I learn, the more I realized I didn't know. I say this knowing that I, myself, would sometimes get in over my head when helping clients in AmeriCorps; our supervisor was a midwife who could help out when we were stuck, but she wasn't always available and I was trying to fix things knowing the patients might not be able to come back for a follow-up visit. I honestly cringe at some of the advice I used to give! It wasn't terrible or harmful, but it was probably really unhelpful.

In general, think of yourself as a "breastfeeding emergency first responder". You should provide the same services as any emergency first responder - do what you can at the moment to help the patient, offer them comfort and support, and then get them to advanced care. So absolutely suggest that the mom whose baby isn't latching do lots of skin-to-skin - and then help her find an LC who can assess why this is happening and how to fix it.

In the meantime, support the mother and remember the rules:
Rule 1) FEED THE BABY (in whatever way is necessary; sometimes bottles and formula ARE necessary);
Rule 2) Protect the milk supply (through pumping and/or hand expression if the baby is not feeding effectively at the breast).

WHEN to refer:

Not sure if your client is having just some normal latch pain and things are going to get better? Not sure if the weight is a real concern or just a temporary dip?

Here's a (partial) list of situations in which your client should DEFINITELY be referred to an LC (do not pass Go, do not collect $200):
  • Painful nipples throughout the feeding...
  • ....especially with any signs of nipple trauma (cracking, bleeding, blisters)
  • ....especially if the mother tells you she "dreads" feedings, that she cries from pain during the feeding, that she puts off feedings or limits their length because of pain, or that she is exclusively pumping because of latch pain
  • Excessive weight loss or poor weight gain in the baby, or any concern for weight that leads the baby's doctor to recommend supplementation
  • A mother who was sent home from the hospital supplementing the baby (via any method, not just bottles) without clear further instructions about when/how to stop supplementing
  • A baby who refuses to latch or does not latch consistently; the mother may describe feedings as "battles" or "fights" that drag out, sometimes for over an hour
(Does anyone have additions or modifications for this list?)

HOW to refer:

To refer your clients, you need to know about the lay of the land in your community. Who are the lactation consultants? Where are they based - pediatric offices, hospitals, private practice? Does the mother have to go to them, or do they do home visits? What do they charge and how do they bill the mother's insurance? (For example, at our hospitals outpatients' insurance is billed for a nurse visit and the mother has a small co-pay; a private practice LC will generally be paid up front and the mother must apply for reimbursement.) For lower-income mothers, is there a WIC breastfeeding support program that has an IBCLC?

As you're getting to know the lactation support resources in your community, please read Best for Babes' Is Your Lactation Specialist an Imposter? Not all lactation "helpers" are lactation consultants; and sad to say, not all lactation consultants are supporting moms the way they should. This is true of every profession; hopefully, you would not refer your doula clients to a midwife just because she had "CNM" or "CPM" after her name, assuming she provided optimal midwifery care, because not all midwives practice in ways that are consistent with a compassionate, evidence-based midwifery model of care. You would want to talk with other doulas, mothers, and providers - or work with the midwife directly - to know that she provided the kind of care you were comfortable recommending. I have worked with midwives I would refer my clients to, and midwives I would warn them away from; the same goes for LCs. You help your clients by finding trusted people you can refer to.

Ask local La Leche League leaders, mothers, doulas, midwives, doctors, and other community resources who they trust and recommend. Listen for specifics of how they deal with different issues, and whether the mothers who use them found them to be sympathetic and helpful. And, while this is a little delicate, keep your ear to the ground for the people who are not recommended or who you hear about giving questionable advice. Of course, even the best provider will have some dissatisfied patients (again, you may have an absolute favorite midwife and meet someone who had a bad experience with her - maybe it just wasn't a good personality fit, or a bad day.) But when you hear the same poor feedback over and over about somebody, it could be a sign to have your ears perked if your client mentions working with that person. (And if you know a hospital doesn't have LCs on staff, and the mother says "But the lactation consultant in the hospital said her latch was perfect!" skeptical.)

If you develop a relationship with an LC, or a few LCs, that you consistently refer to, you may also develop a referral system. Many LCs will welcome a phone message or e-mail from a doula or other professional working with the mother, who can offer an outside perspective on what has been happening and why the mother is being referred. Talk to the LCs you work with about whether this would be helpful.

Even when you've helped your client find a great LC, your client may be hesitant to pay for a lactation consultant - especially since with a private practice LC they will need to pay up front. Help her think through the cost of formula, or even of exclusive pumping (which some women seem to regard as a quick solution for any breastfeeding problem, without understanding that it brings its own distinct challenges.) Talk to her about how she saw the value in hiring a trained labor support person; hopefully she will see the same value in finding professional breastfeeding support.

A lot of women seem to feel guilt or frustration for needing to turn to someone for help at what is supposed to be "natural" (I say "it might be natural, but it doesn't always come naturally!") You can discuss some women's need for lactation support with your client at prenatal visits, so your clients who need LCs know in advance that they're not "failing" or somehow strange for needing an LC. You can include information about LCs you recommend in your prenatal information packets.

If you can, follow up with the mother about the LC visit, how it went, and how things are progressing; or encourage her to call you if things are still not going well. If the mother did not feel helped by the first LC she sees, offer to help her find someone else, especially if you are not sure about that LC's qualifications. And of course, support and empower her in whatever challenges she is facing, and listen to and validate her concerns.

Note for community-based and/or volunteer doulas:
If you are working with low-income women, they may be in a very difficult situation. We confronted this issue a lot when I was working in AmeriCorps. Ask around for low-cost resources like WIC, LCs who are willing to do pro bono work (especially if it is referred by a doula who knows the mother's financial situation), LCs working at hospital-based clinics that may take Medicaid, and free mother-to-mother support groups that the mother would be comfortable attending (keep in mind some women may feel out of place in settings like La Leche League meetings). Be proactive about helping the mother get in touch with these resources.

If you are the only help available to a mom, ask around for LCs/LLLLs/other resources who might be willing to talk you through problems or offer suggestions, and again be very careful about not overstepping your boundaries. While it's hard to see a situation go down the tubes, and you want to throw every idea you have at the problem to fix it, it is actually better for a mother to give up breastfeeding than for her or her baby to be harmed by poor advice... and it's hard to know what's poor advice if you're stepping outside your scope of practice.


I loved the feedback on the last post, and welcome comments on this one! More tips to come!

Wednesday, July 20, 2011

The IUD comeback

When I was in college, I remember IUDs being completely dismissed as a form of contraception - they were barely even discussed, but I got the impression that they were some quasi-medieval little device that was only used by women who had already had at least 4 children.

Come grad school, IUDs were a hot topic in my MCH class, both academically and personally. For the personal side, at least a third of our cohort got IUDs, and academically they came up in almost every class discussion of family planning as an increasingly popular and very effective method of long-term contraception.

This Wired article does a nice job of summarizing the history behind the rise, fall, and rise again of the IUD.

By the early 1970s, 17 IUDs were under development by 15 different companies. The problems started with the fourth one to actually hit the market: the Dalkon Shield. AH Robins (which also made ChapStick and Robitussin) marketed one version of it as a smaller option for women who didn’t have children. Like all medical devices at the time, the Shield wasn’t vetted by the FDA. While drugs got careful screening, safety and efficacy claims on device labels did not. The FDA stepped in only if people started reporting problems. And report they did. ...

The new research [in the 90s] and thinking on IUDs had important implications for the future of the device. For one thing, it’s clear that doctors should not put it into women who have an active STD infection. (And even then, it’s only bacterial infections like chlamydia and gonorrhea that are problems; infection with the widespread human papillomavirus doesn’t disqualify anyone.) For another, inserting it under sterile conditions is paramount. To the people running these studies—and the doctors who read them in medical journals—the results were reassuring. There was nothing wrong with IUDs as a technology. ...

IUDs are on the verge of a remarkable return to popularity. Nationally, 5.5 percent of women using contraception choose them. That sounds unimpressive, but it’s the first time in more than 20 years that the number has risen above 2 percent; in 1995, it was 1.3 percent. By that baseline, 5.5 percent represents a sea change. And a few pharmaceutical companies believe that number is poised to grow.

There is plenty of reason to believe that more American women will be adopting the IUD when you compare our IUD use prevalence to that of other European countries, including Norway which tops out at 27% prevalence IUD use!

One interesting note is the price of getting an IUD in the U.S.

Also, the devices are expensive—the ParaGard costs $500, the Mirena $850. “It’s absolute highway robbery that these companies charge so much,” Espey says. “If you went to Home Depot and got the raw materials for a copper IUD, it would cost less than 5 cents.” And the hormones don’t contribute much more to the cost, she adds.

In fact, amortized over years of use—10 for the ParaGard and five for the Mirena—an IUD is far cheaper than birth control pills, which can cost $30 or more a month. But the initial outlay is difficult for some women to manage, and it’s not always covered by insurance. Schnuriger, who comes from a working-class St. Louis family, split the $450 cost of her IUD with her boyfriend. She used money earned from a work-study job to pay her half. If she keeps the ParaGard the full 10 years, it will end up having cost $3.75 a month.

Most people I know had insurance that did cover a pretty decent amount for the IUD and the appointment to get it inserted. But if you're paying out-of-pocket, it is a big investment even knowing that in the end it will probably be cheaper than other methods. Compare the prices we are paying in the U.S. with this: I have a friend working on an IUD project in West Africa. They offer only the Paragard (copper) IUDs. Price for the IUD + insertion? $3. Her expat friends get their IUDs before they come back to the U.S.

How safe is your medication for breastfeeding? Another app - the InfantRisk app!

I wrote last month about the availability of a free app from Lactmed, the similarly free website from the NIH, to help prescribers and mothers determine whether a medication is safe for breastfeeding.

Now Dr. Thomas Hale, author of the bible on this topic, "Medications and Mother's Milk" (aka "MMM") is coming out with an app version called InfantRisk, also for iPhone and Android. If you've ever used "MMM", you know what an amazing reference it is. Dr. Hale classifies drugs into 5 levels of risk category, from L1 (Safest) to L5 (Contraindicated), provides an extensive monograph on each, provides information such as time to peak plasma level in the blood (so a mother could time feedings/pumping around those peak times), and includes a lot of herbal and OTC meds that Lactmed does not.

Watching this video of the app, I was really impressed by how they've put a lot of value added into the app, even going beyond the information available in the book. "InfantRisk" really is the better term for this app, as each drug now has safety information for not only different stages of breastfeeding, but also for each trimester of pregnancy. You can also search based on specific patient parameters, set bookmarks, and get updates from the InfantRisk Center. There's also a quick way to call the InfantRisk Center for questions that you're still unsure about.

This app isn't free, and compared to other apps that I'm used to purchasing (usually $1.99, maybe $4.99 for something great that I'll use a lot) it's a pretty hefty price tag at $29.99. But after I saw the video, I realized it's a great deal for anyone who would otherwise purchase "MMM". For less than the price of the book ($36 on Amazon), you get the same information PLUS a lot of added functionality. With the pregnancy safety info, it would especially be a great investment for an obstetrician, midwife, or family practitioner who would use it both pre- and postnatally. I probably won't purchase it this second, as my work has the latest edition of "MMM", but I'll probably get it eventually for the convenience of having an updated reference at my fingertips. And also 'cause it looks so snazzy!

And don't forget that if you're not looking to invest in the app or the book, but have questions that aren't answered by a free resource like LactMed, anyone can call the InfantRisk Center helpline. They're available Monday-Friday, 8am-5pm central time: (806)-352-2519.

July link party!

So many starred posts in my Google Reader! So much to share!

Science and Sensibility interviews Dr. Michael Lu on preconception care. Oh, does this warm my MCH public health heart! This man has done such amazing research and I am so excited to see his work getting connected to the birth advocacy communities via S&S:

Allen Rosenfield probably 30 years ago asked the question, “Where is the ‘M’ in MCH?” Where’s the “mother” in maternal and child health programs–because much of MCH has focused on children’s health and much less on maternal health. I think the question we’re asking today is where’s the ‘W’ in MCH—where’s the woman in maternal and children’s health? If we really want to improve maternal and child health in this country, we really have to start by improving women’s health. [Emphasis mine because this is SO IMPORTANT!]

I think it’s pretty much in alignment with what you’re saying; it’s not just about childbirth. If the natural childbirth movement is all about natural childbirth, it doesn’t have the kind of impact that it could have. The focus should really be on promoting women’s health over their life course continuum and how we would be a better society for doing that.

And he talks about reproductive life plans! Be still, my beating heart! Part One is here, Part Two is here, and I am eagerly awaiting Part Three!

The Gates Foundation did a blog series on stillbirth to accompany the publication of the Lancet stillbirth series.

From the Academy of Breastfeeding Medicine blog, a report from the Third Annual Summit on Breastfeeding.

Yup, US maternity leave policy really sucks.

Birth Sense talks induction for premature rupture of membranes when the mother is GBS positive - is it necessary? How soon does it need to happen?

Educational website on tongue tie, including a PowerPoint presentation to help train other doctors perform clips. The best part is lots of photos - there is nothing like seeing photos of tongue ties to help learn which type you are looking at and what are the more subtle signs of a tie. Crossing my fingers that this website helps more practitioners learn about and be willing to clip ties that are interfering with breastfeeding. I found the site via the Kellymom FB page where there are many stories of mothers struggling to find someone who will clip. (A post on tongue ties is coming soon in my breastfeeding-tips-for-doulas series.)

NPR's the Baby Project blogs about doulas! Check out the comments for stories from grateful moms who used doulas!

Another hand expression video. This one uses a similar although slightly different technique to the Jane Morton/Stanford technique, with the fingers slightly closer to the areola. It also shows breasts where the milk is in and engorgement is past. If you want to listen to awesome Norwegian, click on the first video; otherwise, scroll down for the second video with narration in English.

Wednesday, July 13, 2011

What every doula should know about breastfeeding: Tip #1: Hand expression

I've learned a number of things as an LC that I wish I had known earlier as a doula, and that I would like to share with other doulas! I've decided to do a mini-series of tips called "What every doula should know about breastfeeding". All doulas get basic training in breastfeeding (and doulas are an evidence-based way to increase breastfeeding rates!) Doulas are generally excellent supports for helping normal breastfeeding get off to a good start. But often as a doula, before I became an LC, I would encounter situations in the hours after the baby was born, or at postpartum visits, where I wasn't quite sure what to suggest; or looking back, I realize I could have done something differently. I've decided to share some tips with other doulas about things that I wish I had known long ago!

A disclaimer: my breastfeeding tips for doulas aren't meant to turn you into an LC, or offer the same support as an LC does - one of my tips is going to be how to know when to refer to an LC and how to help your doula clients find advanced breastfeeding support (and you will find suggestions to refer to an LC liberally sprinkled throughout the tips as well!) They are meant to help you become a doula who is better at supporting breastfeeding in the doula role, and filling in some of the gaps in breastfeeding education and support that sadly still exist in our system.

So without further ado, the first tip of the series is... hand expression!

I had kinda sorta heard about hand expression before I became an LC. I knew you could theoretically express milk without a pump, but I confess to having wondered why you would WANT to. Couldn't a pump do the same thing, but faster and easier?

Now I teach hand expression on a daily basis, and I find it an incredibly useful tool. Yet many postpartum nurses, and even some LCs, don't know how to teach mothers how to hand express or when it can be useful. A knowledgeable doula can help fill that gap by recognizing when hand expression might be helpful and helping the mother learn how to do it.

WHEN and WHY to help with hand expression:

When are times that, as a doula, you might help a mother begin hand expression? Here are a few that I can think of:

1) The baby who doesn't latch. All doulas should have the training to help the mother get started breastfeeding just after birth, when the baby is most awake and alert. But sometimes, even with assistance, that first latch doesn't go as smoothly as we would like. The baby bobs around, mouths the nipple, pops on and off, or fusses at the breast and doesn't latch. Some babies just aren't ready to feed right away; for example, babies born with a vacuum-assist often seem to have trouble getting their suck organized at first, or a baby whose mother has had IV medication soon before the birth may be sleepy and not interested in latching.

Once that initial period of wakefulness has passed, the baby often falls into a deep sleep for hours and only wakes to feed a few times during the first day. Like so many breastfeeding "problems", it's not an actual problem for the baby, but it tends to cause anxiety for the parents and sometimes also prompts suggestions of supplementation from the medical staff. Sometimes the mother asks for a pump and is discouraged to see that after 15 minutes of pumping, all she has on the pump flange is a drop or two of colostrum. She starts to wonder if she really has any milk at all. If the baby is still struggling to latch, the next step is often a bottle, even when the mother really wanted to avoid formula, and the bottle can further compromise the baby's ability to latch.

If your doula client's baby hasn't latched by the time you leave, try teaching her hand expression so she has an alternative way to feed her baby. Pumps generally don't get out much colostrum compared to hand expression; a mother who pumps for 15 minutes to get a single drop can easily fill a teaspoon in a couple of minutes by hand expressing (and remember, a one-day-old baby's tummy is only made to hold a couple of teaspoons). All she needs is a plastic spoon from her meal tray to express into; when she's got a little colostrum in the spoon, she can spoon feed it to the baby or simply let the baby lick or suck drops off of her finger. A couple spoon feedings often reassure the mother and the nurse that the baby is taking food in, and give the baby time to rest and get ready to start latching and eating. When you leave the hospital after the birth and you know breastfeeding's not off to the perfect start, you can feel more confident that breastfeeding will ultimately go well if you've given the mom this tool to use.

2) Engorgement. This is particularly important for mothers who have had a highly interventive birth with lots of IV fluids - long inductions, many hours with an epidural, a c-section. These mothers tend to end up fluid-overloaded and their breasts fill up with extra fluid as well. When their milk comes in, they may have lumpy, hard, painful breasts that feel like they're full of milk, but only be able to pump a few drops. When you do your postpartum visit, you may discover this situation along with a very uncomfortable and unhappy mother.

I explain to these moms that they can think of their situation like this: There are a hundred people in a room, and they're all trying to get out one narrow door. They all pack around the door and squeeze up against it and there's just no room to open the door. We need to push some of the people away from the door so things can flow more freely. The breast is the room, and the people are the milk and intracellular fluid built up in her breasts. The pump may just pull more and more "people" towards the door. Instead, have her push back on her areolas for a few minutes to soften them (known as reverse pressure softening, with an excellent explanation and illustration here), then gently use hand expression to push a few "people" at a time towards the door. She can express into a bottle or cup to save the milk. Once the breast is somewhat softened, sometimes you can start the electric pump again, but sometimes you need to keep hand expressing for several sessions before the mother is able to pump.

I helped a mom like this recently. She was so engorged it took her an HOUR to soften a single breast with hand expression, but she got two and a half ounces when she was done! She said that neither the pump nor the baby had gotten more than a few drops since her milk came in. When I left she was starting the slow process of getting two+ ounces out of the other side, but at least she was able to move the milk out, get comfortable, and offer breastmilk to her baby.

I have never forgotten the big bold sentence in my breastfeeding educator training book that said "Unresolved engorgement is a breastfeeding emergency!!!" Unresolved engorgement can cause mastitis, compromise a mother's milk supply, and lead to nipple trauma if the baby is no longer latching well on the overfull breast. Hand expression can be a vital tool for working through severe engorgement. Be especially alert to the possibility of severe engorgement when you have seen a lot of IV fluids go into the mom and notice that her hands and feet are very puffy from the fluid retention; check in with her about her engorgement when you talk to her after the birth. If she is engorged and only getting advice to pump, pump, pump and not having much success, suggest hand expression as an alternative; and help her find a lactation consultant ASAP who can help her with issues that may be contributing to or caused by her engorgement.

3) NICU moms. Remember how I mentioned above that pumps are often not very effective at getting out colostrum? This is by far the most discouraging for the NICU mom whose baby is not able to go to breast due to prematurity or other medical complications. These moms may pump and pump and get almost nothing! Days of pumping a few drops at every pumping session are also discouraging and can lead the mom to cut back on her regular pumping schedule, which can compromise her supply. And the baby misses out on much of the colostrum which is one of the best medicines available!

There is also some preliminary research from Dr. Jane Morton at Stanford University showing that "hands-on" pumping and hand expression after pumping can increase the supply of mothers who are exclusively pumping. This is so important for NICU mothers who so frequently struggle with supply!

If you work with a mother whose baby goes to the NICU after birth, help advocate for her by requesting a pump right away. Help her get set up with the pump and use it for 10-15 minutes. Then show her how to hand express afterwards. Ask for a very small container to express into - we use little vials that are just 10 ml. Much less is lost that way and the mother can really see that in comparison to her baby's tummy, she's actually getting a pretty big meal! Encourage your client to follow every pumping session with hand expression. If the pump is slow to arrive, encourage her to go ahead and hand express every 3 hours - don't wait to start until the pump arrives! The earlier she starts, the better for her supply.

HOW to teach hand expression:

Okay, so hand expression is great and all, but how do you DO it?

Hand expression is a learned skill, and not one I learned especially quickly, so be patient and encourage your doula clients to be patient as well.

The single best tool I have seen for learning and teaching hand expression is this video from Stanford's Newborn Nursery (featuring Dr. Morton who is doing the research on hand expression and increased supply!) Watch it - multiple times - and practice the technique on yourself or on a cloth breast model. When teaching, try to find a way for your doula clients to watch it as well - they may have brought a laptop with them, or there might be a computer in the room. (And tell me if you can figure out a way to get it to work on a smartphone.) If you can't have her watch the video, demonstrate (discreetly) on yourself, use a breast model (or even a soft pillow!), or offer with her permission to demonstrate directly on her breast.

The main tips I have for teaching hand expression, which are also highlighted in the video, are to help the mother keep her fingers well back from the areola. The instinctive thing to do seems to be to spread the fingers apart, and then squeeze in right up to the nipple, often pulling the nipple far forward. This generally makes the mother sore and doesn't get her much milk for her effort. If it's helpful, place your hand over hers as she practices and repeat the rhythm of "press, compress, relax" while keeping the fingers in the same place on her breast. That said, if the mother finds an easy comfortable way to express milk, and it's not the "right" way, she should do whatever is working for her and her body.

Sometimes the mother will report soreness or tenderness in the breast when I am trying to teach her how to hand express hands-on, even when I'm trying to be as gentle as possible. When that happens, I suggest the mother be the only person to do the hand expression. It is usually much more comfortable when she is the one doing the compressions on herself.

It's also normal to have some mothers who can easily hand express a lot of colostrum, and some who, even with good technique, still barely get a drop. Encourage the mother to keep practicing and to be patient. Reassure the mother that hands are better than pumps, but NOTHING is designed to get milk out like a baby! The colostrum IS there, and when her baby is ready to latch on well, it will flow. Hand expression is NOT a test to see "if there's anything there" - it's just a tool to see whether in the absence of the baby, we can still get more milk out and stimulate a better supply.

I hope you and your doula clients find this helpful! Please comment with thoughts and if you have had situations where you think hand expression would have been helpful, and if there are other scenarios in which you think your clients might use it.

Friday, July 1, 2011

Follow-up: who should get donor milk?

So a while back I posted a question of who should be offered donor milk in the hospital. I was curious to see what people thought, and follow up with my own thoughts and current practice. I've been letting that follow-up languish, and the recent discussion about milk donation has finally nudged me into finishing it up. Here we go!

The comments were very interesting, and there seemed to be two main themes to the answers:

1) Only babies whose mothers are trying to produce breastmilk for them but are not able to (e.g. supply issues, adopted babies, etc.) should be offered donor milk

As Christie B. said:

...I have a hard time thinking that donor milk should be provided for free to women who are not trying their best to provide their own milk (if not contraindicated) for their own babies. If there is a medical issue, it makes sense for donor milk to be covered like a pharmaceutical but otherwise donor milk seems like a luxury good/service, like eating out instead of cooking.

2) Every baby should be offered donor milk as an alternative to formula, no matter the reason for supplementation (so even if mom is just not willing to breastfeed, the baby should still receive donor milk).

Burrowing In was of this mind:

As a mother whose baby was blessed by donor milk, I want to say that every baby should have access to it if necessary. Forget the mothers and their intentions and their shortcomings and their socioeconomic status. BABIES deserve that milk!

There were also ways to combine these two answers to some extent.

For example, Jespren suggested:

I feel that 1st dibs on donated breastmilk should go to NICU babies whose mothers have supply issues or have dried up and are unable to produce milk. Next I think it should be offered to mothers of healthy babies who can't physically produce any/enough milk. (This would include adopted babies whose new moms can't lactate) finally, if there is still milk availible, it should be offered to babies whose mothers chose not to breastfeed. ... But, for moms that have no physical reason not to breastfeed, they should have to purchase it, preferable at the same cost as formula. (I don't understand for a moment why DONATED breastmilk is so prohibitively expensive once it goes through a 'milk bank')*

So this prioritizes the babies who receive donor milk based on a judgment of BOTH the baby's need AND the mother's intent. Any babies whose mothers intend to breastfeed are prioritized over babies whose mothers don't intend to breastfeed.

Another comment comes from Molly who poses two questions, both of which I think are excellent:

The post's title asks two 'to whom' questions: "Who should get donor milk? Who should it be offered to?" In considering these questions, we should probably ask what 'whom's we mean: postpartum women, babies, families? You can't exactly offer a medical option to a baby, so in the second case presumably we mean the baby's parents (why only mothers, as some responses seem to suggest?). In the first question, the implication seems again to be that parents/mothers are the ones getting the milk: does it make any difference if we reconceptualize the question to mean, explicitly, 'which babies deserve access to donor milk (rather than formula)?'

This is a big piece that I struggle with. When we focus on the mother's intent, we're really asking which mothers deserve to get donor milk - not which babies. If one mother can't produce milk and one just doesn't want to, why is the first baby (not the mother) more deserving of donor milk than the second baby? Furthermore, it quickly becomes a tangled web of hairsplitting over who is "really" deserving. To tread into more politically controversial territory, over and over again I keep thinking of how it reminds me of debates on abortion and philosophical and legal attempts to determine which women are "deserving" of an abortion - women who are victims of nonconsensual sex? women who "just made a mistake this once"? etc.

In those abortion debates, I think it quickly becomes clear that it is not so much about abortion as it is deciding who is "good" and deserving of help, and who is "bad" and needs to "deal with the consequences". Similarly, trying to decide who deserves donor milk could easily be a twisty path. It's easy enough to think about a mother who says, "I'm not going to breastfeed, it's too hard, just bring me bottles of milk that some other woman has pumped" and decide that she'd be abusing the availability of donor milk, but in life, as usual, there are a lot more gray areas than black-and-white.

What about the NICU baby's mother who has a low supply, but it's low because she only pumps four times a day (knowing that she should be pumping more)? What if she only pumps four times a day because she has several other young children at home, and one has special needs? What if she's so exhausted by pumping and only getting 1/2 an ounce per session that she quits entirely? Would you feel differently if she had breastfed all of her other children for a year each, or if she had not breastfed them but had planned to breastfeed this baby, or had not planned to breastfeed this baby but changed her mind when it was born prematurely?

Or what about the mother of a healthy term baby who has a borderline supply, and has nursed and pumped diligently to keep her supply up but needs to supplement several times a day? What if she is offered medications that could bring her up to full production but declines them? Would you feel differently if she was declining them because she had a history of depression and was worried about side effects, or because she just doesn't like to take medications?

There's an element of thought experiment in some of this - in our current situation, generally only the most motivated moms who have exhausted all their resources seek out donor milk for long-term use outside of the hospital. Still, if we are aiming towards a future in which donor milk is more abundantly available to all, it's worth thinking about and examining our own assumptions about who "deserves" milk.

In the hospital, we can edge around this debate to some extent. For a healthy full-term baby the supplementation will generally be short-term (until the blood sugar stabilizes, until her milk comes in, etc.). If the mother is planning to exclusively breastfeed, we can argue that we are avoiding harmful effects on the infant gut of even a small amount of formula, assuming that soon the mother's own milk will be taking over and will be all the baby receives.

On the other hand, if the mother is planning to do some mixed feeding from very early on (as many mothers tell us they plan to do), there seems very little point in protecting the gut since they'll receive formula early on regardless.

But the way this plays out in practice makes Molly's second question very relevant:

How does class privilege play out here? Education, internet access, reading literacy, technological literacy, financial ability to purchase (and leisure time to read) books, access to high-quality mother-centered prenatal care, etc., etc.? If anyone can ASK for donor milk, should my baby get human milk simply because I'm an overeducated overprivileged English-speaking birth junkie who knows to ask the secret right question? Or, if limits on offering ought to be imposed (according to some standard of need or worth or whatever), is there any way to counteract that injustice?

Class and culture absolutely play out here, particularly in cultural terms, which are both linked to racial/ethnic background and to class. Most Hispanic moms tell us they are planning to do breast and formula, and are frequently asking for formula supplements on the first day (sometimes as soon as they come over from labor and delivery). Plans to supplement or switch to formula early are also common with African-American moms, younger moms, low-income moms... you get the idea. In fact, what the nurse asked me was whether we could offer donor milk to mothers on Medicaid. She assumed we couldn't, because she almost never saw them receiving it (just for the record, we can). She particularly wondered about why almost no Hispanic moms were ever using donor milk. But for a Hispanic baby, if we're at the point where they've lost 10% of birth weight and have not been supplemented yet, it is almost certainly because we have already deflected at least one request for formula on the part of the family over the course of the past several days.

So that's how it plays out: if we're only offering donor milk to the moms who are planning to exclusively breastfeed for at least the first couple of weeks, we end up with a real race/class imbalance of who ends up receiving donor milk. So then we tackle Molly's question of this imbalance - is it an injustice?

Part of me says yes - that everyone who asks for or needs supplementation should be offered donor milk and formula, check one. That part of me comes from knowing that there is definitely some power/educational stuff playing out here in that there is a real difference in patient vs. medical perceptions of when the baby needs to be supplemented. We, the hospital staff, have a short list of indications for supplementation, and the most common reasons are hypoglycemia and weight loss >10%. The parents have a longer list, and the most common reasons are that the baby is fussy even after breastfeeding for a long time, and the perception that the mother does not have enough milk. A mother does not necessarily plan to supplement with formula because she thinks it's better than breastmilk - she just thinks she won't have enough breastmilk (and since she has no idea that donor milk is available we have no idea if she would request that instead.) The more highly educated birth junkie types are much more aware of, and confident in, the fact that colostrum is generally all the baby needs for the first 2-3 days. They might need reassurance when the baby is fussy, but are willing to go with the medical staff's interpretation of baby's need for supplementation, whereas people from other cultural backgrounds are bringing their own perceptions of when the baby needs more.

So if we work with the families who really believe their baby needs something extra, and if we can't convince them of our worldview (that the baby is fine), do we do the baby and the family a service by offering donor milk? Does it emphasize the importance of human milk and avoiding supplementation with formula? Could it possibly help keep the mom from supplementing with formula in the future, once her milk is in? If we just accede to a request for formula without giving her the risks/benefits of both supplements available to her in the hospital, are we doing our own beliefs about the risk of formula use a disservice?

Then another part of me says, these families are very comfortable with formula use. They may be OK with donor milk and accept it in the hospital, but they are just as OK with formula and always will be. They will probably go straight to WIC for their first appointment and ask for supplemental formula. If we offer donor milk to those families, we are giving the babies a few more days of exclusive human milk feeding, but we are not really changing their overall situation that much, and we are using donor milk that could go to another baby. That's my view of the situation - is it reality, or is it just bias and perception on my part?

As you can see, I'm still struggling with this! Currently, I am sticking with only offering donor milk to babies with an indicated medical need, but I do generally discuss donor milk vs. formula for medically indicated supplementation even if the mother had previously talked about formula. Further thoughts or questions welcome!

* I think this reaction to the (prohibitive for most) cost of donor milk is fairly common. Having met and talked with people who run milk banks - the cost comes from the expenses of testing donors, paying for shipping, processing and testing the milk (which takes several time-consuming steps), sometimes space to physically host the milk bank, and of course materials and employees to do all of this. I have visited a milk bank - it was tiny! Just a couple little rooms and some very big freezers, and very committed mostly part-time employees. There seemed to be zero excess overhead going into this bank, and all HMBANA milk banks are not-for-profit. When all is said and done, there is a real cost to the shipping, safety testing and processing that donor milk goes through. If people are comfortable getting donor milk through a more informal route like Eats on Feets, they can absolutely get it cheaper (as cheap as free!), but they should understand what steps are being cut out of the process that are cutting the cost. Whether those are steps that are important to an individual mom, and/or important to every mom/baby/donor, is a whole separate discussion that I won't go into now!