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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 €35 at the Early Bird rate. IBLCE CERPs and NMBI CMUs have been applied for. Please email firstname.lastname@example.org for information.
Booking is available here . Timetable is available here.
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.
I have been asked numerous questions since returning from The IBFAN World Breastfeeding Conference in Rio de Janiero, the top one being ‘who paid for you to go’? There is a perception out there that if you go abroad to a conference to somewhere faraway, someone else must be picking up the tab. The answer in my case is ‘no-one’ – except me! ALCI offered the usual bursary of €200 which I readily agreed to! So why did I go?
Number one was that I may not have the opportunity to visit this stunning city in the near future and as I would know a lot of others travelling it would not seem so daunting to take off on a 15-hour flight. Amal Omer-Salim from WABA was on the flight as were my other Irish compadres, Ger Cahill and Fiona Rea. We had discussed the possibility at ILCA in July and as time marched on we just decided to go. This conference is all about Policy so is not for the faint hearted. There is no actual clinical Breastfeeding content – it’s all about protecting and sustaining breastfeeding, developing policy and monitoring the activities of the multi nationals and their allies around the globe.
So what was the conference about? There were three events rolled into one – a local Brazilian Breastfeeding Policy Conference, The Unicef WHO World Breastfeeding Congress and the 1st Complementary Feeding Conference in the World. It was this that particularly attracted me plus the number of sessions that were translated into English. We met up with Mudiwah Kadeshe and Jeanette McCullough from ILCA who were there to meet all IBCLCs present and we had a very productive lunchtime meeting sharing experiences from our many differing countries. We also met up with the three representatives from ELACTA Council and discussed the forthcoming Milan Conference.
The pre-conference session I had been invited to attend as an Irish representative was on WBTi – World Breastfeeding Trends initiative. This was a full day training on implementing the WBTi from those already working in this area. The rest of us were there to observe and listen to their experiences. I was familiar with this as had been in conversation with Lactation Consultants of Great Britain (LCGB) representatives at other meetings during the year. What is interesting about this Initiative is that we (and other countries) can use statistics already available through their national CSO ( Central Statistics Office) and in our case, the HSE as well.
It does not involve gathering more statistics or plaguing already overstretched hospital administrators seeking information. The usual difficulties are present – are we collecting the same data? What constitutes exclusive breastfeeding?, who gathers statistics from the community after the early PHN visits? These are all challenges that Ireland has to address and as yet we have not submitted anything to WBTi. I know there are others working on this and for that reason I declined to undertake any further work in this area, coupled with the fact that I already am in full time employment.
It was an interesting day with Arun Kumar and others presenting on findings from other countries. The majority of attendees were doctors or statisticians from South America, Africa and Asia who had some familiarity with the programme. New friends were made, old friendships renewed and respectful communication was the order of the day.
So to the conference proper: Dr Lawrence Grummer-Strawn from WHO is an excellent speaker on a range of subjects affecting child health. Dr. Grummer-Strawn is widely known in the breastfeeding research and advocacy communities, serving as scientific editor of the Surgeon General’s Call to Action on Breastfeeding. I have had the pleasure of hearing him speak on several occasions. His presentation on the revised Ten Steps was an eye opener. For those who are not familiar with the changes, the major one is that Step 1 now has three sub-sections- 1a, 1b and 1c. For many of the countries represented this was causing somewhat of a stumbling clock because Step 1a requires full adoption of the WHO Code of Marketing in order to embark on BFHI assessment. We discussed the European Regulations and it was felt that they were too weak and we were encouraged to go back to our home countries and push for stronger legislation to protect the health of infants by strong regulation of products within the scope of the Code. He reminded us that it is governments that have a responsibility to legislate and those who are activists need to keep after them.
Under the revised Ten Steps the first two come under the heading of Critical management procedures. They are as follows:
1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.
1b. Have a written infant feeding policy that is routinely communicated to staff and parents.
1c. Establish ongoing monitoring and data-management systems.
Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.
Numbers 3 – 10 remain substantially as they were and are grouped under the heading of
‘Key Clinical Practices’ 3 to 10 as they were clinical practices
Discuss the importance and management of breastfeeding with pregnant women and their families.
Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
Support mothers to initiate and maintain breastfeeding and manage common difficulties.
Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
Support mothers to recognize and respond to their infants’ cues for feeding (this step recognises the importance of anticipatory guidance in helping breastfeeding parents to recognise early feeding cues and also includes some instruction on normal infant behaviours).
Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
Coordinate discharge so that parents and their infants have timely access to ongoing support and care.
We were reminded that there is substantial evidence that implementing the Ten Steps significantly improves breastfeeding rates. A systematic review of 58 studies on maternity and newborn care published in 2016 demonstrated clearly that adherence to the Ten Steps impacts early initiation of breastfeeding immediately after birth, exclusive breastfeeding and total duration of breastfeeding.
There were so many areas that I could have chosen to cover, however the Complementary Feeding talks really took my interest. We look at processed foods, and ultra processed foods and the potential link to lifelong obesity. Many of you will be familiar with Dr Helen Crawley’s work in First Steps Nutrition. Well this was more of the same but much more scary in terms of what our weaning infants are being fed across the globe. Firstly some startling statistics:
41 million children under the age of 5 were overweight or obese in 2016.
The worldwide prevalence of obesity nearly tripled between 1975 and 2016.
This figure is rising year on year. There were a number of speakers addressing this topic from many angles.
The most interesting nugget I picked up was that when foods are ultra processed they do not create satiety so the infant doesn’t have satiety cues so over eats. Because they don’t feel full they then get fed more. We looked at why parents world wide are persuaded that commercially prepared foods are better than home prepared. It often comes down to the word ‘organic’. It’s organic so it must be better. Of the seven countries surveyed our neighbours in the UK have a prevalence of 57% of toddler foods being either processed or ultra processed. The categories shown in the slide are in order:
Blue – breads, Orange – processed cereals, turquoise – crisps and snacks, burgundy – sweetened drinks, Yellow – Sweets and desserts, Mid blue – cakes and biscuits, Green – fast foods, Dark Blue – ultra processed meats, Light blue – Milky drinks ( flavoured milks) and a tiny sliver of white beside yellow represents Infant Formulae.
So many countries have inappropriate feeding of complementary foods and the obesity epidemic can be linked to this, and to not breastfeeding as the obesity rate declines with duration of breastfeeding.
Advertising plays a key role in the persuasion of parents to pay over the odds for foods that are poor nutritional quality. We were shown examples of large multi nationals creating doubt in the minds of parents as to the nutritional adequacy of regular family foods, creating confusion about pesticide residue in home grown products, and other dodgy tactics. The speakers’ closing words were ‘ The only thing that needs to be done to food for it to be suitable for toddlers is to either peel it , or lightly cook it’!
Patti Rundall from Baby Milk Action also spoke on the topic of unethical practices by large corporations and inappropriate tie-ups between food production and Health Depts in many countries. We are all too familiar with this in Ireland. Certain Cereals being associated with fundraising campaigns for really worthy causes, inappropriate sponsorship of local events, and hijacking legitimate government sponsored initiatives like the first 1000 days.
So what can we do:
Keep Health Policies free from commercial influence
Remind Governments that they have a duty to protect children’s rights to health
Monitor and question what companies do
Support whistleblowers – show the film Tigers
Join Baby Milk Action
Slides included with permission from original presenters.
The 4th International breastfeeding Congress will be held in Egypt in 2021. Do I plan to be there – and to quote the inimitable Elizabeth J Brooks – Hell, YES!
Sue Jameson January 2020.
Sue received a bursary of €200 from ALCI to attend the IBFAN World Breastfeeding Conference.
This was an interesting finding from Kair L.R., Colaizy TT whose objectives were to examine the extent to which a mother’s pre-pregnancy body mass index (BMI) category is associated with her exposure to pro-breastfeeding hospital practices. They found that mothers with a pre-pregnancy BMI >30 were less likely to initiate breastfeeding in the first hour, breastfeed exclusively, get breastfeeding support reference in the community on discharge and use a *pacifier more often than mothers with a BMI of less than 30.
CONCLUSIONS: Obesity stigma may be a determinant of breastfeeding outcomes for obese mothers. Breastfeeding support should be improved for this at-risk population.
*As it’s an American Study pacifier not soother is the word of choice.
Looking at the engagement of the baby in the pelvis, Carol used the term ‘fixation‘ rather than ‘engagement’ and challenged us to not always see engagement as a good thing. She looked at how for the babies that are locked from early on can have a difficult journey down the birth canal and subsequently present with feeding issues brought about by prolonged fixation in utero.
Optimizing Brain Development of Late Pre-term Infants. Presenter: Sandra Cole
Glucose uptake by the brain is disrupted at birth. As the Late-Preterm (LPT) Infant has a greater need for glucose to promote continuing rapid growth of its brain, the need for energy is therefore higher than in the term infant. So glucose is pulled from stored fat resulting in large weight loss, low blood sugar and poor temperature control.
Immaturity affects breastfeeding due to poor myelination of nerve cells, meaning poor transmission of signals to and from the brain.
Alterations in the brains of LPT Infants persist over many months and can be measured even years later.
Brumbaugh, J.E., et al. (2016).Altered Brain Function, Structure, and Developmental
Trajectory in Children Born Late Preterm. Pediatr Res. Aug:80(2):197-203.
Kelly, C.E., et al. (2016). Moderate and late preterm infants exhibit widespread brain
white matter microstructure alterations at term-equivalent age relative to term-born
When I received the ALCI 2019 Conference Programme, I was very excited to see Denise O’Brien’s presentation listed, recognising the deep impact the ability to exercise informed decision making around birth has on a woman with implications for her health and well-being into motherhood, and highlighting the importance of listening to women’s voices. The talk did not disappoint. It offered vital insights for all who work with women and families in pregnancy, birth and the postnatal period, and for informing healthcare policy and practice.
Dr Denise O’Brien is a lecturer and assistant professor in the School of Nursing, Midwifery and Health Systems at UCD. Since noticing as a midwifery student in the early 1990s that confident women were saying, “I can’t do it” or “I lost my confidence”, when it came to labour and birth, she has been interested in what happens to a woman’s sense of self when she enters the maternity care system. Dr O’Brien pointed out that until recently maternity service users have not been asked about their experiences, or invited to the table to help shape service provision. This year marks the Irish health services’ first ever national maternity care experience survey (Linda Drummond from HIQA presented to ALCI on this immediately after O’Brien’s talk).
To hear more from women, in particular how they themselves define informed choice, and building on previous Irish research revealing that women have long been asking for improvements in the provision of information to improve their overall birth experiences (O’Hare and Fallon, 2011), O’Brien and co-researchers, Professor Mary Casey and Professor Michelle M Butler designed a fascinating participatory action research study.
The objective of their research was to explore women’s understandings and definitions of informed choice as a concept, during pregnancy and childbirth. In other words, how do women define and internalise their experiences of exercising choice? They also wanted to investigate with women and midwives what supports were necessary to enable informed choice.
The setting for the study was a national referral hospital in Dublin with a normal birth rate of 57% and caesarean rate of 29%, lower than the national average, and a greater diversity of care options (obstetric-led, midwife-led, Domino midwifery services) compared to hospitals nationally. Women were recruited from postnatal wards, the postnatal baby clinic, the community midwives postnatal support group and the breastfeeding support clinics.
O’Brien outlined their study’s three distinct phases:
Interviews with 15 women (11 of whom, O’Brien noted, were breastfeeding) undertaken over a 6-month period.
A series of group meetings (n=7) with 5 women over a 13-month period, using a co-operative inquiry (CI) approach to explore the information and other supports needed to support the concept of choice.
Evaluating the information pack using a CI approach with midwives’ input, as requested by women during the inquiry process, to fully understand the supports and changes necessary to implement informed choice as a cultural norm for women during pregnancy and childbirth. Fathers were invited to be involved in this phase.
O’Brien’s presentation to ALCI honed in on the details of the first – interview – phase, the part of the study that has been published (O’Brien, Denise et al. 2017, Midwifery, Volume 46, 1 – 7). The interviews consisted of 12 open questions asking the women how they would describe informed decision making. Interviews were conducted between three and six months postpartum and lasted 33 minutes to 2 hours long each. The majority of women opted to have the interview in their own home.
In O’Brien’s illuminating analysis of the interviews, she focused on the first-person voice, how each woman spoke about herself. Pulling out the ‘I’ statements from each woman’s narrative, O’Brien created what American psychologist Carol Gilligan (1992) has termed an ‘I Poem’ for each interview. O’Brien explained how the poems revealed what women said about ‘the self’ and demonstrated how relationships influenced the women’s expressed sense of self. She then pulled each occurrence of ‘they’ when the women spoke about their relationships with maternity care professionals, to form ‘they’ poems. The two poems together illustrate the interplay between women and maternity care professionals as each woman exercised (or tried to exercise) choice during and around her birth, as well as the influence of relationships on a woman’s sense of self.
In defining informed choice, the women held multiple meanings, but there were recurring themes:
The provision of up-to-date information and coming to an understanding of that information through in-depth discussions with a maternity care provider of their choice was a prerequisite to making informed choices;
The new sense of responsibility to their baby was hugely important;
If they knew and trusted their midwife or doctor, the women were happier with their choices.
Other themes that emerged in the interviews included
A sense of uncertainty and a sense of regret: Women were certain when they described their desires and expectations of making informed choices and uncertain when they described their actual experiences of making informed choices. Uncertainties and regrets related to choice and access to pathways and models of care, and the inability to build relationships in the current maternity system. Monica’s ‘I poem’ serves as an illustration:
A sense of anxiety and isolation in early pregnancy.
A sense of disappointment in care and support.
Positive and negative feelings of self: 5 women expressed positive feelings of self when they spoke about making informed choices during the birth of their baby, while 10 felt they could not make informed choices and expressed negative feelings of self when they spoke about their experiences.
A sense of conflict between what the doctors and midwives were saying and the women’s intuition.
A sense of empowerment among the 5 women who felt supported to make their own decisions during birth and who expressed positive feelings of self when describing their interactions with their caregivers (midwives). Jo’s ‘They’ and ‘I’ poems highlight this dynamic:
“They told me” “I knew”
“They trust you” “I wasn’t worried”
“They make sure” “I was delighted”
“They are always” “I was really relaxed”
“They are so” “I was very in control”
Of all the take-homes from O’Brien’s presentation, the biggest for me was just how vital it is that healthcare professionals and maternity care systems prioritise the relational aspects of informed decision making and work to foster relationships of trust and mutual respect between women and their care providers. This study shows how detrimental this action is to a woman’s post-birth sense of self, her mental health and well-being.
I look forward to seeing the results and information pack that emerge from phases 2 and 3 of this exciting research study!
Tara Durkin November 2019.
Tara received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.
This session was presented at the 2020 ILCA Conference by Elsa Quintana BA, BCJ, IBCLC, CLE and Jan Tedder BSN, FNP, IBCLC, and this review was written by ALCI President Sue Jameson.
Elsa had worked with Jan in New Mexico to improve breastfeeding outcomes by referencing Child Development Milestones. As this is an area that I have read and presented on, on many occasions I was interested to learn how they had used Jan’s HUG programme to make changes. HUG stands for Help, Understanding and Guidance and from this Jan has developed a Parent Information Sheet that provides anticipatory guidance for what to expect in the early months. She uses the term GPS – Great Parenting Skills and the road map analogy is used throughout. This is very good as it follows the theme that breastfeeding and parenting is a journey with many twists and turns and that some of these can be avoided or planned for if one has a map.
Brazletons Touchpoint Theory is used to underpin the programme as it identifies significant events or Touchpoints (referred to as Leaps in the more familiar Wonder Weeks materials by Frans X. Plooij & Hetty van de Rijt-Plooij seen in Europe) which signal change is on the way.
Often surges or leaps in development cause changes in baby’s eating and sleeping patterns, which are often misunderstood by parents and can cause them considerable distress. The other point to note is that these developmental surges are predictable. Research has shown that understanding infant behaviour and responding effectively to infant cues contributes to longer breastfeeding duration (Shloim et al., 2017); promotes positive interactions between parent and child (Nugent et al., 2007); boosts parental confidence, reduces risk of postnatal depression, and positively impacts both attachment of baby to parents and baby’s development (Lester & Sparrow, 2010).
The materials were used to educate health professionals so that they had an increased awareness and confidence in discussing all aspects of normal developmental behaviours with parents and providing anticipatory guidance to them from an increased knowledge base. Over the areas the scores on all aspects were improved see slide showing results.
The HUG programme is available to purchase and training is available for anyone wishing to be a HUG consultant. Referring to the material, it mirrors what community based support groups in Ireland provide by way of trained breastfeeding helpers and Peer support.
The studies confirm what we know – that is parents do better when they receive timely skilled help and information about infant behaviour to help them understand what’s happening for their little ones.
It was reassuring to hear from another country that similar programmes make a difference to all population groups and to those in the lower SE groups in particular. The HUG programme is child centred and optimizes parent responsiveness to their infant’s needs.
Listening to this talk and speaking to the presenters afterwards I noted that it was an approach that any of us working in the voluntary sector would immediately recognise. Working on improving parents’ knowledge of the normal newborn’s behaviour makes breastfeeding a more enjoyable experience as anticipatory guidance provides them with a road map for the journey over the first year.
Kay Hoover, MEd and IBCLC, was the keynote speaker at the recent ACLI conference held in Limerick. Kay’s presentation on the Friday was titled “Painful nipples during breastfeeding” where she addressed the multiple root causes for nipple pain and highlighted the need to not just manage the symptoms.
Kay’s objectives for the presentation were that the delegates could;
List 5 causes of nipple pain
List 5 dermatological conditions
Draw up a care plan for damaged nipples
Kay spoke from her experience that it can be normal for mums to experience approximately 20 seconds of discomfort with the initial latch but that after this mothers should be able to relax and be less tense throughout the duration of the feed. Days 3-5 post-partum are often the peak of nipple pain and that this is expected to subside by days 7-10 however from experience it is seen that a large percentage of mothers have ongoing pain for a significant period of time.
Kay highlighted that we know hormonal changes such as the menstrual cycle causes breast changes and nipple tenderness, so therefore with the post-partum hormonal shift it is not surprising that we see this peak at days 3-5 post-partum in nipple pain. Kay spoke that there is limited research to back up this theory, however from what we understand about hormones and their impact we can better equip mothers in their expectations in these early post-partum days.
Maternal problems that can lead to nipple pain include the following:
Long nipples – causing infant to gag or pull off the breast frequently
Large nipples (diameter) making it more difficult to achieve a deep latch
Inverted nipples – pain in extracting the nipple to feed
Skin tags on nipples – potential for repeated trauma each time infant feeds
Blebs and blocked ducts
Vasospasm (Raynaud’s syndrome) – often seen on the face of then nipple, unusual to be the whole nipple – can cause a burning sensation in both the nipple and breast. Once blood flow restores the pain is expected to settle
Kay stressed the importance of asking the mother “how does that feel for you?” as our interpretation of what would cause pain during a feed may not be significant for the mother experiencing it.
Trauma can cause blanching, alongside a stinging or burning sensation. Amir et al., (2014) found vasospasm was the reason in 22-23% of breastfeeding mothers as a cause of pain.
Blanching can be on part of the nipple with the associated pain – squeezing blood back into the nipple (which often looks like hand expression) reduces the time the mother is in pain as it increases the blood flow to the affected area and is found to work quicker than warm compresses. These mothers are advised to keep warm – hats, sweaters etc. to minimise risk.
Medications that reduce vasoconstriction could be considered for these mothers – fish oil and evening primrose oil are longer term treatments and don’t provide immediate relief.
Oral Nephetamine (30mg slow release OD x 4 weeks or 5mg TDS) has been used with good effect
Injury or trauma – unrelated to breastfeeding
The baby with a strong suck – nipple shields as a temporary solution have been used in studies as increased vacuum is cause of pain, however this could cause further pain as the nipple can be pulled through the shield – always important to solve the cause of the pain
Incorrect use of a pump at its highest suction – pump should be used at highest “comfortable” setting. Also important to ensure appropriately sized flange and that the nipple is centred in the flange
Pre-natal “preparation” – i.e. rolling of nipples to “toughen them”
Baby not unlatched properly
Long distance runners can have chaffing
Incorrect fitting bra/seam or pressure
Breast pads sticking to nipple
“Spot” on nipple (sebaceous cyst) or varicose vein causing pain near nipple
Dermatological conditions on nipple causing pain
Dry skin (irritation)
Moisture – causing tissue breakdown
Infant food/medication causing maternal eczema due to change in saliva
Teething – acidic saliva (nappy rash and nipple pain)
Reaction to treatment
Poison Ivy of nipple
Psoriasis of nipple or breast tissue – some mothers require steroid cream or light treatment, others might not have any problems
Bloody discharge from nipple – 3% Breast cancer diagnosis (Paget’s disease)
Staph infection or streptococcus infection (could be on one or both breast – get cultures)
Herpes simplex (cold sore virus) – baby to mum transfer is ok, but if herpes lesion on mum could be fatal to infant (handwashing, not kissing baby as treatment)
Hand foot and mouth from toddler
Yeast infection – shooting pain, feels like “shards of glass” burning sensation, some mums cannot hold baby, or describe it hurts to wear clothing (shells can be helpful)
Key question to ask “Is this the normal look of your breasts or nipple?”
Kay then moved on to explain how to draw up a treatment plan for healing damaged nipples.
If nipples are lipstick shaped post feed work on a deeper latch, teach mum how to do suck training with baby, work on positioning to reduce pinching (Kay explained she uses plasters to show placement of hands for shaping breast).
If infant gagging and coming off too soon work on desensitising gag reflect with finger exercises in infant mouth moving back gradually to dampen response.
If mum has large nipples or there is suspected frenulum tie – i.e. nipping from baby address this issue, this may be evident as baby losing milk out of corner of mouth as unable to create seal and vacuum.
Kay explained that with a breast wound and suspected infections or mastitis important to remember that the yellow pus from this wound is not necessarily the infection but the leukocytes starting the healing process and stressed that if a mother is in pain, to use appropriate pain medications whilst breastfeeding to reduce the discomfort. Other strategies to reduce pain –
Reduce duration of feed (hand express into babies mouth)
Use breast shells
Pump exclusively until the damage heals
There are many treatment options and often no consistency with the research
Hand express and add Expressed milk to nipple
Salt soaks (Epsom salts)
Lanolin (purified) – thin coat on face of nipple
Gel pads (hydrogel or glycerine gel) have been associated with increased risk of mastitis as source of infection so ensure washing between use, however others have found these to be extremely helpful
Cotton, breathable clothing
Air drying nipples – avoiding retraction in those with inverted nipples (dimpled nipple ring – Velcro, which holds nipple out whilst allowing it to air dry
Warm soap/water destroys the biofilm – soap has a drying effect therefore wash daily if not twice daily
Sometimes needs to advise the mum to stop what she has currently been doing – ointments, treatments etc
Antifungal preparations to be added topically – nystatin and hydrocortisone cream. Ensure systemically and topically treat to reduce poor outcomes
If believed to be an infection best treatment course is wash with warm soapy water, advise culture from primary care provider and find out source and treat accordingly.
Severe mastitis = might not present with temperatures look at breasts singularly and together – patterns in infection – MRSA, step and Staph
If suspected fungal infection check babies cheeks not tongue, and often the mothers nipple has a “shiny complexion”
Impetigo – highly contagious – use topical +/- oral treatment, wash regularly and ask if too painful to feed and draw up treatment plan accordingly, some mothers can feed fine and others need to express until healed.
There is some research to suggest silver caps are more effective than breastmilk for nipple damage
Kay finished off by highlighting the importance of not dismissing nipple pain as it was in the top 2 reasons why mothers end breastfeeding before they had planned
perceived low supply
Baby wouldn’t latch
Jennifer Ashcroft October 2019.
Jennifer received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.
ALCI Council and members recently represented ALCI as part of a special reception in Áras an Uachtaráin in celebration of National Breastfeeding Week. This year two ALCI members Mairead Murphy IBCLC and Danielle Sullivan IBCLC (and Danielle’s baby) attended along with ALCI Council members Sue Jameson IBCLC, Lorraine O’Hagan IBCLC, Aine O’Leary IBCLC and Fiona Rea IBCLC.
Kay Hoover MEd and IBCLC was the keynote speaker at the recent ALCI Conference. Kay’s final session was about breastfeeding multiples.
Kay highlighted that sometimes people can frighten mothers of multiples by saying things like “Better you than me”, “Were you on fertility drugs?” or “Do Twins run in your family?”
Kay would say to these Mothers “You will have double or triple the amount of hugs. ” Focus on positive comments not on the negative ones.
(Photo: ALCI delegates enjoying the Conference recently.)
Infertility treatments have increased the numbers of multiples from 1991 to 2016 the twinning rate per 1,000 births went from 12% to 19%. In 2016 in Ireland there were 2,363 sets of twins and 79 sets of higher order multiples.
Kay highlighted that there are many Pregnancy, birth and post- partum concerns
Kay stated that there is maternal, physical and emotional strain.
Increased risk of durgical delivery ( caesarean section ) and pre term labour,
Pregnancy induced hypertension increases with each baby
Risk of gestational diabetes increases with each baby
There are Risks with Multiples
Neo – natal Mortality
Birth – defects
Child – abuse
Developmental – disabilities
Kay stated that there can be growth restrictions that affect breastfeeding
Intrauterine growth restriction and prematurity
Increased Incidence of congenital anomalies
Infant death is five times higher than for single infants.
Kay highlighted the importance of mothers not being afraid to ask for help from family. In one case, Kay encouraged one mother to ask her parents to stay with her for a month so that while she was breastfeeding the babies, the parents were making the meals and doing the households jobs.
Strategies for breastfeeding is very important
Make sure the babies can establish a milk – supply,
Pumping if necessary
Transitioning premature babies to total breastfeeding
Sometimes one baby comes home before the other,
Frequently one breastfeeds better than the other at the start.
Kay stated that 60% of Twins are born preterm. When a mother pumps by her bedside nears the babies, she usually pumps more times and gets more milk. Donor milk is available in America until the mother has milk.
Kay highlighted practical tips
Keeping track of each baby by feeding record using different coloured paper for each baby, Individual differences in the normal range,
Ways to tell the babies apart
Toe nail polish
Kay also highlighted the importance of mothers getting out of the house
Take one baby and leave one at home
Strollers made for multiples
Elastic waist band so she can go the toilet easier herself,
Start saving weekly for the children
Accept all help offered
Remember it does get easier when the babies get older and the night feeds stop
Barbara Noonan Sexton October 2019.
Barbara received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.