The American Academy of Pediatrics released new sleep and SIDS guidelines on the 24th this month to promote the safest arrangements for babies everywhere. According to the new guidelines, you are encouraged to keep baby close. The AAP has recommended that infants now sleep in your room close to your bed for at least the first six months, and there is no evidence for moving a baby to their own room before 1 year of age. Evidence has shown that sleeping in the same room on a close but separate surface decreases the risk of SIDS by as much as 50%! These new recommendations do state that bedside sleepers that attach to the side of your bed have been shown safe, and that you can consider using one. I actually adore the sidecars designed to attach to our bed, but do avoid taking a side of your crib off to push against the bed as this is not proven safe, or part of any recommendations. Placing baby next to your bed so that baby is within view and reach facilitates feeding, comforting, and continuous monitoring of your baby.
So what does safe sleep look like?
AAP TASK FORCE ON SUDDEN INFANT DEATH SYNDROME. SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2016;138(5):e20162938
Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence report/technology assessment No. 153 (Prepared by Tufts-New England Medical Center Evidence-based Practice Center, under Contract No. 290-02-0022). AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality, April 2007.
The other day I gave a presentation on VBAC's, and so I am going to share a little of that with you. This information is also pulled out of my VBAC class, if anyone is interested, it is available online.
What are the current guidelines?
The American Congress of Obstetricians and Gynecologists (ACOG) is one of the most reliable sources to pull information from. Here are some of the current recommendations they list for a VBAC delivery in Practice Bulletin 115.
So what are some of the Benefits/Harms of Implementing the Guideline Recommendations?
Contraindications for Vaginal Birth after Cesarean Delivery:
The thing we hear the most about it uterine rupture, the risk is there. This infographic lays out our risks of having a rupture vs dehiscence, and what the infant mortality rates are if we do have that true rupture.
Questions? Comments? Let me know!
This week I got an email from a local hospital asking about the recent refresher the CDC sent out on the sterility of powdered formulas. They are currently sending home powdered formula, and wondering if they should consider passing out instructions to the new families. Of course I think that instructions should be sent out at discharge, because a lot of us come into parenthood not knowing quite what to do!
The CDC sent this out to remind consumers that powdered infant formula is not a sterile environment, it can and does at times grow certain bacteria. The bacteria they discussed in this reminder was Cronobacter, or Enterobacter sakazakii. This is a germ found naturally in our environment, and it survives in extremely dry conditions. It can also be found in other various dry foods, such as powdered milk, herbal teas, and other starches.
While it is uncommon that adult’s and older children get sick from it, it can be deadly to infants and those with compromised immune systems. What Cronobacter does is cause a severe blood infection or meningitis. While this is a rare but serious illness, infants two months or younger, premature infants, or those with compromised immune systems are those that are most likely to develop meningitis with the infection.
The CDC states that it generally begins with a fever, and can include poor feeding, crying, and very low energy. These infants should be taken to a doctor for evaluation. Here are some ways the CDC states you can protect your infant:
Breastfeed. Breastfeeding helps prevent many kinds of sicknesses among infants. Almost no cases of Cronobacter sickness have been reported among infants who were being exclusively breastfed.
If your baby gets formula, choose infant formula sold in liquid form, especially when your baby is a newborn or very young. Liquid formulations are made to be sterile and therefore should not contain Cronobacter germs.
If you use powdered infant formula, follow these steps:
1. Clean up before preparation
2. Prepare safely
3. Use up quickly or store safely
You can find more information here.
Need a handout?
I want to talk about bit about something most parents aren’t aware of, and we call it the second night syndrome! What?... Yes, a group of “symptoms”, that occurs together. Sounds a bit scary, but don’t worry!
For the first 1-2 hours after birth your baby is going to be very active and alert, this is the time they breast crawl and latch on. They generally get a really good feed during this time, but after that second hour they fall into a deep sleep. They usually do not want to be woke up much, or remain alert until the next day. On the second day baby is going to go through neurological function changes that quite frankly may make you start questioning everything.
Do you remember during pregnancy when it seemed as though baby would be awake and active during the times you wanted to sleep (mostly at night), and would be still and quite during the times you were up and active? This is because all that swaying was comforting to baby, and you essentially rocked them to sleep in the womb. Well, baby is still going to want this type of schedule. You may find active periods during the night more often than you will during the day, and baby may be fussy and want to be held and fed during the day.
Right now on this second day, baby is probably thinking “Hey, I want to go back where I came from, why can’t I?! I guess the second best thing is to be skin to skin and fed. Let’s do this, A LOT! I love it!” So, on this second day you may find yourself with a fussy baby; a baby who may not want to be put down, and who wants to constantly nurse. The closest thing they can find to still being in your belly is skin to skin, feeling your warmth, hearing your heart beat, and breathing. I promise you, it will be over soon. You are awesome, and you can get through this! You have enough milk, and you are not doing anything wrong.
The best thing I can tell you is to be prepared. Nap when you can! Take turns doing skin to skin with your partner. Spend that day in bed with baby on you when you are not sleeping. Limit visitors. Don’t worry about your milk not being in yet, baby is getting enough! Take a deep breath, because you got this.
Did you know that doulas, lactation counselors, placenta encapsulators, etc. are not licensed or regulated in the United States! This means that anyone without training, experience, or certification can call themselves a doula, placenta encapsulator, or lactation counselor without even having training. I feel that it is very important before you hire anyone to ask them about where they trained and certified, and what specifically are they trained to be. I’m not saying that anyone without certification is not trained to perform the duties that they are performing, but there does need to be some standards in place.
Becoming certified means that you have taken a training program and “passed”, thereby you have received your certification to practice. Certifying means that you are regulated and held accountable by your certifying agency. Your certifying agency provides you with a scope of practice that you should abide by; these are your standards. Most certifying agencies also require you to meet continuing education requirements and submit for recertification every so often. Certification means that we have the education, skills, ethics to abide by, and a scope of practice to not go beyond. If you are hiring a non certified doula or breastfeeding counselor, please ask what agency they are trained with, and what their potential credentials would be if they were to become certified.
Many people providing lactation and birth support have no scope of practice to answer to, because they chose not to certify. They are self regulated. This is scary to me. It can, and has had serious consequences. To add to all this mess, there are many different certifying agencies in the United States, and each one has their own rules and regulations.
I’ll try to give some examples for lactation.
There are a few trainings who offer the role of a Breastfeeding Counselor; many of them are through agencies that offer doula certification. A breastfeeding counselor can very well counsel you; they can help educate you on what to expect, what is going to be normal. They can show you how to get a basic good latch, how to hold your baby. They can be an amazing peer support! What they cannot do is assess and solve problems; they should not being trying to help you with supply issues, or a continued painful latch. If the dyad is having any problems they need to refer out to an IBCLC (International Board Certified Lactation Consultant), this is beyond their scope.
I am trained as a CLC (Certified Lactation Counselor) through the ALPP, there are no other organizations who offer the title of a “lactation counselor”. A CLC takes a 40 hour training, and an exam. They are trained to counsel the needs of the dyad, conduct comprehensive assessment, and identify and address problems the mother may be having. If a CLC notices something like your infant possibly having a tongue tie, we can point out the difficulties we see you are having and refer you to an IBCLC and a clinical healthcare provider, because telling someone their infant has a tongue tie is a medical diagnosis. We are not there to diagnose or treat anything. We are not there to clinically help you through extensive and/or long lasting difficulties, but we will still be there to emotionally and physically support you through this time while you are working with a specialist.
An IBCLC is the specialist in the field of lactation, and the IBLCE is the only certifying body to award this credential. Sometimes women simply call them “lactation consultants”, but they should be the only ones who are referred to as this. A CLC is not a “lactation consultant” (IBCLC), just as someone trained in basic breastfeeding support is not a “lactation counselor” (CLC). There’s a lot of confusion on this, and it can cause a lot of issues! An IBCLC is required to have college education, comprehensive lactation training (90 hours), and up to 1000 hours of clinical experience before they can even sit for their board exam! I know these women pour their hearts into it, because I am working my way to be able to sit for this exam. Saying that, you should see why they have a large scope of practice, and why we should always refer the dyad to them for anything beyond our scope.
Each individual who provides breastfeeding support is wonderful, and we all need to work together to take appropriate steps to maintaining our scope of practice. We all make mistakes to get experience, but when someone who is not an IBCLC makes the mistake of not referring women who are having difficulty breastfeeding, health issues, or by trying to solve problems that we shouldn’t be solving we are providing a disservice to these women, and the impact of those errors can cause a lot of pain and trouble for the dyad.
I trained with Childbirth International and am a Certified Labor Doula, they also offer childbirth education and a breastfeeding counselor program. They have one main scope I’d like to point out for all of their professionals: “Does not provide clinical care, medical assessment, diagnosis, or advice”; “do not provide prescriptions, advice, or recommendations including regarding use of “natural” remedies or “alternative” therapies”.
Previously women were actually told that drinking alcohol while breastfeeding was fine, and sometimes encouraged. Discussions and recommendations were based off of alcohol being beneficial. Mother’s were told that it would help you relax, promote MER, increase supply, and help both mother and baby sleep better. Then this went downhill, and a lot of mothers were being told they couldn’t drink while breastfeeding. Now we are being told its okay in moderation. So what on earth should you do?!
In reality you do not have to completely abstain from drinking any alcohol while on your breastfeeding journey. I’m going to give you a brief evidence based piece on this.
It has been shown that to some extent alcohol can actually inhibit lactation. It has been shown that alcohol can inhibit oxytocin, which probably can explain the reduction in milk. For a normal breastfeeding mother, who has the occasional drink, potentially having their oxytocin inhibited for a brief period is most likely not going to cause any harm.
Alcohol passes freely into breast milk just about the same as the alcohol concentration would be in your blood. Some studies show it is a bit higher in your blood, some show it is higher in your milk. The highest concentrations have about an average of 30-60 minutes after drinking, and then the concentration looks to decline at about the same rate as your blood concentration level. Alcohol is never “trapped” inside your breasts. Pumping and dumping doesn’t solve a thing, unless you are engorged and just need to get it out. I highly suggest nursing your child right before to help with that throughout the few hours you will not be nursing. As with your blood concentration, there are a few factors that determine just how fast it will exit your system, like your weight.
So in conclusion, the benefits of you breastfeeding are going to outweigh the occasional drink or two as long as you practice safe drinking. Think of it as driving; if you shouldn’t drive, you shouldn’t breastfeed.
Motherisk is an amazing resource for evidence based information, and they have an awesome nomogram you could use to calculate around how long you should wait after consuming an alcoholic beverage, before resuming nursing! The link to download that is below.
Happy New Year!
- Michelle Mansker
Chien YC, Huang YJ, Hsu CS, Chao JC, Liu JF. Maternal lactation characteristics after consumption of an alcoholic soup during the postpartum ‘doing-the-month’ ritual. Public Health Nutr 2009;12:382–8.
Mennella JA, Pepino MY. Biphasic effects of moderate drinking on prolactin during lactation. Alcohol Clin Exp Res 2008;32:1899–908.
Giglia RC, Binns CW, Alfonso HS, Scott JA, Oddy WH. The effect of alcohol intake on breastfeeding duration in Australian women. Acta Paediatr (Oslo, Norway: 1992) 2008;97:624–9.
Chaves RG, Lamounier JA, Cesar CC. Factors associated with duration of breastfeeding. Jornal de Pediatria 2007;83:241–6
Kesaniemi YA. Ethanol and acetaldehyde in the milk and peripheral blood of lactating women after ethanol administration. J Obstet Gynaecol Br Commonw 1974;81:84–6.
awton ME. Alcohol in breast milk. Aust N Z J Obstet Gynaecol 1985;25:71–3.
I adore Christmas time, all the laughter and lights that come with it. I’m unsure how Christmas will play out this year, but years past I honestly remember how stressful things can actually become sometimes. It’s not because you don’t love this time of year, or anything else that can encompass it. It’s such an amazing time for the children too, and they get so overjoyed, it’s wonderful to gaze at them for hours. Then they get over stimulated and tired, and that joyous moment comes crashing down around us! So how do we handle it? is there anything to make it easier? Sure!
What are your holiday plans? Any tips for the rest of us?!
So what exactly is the point in skin to skin after birth? It has a lot of amazing benefits! Ideally this moment begins immediately after birth, with the baby placed prone directly onto the mother’s uncovered chest. A blanket can then be placed over both, and they will be left alone to bond and learn more about each other. Routine procedures are delayed. When your baby is placed skin to skin, nine behaviors can be seen that lead to the first breastfeeding. You may have heard of the breast crawl? So let’s get to some of the benefits!
- Facilitates bonding
- Improves dyadic mutuality
- Stabilizes infant breathing
- Stabilizes infant heart rate
- Stabilizes infant body temperature regulation
- Stabilizes infant blood glucose levels
- Decreases infant crying
- Improves rates of breastfeeding initiation
- Improves breastfeeding self-efficacy
- Increases mother’s confidence in caring for her baby
- Begins infant’s microbiome*
I want to speak a minute on those 9 behaviors that you can observe your infant doing.
1. The birth cry is the first; this is the cry you will hear immediately after delivery. It is very distinct, high pitch cry as your baby first expands his lungs.
2. The second is relaxation, and will occur as baby is placed onto your bare chest to begin the golden hour. You can look for things like your baby’s hands being open and relaxed.
3. The third stage is the awakening stage. You may notice that your baby will open his eyes, and begin to move around his head and shoulders.
4. The fourth stage is called the activity stage, and this is where you will begin to notice mouthing and rooting reflexes.
5. The fifth stage will be rest, and you may notice other periods of resting between all the activities.
6. The sixth stage is called crawling. This is the stage where you baby will begin sort of thrusts and kicks to bring himself closer to your breasts.
7. Seven is familiarization. Your baby will begin touching and kneading/massaging your breast, and will lick and mouth around at your nipple.
8. The eighth stage is sucking. Your baby will latch onto your breast and begin nursing.
9. Nine is sleep, after all the wonderful activity and the first nursing your baby will be tired and want a period of sleep.
Regardless of how you feed your baby, every baby still can greatly benefit from doing skin to skin immediately after birth. If there are medical reasons why you must be separated, you can begin as soon as able to.
*The human microbiome is a fascinating thing! This is our own personal ecosystem of sorts. It consists of the trillions of microorganisms (bacteria, fungi, and viruses) that live inside and outside of our bodies. Your gut, skin, even your breast milk. Our health is determined by the balance of the good and bad microbiomes we have within our bodies. Providing our infants with skin to skin, vaginal births, and breastfeeding starts them off with the best possible microbiome. If you’d like to learn more about seeding and protecting your infant’s microbiome, I will be writing on that in the near future. Penny Simpkin’s work is absolutely fabulous on this subject!!
Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
Mikiel-Kostyra K, Mazur J, Boltruszko I (2002). Effect of early skin-to-skin contact after delivery on duration of breastfeeding: a prospective cohort study. Acta Paediatr 91(12):1301-6
Bystrova K, Ivanova V, Edhborg M et al (2009) Early Contact versus Separation: Effects on Mother–Infant Interaction One Year Later. Birth:36; 97-108
Aghdas, K., et al. 2014. Effect of immediate and continuous mother–infant skin-to-skin contact on breastfeeding self-efficacy of primiparous women: A randomised control trial. Women Birth 27. Pp 37-40.
Kajsa Brimdyr, PhD, CLC. (2011). The First Hour After Birth: A Baby’s 9 Instinctive Stages. http://www.magicalhour.com/aboutus.html
This past weekend I held a meeting, and discussed ways we could make a difference in our community. A difference for not only vbac mother and families, but also for every mother and family. In the northeast area we have total bans across the board on VBACs. I've had mothers come to me speaking of unassisted birthing, traveling hours away and having amazing VBACs, having an amazing repeat cesarean, or having a birth they feel was not great at all. It's a big deal, but one that we don't really see a lot of talk about.
The truth is, it's one of those topics that tends to get brushed aside. We all have heard "once a cesarean, always a cesarean". But how true is that?
I feel statistics aside, we should consider the mother's autonomy. She should be able to make an informed decision about any aspect of her life, including how she feels about her birth. All birth stories are different, and what makes them powerful is the choices you make and how you feel about those choices.
So in turn, ICAN is now hosting a letter writing campaign to one of our local hospitals. So they can hear the stories of mothers. The stories of successful VBACs, the stories of not having a choice, driving hours away, and even past stories held right there at their own facility. So they can hear how mothers in our community feel about the bans across the board, the lack of choice. This is important. This is a start of change.
First of all, happy World Breastfeeding Week! I am devoting a lot of my time to this, in both professions. I feel that it is very important that we are able to discuss these concerns with each other. It can be hard to decide where to start, or the best way to go about it. Every baby and mother are different, but hopefully these common tips will help you get started on that journey!
The first thing you are going to need is a pump; try to find a personal double electric pump. If you have insurance, chances are they now cover pumps. The ACA singed in 2010 requires that health plans cover breastfeeding support and supplies. This is not required for Medicaid coverage so be sure to call and find out more information on your plan. Contact your local WIC office, women who are on WIC and are going back to work, school, or have a medical issue can receive an electric pump.
Prepare yourself. If you are planning to go back to work around 6 weeks, which I find is the average, get your pump as soon as possible after delivery. Start by pumping for about 15 minutes once a day when you are com for table with beginning. The best time to do this is between 1-5 a.m.. Don't skip a feeding for this pumping session, you can choose to do this between nursing sessions or right after. Don't fret if you don't get much! The bottles that come with the kits are large, and it can be overwhelming thinking you have to fill those up! Remember you are feeding a newborn, and trying to establish your supply. Anything you pump is extra, and no matter what the amount, that is amazing! Take this extra milk, put it into a storage bag, label it, and stick it in the freezer. This is all to help you get accustomed to using your pump, and to help you get a stash going!
If you haven't done so yet, meet with your employer. They will appreciate the heads up and time to prepare, especially if there is not an established lactation room. Be sure to go over your daily schedule that will include taking pumping breaks.
Find a childcare provider, whether it be family or a daycare. If you are searching for a daycare, find one that is close to where you work. Be sure to ask questions about the support they provide for breastfeeding mothers. Visit a few times before baby’s first day, get to know the staff, and touch toys and items in the center. Your body will produce immunities to the germs in the daycare, and these will help to protect your baby through your milk. Be sure to have a backup plan in case you or baby gets sick on a workday!
At around 4 weeks your supply will be more established. This is the time to introduce a bottle and the childcare provider.
You may find that you need to have someone other than you give the bottle, this is okay. Baby refusing the bottle from you is a very common occurrence. Try having dad or grandma give it a go! You don't have to skip a nursing session to introduce bottles; you can do this at any time. Just as with breastfeeding, trying while baby is ready to nurse and getting fussy makes it more difficult. Pick a time when baby is in a great mood.
Introduce the care provider in baby steps! Start with just a few hours a day, and work your way up to the amount of time you will usually be gone.
When starting work, you may want to start back at just part time, and work your way up like you did with your childcare provider. A great tip is to also start back later in the week. Starting back work can be stressful; having a short week in order to look forward to the weekend with your baby can help relieve some of that stress.
Hopefully these tips will help you get started into preparing for returning to work! As always, if you’d like feel free to contact me! Talk to other mothers who have gone back to work, meet with a lactation consultant, or your local WIC Peer Counselor.