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How can we help when a tongue tie procedure is not possible? By Meg Nagle IBCLC Reviewed by Dr. Vanessa Stitt

GOLD Learning Online Tongue-tie Symposium 2020
Date: September 14, 2020

Meg starts with listing her objectives- to describe the positions that tend to work best for babies who are having trouble latching, to explain how planning with the family helps leads to better outcomes, and to discuss possible challenges that might arise and how to best support families through them.
Factors that may lead to a tongue release not being possible or preferable are geographical, financial, cultural or personal preferences, or availability of services, especially in the light of COVID. Listening to the parent’s individual and personal preferences around feeding is paramount.
Meg describes the different symptoms of ties -the most common being infant’s inability to initiate and maintain a deep latch, to drain the breast efficiently and effectively, and maternal nipple pain. She explains colic appears to be linked to ties because digestion starts in the mouth and so ties can affect that first step in digestion, but that more research is needed.
Meg describes IBCLCs as detectives, not magical! It is up to IBCLCs to figure out what is going on with the breastfeeding dyad, and address these issues by offering different options to mom. She describes how to put the pieces together with four cardinal questions– how does it feel for you? Is your baby settled during feeding? Does your baby effectively and efficiently drain the breast? What are you feeling concerned about?
Meg states that there are many different tongue-tie assessment tool kits, and how this can lead to conflicting advice, but emphasizing the importance of symptoms, not just the oral assessment. She advises against the use of the term “mild” or “severe” tie, and the term”the latch looks fine” as being unhelpful. There is either a restriction causing issues with feeding, or not. How she asks the question of maternal nipple pain is important -is breastfeeding going to be sustainable in the context of this pain, or not?

• Latching and positioning – videos show babies diagnosed with tongue-tie. Video one shows a shallow latch, basically nipple feeding or straw feeding. Video two shows a baby struggling to initially latch, and difficulty maintaining suction. She suggests that we take the least invasive approach first.
• Techniques – Meg reminds us that laid back breastfeeding, self attachment and side lying has an evidence base (Genna 2015). The more hands on flipple technique is a second line option, with more maternal input. She has found that the half-koala/football upright hold, with a pillow providing baby some support at the back, in combination with self attachment or flipple can help. The best positioning is what works for the breastfeed dyad – offer different options. Supply lines like SNS can come in different options including homemade options. A plan should include short term and longterm goals, with reassessment and follow up. This plan must be formed by asking questions – are you feeling that you can continue to breastfeed as things are going now? Is getting a release an option if things don’t improve? Do you feel as though this plan that we’ve made is working for you? Outlining the different possible outcomes are also important – how does mom feels about these outcomes?
• Evidence, research and the internet – Meg makes the point that the internet often acts as a “broker” between parents and healthcare professionals. Linking with local release providers to keep up to date on current research is recommended. Giving parents up-to-date clinical evidence about the procedure is paramount.

 

Dr Vanessa Stitt September 2020.

Vanessa received a bursary of €50 from ALCI to virtually attend the GOLD Learning Online Tongue-tie Symposium 2020.

ALCI 2020 Conference Online

The Association of Lactation Consultants of Ireland (ALCI) will be hosting its annual breastfeeding conference online this year, to enable members to update their knowledge and skills while staying apart to stay safe.  The conference will go live on Saturday 26th September and is free to all ALCI members (join here) .  This date as always will coincide with the beginning of National Breastfeeding Week which takes place from 1st to 7th October.  There is a fantastic line up of speakers including Lyndsey Hookway IBCLC and Sleep Consultant.

 

Lyndsey is a co-founder of the Holistic Sleep Coaching Programme as well as renowned author of the book Holistic Sleep Coaching.  Lyndsey, an international Speaker has worked with infants and children for almost 20 years, and regularly teaches health, lactation and childcare professionals.  Lyndsey is a passionate believer in gentle responsive parenting that never compromises on infant mental health or feeding.  Lyndsey will present a live webinar on helping families with sleep issues while supporting responsive feeding and attachment.

 

Other speakers include Anne Fallon who will present the topic of Supporting Traveller Women in Ireland to Breastfeed; Denise McGuinness and Marie Conway will provide an update on the findings of The Latch On Study; Carol Smyth will present a case study on the establishment of breastfeeding in a baby with  Congenital Arhinia and Caoimhe Whelan will present on Supplementing at the Breast/Chest exploring the why, when and how.

 

During the online conference participants will be welcome to submit questions and time will be allocated at the end of each session for answers.  ALCI anticipate a lively interactive conference, with a difference and encourage as many members as possible to join on the day.  Following each webinar there will be a live interactive session to generate discussion and promote interaction and participants are encouraged to settle in with a drink of their choice to enjoy the catch-up.   The conference will be recorded and made available for a further week to ALCI members to review.

 

Similar to other years, three Annual Scholarships will be awarded; one to a first time IBLCE candidate from a non medical background, one to a first time IBLCE candidate from a medical background and one to a recertifying candidate. Each candidate will receive a €150  book fund and € 250 towards the cost of the exam.

 

In a year like no other, ALCI are proud be offering online education to members, while staying apart to stay safe.

 

Email info@alcireland.ie with any queries.

The WHO Code on the Marketing of Breastmilk Substitutes

by Stephanie Murray

It’s the week of WHO Code’s 39th birthday and a great opportunity to heighten awareness of “the Code” to all organisations and individuals that are passionate about infant and young child feeding.  ALCI, as part of its goals, supports the full implementation of the International Code of Marketing Breastmilk Substitutes and subsequent resolutions of the World Health Assembly.

 

 

What is it?

The Code comprises of the original WHO/UNICEF International Code of Marketing of Breastmilk Substitutes adopted in 1981 and all updates to this, in the form of resolutions https://www.who.int/nutrition/publications/code_english.pdf These are made every two years or so to strengthen and clarify the code at the World Health Assembly.  The Code is an internationally agreed code of practice, designed to protect breastfeeding by preventing unscrupulous marketing and claims about breastmilk substitutes. This incorporates infant formulas, follow-on formulas and any other food or drink, feeding bottles and teats along with setting standards for the labelling and quality of products. As of April 2018, 136 out of 194 countries had some form of legal measure in place covering all, many or few provisions of the Code. Irish affiliation and laws are found here  http://bflgireland.ie/irish-laws/

 

What does it mean to me as me as an IBCLC-private/Hospital?

The IBCLE’s Code of Professional Practice states that a crucial part of an IBCLC’s duty is to protect the public health of mothers and children and therefore adherence to the principles and aim of the WHO Code and subsequent relevant documents of the World Health Assembly is vital. Also, ILCA, the professional organisation of an IBCLC endorses all divisions of the WHO Code and encourages all members to do same. The HSE- National Breastfeeding Strategy Committee approves and recommends  the Who Code as per their fact sheet for health professionals https://www.hse.ie/file-library/the-who-code-of-marketing-of-breast-milk-substitutes.pdf.

 

The main points in the Code for healthcare workers both professionals and volunteers to adhere to are:

 

  • no advertising of breast-milk substitutes and other related products to the public: this can relate to advising on products such as pumps, nipple creams etc with clients and promoting companies that adhere to the code is preferred practice. Important also not to recommend any particular brand of formula to the formula feeding mother.
  • no free samples to mothers or their families: Again, here be mindful of the companies we as health carers obtain feeding accessory products from and provide families with such as nipple shields/creams, latch aids etc. Consider if these companies are code-compliant and the claims that they make – eg. are the claims they make about healing cracked nipples  clinically proven ?  Also included here would be to involved with events such as baby fairs that supply mothers and their families with loads of free samples.
  • no promotion of products, i.e. no product displays, posters, calendars, or distribution of promotional materials. This encourages brand recognition and a means of gaining media exposure and what better way than to get a well-respected person endorsing or being photographed with your product or logo. Individuals sharing information online or on social media in relation to products within the scope of the code is also a violation. It is very difficult to keep up to date with all companies that are code compliant as this is ever changing as companies merge and acquire subsidiaries. it is important to be aware that companies that maybe code compliant but owned by a code violating company that they are to be considered the same of the parent company. A heightened awareness prior to sharing information online is advised.
  • no donations of free or subsidised supplies of breast-milk substitutes or related products in any part of the health care system.
  • no company-paid personnel to contact or to advise mothers: This can relate to a healthcare worker being asked to speak at an event for mothers that is sponsored by a company that violates the who code.
  • no gifts or personal samples to health workers: This includes attending events and having dinner provided, research funded, conferences paid and invites or any personal gain. In cases where an event or some part of an event is sponsored by an entity not meeting its obligations under the International Code, the IBCLC/healthcare worker may refuse to attend that event; attend, but not those portions sponsored by this entity; or waive a speaker fee, but acknowledge to attendees this disassociation.
  • no pictures of infants, or other pictures or text idealising artificial feeding, on the labels of products
  • information to health workers should only be scientific and factual: Healthcare workers should be able to identify research that could indicate bias or a conflict of interest. The Code permits educational activities as long as no affiliation to companies with a return of interest is involved, they are scientific and factual
  • information on artificial feeding should explain the importance of breastfeeding, the health hazards associated with artificial feeding and the costs of using artificial feeding
  • all products should be of a high quality, and unsuitable products, such as sweetened condensed milk, should not be promoted for babies.

 

It is important to note that companies can be associated with products that are under the scope of the WHO Code but as long as there is no marketing of them then no violation has occurred. Mothers who decide to use infant formula should be given one-to-one or small group instruction on the safe preparation on formula feeds in the postnatal period. Also, to note that any product covered under the International Code may be sold when medically indicated and an IBCLC/healthcare worker should explain the clinical use, the required duration of the use and the risks of the products.

 

The WHO Code states that non-governmental organisations, professional groups, institutions and individuals should monitor for Code violations and report violations.  If you suspect you have come across a Code violation you should bring this to the attention of

 

An in-store Code violation, you might like to bring it to the attention of management as a first port of call. If this is unsuccessful you should contact the FSAI.  FSAI is the body tasked with implementing and enforcing EU and national food law only. Report a Code violation via the FSAI online complaints form here. Also you can choose to inform The Baby Feeding Law Group Ireland  by email at bflgireland@gmail.com.   The Advertising Standard authority of Ireland (ASAI) accepts violations relating to radio, tv or internet.

 

Breastfeeding Support during the COVID-19 Restrictions

Since the introduction of COVID-19 restrictions and social distancing measures, everyone providing breastfeeding support in Ireland, from hospital IBCLCs to voluntary breastfeeding supporters, has had to make significant changes to how they help breastfeeding parents . Many have had to switch from doing  face-to-face support to doing virtual antenatal and postnatal breastfeeding support.

 

Regina Keogh, IBCLC, Midlands Regional Hospital Mullingar

Hospital staff have cancelled face-to-face antenatal breastfeeding classes and many are now doing them online via a range of different platforms. Some record the classes and provide them to parents via a link, while others are doing interactive live classes. Staff provide breastfeeding support as normal during the mother’s hospital stay, albeit while wearing PPE. Midwives and IBCLCs are trying to provide care from a distance wherever possible. They will demonstrate using a doll and breast wherever possible to avoid going closer.  Efforts are being made to minimise the mother’s postnatal stay in the hospital, and discharged, staff will continue to provide support over the phone. One of the biggest challenges in the maternity hospital system in Ireland has been how to safely facilitate parent visits and breastfeeding for babies in the NICU and SCBU. At the moment, parents are limited to one 15-minute visit per day, but ongoing discussions around this continue.

 

Stephanie Murray, Antenatal Educator Wexford University Hospital

 

Public health nurses, who normally do a couple of home visits to a mother after she has been discharged from hospital, have made a number of changes to how they work. They are doing phone consults where possible. And if they need to do a home visit, they will wear PPE and do a risk assessment to ensure there is no one in the home with symptoms of COVID-19. They will advise that only the mother and baby be in the room, try to maintain social distancing and keep the visit under 15 minutes (some will set an alarm to go off 15 minutes after the visit starts). For parents who prefer not to have anyone in their home, the PHNs will also offer clinic visits and apply the same precautions. The Dublin North Central PHNs have set up a mothers’ peer-to-peer WhatsApp group and they have found it to be invaluable. None of the PHNs are in the group themselves, but they have a couple of mothers who are admins and will add mothers when provided with their phone numbers by the PHNs.

 

The HSE is in the process of rolling out a new telehealth platform which will enable HSE staff to offer secure video consults to people, including mothers seeking breastfeeding support. In the meantime, HSE IBCLCs are continuing to provide breastfeeding support online 10am – 3pm, Monday to Friday, via www.mychild.ie.

 

Regina Kincaid, IBCLC in Private Practice

IBCLCs in private practice are unable to do home or clinic visits while the restrictions are in place, so most have switched to providing online video consultations using platforms such as Zoom, IntakeQ, Skype and WhatsApp video. The consensus among the private practice IBCLCs is that these video consultations can be effective in providing breastfeeding support, and that they help to promote breastefeding self-efficacy. However, they have limitations and most IBCLCs tend to find them more tiring than face-to-face consultations.

 

Voluntary breastfeeding supporters are continuing to provide breastfeeding support over the phone, and they are all currently running their breastfeeding support groups virtually using Zoom. Apparently, these groups are proving just as popular as the face-to-face support groups.

Lactation Support amid Covid 19 Measures

Are you looking for lactation support? Please be aware that the majority of the International Board Certified Lactation Consultants who are in Private Practice are offering skype/phone/email/online support. Please search for an IBCLC on the right (“Find A Lactation Consultant“) and ask them.

 

Please follow HSE guidelines at this time, and these may be found here.

Information about pregnancy and breastfeeding in relation to the Coronavirus may be found here.

 

Brazilian Food Guide for Children under 2 to Prevent Obesity by Fiona Rea

There was a lot of claps and cheers of excitement in the audience when the Brazilian Ministry of Health’s new food guide was presented. There were tickets stuck under each seat and those with the lucky tickets were thrilled to be given this guide for themselves. I was the recipient of one of the tickets and collected the book but unfortunately for me it was printed only in Portuguese. I made a present of it to a wonderful young lady who was kind enough to act as translator for us at the informal ILCA ‘getting to know our IBCLC colleagues’ meeting on one of the lunchtimes over the course of the conference. She was thrilled to get her hands on it!

 

Very similar to all healthy eating campaigns this one also drives the message and education to help families prevent childhood obesity by producing healthy, home cooked, non processed foods. Dissimilar to a lot of other healthy eating campaigns however is the lack of food pyramids or divided plates etc. The thinking here was that simple rules are easier to understand than gram measurements of protein and fat on graphs or tables.

 

Similar to many other middle-income countries, during the past few decades Brazil has whiplashed from an epidemic of malnutrition to one of obesity. The majority of Brazilians are overweight and around one in seven are obese.

 

Brazil has only had universal healthcare since the late 80s. This has enabled them to build a system that has learned from their observations of many of the mistakes other industrialized nations have made. Brazil has currently some of the most up to date state of the art electronic medical record coverage in the world. They have family health teams in many of the most remote areas of the country, and they reached their UN millennium development goals early, which has seen a dramatic reduction in infant mortality in the country by adopting a series of programs that helped mothers and their babies become healthier. This has led to a rise in continuance of using these healthy eating habits. 54.4% of mothers currently fully breastfeed their babies in Brazil. They are hoping this guide will encourage a rise in these rates.

 

The guide itself is a lovely colourful book of 143 pages and contains lots of colourful pictures as well as solid practical advice on how to make significant changes. It is described by the Brazilian health ministry as the most intelligent food guide in the world. In it there are suggestions for using natural or minimally processed whole foods and making these the basis of the family diet. It encourages the use of these foods in large variety and using foods that are mainly of plant origin. They state this is “the basis for diets that are nutritious, delicious, appropriate, and supportive of socially and environmentally sustainable food systems.”

It goes on to guide families to use oils, fats, salt, and sugars in small amounts for seasoning and during cooking. They tell us as long as these ingredients are used in moderation and on natural or minimally processed foods, oils, fats, salt, and sugar can contribute toward diverse and delicious diets without rendering them nutritionally unbalanced.

 

We are told that because of the unhealthy ingredients in ultra-processed foods like packaged snacks, soft drinks, instant noodles etc they are nutritionally very unbalanced. People have a tendency to consume these foods in excess and in favour of minimally processed foods because of time constraints and out of convenience. Along with processed foods being extremely bad for our health, how they are produced, distributed, marketed, and consumed adds to the damage of our culture, social life, and to the environment. Heavily processed foods are in the main ready to consume without any preparation. This has contributed to meal preparation becoming less frequent in family kitchens and families sitting having meals at the table fast becoming rarer and in some homes a thing of the past. Ultraprocessed foods can generally be consumed anytime and anywhere. Enjoying food as a social experience with family is happening less and less. We are social beings who benefit from the relationships and knowledge we build over family meal times. Eating together is ingrained in human history, as is the sharing and division of responsibility for finding, preparing, and cooking food. Eating together, with everything that is involved with eating, is part of the evolution and adaptation of humanity and the development of culture and civilisation. Eating together is a natural, simple, yet profound way to create and develop relationships between people. Eating is a natural part of social life. The excess packaging that comes with processed foods is also adding to the strain on our already struggling environment.

 

We are told in this guide that clean, quiet and comfortable places to eat encourage attention to the act of eating mindfully and slowly, which enables meals to be fully appreciated, and helps decrease overeating. We are also told we need to eat more vegetables, fruits, and whole food, and fewer added sugars and processed foods. Studies show that people typically consume about 20-40% more in restaurants than they would typically eat at home. We are more in control of what we eat when we prepare and portion control it ourselves. The guide goes on to tell us to limit our children’s screen time and time spent on video games and to encourage an increase in physical activity for both our children and ourselves.

 

The biggest message I heard during this presentation was PEEL MORE AND UNPACK LESS.

 

Added to this is to eat as much as possible in its natural form and to eat foods that are in season. They are educating parents to know processed foods cause cancer, diabetes etc. and that good food habits are formed in the first years of our lives. They have a started project called ‘growing up healthy’ which assesses a child’s nutritional state.

 

Included in the 12 steps they discussed they are actively promoting….

-Increased physical activity, encouraging children to play and move more, more skipping and jumping!

-Encourage less screen time on games and TV

-Eat food according to the level of processing

-Giving no sugar before a child is 2

-No highly processed foods at all.

-Encouraging the rethinking of food prep and eating habits

-exclusively breastfeed until 6 months and continue once solids have been introduced at 6 months to breastfeed until 2 years

-Avoid sweetened foods

-Avoid salted foods

-Prioritise water over sugary drinks

 

The Guide has a chapter on how to cook and it encourages sharing the art of cooking through the generations.

There is also a Chapter on rights to food in the Brazilian constitution which can be read here http://www.camara.gov.br/sileg/integras/130607.pdf

 

The main message of this guide is….

PEEL MORE! UNPACK LESS!

 

Fiona Rea February 2020.

Fiona received a bursary of €200 from ALCI to attend the IBFAN World Breastfeeding Conference.

Lyndsey Hookway: Keynote Speaker at Spring Study Day 2020

“Let’s talk about sleep, baby!”

Saturday March 28th 2020. Radisson Blu, Athlone

 

The Association of Lactation Consultants of Ireland is delighted to announce that its’ Annual All Ireland Spring Study Day will take place this year on Saturday 28th March at the Radisson Blu Hotel, Athlone.

 

Booking is available here . Timetable is available here.

 

This year, the keynote speaker is Lyndsey Hookway IBCLC. Lyndsey qualified as a paediatric nurse in 2004, then undertook further training to become a health visitor in 2007. She qualified as an International Board Certified Lactation Consultant (IBCLC) in 2011 and trained as a holistic sleep coach in 2012.

 

Plastic Surgeon Eilis Fitzgerald will also be speaking on the topic of breast surgery and breastfeeding, and there will be a case studies workshop in the afternoon.

 

The annual ALCI AGM will take place in the middle of the day. The event is for ALCI members only, and all are welcome to join or renew, and register for the event online. Handouts, lunch and refreshments are included in the registration fee of €50. IBLCE CERPs and NMBI CMUs have been applied for. Please email info@alcireland.ie for information.

 

Booking is available here . Timetable is available here.

Why Breastfeeding Grief and Trauma Matter by Amy Brown. Book Review.

Review by Orla Dorgan

 

Short book 135 pages. ‘Why Matter’ series published by Pinter and Martin.

I was excited to be able to review this book by Professor Amy Brown. Breastfeeding grief and trauma is something we deal with very regularly in our personal lives and also in a professional capacity. It can really affect women’s’ mental health.

Professor Amy Brown is based in the Department of Public Health, Policy and Social Sciences at Swansea University. She first became interested in the many barriers women face when breastfeeding her first baby. She has spent the last 12 years exploring psychological, cultural and societal barriers to breastfeeding with an emphasis on how we can support these women and how we can increase our breastfeeding rates.

The book is a research book written over 3 years. It is collections of experiences that Amy has analysed over these years.

The book discusses why breastfeeding matters so much to mums and why we really want it to work. Breastfeeding is natural, a way of mothering, can help heal traumas, is healthy for baby and can be for cultural and religious reasons. For many mums, for these reasons, breastfeeding matters a lot. Many mums contribute their stories. One mother was breastfeeding her pre-schooler when her child was diagnosed with Cancer at the age of 3.5 years. Its importance was brought into sharp focus. The toddler suffered less due to breastfeeding – less pain, eased her nausea, never suffered with painful ulcers. It was her connection to normal.

The emotions women feel when they are unable to meet their goals can be long lasting even until those babies are fully grown children. “If you can redirect and attribute the emotions you feel to an external cause, particularly a justifiable one such as lack of professional support, the feelings of guilt and failure can ease”. I think this is a big statement and shows how much of an impact we have as IBCLC’s, midwifes, practice nurses, GP’s, Consultants and other HCP’s to breastfeeding mothers. Every encounter counts.

The risk of post natal depression (PND) and stopping breastfeeding is often overlooked when in fact it can be a grieving process. “Grief is an utterly normal reaction to loss”. Loss of breastfeeding goals, experienced pain or difficulty can all suffer from PND. Breastfeeding helps protect mental health.

Post Traumatic Stress Disorder (PTSD) is associated with soldiers post war. But Amy argues that Mums who have suffered breastfeeding trauma and grief can suffer with PTSD. “The oldest baby in the study was 36 years old. Thirty six years old and the mother still felt hurt and the guilt and the frustration of the system”.

“Epigenetics have shown that trauma can be inherited. Imagine a trauma your grandmother experienced while 5 months pregnant with your mother, when the egg that would one day make you that is present and fully formed”. It can influence what can be experienced many generations on. Mental health can have many implications not from just our lifetime but our generations back.

Amy goes on to discuss why do so many women struggle to breastfeed? Rates in the UK and Ireland are among the lowest in the world. 2/3 of women in Scandinavian countries are breastfeeding at 6 months compared to 1/3 in the UK. Amy believes it then cannot be “purely physiological issue that are preventing women from breastfeeding – something complex is going on at the societal level that is directly and indirectly harming their ability to breastfeed”. Approximately 1% of women have physiological issues that doesn’t allow them to breastfeed.

The wider environment can affect how women feel about breastfeeding, the lack of professional support, family support and critical friends play an important part in mothers’ lives and if it is not present, it can make breastfeeding seem impossible. “Society just doesn’t ‘get’ babies”.  “It believes babies should be ‘good’- sleep through the night, feed in a routine and be happy and put down. And the messages that women get from society imply they are failures if their baby breaks the rules”.

Generational experiences have led us to this point. “Back in the 1950’s we were sold the idea that  formula milk was scientifically superior to breastfeeding and freed women from being tied to their babies”. The natural way to feed our babies was lost and the experience that comes with that. This has been detrimental to our breastfeeding mothers. And some of our own mothers who weren’t able or couldn’t breastfeed for whatever reason be it support, knowledge or pressure to formula feed may still be grieving their own lost breastfeeding experience. And in a way “consciously or subconsciously” they find themselves harming their daughters’ chances and passing on an inter-generational trauma”.

To help grieve this lost or traumatic breastfeeding experience, feelings need to be validated and mums need to be listened to. Many mums in her research believed this was a big part of healing and important. Letting mums grieve like they would do a loved one. Talking, attending counselling and certain therapies e.g. Cognitive Behaviour Therapies can help, including many more.

To look at the bigger scale of things, we need to be able to make things better to help future generations. These suggestions came from mums who were still hurting deeply after a failed breastfeeding journey. These included more skilled support, better training for professionals, being honest about what breastfeeding is really like and further suggestions which all sound achievable but will they be acted on!

I have really enjoyed reading this and it has made me think about it, in simple ways and avenues we can explore with these grieving mums.  As a private IBCLC, time and support is what we do have to a certain extinct and one on one time with our mums to give them time to talk and we listen.

This book was a great read and I would highly recommend to anybody who works with breastfeeding mums and also, for mums who have not reached their breastfeeding goals. They would find comfort in this. Professor Amy Brown has done great work and I agree wholeheartedly with all she says.

She says it in a simple and straight forward way.