Ask Nurse Wendy


Ask Nurse Wendy

What is an IBCLC and why they are the preferred provider in lactation?

In every medical field there are specialists. If you had a strange looking mole you would be referred to a dermatologist. If you were diagnosed with diabetes, you would be referred to an endocrinologist. If you were diagnosed with cancer you would be referred to an oncologist. However, not many people, not even physicians who work with mothers and babies, know who to refer you to when you’re struggling with breastfeeding.

An International Board Certified Lactation Consultant (IBCLC) is a healthcare professional who specializes in the clinical management of breastfeeding. An IBCLC is considered the Gold Standard in lactation education and clinical management of breastfeeding. IBCLCs are the only healthcare professionals with an internationally recognized credential in lactation, which means they could work as an IBCLC in far-away countries like Germany or China because babies are breastfed essentially the same way as they are here in the United States. In terms of breastfeeding education and management, no other initials come close, not even the initials of MD.

IBCLC’s work in clinics, hospitals, and private health practices. They sometimes have backgrounds in other medical fields such as nursing, dietitians, speech pathologists and even physicians, but you don’t need a medical background to be an IBCLC. Prior to me becoming a board certified and registered lactation consultant (IBCLCs are the only lactation consultants which are registered and can use the initials RLC after their name) I needed hundreds (non-medical persons need thousands) of supervised hours prior to sitting for an exam. The exams/boards given to become a Registered Nurse(RN) are only taken once in our lifetime, whereas IBCLC’s have to continue to sit for boards every 10 years. They have to PROVE they are current in breastfeeding education and management.

Here is even better news when choosing an IBCLC to assist you with breastfeeding: Private health insurance companies now recognize the initials IBCLC and are reimbursing and covering lactation services included in The Affordable Care Act (ACA).

How do I assure a good milk supply from the start?

Getting a thorough history of the number and frequency of feedings in the days to weeks immediately following birth reveals a really good picture of what the milk supply should be when meeting with a new patient. Most moms have heard lactation professionals use the term, Supply & Demand, when speaking of milk supply regulation, but many do not explain why the demand equals the supply. To put it simply, if there is no demand made of breastmilk removal or it’s been demanded so poorly by a bad latch or too infrequently, then as a result, there will be limited or no supply.

Here is my “Wendyism” which is even simpler: The first days to first few weeks following birth, every time a baby or pump comes to the breast “an order” is placed. Just like any good food establishment, if they consistently get slammed with orders, the management will accommodate for this increase in business by hiring more staff to meet demands. Therefore, the more orders a baby (or pump) places at the breastaurant in the early postpartum days, before milk supply is established, determines how much milk will be available (supply). However, your supply won’t last long if the milk made from your breasts isn’t removed effectively and frequently(> 8 times a day).

Obtaining an effective latch and effectively removing milk frequently from the breast are the most critical components to assuring your milk supply is plentiful. Some examples of conditions that can cause a “poor latch” are from improper positioning or a tongue-tie where milk is not being removed adequately. This is equivalent to placing a “half-order”. If there are too many half-orders placed, then your milk supply is put at risk. Additionally, your baby may begin to show signs that they are not receiving enough milk.

The best way to assure your breastaurant is on its way to being fully staffed is to be seen by a member of the lactation healthcare team. If you are struggling in any way, consult the help of an IBCLC or other lactation professional. This could not only save your fragile milk supply, but also save your sanity.

When Can I Begin Pumping?

Moms who are doing a good job removing milk while breastfeeding often think more is better.  However, demanding too much too soon could communicate to your breasts the wrong message and cause the following problems:

  • Oversupply– this can cause forceful let-downs and feedings that are too short. I don’t mean to imply the volume transferred isn’t enough because this is not usually the case. Instead, I mean the baby is still wanting to satisfy their “high suck need”.  Therefore, despite the adequate meal, baby will be fussy after feeding instead of content, or sleepy like a newborn tends to be after nursing.
  • Breast is too full after feedings – baby often refuses opposite breast which results in milk stasis.
  • Increased risk for recurrent plugged ducts and mastitis due to milk stasis.

Refrain from pumping until after the first growth spurt (around 14-21 days) unless you’re engorged, it’s medically indicated to supplement your baby, there is some mother-baby separation, or you have to return to work/school right away.

Don’t worry, you will not get bored in the first few weeks breastfeeding 8-12 times per day. Instead, try to relax, rest, and get to know your new baby!

What Are The Best Breastfeeding Holds?

The four newborn breastfeeding holds are: laid-back, football, cross-cradle, and side-lying. Each one is good for a different reason. Try them all and determine which one works best for you. These are optimal until the baby can independently control his head, allowing the mother to be in control. I tell my moms to, “Place the baby across from the dinner table” in a nose to nipple start position. This will assure an asymmetrical latch.

Once head control is present you can move into a cradle-hold, continue one of the previously mentioned holds, or make up your own! Hang in there mama, when it’s your first baby or it’s been a while since you last breastfed, there is a learning curve which takes place. The silver lining is that once a baby becomes experienced on the breast, they will latch and re-latch themselves independently if the position isn’t right for them.

When Can I Begin Pumping?

Moms who are doing a good job removing milk while breastfeeding often think more is better. However, demanding too much too soon could communicate to your breasts the wrong message and cause the following problems: Oversupply– this can cause forceful let-downs and feedings that are too short. I don’t mean to imply the volume transferred isn’t enough because this is not usually the case. Instead, I mean the baby is still wanting to satisfy their “high suck need”. Therefore, despite the adequate meal, baby will be fussy after feeding instead of content, or sleepy like a newborn tends to be after nursing. Breast is too full after feedings – baby often refuses opposite breast which results in milk stasis. Increased risk for recurrent plugged ducts and mastitis due to milk stasis. Refrain from pumping until after the first growth spurt (around 14-21 days) unless you’re engorged, it’s medically indicated to supplement your baby, there is some mother-baby separation, or you have to return to work/school right away. Don’t worry, you will not get bored in the first few weeks breastfeeding 8-12 times per day. Instead, try to relax, rest, and get to know your new baby!

 

How Long Should I Pump For?

Pumping is one of our customers’ favorite times to eat Boobie Bars! If you are given a breast pump for any medical reason during the hospital stay, the goal of pumping is to stimulate the breast. Therefore, you should pump for a specific timeframe such as 15-20 minutes. Once your milk supply has become established you can customize that number more precisely to YOU. Stop pumping, 1-2 minutes after you see the last drop. The reason why you don’t just turn off the pump when you no longer see milk is because a typical feeding session includes 2-5 let-downs. You can actually observe this when pumping. Moms become very good at learning how many let-downs they actually have. A let-down happens when you can see the milk spraying into the back of the flanges. The largest let-down is typically your first one. When you observe the milk returning to a slow drip, you are in-between let-downs. This cycle will continue and the number of let-downs vary by mother and time of day. Often, the milk dripping is so slow it even stops and many moms mistakenly stop pumping. By keeping the pump on for an additional 1-2 more minutes, you are waiting to see if there will be another let-down which enables you to, not only obtain more milk, but also increase supply. To increase your supply even more, use hand massage and express your breast before removing your flanges. Stay behind the flanges, being careful not to break the flange’s seal. Getting 2-5 milliliters more consistently will add up not only to more milk volume, but will also increase your overall supply. Typically if you demand more, your supply will follow. Want even more milk? Try Hands on Pumping by hand expression (HE) following the removal of the flanges. Pumps often leave behind milk which mothers can get more effectively by using their own hands. By incorporating hand expression after pumping with an electric pump, moms can obtain close to or even equal amounts to what was already collected. Watch this video to learn more about Hands on Pumping. Learning how to hand express has its benefits in the early colostrum days too when electric pumps are often insufficient in collecting the milk because the colostrum is so thick.

Do I Still Need To Pump When A Partner or Caregiver Gives A Bottle?

Yes! Pumping is especially important initially when your milk supply is still being established and it is not yet regulated. Some moms can have mixed feelings towards bottles in the first few weeks while establishing their milk supply. They are so pleased to hear they are producing enough milk, yet they feel “trapped” because all the feedings are their responsibility. Many tired moms have this fantasy that if they have their partner give a bottle of expressed breastmilk or formula they will get a break. However, this isn’t exactly the break you imagined. In the first few weeks when your milk is in overdrive, you cannot afford a full break because you still need to sit down to pump or hand express while the baby is getting that bottle. Remember your body produces milk based on the demand. Skipping even one feeding without pumping in the early days of lactation can lead to uncomfortable fullness, engorgement, plugged duct(s), low grade fever, and can lead to a decrease in supply! That’s right, giving bottles too soon and not emptying your breast will reduce milk production. Better solutions to protect you milk supply: Try the side-lying hold. Lying in bed allows for some extra time to relax and rest. It’s what those of us who work with babies like to call a “Babymoon”. You Honeymoon with your spouse and Babymoon with your baby! It saved me and saves the sanity of so many of my moms, especially during the night. Ask for help with the household chores and childcare of other children. By enlisting the help of your support system, you will find more time to relax and breastfeed so you can establish your supply. Sadly, a mom taking time off from life to breastfeed post-partum isn’t the norm like in other countries and cultures where the new mother is waited on hand and foot so that she may recover from childbirth and take care of the needs of just the newborn. Consult with an IBCLC or other trained lactation professional and request a home visit. She can assess you feeding, your environment, and can make suggestions specific to your individual needs to help you feel more rested. Half of my home consultations include teaching and demonstrating the side-lying feeding position, assisting moms to relax more while still caring for their newborn. This is especially helpful during growth spurts.

When Can I Introduce Bottles?

This answer has so many variables, but in general when speaking about a healthy term baby who is latching well, I say you can introduce bottles THREE weeks or AFTER the first growth spurt which happens around two weeks. Since the goal of the newborn is to learn to breastfeed and the goal of the mother is to learn how to breastfeed (plus have her milk removed regularly), bottle-feeding before or during any growth spurt would cause an interruption in nature’s plan. Your supply could not only suffer, but it could take some time to recover or not recover at all. The early weeks of lactation set the precedent for the volume of breastmilk that will be available in the coming weeks. Have you heard the term supply and demand? Well, I like to say demand and supply, because that’s how our bodies know how much milk to make. Milk production is so individualized. Therefore, I recommend to exclusively breastfeed until after the first growth spurt is complete (14-21 days) and/or the milk supply has been established. The purpose of the initial growth spurt, which is comprised of frequent cluster feedings (sometimes 14-20 times per day) for 2-3 days, helps drive the demand and establish your supply. By offering bottles before this time, it could make your baby demand your breast less and would be catastrophic for your milk supply. In my opinion, it is a big risk to take. Encouraging your spouse/partner to support you in breastfeeding is crucial since studies show that mom’s who do not have a supportive partner will wean earlier than those moms who have a supportive spouse/partner. Try to assure them they can still bond with their newborn by participating in other activities besides feedings, such as skin to skin (kangaroo care), giving the bath, baby-wearing, and assisting in changing the countless diapers. Reassure your partner that in baby’s first year, there will be plenty of time for them to bottle feed, but establishing your milk supply is the highest priority during those first few weeks after delivery.

How Do I Begin To Build My Freezer Stash For When I Return To Work If I’m Always Breastfeeding?

This is one of my most commonly asked questions at my weekly breastfeeding support group. How soon your baby’s caregiver needs this milk stash will determine how aggressive you have to become in saving milk.

Remember: Baby comes first, pump comes second Mistakenly, moms try to pump in-between feedings, but this can backfire since babies’ hunger doesn’t always follow clocks (or a schedule). Instead, pick 1-2 feeds and pump immediately following breastfeeding. Expect to collect less volume since you just fed. But by doing this consistently, over the next few days to weeks, you’ll see how it adds up quickly without disturbing your breastfeeding relationship.

I suggest pumping after the first one or two morning feeds when milk is plentiful from the extra dose of prolactin that happens at night. If mornings are too busy for you, pumping after one morning feeding and after the last feeding before you go to bed will have you building your stash in no time! Single pump on one side and breastfeed on the other Moms who typically only feed on one breast per feeding can do this as a way to collect expressed milk easily. Ideally, latch the pump on first and try to go hands-free by using a bra or tank to hold the flange on the breast. That way, you can still breastfeed on the opposite side as usual.

If hands-free pumping is not possible, then latch baby first, followed by the pump, and hold one in each hand (like a mother who breastfeeds twins). Football hold works nicely with this technique. Feel free to switch the baby to the side that the pump was just on because the breast is never truly ‘empty’ and baby is more effective than a pump at getting the milk out. Older baby who sleeps through the night already ADD a “feeding” or pump session over time. Example: if your 7 month old always sleeps from 8 P.M. until 6 A.M., sit down and pump right before you naturally go to bed around 10:30 P.M. “Feeding” the pump each night with this additional pump session won’t disrupt the nursing relationship and will help you find the time to make milk to store for future separations.

Are Lactation Consultations and Breast Pumps Covered by Insurance?

Yes, private or commercial health insurance carriers now cover lactation support. The Affordable Care Act (ACA) was signed into law in 2010. The ACA requires health plans to cover breastfeeding support and supplies. Unfortunately, although the law has been in effect since August 1, 2012, insurance carriers lag behind in adding lactation consultants to their “network” of providers. I have been turned down to be added to a few networks because they state that I’m not a physician. Ironically, these companies have both massage therapists and acupuncturists “in-network” but NO lactation consultants! Seeing a lactation consultant who is out-of-network could cost the mother more if she has a higher, unpaid deductible and/or co-pays which needs to be met prior to lactation services being covered for seeing an out-of-network specialist. Luckily, there are a few health insurance carriers which have embraced the ACA and welcomed IBCLCs (the gold standard in lactation education being recognized by insurance carriers).

Facts and Tips for obtaining lactation consultations through insurance

HMOs/Kaiser Healthcare Plans

Lactation visits are covered by law. However, you must receive pre-authorization from your physician/mid-wife office prior to seeing an IBCLC. This gets tricky since when a mother reaches out for the assistance of an LC, she usually needs immediate help. The preauthorization process can take up to 2 weeks and is not guaranteed since the ICD codes the physician orders have to match the LC’s ICD codes who you request to see. It’s helpful for the LC to call the doctor’s office and make sure the codes will match prior to the office submitting it to avoid the claim from being denied. Because the early post-partum days are critical to establishing supply and making breastfeeding a success, I have had some patients pay me out of pocket and then submit the claims to their HMO after their consultation with approximately a 60% success rate. Kaiser, the nation’s largest HMO has in-house LC’s for their in-patients and out-patients therefore, they will not cover or reimburse any outside IBCLC visit.

Medicaid(Medi-cal for California)

These plans are excluded from paying for lactation services from a private practice IBCLC. A few doctor’s offices who see a high volume of these moms have an in-house lactation consultant and will submit the bill for lactation directly to Medicaid(cal). Unfortunately, these practices with in-house lactation are few in numbers. To help fill the gap in lactation services with our nation’s poorest, WIC offices offer some assistance by training and staffing their offices with breastfeeding peer counselors. Since the education and advice can vary without board certification, the help is better than nothing, but not always ideal since a good percentage of breastfeeding difficulties need a higher level of assessment and hands-on treatment. For instance, in Southern California, the WIC IBCLCs have to see patients from multiple offices and, due to policies, cannot perform “hands on” lactation care.

Tricare

The military’s largest health care insurance carrier, just added lactation services and pumps to its services covered. However, the law precedes the plan on how they will implement it. Tricare is suggesting for its nursing moms to save their receipts and to submit for possible reimbursement. To this date, they have not added any in-network private practice IBCLCs to their “network” of providers. Therefore, most military moms I see in my practice pay out of pocket to see an outpatient IBCLC.

 

Will the IBCLC submit the claim or do I?

More and more LC’s with large private practices are submitting the claims for the moms. 98% of my practice is PPOs under the ACA. This is great news for moms, but this method is still not fool-proof yet. It gets tricky since we do not have access(we don’t have time to call before seeing each mom) to know what each insurance plan will pay(it’s not universal with the carriers it’s dependent on your employer’s health care plan), if you have unpaid deductibles, co-pays for specialist etc. Therefore, most LC’s cover their time and will refund the payment/deposit partially of fully after the insurance company responds to our claims. Otherwise, the standard it still to pay in full at the time of service and submit the receipt known as a superbill on your own.

 

IBCLCs located in physician offices or outpatient clinics

These visits may require a co-pay just like when you or baby go see a physician/NP/midwife. If the LC is employed by the office, the medical office will bill your insurance directly. If she has been hired as an independent contractor and works independently she may want payment in-full and provide you with a superbill or she could submit the claim herself.

 

Call the Human Resource Department of the employer who provides the health insurance

If you are told you/your partner’s employer opted out of the ACA and does not include lactation services notify the HR person of this. On the two occasions this occurred the HR person had no idea and had it resolved immediately. They innocently did not know their insurance salesperson excluded lactation benefits. The squeaky wheel gets greased!

 

Call ahead (before baby is born)

Having one to two IBCLCs picked out prior to delivery who are in-network can be not only a time saver, but a stress saver! Call your insurance provider and ask who they have in-network. If they say no one, then ask them under the law will they provide you with coverage after your standard out-of-network deductibles are met.

 

Use your flex spending accounts(FSA) to pay for lactation services & supplies!

Check the website for your specific FSA for exclusions to the law(ACA), but I have always found every FSA credit card to accept my services and any missing pump parts. Don’t have a credit card preloaded with your pre-taxed dollars? No problem, ask for a receipt and you can still submit on your own to your FSA to cover the cost, saving you money out of pocket.

 

Turn in any Superbills!

If the LC you end up seeing takes full payment at the time of service, but gives you a superbill for you to submit the claim on your own, do it!! I have had patients whose insurance companies told them on the phone when they inquired ahead of time they would not get anything back, yet they received 1/3-1/2 of what they paid. It’s always worth a try!

 

Some insurance providers limit the number of visits or they expire when your baby reaches a specific age.

The best coverage I have seen is unlimited visits with an IBCLC, some limit to six visits, some say the consultations won’t be covered after the baby reaches six months of age. Again, call ahead and learn your plans “rules” to save you a lot of stress. Call your insurance to get details on which breast pump brands are covered and how to be reimbursed.

If none of these suggestions will work for you in your area find a local breastfeeding support group or Le Leche League (LLL) meeting to get the support you need.

 

I Think I Have a Clogged Duct…

How can I identify a clogged duct? Clogged milk ducts, which can lead to mastitis, can be very uncomfortable and painful. In a lactating mom, the hormones responsible for milk production never sleep! Therefore, you must keep milk moving by frequent breastfeeding or pumping.

Appearance of a clogged duct: Tender or painful hardened lump(s) or area could appear reddened, swollen, and feel hotter than the surrounding breast. Usually affects only one breast. Pain is lessened after nursing or pumping. Common Causes: Skipping feeds, waiting until full or engorged before emptying, decreasing frequency of feeds (baby begins to drop nighttime feedings), delatching too soon and not “emptying”, or sleeping in a position (on your stomach) smashing your breasts.

Lifting and placing your tight bra/clothing on top of the breast while feeding/pumping (think what happens when you drive over the garden hose while it’s flowing with water). Instead, lift your breasts out of any non-nursing bras and tanks being careful not to cut off any milk flow. Wearing a push-up bra – whether you’re a lactating mom who has boobs for the first time or you’re wearing a push-up bra for that certain blouse, you may find yourself with a plugged duct. Instead, choose a nursing bra or other support garment which allows the breasts to lie more naturally.

Nipple Bleb (Milk Blister) is present and blocking a nipple pore. An undiagnosed tongue/lip tied baby who is not emptying the breast completely during feedings.

Oversupply Treatment: Since the root cause is most always milk that gets left behind, the treatment is to simply get the milk out! Frequent feeds, heat before feedings with massage, cool compresses between feedings with lymphatic massage, thorough emptying by pump after feeding (oversupplyers: do not worry about creating a worse oversupply, this milk needs to get out or it will grow bacteria). If you have trouble identifying the cause or do not know how to treat a clogged duct, do not delay! Contact an experienced International Board Certified Lactation Consultant (IBCLC) or lactation professional in your area who has experience locating and treating plugged ducts. She could save you from getting mastitis, a breast infection, which presents with flu-like symptoms.

 

Do I Need to Give up Coffee While Breastfeeding or Exclusively Pumping?

It is perfectly fine to consume coffee while breastfeeding, so enjoy a cup of Joe! Caffeine is like the majority of other medications – the amount in breastmilk which gets absorbed into the baby’s gut which further reaches their bloodstream is so minuscule when compared to a baby ingesting the substance straight on his own. Wondering if babies drink coffee? Well, not exactly – but ask any neonatologist and NICU nurse about caffeine and you may be shocked to learn how it’s used to treat breathing issues (apnea) in the most fragile premature babies in the NICU. When working in the Neonatal Intensive Care Unit (NICU), I would administer straight caffeine into the IVs of babies who weighed less than three pounds! Therefore, it’s safe to assume any medication or substance a baby can ingest, or receive intravenously, is considered safe for a mother to ingest since the amount that reaches the bloodstream of the baby is so small. The American Academy of Pediatrics considers consumption of less than 3 cups of coffee per day safe while breastfeeding. However, I caution moms who gave up coffee during pregnancy to ease back into consuming coffee. Start with decaf, then progress to “half caff”, slowly transitioning back to full caffeine if still preferred.

References and additional resources:

  • NCBI PubMed.gov
  • Boston Children’s Hospital – Vector Magazine
  • http://www.infantrisk.com/content/caffeine-intake-pregnant-and-breastfeeding-women
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    Nurse Wendy’s Favorite Online Breastfeeding Resources

    I always caution my mom’s when they have a breastfeeding question to avoid “Dr. Google”. The amount of myths and flawed information out there on the web is frightening! My favorite evidence-based websites are:

    • Dr. Jack Newman (drjacknewman.com), a pediatrician who opened and runs the largest breastfeeding clinic in Canada. He is considered an expert and advocate in the field of lactation. His website provides answers to common questions written in handout format and provides videos to watch. Be sure to “like” his Facebook page to stay current and educate your medical caregivers on the subject of lactation.
    • Kelly Mom (kellymom.com), is another great website. Written by an IBCLC, I love how she provides the references to what she says on her site which eliminates all the crazy myths and misinformation out there on the web.
    • Infant Risk (infantrisk.com), is Dr. Hale’s website who authored, Medications and Mother’s Milk, which is the book lactation professionals reference (and hopefully physicians) when advising moms on the safety of breastfeeding and medications. The best way to know what to take is to seek out a lactation professional such as an IBCLC who knows how to interpret and explain what the difference really means between an L1 and L5. I love how Dr. Hale suggests in both his website and book other alternative drugs in the same classification. For example: SSRIs (antidepressants) he suggest using Zoloft or Paxil if possible instead of Prozac. Most OBs and pediatricians are well versed in medications and breastfeeding but doctors and dentists who do not have much exposure to lactating moms will often make up answers when they do not know; suggest pumping and dumping, stopping breastfeeding for X time, or even weaning. As an IBCLC, it’s one of my biggest jobs while working in the hospital and in the community to advocate for the nursing relationship.
    • Infant Risk Call Center- answers calls Monday-Friday 8am-5pm central time, (806)-352-2519 if you cannot find the answer regarding a medication’s safety from a local board certified lactation consultant near you, or on the above website please call them.