Certified Lactation Consultant Exam

The World Health Organization and UNICEF have set out three strategies needed for increasing breastfeeding initiation and duration in every country. What are the 3 strategies?

Breastfeeding Promotion

Breastfeeding Protection

Breastfeeding Support

Focuses on advantages of breastfeeding on a personal (personal connection), community, country (amount spent on healthcare), or global level (waste from formula & formula products)

Focuses on the good "advantages" of breastfeeding

Breastfeeding Promotion

Focuses on government, manufacturer, and social responsibility to assure breast feeding's ability to compete with commercial interests.

Includes addressing improper marketing practices

Addressing breastfeeding in public, at work, jury duty, family law, mothers in prison, etc..

Breastfeeding Protection

Focuses on the interaction of "helpers" with family as well as program development and implementation

Breastfeeding Support

Women how do not breastfeed are at a greater risk for what diseases?

Myocardial infarction

Metabolic syndrome

Coronary artery disease

Stroke

DMII

HTN

Hyperlipidemia

Cardiovascular disease

Breast, endometrial, and ovarian cancer

Reason #1 why women do not exclusively breastfeed

Unrealistic expectations from society about motherhood. Along with lack of preparation for what the newborn period would be like.

Reason #2 why women do not exclusively breastfeed

Lack of timely interventions. Mother's problems at 3-7 days posed the greatest risk for stopping which is when they are home from the hospital and alone with no support. The fastest drop-off is in the first 10 days following discharge from the hospital

The International Code of Marketing of Breast milk Substitutions

An international health policy framework to regulate the marketing of breast milk substitutes in order to protect breastfeeding. It was written in response to the marketing activities of the infant feeding industry which were promoting formula feeding over breastfeeding, which in turn was leading to a dramatic increase in maternal and infant morbidity and mortality.

What does "The Code" do?

Regulates the marketing of breast milk substitutes which includes infant formulas and any other food or drink, together with feeding bottles, and teats, intended for babies and young children. Sets standards for the labeling and quality of products and for how the law should be implemented and monitored within countries. Aims to make sure that parental choices on feeding are based on full, impartial information, rather than misleading, inaccurate or biased marketing claims.

The Global Strategy for Infant & Young Child Feeding

Is intended as a guide for action; it identifies interventions with a proven positive impact, it emphasizes providing mothers and families the support they need to carry out their crucial roles, and it explicitly defines the obligations and responsibilities in this regard of governments, international organizations, and other concerned parties.

What contributes to low rates of exclusive breastfeeding globally?

Caregiver and societal beliefs favoring mixed feedings (believing that breast milk is not enough or that babies actions/issues are related to the breast milk/breastfeeding)

Hospital and healthcare practices and policies that are not supportive of breastfeeding

Lack of adequate skilled support

Aggressive promotion of infant formula and other breast milk substitutes rather than promoting support for breastfeeding

Inadequate maternity and paternity leave legislation and other workplace policies

Lack of knowledge about the dangers of not exclusively breastfeeding and of proper breastfeeding techniques

How to support exclusive breastfeeding

Increase hospital and health system capacity including revitalizing, expanding, and institutionalizing the baby-friendly hospital initiative in health systems

Provide community based strategies including communication campaigns tailored to the local context

Strengthen the monitoring, enforcement, and legislation related to "The Code" and subsequent resolutions.

Enact at least 6 months paid maternity leave

Invest in training and capacity building in breastfeeding protection, promotion, and support

What is the role of the pituitary glade in milk making?

Messages from certain stimulation travels through the breast to the pituitary gland which triggers it to produce prolactin and oxytocin which are two hormones needed to make milk.

How in prolactin produced?

Breast stimulation

Nipple stimulation (makes the most)

What is the first way oxytocin can be triggered?

Conditioned response/Conditioned Milk Ejection Reflex (Let down). Automatic response that comes with the association of smell, touch, sounds of baby at the breast. Also occurs on babies end with knowing what to do when placed at the breast.

What is the second way oxytocin can be triggered?

Nipple stretching that occurs with a proper latch

What is a third way oxytocin can be triggered?

Baby hand massage

What does prolactin do?

Enters receptor sites in the milk making cells and helps produce breastmilk

What does oxytocin do?

Allows for the milk to move from the milk making cells and through the nipple with "contractions" that squeeze the cells and the ducts.

Preterm milk

Appears to have different composition for the first 5-7 weeks after delivery independent of gestational age

Preterm milk appears to be higher in protein, fat, and electrolytes than mature milk

This is determined by being preterm not just having a small baby therefor it does not matter if the baby is SGA or LGA only dependent of gestational age

1+ year of lactation

After one year of lactation the milk expressed has significantly increased fat and energy contents, compared with milk expressed by women who have been lactation for a shorter time.

The volume of milk does not have to change as the baby gets older/bigger because the composition of the milk changes

Breast milk composition changes...

Over the course of lactation

Within the day there are variations on the composition of milk

Within a feeding

By the way it is taken during a feeding

and also between feedings

Fat content in breast milk

Longer times in between feedings made for a lower fat content but faster feedings made for a higher fat content where as feedings lasting longer than 30 mins made for a lower fat content

Breastfed babies can regulate fat intake quickly and thus mothers should be encouraged to practice baby led feeding

Maximum fat levels were obtained 30 mins post-feed

1 breast or 2?

There is no difference in baby's net fat intake according to the number of breasts suckled per feeding or the breastfeeding frequency

Offer the 1st breast 1st and the 2nd breast 2nd it really doesn't matter 1 breast or 2 whatever they want

Lactogenesis 1/Secretory Differentiation

Production of colostrum from the placental hormones (progesterone)

When placenta delivers the progesterone levels drop to allow for prolactin to take its place in the milk making cells

Lactogenesis 2/Secretory Activation

Begins when progesterone leaves the cells and prolactin enters the receptor sites

Milk will be a mix of colostrum and mature milk

Lactogenesis 3/Galactopoesis

Long term production of mature milk

Need frequent removal of milk and frequent nipple stimulation to continuously produce milk

How does pH of the gut effect babies

Gut pH of breastfed babies is higher than those who are formula fed or even mixed fed. Higher pH means less harmful bacteria is able to grow which helps have less issues with diarrhea

How does iron effect baby's gut

Low iron in the gut is good, breastmilk has relativly low iron content

Tons of different bacteria thrives on excess iron so having to much can cause issues

How does the presence of lactobacillus bifidus affect baby's gut

Presence of bifidus factor in breast milk promotes the growth of lactobacillus bifidus which helps maintain the low pH and crowd out the harmful bacteria

How does the presence of SIgA antibodies effect baby's gut

Antibodies such as SIgA bind to microbes in the baby's intestinal tract and prevent them from being absorbed into the rest of the body. Mothers IgA has been found to protect against the development of necrotizing enterocolitis in preterm infants

Weight loss in breastfed infant

No more than 7% weight loss from with birth weight and no more weight loss by day 5 and should be back to birth weight by 2 weeks

Weight loss greater than 7% from birth weight indicates a possible breastfeeding problem and requires more intensive evaluation of breastfeeding and possibly intervention (not supplementation!) to correct problems and improve milk production and transfer

What causes infants to lose weight in the first postpartum days

Labor medications

More intrapartum fluids are given, they have more fluid to loss which is a normal process

No labor prior to a c-section, maybe they weren't ready to be born

How do I know my baby is getting enough milk?

One wet diaper for how old the baby is (however this can be skewed by the diuresing process and is not a good indicator of adequate hydration)

4 wets on day 4 and each day after

Multiple poops each day that change in consistency and color

How much weight should my baby be gaining

Approximently 1 ounce per day is expected in the early months by more may be needed for babies with metabolic or respiratory distress because they tend to burn more calories breathing, keeping warm, etc..

Size of the breast relates to the amount of milk produced

No!! the proportion of glandular and fat tissue and the number and size of the ducts are not related to milk production

Need to drink a lot of fluids to produce a lot of milk

No!! There is not enough evidence to support increasing fluid intake beyond what breastfeeding mothers are likely to require to meet their needs

Maternal exercise is related to infant weight gain growth

No!!

Increased worry of stress my diminish milk supply

Not necessarily, worry/stress may alter behavior which could alter supply but not nursing enough or removing milk often enough

How do we assure an adequate milk supply?

Universal understanding of how breastfeeding works

Early initiation and adequate breastfeeding (10-12x per day)

Appropriate breastfeeding assessment

Improved and early breastfeeding support

Appropriate HCP and LCP follow-up in the postpartum period

Admitting there is no magic bullet

More nursing= more milk

Negative influences on milk production

Long spaced between feedings

Long, slow feedings-can effect prolactin production

Negative influences on milk production: Excessive pressure in the breast

Pressure on the milk making cells causes less milk to be made

Pressure can result from: vascular, lymphatic, and third spacing forces

Too much milk in the breast (engorgement)

Missed feedings

Restrictive bras and clothing

Brest implants: decrease storage and capacity and also increase the pressure on the milk cells

Engorgement

Breasts hard, hot, and shiny

Temp above normal

Feels discomfort in the breast

Nipple difficult to grasp, makes difficult for baby to latch

Occurs most commonly day 3-5

As the pressure builds up inside the breast milk production decreases, this is natures early dry up mechanism

Failure to effectively resolve prolonged symptomatic engorgement may have a negative impact on continued adequate milk supply

Placing breasts in a bowl of warm water will stimulate the milk to flow out to relieve some pressure so you can then feed

Negative influences on milk production: Breast surgery or injury

With surgery concern centers on damage to nerves which makes stimulation difficult or impossible, and damage to ducts which makes milk flowing out of breasts difficult or impossible

Counseling implication after breast surgery:

Likelyhood of full breastfeeding is unknown

The hormonal exposure of pregnancy and lactation may mitigate some effects of surgery

Assessment and close follow-up are the keys

Assure adequate nutrition for the infant

Negative influences on milk production: Sub-optimal breast anatomy

Anatomical concerns

Absence of breast changes in pregnancy or early days postpartum

No postpartum breast fullness or signs of abundant milk production

Hypoplastic breast(s) (underdeveloped, tubular, or inadequate glandular tissue)

Discrepant breast size (Unilateral underdeveloped breasts)

Inverted Nipples

Grade 1: are easily pulled out with a breast pump or infant nursing (look inverted with rest but evert with use)

Grade 2: can be pulled out but don't maintain their projection (may invert as soon as baby comes off breast)

Grade 3: difficult or impossible to pull out

Classification is about function during feeding not about how inverted or flat the nipple looks at rest

Does the nipple ever evert?

Look over the mothers shoulder to see what the nipple looks like immediately following feeding

Negative influences on milk production: Sub-optimal or altered physiology

Iron deficiency Anemia: Physiologic (poor O2 to milk making cells) or due to exhaustion or depression altering mothers coping behavior

Hemorrhage: Sheehan's syndrome (the pituitary gland is deprived of blood and its functions are impaired)

Hormone imbalance: Thyroid, obesity, GDM

PCOS

Certain drugs: Pseudoephdrines & corticosteroids (betamethasone)

Smoking and breastfeeding

Smoking mothers make less milk

Smoking mothers may have lower prolactin levels because prolactin doesn't rise like it should

Babies tended to nap less when fed milk from mothers who smoked vs those who did not smoke

Quiting smoking during pregnancy resulted in a lower chance of preterm birth

22% of SIDS cases can be directly attributed to maternal smoking during pregnancy

Canabis use and breastfeeding

Exposure of infant to any kind of passive smoke is a concern. There is no safe threshold limit for cannabis use in pregnancy. Among pregnant women cannabis use was significantly associated with an increased risk of preterm birth and low birth weight

The high fat solubility of cannabinoids make them difficult to analyze in breast milk. THC (delta-9-tetrahydrocannabinol) is measurable in milk 6 days after maternal use

Anemia and breastfeeding

Postpartum hemorrhage can cause sheehans syndrome which in turn causes hormonal issues including milk making hormones

Retained placenta fragments prevents the shift from lactogenesis stage 1 to stage 2 which can affect your mature milk coming in

Is nursing during pregnancy safe?

It is safe as long as you are not at risk for preterm delivery, however the composition of your milk might change due to placental hormones being on board and your toddler may not want to feed anymore

Tandem Nursing

The practice of breastfeeding 2 babies not from the same pregnancy at the same time

Milk volumes increase faster but less engorgement is experienced with two nurslings

May require specific teaching to manage faster flow

Help parents respond to different needs of each child

Nurse newborns frequently

Find time for non-nursing interactions with older babies

Negative influences on milk production: Physical objects

Pacifier use may be an indicator that parents need extra breastfeeding teaching Ask questions

Nipple shields

Postpartum depression

Women who are more likely to wean early are those who have experienced depression either in pregnancy or postpartum

Among women with breastfeeding difficulties, women who had a negative experience with breastfeeding support had a significantly higher risk of postpartum depression and more likely to show symptoms at 2 months

Silence learner

A position of not knowing in which the person feels voiceless, powerless, and mindless

Afraid of words

See themselves as relatively powerless and dependent on others for survial

Do not trust their ability to understand or remember

Have little awareness of their intellectual capabilities

Live at the behest of those around them

To develop a relationship with Women in Silence:

Few words

Familiar words

Short, easy, comfortable

Nothing to remember

You may need to be an advocate

Receivers of knowledge

Believe that all authorities tell the truth

Like to learn the right answer and repeat it to the teacher

Can not tolerate ambiguity

Submit to the command of authority-not inner voice

Sense of self is embedded in external definitions and roles

Live at the behest of those around them

To develop a relationship with Receivers of knowledge:

Teacher or counselor must project authority

Never be ambiguous

Advantages must be concrete and appropriate for her

Teaching should be centered on the right way and include return demo

Subjective knowing

Believes knowing is personal, private, and based on intuition and/or feeling states, rather than on thought and articulated ideas that are defended with evidence

Sense of self is embedded in external definitions and roles

Sense of authority arises primarily from the power of a group

Trust their own intuition

Inner voice helps guide them

Distrust male authority figures

"Experts don't know what they are talking about"

Trust other women with similar experiences

Find female support groups helpful

Attracted to natural things, like breastfeeding

Want to be helped by someone who has breastfed

Interested in breastfeeding from her own point of view

To develop a relationship with Subjective knowers:

Create time for them to talk about themselves and what they think about breastfeeding

Offer help with possible misconceptions about breastfeeding

Offer to make contacts and referrals

Procedural Knowing

The position at which techniques and procedures for acquiring, validating, and evaluating knowledge claims are developed and honored

Invested learning, constantly taking in new information

Interested in obtaining and applying knowledge

Want to understand other people's points of view

Assume that every one including themselves can be wrong

Will read a variety of books with different points of view

May attend several classes and change health care providers easily

May be viewed as inconsistent by others

May want very technical information about breastfeeding

To develop a relationship with Procedural knowers:

Be prepared to back up statements with evidence

Be knowledgeable about multiple sources of reference

Limit personal stories

Understand that options and change are part of the process

Constructed Knowing

The position at which truth is understood to be contextual, knowledge is tentative, and it is understood that the knower is part of the known

Have abandoned either/or thinking

Have learned to live with conflict and have high tolerance for internal contradiction and ambiguity

Believe all knowledge is constructed and the knower is an intimate part of the known

Want to avoid compartmentalizing thought and feeling, home and work, self and other

Want to embrace all the pieces of the self in some ultimate sense of the whole: mother-daughter-wife-artist

Aspire to work that contributes to the empowerment and improvement in the quality of life of others

Believe that ideas and values must be nurtured

Have a unique and authentic voice

Storing fresh expressed or pumped breast milk

Up to 4 hours on the countertop

Up to 4 days in the refrigerator

Within 6 months but up to 12 months in the freezer

Storing thawed, previously frozen breast milk

Up to 1-2 hours on the countertop

Up to 24 hours in the refrigerator

Never re-freeze previously thawed milk

Storing breast milk that is leftover from a feeding

Use within 2 hours after the baby is done feeding

Formula preparation and storing

Formula needs to be mix with water that is at least 70ºC or 158ºF in order to kill Enerobacter Sakazakii

Formula made with hot water need to be cooled quickly to body temperature if it is being fed to the baby immediately

If the formula is not being fed immediately, refrigerate it right away and keep refrigerated until feeling

Hierarchy of infant feeding choices

1. Baby at mothers breast

2. Mother's own expressed milk

3. Milk from a milk bank

4. Cows milk forumla

5. Soy formula

Colic

An easily identifiable childhood problem that has no clearly identified treatment

Does not seem to be associated with GERD

Colicky babies had more than double the abundance of microbia in the gut

How much milk do moms make on average?

750-1000mL per day

If baby is diagnosed with Galactosemia

recessive genetic disorder; characterized by body's inability to tolerate galactose

Can be rapidly fatal is lactose is not completely removed from the infants diet

Breastfeeding is contraindicated

If mother is infected with HIV

Breastfeeding or feeding at the breast is not advisable

If mother is infected with T-cell lymphotopic virus

Breastfeeding or feeding at the breast is not advisable

If mother is using illicit street drugs such as PCP or cocaine

Breastfeeding or feeding at the breast is not advisable

Exceptions being narcotic dependent mothers who are enrolled in a supervised methadone program and have a negative screening for HIV infection

If mother is suspected or confirmed of having Ebola

Breastfeeding or feeding at the breast is not advisable

If mother is infected with untreated brucellosis

Mothers should temporarily not breastfeed or feed expressed breast milk

If mother is taking certain medications (medications and decrease cells proliferation: cancer drugs)

Mothers should temporarily not breastfeed or feed expressed breast milk

If mother is undergoing diagnostic imaging with radiopharmaceuticals

Mothers should temporarily not breastfeed of feed expressed breast milk

If mother has an active herpes lesion on the breast

Can breastfeed from unaffected side if affected side is completely covered

If both sides are affected mother should temporarily not breastfeed or feed expressed breastmilk

If mother has active TB

Mother should temporarily not breastfeed but can feed expressed breast milk

If mother has active chicken pox that developed within the 5 days prior to delivery to the 2 days following delivery

Mother should temporarily not breastfeed but can feed expressed breast milk

Less engorgement is associated with

More time spent in the first 48 hours