Infant Formula: The “Supplement” Paradox

I’m an absolute stickler for language when it comes to infant feeding, and “supplement the baby” is one of those phrases that really creates conflict for me.

This isn’t an article about supplementation of babies with infant formula, the reasons why it’s sometimes necessary, or the science of how it affects babies and their parents. That’s a story for another day.

For now, let’s just look at the word “supplement“. The Cambridge dictionary defines the noun as “something that is added to something else in order to improve it or complete it; something extra,” while the verb is defined as “to add to something.” There’s a few different implications here: first, that a supplement makes something whole, and second, that a supplement improves something.

Is there any particular reason the word “supplement” is used to mean “give the baby some formula?” This is common in the United States, and that cannot be by chance. A quick Google search demonstrates that all infant formula manufacturers which are currently active in the U.S. use this term in their marketing.

So even though “supplement the baby” could be taken to mean “give the baby some expressed human milk or some donor milk or some infant formula,” it is most often associated in our culture with feeding infant formula in addition to breastfeeding. To a new parent, the use of the word “supplement” generally implies that giving the baby formula makes breastfeeding better. After all, when we are deficient in a nutrient, we can take a – say it with me now – supplement.

Why are we using this word? It’s not the right word for the situation. When a baby needs a supplement, that means they need more volume of the food they are taking. We can always be more specific in our conversation around this topic. It’s important to helping parents understand the why of their need or choice to give their baby more food. Infant formula does not inherently make breastfeeding better. It is not a supplement in the way that most people understand a supplement to be – and that’s because, in the end, this is actually an article about the why of supplementation and the reasons and the science. Infant formula is not better than human milk, it does not correct a deficiency (other than a lack of appropriate volume), and it does not make breastfeeding work better (as some research articles have actually implied.)

Infant formula is a substitute for human milk, best reserved for situations where it has been determined that a mother’s own milk is not available and pasteurized donor human milk is not available. Should a baby in that situation require additional food, then safely-prepared infant formula would be the appropriate option for ensuring proper intake. This requires access to sanitary conditions as well as a clean water supply.

When we use the word “supplement” as a way of saying “give the baby formula,” it is confusing and inaccurate. Parents may think that breastfeeding is not enough, or that feeding their baby only expressed breast milk does not provide the proper nutrients. This can lead to them being vulnerable to predatory infant formula marketing which makes incorrect and unproven claims about health.

Through consultation with an IBCLC©, a physician trained in breastfeeding medicine, or another appropriately qualified health care provider, it can be determined whether a baby requires more food than they are currently receiving. It is only in those situations that there is a medical indication to give a baby additional food, and the first way to do that is by improving the quality of breastfeeding as well as the frequency when possible. Let’s not confuse parents with the word “supplement.” Let’s talk to them about what’s actually happening, based on excellent clinical observation, and let’s give them very specific instructions on how to proceed if additional feeding is needed. That’s how we level the playing field and respect the value of breastfeeding and human milk feeding.

An Enhanced Model of Care for the Breastfeeding Dyad: Proficiency in Tongue and Lip Restriction Assessments

An Enhanced Model of Care for the Breastfeeding Dyad: Proficiency in Tongue and Lip Restriction Assessments

by Christine Staricka, BS, IBCLC, RLC, CCE

The privilege and responsibility of providing excellent, evidence-based care of the breastfeeding dyad in today’s culture falls on the shoulders of many: physicians, IBCLCs, nurse practitioners, registered nurses, dentists, occupational therapists, chiropractors, speech pathologists, trained volunteer breastfeeding supporters, and many who are cross-trained in those and other specialties. The evidence base grows rapidly, and staying current is a welcome challenge for most. In the field of human lactation, the knowledge base about tongue and lip function is particularly rapid in its growth and expansion, and the number of healthcare providers who are proficient or expert in handling these situations is growing daily. How can you participate?

Begin by assessing your comfort level with the topic. Which of the following applies best to you?

– I know I need to learn about this but I haven’t figured out how.
– I know a little but it’s really intimidating and I am unsure about how to apply what I know.
– I am learning more every day – this stuff is fascinating and it’s why I love working in lactation! It is helping me connect the dots on many past cases of unsuccessful breastfeeding.
– I already have my lactation niche, and I’m not interested in making changes.

Next, complete the following:

Personal Checklist for Comprehending Tongue Restriction and Lip Tie

– can identify red flags indicating to check for Tongue Restriction and Lip Tie
– can visually assess infant oral anatomy
– can digitally assess infant oral anatomy
– can functionally assess infant oral anatomy during suckle
– can identify mispatterned or dysfunctional suck/swallow/breathe rhythm
– can explain ideal tongue mobility and function
– can explain positioning and purpose of lip placement during latch
– can identify patterns of nipple trauma indicative of tongue and lip restriction
– can identify other infant indicators of structural dysfunction related to Tongue Restriction and Lip Tie
– can identify priority of revising tongue/lip function in an overall bf improvement plan for a specific dyad
– can understand why Tongue Restriction and Lip Tie are poorly understood and often dismissed
– can properly document observation and assessment of tongue function during breastfeeding to facilitate reporting to other healthcare providers

Proficiency in these standards ensures that the breastfeeding dyad is receiving care from a provider who is assessing their situation from multiple angles and with regard to the most current knowledge base.  The standards directly reflect and relate back to all other functions required of the IBCLC in particular, and they strengthen the IBCLC’s ability to perform according to their Scope of Practice.  If you feel you are unable to meet these objectives, it would benefit you to ally yourself closely with and begin making referrals to someone who is proficient in recognizing tongue and lip restriction issues.

Adopting standards such as these is inevitable for the IBCLC profession.   Creating an expanded circle of many types of healthcare providers proficient in recognizing and addressing these issues will greatly enhance our society’s ability to properly and fully support the health of infants and their mothers through normal breastfeeding.

After completing the above inventory of current knowledge, skills, and motivation, in order to learn more about Tongue Restriction and Lip Tie, you may wish to familiarize yourself with the following rich resources.  Each of these links will also connect you to additional valuable resources and published research on infant tongue and lip restriction.

*You are highly encouraged to get involved with your local breastfeeding coalition or task force to network with other breastfeeding professionals and volunteers who have experience in this area.  *If you are already proficient at assessing and helping dyads experiencing these issues, make sure your local coalition or task force knows what you can offer so they can include you on their list for referrals. *

Finally, if you have doubts about how complex this issue is, please consider the following:

We know that sub-par breastpumps don’t work well. Why? Because inconsistent vacuum creates problems with seal, causes nipple damage, and provides incomplete milk removal from the breast. Guess what (who) else does that? Babies with tongue restriction and lip tie. Why do high-quality breastpumps work? They create a seal and use perfectly rhythmic and timed pressures which allow the mother’s nipple to maintain a stable teat throughout the process and which do not cause friction/nipple damage. With these factors in place, complete milk removal is accomplished and milk supply can be sustained over time. Why do babies with normal tongue function and normally flanging lips breastfeed efficiently? They create a seal and use perfectly rhythmic and timed pressures which allow the mother’s nipple to maintain a stable teat throughout the process, they do not cause friction/nipple damage, and this permits complete milk removal for long-term milk supply stability.

Similarly, we know that one of the reasons premature infants can be ineffective at feeding from the breast and ineffective at complete milk removal is that they are unable to maintain a seal due to low muscle tone; thus, retaining the mother’s nipple in the oral space is a challenge (this has been the primary reason given for experimenting with the use of nipple shields for premies!)

Why do nipple shields work? They create a constant and unchanging teat for the baby who is unable to maintain that himself. In some cases, we have historically thought this was because the mother’s nipple protractility was low (described as short, flat, or inverted nipples.) In other cases, we attributed it to baby’s inability to latch deeply enough, blaming it on latch technique or baby “needing to learn.” The theory of the learning curve is not biologically realistic. Sucking is a reflex, and babies practice it thousands of times before they are born. (Establishing a normal suck/swallow/breathe pattern does indeed involve a short learning curve; thus, milk flow during the colostral phase is slow, building gradually as the baby practices frequent suckling in the first few days of life, coordinating an efficient pattern for managing the flow of milk within days of birth.)

But what if one of the real reasons babies ever needed nipple shields to successfully breastfeed was that their tongue function was restricted, and/or their lips were unable to flange properly? What if nipple shields have been masking these problems all along? Why would a baby “need” a piece of plastic to improve their ability to breastfeed? Even if a mother has nipples which do not evert easily, shouldn’t a normal baby have the ability to hold a teat in their mouth by creating the appropriate vacuum and alternating pressures during suckling? Have we not used breast shells for many years on pregnant women with shorter nipples in a (usually successful) attempt to create a continual vacuum which improves nipple protractility prior to the baby’s birth? Shouldn’t the normal vacuum of a normal baby during breastfeeding, occurring multiple times over the course of days, also provide gradual increases in protractility and allow for effective breastfeeding?

Accounting for the experience of breastfeeding dyads who did successfully breastfeed for any amount of time in the presence of tongue and/or lip restriction, it is also possible that in some cases, an overabundance of milk or high number of milk ejection reflexes per feeding were able to partially or completely compensate for the anatomical restrictions of the baby.  In light of this, there is a theory that it is perhaps better to take a “wait and see” approach to an early observation of tongue and/or lip restriction.  However, it is not possible to predict the likelihood of oversupply or the number of milk ejection reflexes a mother will experience, nor the likelihood of pain or nipple trauma.  The risk of the poor outcomes associated with tongue and lip restriction is high, early weaning being the most critical negative outcome.  

Copyright 2014, Christine Staricka, BS, IBCLC, CCE


Why Should You Pay for Lactation Education?

Why Should You Pay for Lactation Education?

If you work with moms and babies, you need to know how breastfeeding, or Normal Infant Feeding, works. If you don’t, you’re not going to be able to provide complete and ethical medical care to your patients. Lip service isn’t enough. Healthcare providers need to know enough about breastfeeding to be more than just cheerleaders – and if they don’t, they should know to whom their patients should be referred for assistance.

So why pay for more education if you are already a physician, nurse, dietitian, Occupational Therapist, or any other medical professional? The answer is simple: the education you received to prepare you for your profession did not include up-to-date information about breastfeeding, and some of what you learned may have even been influenced by the infant formula industry. Pediatricians, nurses, speech language pathologists, and more – we’ve heard from multiple healthcare specialties that they did not learn about breastfeeding during their training, and they are frustrated that the topic is not covered in any amount of useful detail.  Without objective information from an International Board-Certified Lactation Consultant, you may not have heard the most complete information on how to support and educate new mothers on feeding choices.

Lactation education is monitored and vetted by the International Board of Lactation Consultant Examiners, the organization which is responsible for administering the board examination of potential IBCLC candidates. To qualify for the board exam, didactic education must be completed and supervised clinical hours documented and reviewed. Upon passing the board exam, the credential IBCLC is bestowed for a period of 5 years, after which re-certification is REQUIRED via continuing education or passing the board exam again. Compared to most healthcare credentials, that requirement is far more stringent and ensures that IBCLCs stay on top of their field’s emerging research and trends.

But what of the non-monetary value of such endeavors?  Why should a healthcare provider pay for lactation education?  The value to a new mother and her baby of having care provided by someone knowledgeable about breastfeeding is immensely underrrated.  It is crucial that experts in lactation are available to all mothers to ensure they receive the highest level of breastfeeding care so that they are able to breastfeed for as long as possible.  Breastfeeding reduces medical expenses in the long-term for both mothers and babies; this fact has been widely researched, calculated and reported.

One final thought: how many experts are really needed?  Well, with the proliferation of complicating factors which confound the breastfeeding relationship, Western cultures truly do need as many lactation experts as possible.  Maternal obesity and gestational diabetes, premature births, large numbers of labor inductions, a high rate of surgical births: among many others, these are factors which render breastfeeding difficult for many modern mothers.  Factor in the lack of culutural awareness of appropriate expectations for human infants with a general lack of acceptance in Western cultures of breastfeeding anywhere outside a woman’s home, and there’s a recipe for multiple lactation issues.  The bottom line is that babies are cheated when their mothers are unable to breastfeed them, and investing in lactation education advances our society’s ability to correct this injustice.

Christine Staricka, BS, IBCLC, RLC, CCE


Creating a current curriculum is an endeavor which requires many work hours and many physical resources.  Every hour of teaching requires approximately 3 hours of preparation for the first time it is taught.  Updates to subsequent offerings of the same teaching can take 30-60 minutes each when factoring in applying newly published research and textbooks. Full references in APA style must be provided as part of every offering of lactation education.  Presentation software is required to create a dynamic presentation for classes.  Equipment on which to present material is a necessary expenditure.  Printed materials are generally provided to participants in lactation education courses.  Props such as cloth anatomical models, examples of feeding devices, and DVDs of relevant topics must be made available to provide the richest learning environment.  In some cases, the facility in which a course is taught must be rented, meals are provided by the facilitators, and additional miscellaneous costs accumulate.

Providers of lactation education are verified to be current in their own education, and they are subject to high standards by the IBLCE. Remaining currently certified is not only mandatory, but subject to fees for licensure.  These costs are borne by the IBCLC her/himself as part of the cost of doing business.  Most IBCLCs have made significant, personal financial investments in their certification, and those costs are ongoing.

Normal Infant Feeding: Finding Our Way Back

Leading The Way Back to Normal Infant Feeding

Happy Baby

Whose responsibility is it to re-direct policies, procedures, and attitudes back in the direction of Normal Infant Feeding (NIF)? Those who recognize that it is their obligation and those who accept that it is their ethical responsibility search fervently for useful guidance on effecting change. Statistics on how babies are feeding before their parents even get them home from the hospital are clearly showing that NIF remains poorly understood, weakly championed, and vastly unsupported by cultural norms. Altering momentum in the direction of NIF needs to happen on many levels, and here are some places it must be shifted if maternal/child health outcomes are to be improved.

1. Defining Normal Infant Feeding (NIF)
Normal Infant Feeding (NIF) is defined as an infant feeding at breast beginning at birth and doing so exclusively until at least the age of 6 months, after which time complementary solid foods are gradually added to the infant’s diet as breastfeeding continues.  Normal, healthy term infants are born able and willing to feed at the breast.  If they cannot, the cause(s) must be identified and then the infant’s parents provided with appropriate education and skills to ensure NIF can resume as soon as possible. When infants are born early, ill, or with structural issues affecting feeding, appropriate consultation with NIF experts such as International Board Certified Lactation Consultants (IBCLCs) is crucial to ensuring optimal outcomes for these at-risk populations.

2. Defining Infant Feeding Interventions

Interventions to assist infants with feeding must be research-proven, not just used due to custom or tradition. Interventions currently promoted and used, including bottlefeeding mother’s own milk or artificial milk, are often NOT the evidence-based first choice for ensuring NIF can be resumed. Interventions must be clearly defined as such and labeled properly with an ending date or benchmark. Without those precautions, the intervention becomes the routine and NIF is discarded and devalued.  See previous post here

3. Creating Efficient Breastfeeding Policy in Healthcare Environments
Policy writers need not re-invent the wheel as many existing NIF models have been created and are widely available for adoption. The Baby-Friendly Hospital Initiative and the Academy of Breastfeeding Medicine Protocols are two well-known and widely-accepted standards. These models incorporate the preponderance of evidence regarding procedures for protecting NIF and the interventions which are appropriate for alternate scenarios. 

4.  Applying Research Ethically
Meta-analyses are, in this day and age, close to the best way available to factor all existing evidence into a practical conclusion. When available, meta-analyses should be the basis for incorporating ideas and practices. Research is frequently released which is industry-influenced and/or poorly structured. When using single studies, whether large or small, a person trained to evaluate research should be thoroughly assessing the study or publication before its conclusions are accepted and put to use.

5.  Centering Care Decisions on the NIF Model
Simply asking the question “How will this care plan affect NIF in the short- and long-term?” is a critical step for all providers caring for mothers and young children. One caveat: a solid understanding of how interventions affect long-term outcomes is necessary for this step to work properly – simply assuming that it will work itself out or blindly assigning intervention because it’s the way one has always done it is not appropriate care. Assuming personal responsibility for ensuring a mother has the correct information when intervention is suggested is the ONLY way for the provider to ensure the mother can make informed consent.

The path back to Normal Infant Feeding is being illuminated by many IBCLCs, nurses, physicians, lactation educators, doulas, midwives, and countless others who provide mothers with excellent breastfeeding support.  This tireless group leads the conversation about NIF on a one-to-one level with mothers as well as in the public eye.  As 2013 comes to a close, we thank these people for holding high their lanterns as they lead mothers and babies to a more hopeful and healthier future.

Want to read more about lactation advocacy and messages of hope?

Bad information About Breastfeeding

It is MUCH WORSE to give out bad information about breastfeeding or to imply that it is not important than it is to say “Wow, I don’t know, but here’s how to get in touch with someone who can answer that question for you.” It is unethical, it is unjust, and it causes premature weaning. Worst of all, it causes mothers to feel as if they did not have any control over when they chose to wean their babies. They didn’t – someone told them they had to! – Christine Staricka, IBCLC, RLC, CCE

I’m Sorry, Can You Tell Me Again Why You Were Told to Stop Breastfeeding?

Can you repeat that?  I am certain I didn’t hear it correctly.  They told you to stop breastfeeding because of what? You were told not to breastfeed because (insert potentially bad outcome here)?!

Ok, let’s start with this: this is not your fault.  If you and your baby have been the victim of poor breastfeeding information and advice, I highly recommend you visit the website right now for some serious and important support.  You will feel better after reading their incredibly compassionate truths about how women and babies are victimized by The Booby Traps© in our culture and society.

Are you back? Good.  Let’s talk about the true contraindications to breastfeeding (the evidence-based, real-life situations in which breastfeeding is actually NOT recommended by health organizations.)  In the U.S., the American Academy of Pediatrics, the Academy of Breastfeeding Medicine, and the American College of Obstetricians and Gynecologists have put forth the following list of contraindications to breastfeeding based upon the best available evidence:

– Infant : Galactosemia – a rare genetic disorder which is diagnosed through newborn screening

– Mother: HIV + (in the U.S.)

– Mother: Human T-Lymphotrohic Virus Type I or II

– Mother: Active Herpes Lesion on breast which would come into contact with baby’s mouth during feeding or pump parts during pumping

– Mother: Therapeutic dose of radiopharmaceutical medication such as chemotherapy for cancer

– Mother: Untreated tuberculosis (until treated for 14 days, then not contraindicated) or varicella (only if diagnosed within 5 days before and up to 48 hours after delivery; otherwise not contraindicated)

– Mother: Illegal drug use

That’s it.  (When we teach health professionals in our Basic Breastfeeding Management courses, we require them to memorize that list – it’s the only thing they need to know by heart because it’s that important.)  Now think about all the reasons you’ve heard from mothers who were told to stop breastfeeding: temporary anesthesia, flu, diarrhea, pain medications, postpartum depression medications, premature baby, ill baby, mother has a fever, baby has a fever, baby with respiratory problems, baby not gaining enough weight, baby jaundiced, baby spitting up, baby with reflux, baby waking too often to feed during the night, nipple trauma, blood from nipple trauma, milk not rich enough, milk too rich, mom pregnant, baby too old for that, baby has teeth/can talk/can walk so shouldn’t be breastfeeding, milk isn’t nutritious “anymore,” breastmilk doesn’t have enough vitamins, mom tried to pump and nothing came out so she must not have any milk, can’t mix breastmilk and formula at the same feeding, grandma didn’t make milk so mom probably won’t either, can’t pump at work so might as well stop breastfeeding, mom is diabetic, baby has low blood sugar, mom has Hepatitis, mom is obese, mom is too skinny, mom doesn’t eat a good diet, mom doesn’t drink enough water/milk/tea, mom smokes, mom had a glass of wine, etc.  This list could go on for a long time.

Mothers are told every day that breastfeeding is not important when they are discouraged from breastfeeding or encouraged to wean.  There are hardly any true contraindications, so the real problem here is misinformation.  Health professionals of all kinds are telling mothers that breastfeeding is not important when they give out incorrect information, when they perpetuate myths instead of evidence-based information, when they “pick and choose” the information THEY think mothers can handle, and when they simply guess at the right answer to a breastfeeding question because they don’t want to seem uninformed.

It is MUCH WORSE to give out bad information about breastfeeding or to imply that it is not important than it is to say “Wow, I don’t know, but here’s how to get in touch with someone who can answer that question for you.” It is unethical, it is unjust, and it causes premature weaning.  Worst of all, it causes mothers to feel as if they did not have any control over when they chose to wean their babies. They didn’t – someone told them they had to!

As an IBCLC, a healthcare professional who is specially trained to provide information, assistance, and support to breastfeeding mothers and babies, it pains me every time I hear someone share the reason they were *told* to stop breastfeeding.  It’s frustrating to hear mothers describe poor breastfeeding management practices which led to early weaning, but to hear that someone stopped breastfeeding because someone else did not take the time to find the right answer or refer to an IBCLC – that really gets to me.

You can help – encourage moms you know to seek qualified breastfeeding help if they are having problems and to attend support groups if they are breastfeeding well.  Moms need connections with good breastfeeding support to prevent early and unnecessary weaning.  If they receive poor information or advice, they need a reliable source of information which will help them make an informed decision about when to wean.

It’s super-easy to find a local IBCLC – the websites and both contain Find A Lactation Consultant links. There’s an app called LatchMe (available for Android and iOS.) has a listing service for lactation support providers.

Copyright 2014 Christine Staricka, IBCLC, RLC, CCE

Copyright 2014 Christine Staricka, IBCLC, RLC, CCE



I’m Sorry, Can You Tell Me Again Why You Were Told to Stop Breastfeeding?

For National Breastfeeding Month 2014

Christine Staricka's Blog

Can you repeat that?  I am certain I didn’t hear it correctly.  They told you to stop breastfeeding because of what? You were told not to breastfeed because (insert potentially bad outcome here)?!

Ok, let’s start with this: this is not your fault.  If you and your baby have been the victim of poor breastfeeding information and advice, I highly recommend you visit the website right now for some serious and important support.  You will feel better after reading their incredibly compassionate truths about how women and babies are victimized by The Booby Traps© in our culture and society.

Are you back? Good.  Let’s talk about the true contraindications to breastfeeding (the evidence-based, real-life situations in which breastfeeding is actually NOT recommended by health organizations.)  In the U.S., the American Academy of Pediatrics, the Academy of Breastfeeding Medicine, and the American College of Obstetricians and Gynecologists have put forth…

View original post 718 more words

Breastfeeding in the Real World: Meeting Mothers’ Needs Through Listening

I, along with hundreds of others, will be recharging my professional batteries this week at ILCA 2014 ( #ILCA14) in Phoenix, AZ. I will attend expert lectures, participate in clinical workshops, network with peers from around the globe, examine the latest research, visit exhibit booths of vendors and educators, and arrive home armed with new information and techniques to enhance my IBCLC practice. But what I will actually be doing is strengthening, fortifying, and improving my ability to counsel mothers. It’s really the most important thing we do as IBCLCs. Our field has been amassing facts and statistics, developing hands-on techniques, and creating handouts for years, and the internet and digital media have supported this proliferation of words and data. Fundamentally, though, the impact we have on individual mothers is the lifeline of our work. Without listening and counseling skills, any individual IBCLC will never rise above the other voices in a mother’s world to work in unison with that mother’s own personal breastfeeding goals.

When women become mothers, their identity shifts. The person they previously were moves into the shadows of memory, and the confidence and self-worth they spent years accumulating sometimes follows the old self into the shadows. Women who practice law, perform delicate surgery on animals, teach foreign languages to 12-year olds, or who have successfully mothered multiple other children may suddenly find themselves feeling a loss of control over their ability to perform what they consider a fundamental act of humanity. They may question their ability to reason out solutions to breastfeeding dilemmas even though they have written a dissertation on anthropology. They may doubt their choices on baby care issues even though they have made life-and-death decisions in war zones. They may become angry and irrational when they face breastfeeding challenges even though they are generally even-tempered people who face the world with a smile. These identity shifts make mothers sensitive to others’ opinions, which disempowers them further.

Every woman moves through every pregnancy with her identity, a unique story of where she has already been in life, and she imagines and dreams about what is to come with this new baby. Inside that vision is the understanding that nurturing, nourishing, and protecting her young is her responsibility. Many modern mothers express great trepidation at these responsibilities and display only small flashes of confidence in their ability to perform them. The idea of breastfeeding is, in Western culture, so fraught with controversy and differences of opinion that mothers-to-be can become trapped by feelings of helplessness. Somehow, through the noise, mothers arrive at a vision, be it cloudy or crystal-clear, of how much breastfeeding they want to do.

Mothers’ personal breastfeeding visions range from never breastfeeding to nursing for years, but they don’t always know that on the day their baby is born. Putting a baby to your breast is a visceral and intimate act, and there are women who find they cannot do it at all, while others cannot imagine mothering without the frequent repetition of that act. Truly excellent breastfeeding support persons are skilled at setting aside every bit of their own opinion or judgment and simply providing the information a mother requires to enact her own vision of what breastfeeding means. When performed in a culturally and emotionally supportive manner by a practitioner who is well-informed by evidence and research, the mother’s need for appropriate lactation support is met and she can remain in control of her own vision.

When a mother begins to feel that her breastfeeding reality is not within her control, she loses the ability to follow her vision. Platitudes and patronizing statements about breastfeeding like “Just keep trying, it will get better” and “Isn’t 5 months of breastfeeding long enough for you? If you just wean then ‘I’ can feed the baby, too!” or “You know, that’s why they invented breastpumps/bottles/formula/etc.” begin to sound the alarm in the mother’s head that her vision is possibly out of reach or that it was unreasonable anyway. Likewise, if the mother is provided false or outdated information about normal breastfeeding, she can be derailed quickly and her long-term breastfeeding plan will disappear with her milk supply.

The breakthrough moment in a lactation consult occurs when the mother reveals her true, personal breastfeeding vision. It is not useful to assist her with improving latch if she is actually looking for information about exclusively pumping instead. She cannot possibly succeed at fulfilling her own vision if the IBCLC gives her the help and information he/she assumes she is seeking. (Experienced IBCLCs begin with the assumption that it’s never really the first question the mother asks. It might be related, but that’s not the real reason she called/scheduled a consult/emailed). Without quality counseling skills, the IBCLC might never reach the core questions. Without the IBCLC’s 100% attention and focus, she might not notice the accompanying body language that belies her true feelings. Without setting aside a broad agenda of “helping mothers breastfeed longer,” the IBCLC could easily miss a subtle plea for weaning.

Christine Staricka, IBCLC, RLC, CCE
July 22, 2014

Addressing Breastfeeding Ambivalence

The First 100 Hours©
Addressing Breastfeeding Ambivalence

The First 100 Hours© is a strategy designed with flexibility to encompass even mothers in whom ambivalence or low level of commitment to breastfeeding has been observed. Mothers with low levels of understanding regarding the importance of human milk are more likely to feed formula in the hospital and in the early postpartum period overall, to supplement breastfeeding with formula even after copious milk production has begun, and to wean earlier than mothers who prenatally state an intention to exclusively breastfeed. This strategy has the potential to influence this population of less motivated mothers and to increase rates of exclusive breastfeeding in the hospital, to reduce the number of babies receiving formula while in a NICU or special care nursery, and to increase the duration of any breastfeeding. These are valuable outcomes for the health of mothers and babies, for clinical care providers who struggle to support mothers’ breastfeeding intentions, and for hospitals and birth facilities looking to improve their breastfeeding rates.


Expectant mothers have widely ranging reasons for being ambivalent, neutral, or wary of breastfeeding. Education has historically been the tool of choice to overcome this particular situation. Adult learners require active, kinesthetic learning modalities. What is more kinesthetic than simply supporting their once-in-a-lifetime opportunity to provide their baby with 100 hours of breastfeeding and/or breastmilk?


A mother who has not been informed of the risks of formula feeding or the importance of feeding breastmilk in the first days of life in particular requires thorough education. The message that formula has no health benefits is largely missing from the cultural breastfeeding discussion, and some mothers misinterpret formula marketing messages to mean that formula is actually better than or the same as breastmilk. The First 100 Hours© Strategy proposes to shift attitudes and motivation on the individual as well as the cultural level.

In combination with verbal education, a mother should be experiencing breastfeeding. Assisting a mother with breastfeeding and providing appropriate verbal instructions and encouragement to continue breastfeeding for The First 100 Hours© of life is the most basic and fundamental part of this strategy. A target of 100 Hours of breastfeeding is much easier to envision accomplishing than the “6 months of exclusive breastfeeding” which is recommended by health organizations. Upon reaching 100 Hours, she will then have options: a) continue exclusively breastfeeding for 6 months with an optimally stimulated and protected milk supply, b) discontinue feeding at the breast but initiate pumping to ensure her baby receives only breastmilk for the first 6 months of life, or c) elect to wean completely from breastmilk, having provided her infant the ideal nutrition for the first 4 days of life, including an unparalleled immune system boost, while also improving her recovery process.
For the mother who expresses a deep desire to avoid feeding at the breast, that preference should always be respected and honored. However, she should be provided with appropriate education regarding the importance of a non-breastfed baby receiving breastmilk as its only nutrition.

In cases where a mother states she “only wants to pump and bottlefeed,” education and assistance are crucial to her potential for successfully meeting that goal. Pumping is vitally important, yet largely ineffective at yielding significant amounts of milk during The First 100 Hours©. A mother who plans to exclusively pump milk for her infant for any length of time should be taught hand expression from the time of birth so that she, like the breastfeeding mother, can honor her infant’s feeding cues by expressing milk when she notes hunger cues. She should also be provided education and assistance with using a high-quality breastpump (if available) as soon as volumes of expressed milk begin to increase, or earlier if preferred. A non-breastfeeding mother should still maintain continuous skin to skin contact with her infant, expressing milk into a spoon with baby still on her chest and feeding immediately.

Similar to the widespread promotion of immediate skin to skin contact between newborns and mothers directly after birth, The First 100 Hours© Strategy can reasonably be expected to have positive results on the overall health and well-being of mothers and babies and to have the side effect of increasing the number of mothers initiating and continuing to breastfeed, which benefits everyone.

Christine Staricka, BS, RLC, IBCLC, CCE

June 2014

Happy Mother’s Day!

imageHappy Mother’s Day to all! We would like to take this opportunity to tell you how things are progressing at Baby Cafe Bakersfield.

Since our first drop-in meeting on March 7, we have logged over 100 visits from local mothers. Mothers are coming in with a very broad range of needs: some join their peers for basic mother-to-mother support and encouragement, others come with specific questions about breastfeeding, and many have come in to see an IBCLC – in fact, almost half have had IBCLC consultation or followup via the Baby Cafe. Some have received referrals for other healthcare providers, some needed intervention to save flagging milk supplies, and some have come in for serious problems such as failure to gain weight and poor breastfeeding by an infant born prematurely.

This means that in 2 months, we have provided professional, clinical, documented lactation care to nearly 50 mothers. The need for this service is deep in our community – we always “knew” that, but now we have solid proof.

At our first volunteer training, held prior to the first drop-in, 12 people were in attendance. Since opening, one additional person has been oriented to volunteering at Baby Cafe. Several trained volunteers have not been to any drop-ins at all. A small number of volunteers is providing all of the services.

2 of our trained volunteers are documenting clinical hours toward taking the IBCLC exam. Anyone who is in the process of or has completed their didactic lactation education is eligible to assist at Baby Cafe and document IBCLC-supervised clinical hours. 3 nursing students from Lancaster and 1 RN from Bakersfield have precepted Baby Cafe drop-ins as part of their training and experience. The Baby Cafe is providing another necessary service by offering this opportunity to those seeking to become lactation and birth professionals.

We have received 1 cash donation of $100 and 1 donation of a brand-new infant scale. These donations are from Dr Hitesh Shah.

Referrals to Baby Cafe are coming from Facebook, from discharge packets at local hospitals, from word-of-mouth, from our gracious host and donor of our meeting space, Planet Bambini, and from local pediatricians and OB/GYNs. Almost daily we speak to physicians about the service we are providing and most are glad to hear that it is available.

We have learned that mothers in our community need evidence-based information to take back to their healthcare providers regarding normal breastfeeding, that they are unhappy about receiving mixed messages about breastfeeding from physicians, and that they wish their employers were providing better support for their need to pump.

Clearly the Baby Cafe is a necessary resource for our community. Now we need to reinforce the resources of the Baby Cafe itself in order to ensure we can remain viable and continue helping mothers.

We need 2 things: volunteers and funding. We have reached the point in the season where the weather is severely impacting our ability to hold drop-ins. We knew the hot weather would require some alterations to our location, and application for a grant to purchase cooling equipment has been made, but that process has unfortunately been delayed. Now the temperature on Tuesday and Friday is expected to be 100 degrees.

We simply cannot hold a Baby Cafe drop-in when the temperature exceeds 90 degrees without cooling equipment. It is highly unlikely that the temperature will be 90 or less during the next 4-5 months. We have to purchase cooling equipment. Bakersfield Breastfeeds is willing to advance funds to do this, with the expectation of reimbursement,  and make sure the temporary equipment is in place before Tuesday’s drop-in.

We need to be soliciting donations as soon as possible. Please brainstorm all the potential donors you know. Donations for the Baby Cafe can be made via check made payable to WarmLine, our umbrella organization. Donations are tax-deductible ( 95-3245263 )

If you have contacts who can donate funds, equipment, or even refreshments for our twice-weekly drop-ins, please arrange these donations as soon as you can.

Our need for volunteers is significant. Ideally, at every drop-in there would be multiple volunteers to ensure that mothers are greeted properly, served refreshments, that sign-in sheets are properly completed, that mother-to-mother support discussions are appropriately facilitated, and that the IBCLC is free to provide the clinical care our attendees are requiring.


The reality is that some drop-ins have been chaotic because the few committed volunteers we have are overwhelmed by the number in attendance, plus the IBCLC is strained by the multiple roles she is attempting to fulfill.

We need volunteers with all levels of commitment to this project, including people who have no formal breastfeeding training, people who do have lactation education and/or experience, and IBCLCs. We have an online calendar where volunteers can sign up for only the days they are available. We can schedule a brief orientation for any interested persons as soon as possible to facilitate expanding our volunteer base.

In conclusion, we would like to say that there are over 100 Baby Cafe drop-ins overseas, and there are an expanding number of Cafes here in the US. Many of the US Cafes, none of which are in California, are receiving funding through WIC or a hospital. Because we do not have a permanent funding source, it is ALL of our responsibility to the mothers of our community to ensure we maintain this resource through our fundraising efforts and volunteer efforts at the drop-ins.  We can think of no better way to honor mothers than to commit to being part of Baby Cafe Bakersfield.  Thank you for all that you do every day to support mothers and their families through excellent breastfeeding care!

On behalf of Baby Cafe Bakersfield, Central Valley Lactation Association, and Bakersfield Breastfeeds,

Christine Staricka, BS, IBCLC, CCE

Adrienne Guirguis, IBCLC, CCE

©2014, Bakersfield, CA

Happy Baby

Shining a Light on In-Hospital Breastfeeding Support

Supporting exclusive breastfeeding from birth to discharge requires a very specific skillset. Much of what is written online today for lactation professionals skims over this critical juncture of a mother and baby’s breastfeeding journey.  There are model breastfeeding policies, protocols, guidelines, etc. There are recommendations for physicians caring for newborns and postpartum women.  There are nursing protocols to help nurses keep their patients safe as they recover.  But for those whose specific duty it is to ensure breastfeeding is successful, the instruction manual is broadly painted and depends largely on the institution in which they work.  The daily objectives can vary, the support of other staff can confound the practice, and the long-term recommendations for babies to be exclusively breastfed for at least 6 months can easily be lost in the chaos of the lightning-fast discharge process.  Keeping it simple is always the best course, and applying The First 100 Hours© strategy ensures consistency among staff and patients.

– Consider each dyad from the perspective of how many hours postpartum they are.  By thinking specifically about how many hours it has been since the birth, rather than how many days or nights it has been,  you can form an estimate or vision of what *should* be happening right now.

– Know the indicators and assess the dyad thoroughly.  What is happening with their breastfeeding situation, what has already happened, what should be coming up next?

– Provide appropriate clinical care and education based on the exact timeframe of the dyad.  A 6-hour old baby who hasn’t latched needs far different clinical care than a 24-hour old who hasn’t latched.  A dyad being discharged home at 28 hours postpartum needs different teaching than a dyad being discharged home at 56 hours and in Stage II Lactogenesis.

Let’s play with the strategy here with some fictional examples:

– Dyad 1, the Washingtons: still in postpartum unit, 50 hours old, baby born at 39 weeks + 5 days after induction of labor and with epidural pain management.  Now exhibiting a high intermediate jaundice level and physician is recommending supplementation after every feeding.  To this point, baby has been exclusively breastfeeding.  Mrs. Washington reports to nursing staff that breastfeeding is going well, she is experienced (nursed her previous baby past one month) and denies pain with latch or nipple trauma.  When I focus on this dyad through my First 100 Hours© lens, the first thing I think, without knowing any other information, is that at this time there is a strong likelihood that Mrs. Washington is in Stage II Lactogenesis.  When I speak to her, that is the primary factor I want to research because it will determine whether she will be supplementing with her own milk or with formula.  If she has copious amounts of colostrum or if her breasts are already feeling fuller or (hopefully not!) engorged, these factors mean she is unlikely to need to interrupt breastfeeding or breastmilk-feeding.  *(In facilities where policies or physician practice dictate automatic additional feeds with formula in cases of jaundice, The First 100 Hours© strategy addresses the importance of teaching the mother to protect and manage her milk supply until she can resume exclusive breastfeeding.)

– Dyad 2, the deOliveiras: 9-hour old, healthy baby born at 38 weeks in a very fast labor and birth process with minimal pushing effort, has breastfed 3 times since birth, has not had a bath yet, and has had 2 stools.  Baby is sound asleep, skin-to-skin on his mother’s chest.  What do we need to do to help? Nothing.  They’ve got this.  There are No Indicators of Problems here.  When this baby is ready, he will easily let his mama know.  If he were wrapped in 3 receiving blankets and being passed around to visitors, it would be wise to intervene and resume skin-to-skin contact.

Dyad 3, the Garcias: a 35-week, 5 lb 10 oz girl born by cesarean due to breech presentation, now 80 hours old.  Baby has mild jaundice, has lost 9 oz since birth, and mother has had difficulty waking her and keeping her awake during feeds.  When you ask Ms Garcia, she says her breasts do not feel “different” yet; you can see her swollen feet sticking out from her blankets and her hands are so puffy she has trouble changing the baby’s diaper.  She started giving the baby formula every 3 hours yesterday because she knew the baby was not eating enough, and she has been breastfeeding as often as the baby is willing. My first thought: if her breasts don’t feel different, are her areolas puffy like her hands from all the excess fluids? Or is she experiencing Delayed Onset of Stage II Lactogenesis? Either way, her milk supply needs intervention quickly.  If we don’t address it now, it may be compromised permanently, rendering her unable to ever fully breastfeed if that is her intention, or creating complications for her such as plugged ducts or severe engorgement, mastitis, or even abscess.

Now that we have examined some narrative examples, let’s look at some documentation.  These forms were developed as part of The First 100 Hours© strategy to facilitate thorough, efficient assessment of the breastfeeding dyad within or just after the first 100 hours postpartum.  As above, the dyads are not based on real patients but represent common situations recognizable to any hospital-based IBCLC in 2014.

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This type of documentation tells a story.  In this example, the story is that breastfeeding has been interrupted by non-medically indicated formula use, and the mother has not even reached Stage II Lactogenesis yet.  This mother needs a great deal of education and support at this point, an observation of breastfeeding with specific attention to helping the mother to observe signs of milk transfer, and a really good follow-up plan.  This mother can likely resume exclusive breastfeeding rather quickly – some timely teaching may just be what motivates her to do so.

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Here we read the story of Jennifer and her 4th child, Jayden, who are experiencing breastfeeding difficulties even though she has plenty of experience.  Note that in this example, Jennifer and her son have passed the First 100 Hours© landmark already.  She knows that something is not right, and the fact that she is only able to pump right now when she really intended to breastfeed tells us that this dyad needs a face-to-face consultation as soon as possible.  It’s really helpful to have the information about how things unfolded during this baby’s first days of life because it tells the story of how much this mother already understands basic breastfeeding management.

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Ooh, look, an easy one!  The biggest challenge we can predict for Tameika is avoiding the engorgement she experienced with her previous baby.  We’ll give her lots of tips on preventing engorgement, and we’ll talk about exactly who to call if she runs into a problem.  Most of us who work in hospitals wish more of our patients were like Tameika and Ashantae – straightforward, uncomplicated, basic breastfeeding management.

However, a lot of our time is actually spent with dyads like the next one:

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These cases can be overwhelming.  When we have a really complicated case like this one, it’s easy to think: where do we even start?  Well, when the relevant information is listed out like a story this way, it’s a bit easier to go step-by-step through all of the interventions this situation demands.  Since this mother is calling on the phone to get help, the first priority based on all of this information is to determine when, what, and how the baby last ate.  Once we know the baby has recently had a feeding, we can begin addressing the gaps: Alexis needs a really specific plan for keeping her baby feeding regularly and for regular milk expression, and she needs to understand her baby’s individual needs as a Late Preterm Infant who has not been feeding well overall since birth.  Finally, Alexis needs to know who will be there to help her in her breastfeeding journey, and that it’s not over just because she came upon some early challenges.

Caring for breastfeeding dyads in the hospital during the first postpartum days is really challenging work.  Hospital-based IBCLCs as a group are accustomed to not getting feedback from the majority of their patients.  The relatively few mothers who do call us back with questions or come back in for more help are the ones who educate us, inspire us, and strengthen us for our future patients.

Copyright 2014 by Christine Staricka, BS, IBCLC, CCE

Influencing Breastfeeding Rates on a Local Scale

Happy BabyWelcome home from the California Breastfeeding Summit! I was unable to attend, but I have heard reports of excellent communication and interesting educational topics. According to my colleagues who were there, the vibe was very positive and uplifting, as is usually the case when lactation professionals meet!
My colleagues and I have a meeting scheduled this week to work on our future plans based on everything they heard and absorbed in Sacramento. Many of you probably already have something similar coming up soon. One of the topics we have on our agenda is the continued application of The First 100 Hours© when we are working with moms in the hospital and in multiple outpatient settings.

My Bakersfield Breastfeeds co-founder, Adrienne, and myself have been fortunate enough to see our reach expanding over the past year to encompass more mothers outside the hospital experience. We are primarily hospital-based IBCLCs, but now we also see many more moms outside through support groups (including the soon-to-be-opened Baby Cafe© Bakersfield!) and outpatient contacts. Here’s what we know: the truth is that we all can work together to improve breastfeeding support all along the spectrum. Families have a right to quality care from the moment they learn their family is growing by 1 (or 2,3,4…:) Anyone who attended the Summit knows that new postpartum guidelines for hospitals and birth facilities have been implemented and breastfeeding rates will be scrutinized even more carefully in the coming months and years. Here are some steps you can take right away to create momentum.

– Start by scrutinizing your breastfeeding rates yourself. Use your unique perspective to look at all the angles. We spend a lot of time breaking down our statistics for “Mixed/Personal Choice” in our workplace. We look at those numbers constantly and watch for trends which influence them – things like changes in staffing, assimilation of nurses having just completed Birth & Beyond California, altering the way formula bottles are accessed by nurses, changes in hospital policy regarding informed consent for formula use, which pediatrician is on call, etc. These types of factors cause peaks and valleys in the number of breastfeeding mothers who are also using formula without medical indication. Numbers don’t lie; numbers tell a story. Find the story and become the storyteller in your sphere of influence.

– Ask for really specific information from administration when they start pushing for changes in breastfeeding rates. “Great, I have lots of ideas for things we can do in the short- and long-term. What kind of timeline were you imagining? What’s our budget? How many people can we train? Will we be making facility-wide policy changes?” There’s no sense beginning a project without knowing the scope. If the sky’s the limit, you have your work cut out for you! If your have virtually no budget but lots of room to change policies and protocols, that’s your focus.

– Participate in your local breastfeeding coalition! The collaboration is useful to the community, allows you (and, by extension, your workplace) to ride the wave of momentum created by others, and provides you an outlet for the type of professional de-briefing and support system necessary to maintain forward movement in the field of lactation.

If you are not in a position to do any of those things because your main function is to help mamas and their babies, but you still want to do more to advance breastfeeding, we encourage you to spend time teaching others.  Try sharing your style with others in your workplace who have the honor of helping breastfeeding moms. Make sure the nurse who refers you to a patient follows you into the room to observe and listen. Invite them to join you for a interesting lactation training or a coalition meeting. Ensure that your co-workers understand what you mean when you use lactation jargon like “medical indication for formula” or “supplemental nursing system.”  Reach out to say thanks to a pediatrician who has referred some dyads to you for consultation and keep the conversation about breastfeeding going.  Stop by the local “ultrasound boutique” or maternity wear store and make sure they have breastfeeding resource lists for pregnant moms.

We can’t wait to see what 2014 brings for the field of lactation!  We know we will be educating professionals, some of whom are already planning their IBLCE exam dates, we will be meeting many new moms and their babies at the Baby Cafe© Bakersfield, and we will be sharing The First 100 Hours© all along the way.  Good luck getting all your new ideas going!  Let us know how things are working for you!