Part III – Goldi-Nurse and the Three Babies: What if Milk Supply isn’t Just Right?
Gloria Dudney, RN, BSN, IBLC, RLC
Gloria has been practicing maternal/child nursing for 30 years. She has experience in levels 1 & 2 newborn nurseries in Texas and Tennessee. She served 24 years at a private pediatric practice, where she launched the region’s first primary care lactation clinic. She now serves as director of lactation for East Tennessee State University Health.
RACHEL AND SOPHIE – THE NEXT CHAPTER (IN THE AMERICAN BREASTFEEDING FAMILY STORY)
In the first three parts of our blog series, we explored the baby getting too much breast milk, the baby not getting enough breast milk, and the process of preparing during pregnancy for a breastfeeding journey with just the right amount of breast milk. In our fourth and final installment, we will discover what happened to Rachel and Sophie and how their story can impact other breastfeeding families.
What happened to Rachel and Sophie?
Rachel–our 38-year-old mother with multiple lactation risk factors, including a history of breastfeeding difficulty—was able to deliver Sophie via vaginal birth after a caesarian. However, due to a cluster of episodes of elevated blood pressure, she was induced at 37.4 weeks gestation. Sophie’s weight was appropriate for gestational age, and she did not experience blood glucose instability following delivery. During her final weeks of pregnancy, Rachel used a stuffed animal to practice several alternative breastfeeding positions, such as the reclining positions shown on naturalbreastfeeding.com. She sensed that Sophie’s attachment to the breast was much better than Connor’s regarding the comfort and effectiveness of milk removal.
In the first days post-delivery, Rachel also hand-expressed colostrum following each of her breastfeeding sessions with Sophie to provide extra milk for her and extra breast stimulation, which she hoped would maximize her milk production this time. Her milk transitioned from colostrum to mature milk sooner than it did with Connor, and the amount of infant formula she needed for supplementation during Sophie’s two days of elevated bilirubin levels was also much less. This time she did not see the limited formula supplementation as a failure but as a bridge to more breastfeeding.
Rachel shared that her mind and body were in a much better place this time and that the results were equally better—now, at three months post-delivery, Sophie’s formula intake is consistently less than 8 ounces per day. She credits her obstetrician for referring her to a lactation consultant for prenatal consultation and receiving individualized care planning based on her risk factors. She added that she hoped her devastating journey with Connor could be redeemed by sharing her experience with Sophie. She encourages other mothers to trust their instincts and to see their “breastfeeding success” through an individual lens.
Why did Rachel not have different support with Connor?
Many roads have led to our current location. However, one powerful pathway is that our regulatory bodies adopted breastfeeding exclusivity monitoring policies before adequate studies were available regarding the possible unintended effects on breastfeeding families.
In their commentary publication in Pediatrics in May 2011 and thoughtful response to letters to the editor in November 2011, Drs Valerie Flaherman and Thomas Newman provide not only accurate prophecy but also prescient insights regarding the likely unintended consequences of “regulatory monitoring of feeding during the birth hospitalization” without adequate studies prior to implementation.
How do we reimagine policy and increase access to knowledgeable support?
The time is right for a paradigm shift from exclusivity-focused policies to duration-focused policies. Perhaps, as Rebecca Mannel suggests in her landmark publication in the Journal of Human Lactation, we can “improve patient safety and outcomes” by “defining lactation acuity.” Most areas of healthcare have risk-stratified their populations for their safety. For example, high-risk pregnant mothers have special physicians, special treatment plans, and sometimes even special hospitals in which to deliver. Why would we then not extend that special care to their breastfeeding journey? Many patients and healthcare professionals are calling for the breastfeeding family to benefit from individualized and risk-stratified care that supports the maximization of their milk production and underscores the importance of shared decision-making.
One of the keys to Rachel and Sophie’s breastfeeding success was having access to the right help at the right time. Due to the long-term impact of the first few days post-delivery, the optimal time to educate and prepare for breastfeeding is in the antenatal care setting. It is unfair and unrealistic for both the patient and the inpatient healthcare professional for the entire burden of breastfeeding education to fall on the brief inpatient interaction. However, lactation consultants practicing in the outpatient environment have historically not been guaranteed universal insurance reimbursement. In many cases, the breastfeeding families who need them most have been robbed of guidance before and after their hospital stays. A handful of states, most recently in Tennessee, have passed legislation describing lactation support services as a permanent perinatal benefit. As a result, Tennessee Medicaid now reimburses lactation healthcare professionals for outpatient care–both in the prenatal and postpartum seasons. They further removed barriers to care by covering services in the clinic via telehealth and home visits.
Rachel and Sophie benefitted from proper continuity of care. This care can be replicated. Risk factors can be accounted for and planned for. Breastfeeding success for the at-risk dyad can be redefined as “doing as much as you can for as long as you can.” Furthermore, perinatal healthcare professionals can be equipped with the knowledge and skills to assist breastfeeding families in accomplishing their goals. The defeats of the past are in the past. Like Rachel and Sophie, we can journey to a victorious future!
Key concepts from the series
- Too much breast milk production can be just as distressing for infants and their parents as not having enough.
- The well-established long-term maternal and infant benefits attributed to breastfeeding and breastmilk are only enjoyed if maternal milk production is built and protected during the brief calibration phase of lactogenesis II.
- Maternal stability in terms of emotional health and a sense of self-efficacy is vital to breastfeeding success.
- Perinatal healthcare professionals have the responsibility to be educated on emerging evidence regarding lactation risk factors as well as the privilege of walking alongside new families to provide knowledgeable care as they navigate their breastfeeding journeys.
- Maternal feelings of defeat can be transformed into victory by defining breastfeeding success for at-risk families as “doing as much as you can for as long as you can”!
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