Dr. Corinn Cross (Host): This is Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Cori Cross. Providing infants with human milk gives them the most complete nutrition possible. Breastfeeding provides the optimal mix of nutrients and antibodies necessary for babies to thrive. But sometimes parents need a little extra help, or we hit some hiccups along the way.

The Carle Foundation Hospital Community Breastfeeding Clinic is where families can turn if issues arise. Today we're joined by Dr. Dionne Smith, a Board Certified Pediatrician, and Laura Christman, an RN and Internationally Board Certified Lactation Consultant at the Carle Foundation Hospital. And they're here to discuss breastfeeding awareness and how best to support our breastfeeding families.

Thank you for being here.

Dionne Smith, MD: Thank you for having us.

Host: So let's just jump right in. When babies have a hard time latching on, one of the things we evaluate for is the child's tongue and how tight the frenulum is. Can you walk us through this evaluation and what you do at the clinic?

Laura Christman, BA,RN, IBCLC: So, ideally, do an oral assessment on every infant once they're born in the hospital and then again in the clinic. So a lot of times they will catch them immediately in the hospital, which is helpful because then we can get a referral sooner and the sooner we intervene, the better chance things are going to go well.

What we look for is how the tongue is able to move side to side, out, up, if it can and something snap back, which is when the baby tries to suck, it starts to stick its tongue out, but the tongue tie doesn't let it, so it pulls it and those behaviors with the tongue tie don't necessarily have an impact based on how the tongue looks, so that's why we assess those mobility factors.

And then we also assess for maternal pain as well as baby's ability to the milk out to decide whether the tongue tie is truly a or not.

Host: Got it. So a baby might have a short frenulum, but if it's not particularly tight, they may be able to still do the work of breastfeeding without hurting the mom and able to get sufficient milk. Right?

Dionne Smith, MD: Correct. In my experience too, and it's not always visible, so in some cases there may not be a frenulum, but the tongue mobility is limited regardless. And sometimes those cases are called posterior tongue ties, in which case I'm not able to see them visibly in the clinic. So you kind of have to observe direct breastfeeding and observe the tongue mobility during feeding to make that diagnosis.

Host: And then, when do you recommend a frenotomy?

Laura Christman, BA,RN, IBCLC: Obviously, as absolutely soon as possible because the baby to relearn how to suck with it's free tongue. So, it would be so nice if we could do it in the newborn nursery, but since we can't, as soon as possible after discharge is ideal.

Dionne Smith, MD: Right. I'm often making those referrals after the newborn visit or a follow up visit if it's obvious that the mom is uncomfortable with breastfeeding because the tongue just isn't going around the nipple well enough, so there can be pain throughout the entire breastfeeding session or if it's obvious that the baby's not getting enough food and not growing well enough, then that referral is made right away.

Host: And just for everybody listening, to whom do you refer and about how long after the referral process does it take to basically have the procedure done?

Dionne Smith, MD: In my experience, one to two weeks at most, and we make the referral to our oral maxillofacial clinic, to our surgeons there.

Host: And generally, I mean, I'm a pediatrician as well, it's a pretty simple thing.

Dionne Smith, MD: Very, and afterwards, the babies usually are encouraged to feed again right away. So you know, the recovery course is minimal, if any.

Host: Dr. Smith, do you notice that there's more weight loss or anything to do with the baby's health if the referral is delayed?

Dionne Smith, MD: I've noticed that supply becomes an issue. If the baby's not getting enough but mom is producing more than the baby's getting, then there can be issues with oversupply and engorgement from that. And we do see inadequate weight gain, yes, if it's not jumped on right away and it is let gone, if it goes on too long.

Host: So Laura, in the clinic, are you encouraging mothers to then supplement with formula if they are having this problem until they can get the referral taken care of?

Laura Christman, BA,RN, IBCLC: So, ideally, we always encourage them to pump with breast milk if they have it. It is a lot of work if the baby can't take the milk out on its own. The mom needs to pump eight times a day. And, takes about 15 minutes do that, and then if they don't have anyone to help them at home, they still need to give the bottle.

 We do use a slow flow nipple so that the baby doesn't prefer the bottle over the breast. The only time we use formula is if mom's milk supply is an issue. And then we always still use all the breast milk available first, and then just add the calories, with formula if we need to.

Host: Got it. So let's move on to another problem that is common, mastitis. So, I know that there is a new, protocol. Could you walk us through that?

Dionne Smith, MD: The protocol that seems to have been newly developed as of last year, I could summarize by just saying less is more. I feel like we used to do a lot with mastitis and it would kind of automatically be treated with antibiotics. We would assume it was a raging infection and it starts off typically as a blocked milk duct where there's supply, but the baby's not getting enough from that particular duct.

So the longer, time fluid sits in a space, the more ability it has to become infected. So right now, what the recommendation is, is instead of using warmth and trying to massage the breasts and get the milk out, you promote direct breastfeeding, because babies are often able to get milk from us better than a pump can, or certainly hand expression.

And then using ice, things that are anti inflammatories. So use of ibuprofen would be reasonable, and then using like ice packs. We used to suggest using, like, a warm shower right before breastfeeding just to get things supple, but that doesn't show to prove, or doesn't prove to prevent mastitis as much as we used to think it did.

Just lots of comfort techniques, cooling, anything that would be considered an anti inflammatory before we jump on the infection.

Host: So, you know when you have mastitis, sometimes women would pump one breast, as a pediatrician again, I would say that it's totally fine if the duct is just a little clogged to breastfeed on that side, right? But I think that most women would have that question, right?

Dionne Smith, MD: Absolutely, and that makes sense that they would have that question. But the solution, we think, to the problem really, aside from using the pump, is to have your baby directly breastfeed. And no baby is going to ingest or take in milk and then spit it out. So they will be swallowing it, but in the setting of possible infection, you're also going to have antibodies within that space. So the baby is ingesting infection fighters at the same time. So it is safe to continue breastfeeding and not dumping the milk.

Host: And then when is it that you need to move on then? When do you go from mastitis to an infection with, something that you would treat with antibiotics? And then how have you noticed, are there any increases in breast abscesses with this delayed approach?

Laura Christman, BA,RN, IBCLC: We've seen less abscesses, which surprised me, because when I read the new protocol number 36 from the Academy of Breastfeeding Medicine last year, it was opposite of almost everything I've been doing for 20 years, and I was shocked, and of course skeptical, but given the research behind it, obviously I've followed through with what Dr. Smith talked about earlier. What they were saying in the protocol is all the massage that we used to do and everything would cause maceration of the breast tissue underneath and that's what would cause the abscess. So now that we're not doing that anymore, the only massage we do is very, very gentle, like petting a cat. Then we aren't seeing those severe infections like we did before because we aren't damaging the tissue in the breast.

 Another thing that we've done is added an emulsifier, sunflower lecithin, helps make everything slicker, so ideally, we get the plug out before the area around it gets infected. And generally, the infection is never in the duct, it's around the duct. I mean, I won't say never because, you know, there's always something weird. But, almost never see pus coming from the nipple it's all inside the breast.

Host: Got it and so when say the emulsifier, you're putting that around the nipple.

Laura Christman, BA,RN, IBCLC: No, you're taking it orally, so that the milk is slicker and comes out more easily. And opens it back up again. And so, moms who get repeated plugged ducts we'll put them on a maintenance dose of five grams a day, and if they actually have a, an area that's backed up and uncomfortable, then we double that and have them take grams a day until about three days after it opens back up.

Host: And what did you say the emulsifier was?

Laura Christman, BA,RN, IBCLC: Sunflower lecithin, L-E-C-I-T-H-I-N.

Host: So then, I guess just, I hadn't heard of this, so I guess following that train of thought, are there some women who get repeated mastitis, could it be that their diet is less fatty, or has less of these emulsifiers in it just naturally?

Laura Christman, BA,RN, IBCLC: Not usually. It's usually an issue of the baby not emptying well, like with a tongue tie, or a premature baby that has a poor suction when they're latched on. Moms with bigger breasts tend to have a little bit more trouble emptying as well,

So it's just an added, because that's quite a bit more than you would get in a regular diet.

Dionne Smith, MD: I was just going to say, or overuse of a pump, anything that creates increased supply more so than the demand is there.

Host: So stagnant milk.

Dionne Smith, MD: Right.

Host: And so do you see this sometimes when women return to work and they're not able to nurse as often?

Dionne Smith, MD: I have seen that. Although, I think, conversely, I probably see more of the opposite, that they're not able to get as much out, and so milk supply ends up decreasing. Usually, I see mastitis more in the early newborn period, when baby is not quite getting as much as mom is producing. And I usually see things even out, as far as supply and demand, closer to six weeks. And most moms aren't going back to work until after that.

Host: And then the other interesting thing about what you said is that it's opposite of what we've done with temperature as well. When you're talking about the warm shower, keeping the breast warm, now the advice is to really cool it for an inflammation purpose after nursing.

Dionne Smith, MD: Correct, that's the new recommendations. And you would think that that didn't make much sense because, well, doesn't that cause a, I guess, slower moving environment? But the idea is to reduce the inflammation so that it doesn't progress to infection.

Host: Got it. What do you see as the most common reason families contact the breastfeeding clinic?

Laura Christman, BA,RN, IBCLC: Usually, number one is pain with breastfeeding and number two is concerns over supply.

Host: And would you say that both of these are something that's pretty easily fixable?

Laura Christman, BA,RN, IBCLC: The latch and the pain tends to be more fixable than supply. If it's just a perceived low supply and there's enough milk, that's not problem. But unfortunately the old adage that anyone can breastfeed if they just try hard enough, is honestly false, because some moms have physiological reasons why they do not make an adequate milk supply. And if that is the case, it's very, very difficult to fix, and often we end having to supplement the whole time. They can usually still breastfeed, just not with a full milk supply.

Dionne Smith, MD: One of the things I say to my patient's moms for support is that nobody tells you how hard breastfeeding is. You'll get all of these tips and tricks and all of this advice about labor and delivery and pregnancy itself, but when it comes to breastfeeding, it's extremely difficult and every baby is different and every mom is different, so it takes practice on both sides.

Host: Well to your point, I had three children and every baby is absolutely different. You can do the same thing every time and so, I would love if both of you would give us some closing advice as to how to best support our breastfeeding families.

Dionne Smith, MD: I often start by saying that and just by supporting moms because when I see them in that brand new newborn visit, which is usually the babies are two or three days old, we as moms just by default don't really create enough milk in those early days to really fill a baby up. So it's going to be a lot of cluster feeding. It's going to be painful nipples. It's going to be babies constantly seeming hungry. And so there's a lot of questions. There's a lot of stress. There's a lot of sleep deprivation. And so I just try to meet them where they are and let them know, you know, I've done this before too. And, I think if we all didn't forget how hard it was, we would all have like five or six kids. So I try to let them know this is normal. Your body is going to do what it needs to do. If we need to do some supplementing, that does not, damage the process further along. It just is something that we need to do. A fed baby is what we like to see. And so I think that sometimes gives moms peace of mind to know that, you know, you can supplement for a day if you need to until your milk supply is there.

 I don't know, that comforts a lot of people because for me, myself, I did supplement both of my kids maybe for a day with some formula until my milk came in. And then we went on to breastfeed for nine to twelve months, each of them. So, it can be done, and I just like for parents to not be so stressed about it. Because stress can inhibit breastfeeding as well.

Host: I would say I completely agree with you, and I wonder if being in this profession allows us to have that sort of confidence because I feel like a lot of women feel that supplementing equals failure and I hate that because even for me, my first baby was starting to turn a little yellow because my milk just wasn't in and so I had no problem supplementing for a day.

I was like, we're just going to get right through this and get right back on it and it's not going to be a problem. And the same, I had the same experience with you. It was very easy to go back to continue nursing despite having given a couple of bottles for a day or two.

And so I just think we need to stop with the messaging to mothers and making them feel all of this pressure, because it does lead to all these sleepless nights and guilt and everything else when really it's not a failure.

Dionne Smith, MD: Right.

Laura Christman, BA,RN, IBCLC: Yeah, I completely agree. I think the biggest gift we can give these moms is to ensure that they know we are not going to judge them and that we're going to help them succeed in what they choose for their family. I always provide education to the moms about what is optimal and then we work together to see what's going to work for them and their family. With latch, we have a good six weeks to work it out, so the moms who come in tearful and upset because the baby's not latching and they're afraid they've already failed at breastfeeding, I let know as long as we protect and build the milk supply, the latching, we have time to work on. The bottle is not a bad thing because nipple confusion is really an old wives tale. Babies just like what they get more easily. So, we an extremely slow flow nipple so, the baby doesn't like the bottle better. And then it's pretty easy to go back forth once they learn how to latch. So, basically it's just support because like, Dr. Smith said, I mean, one of the primary components of motherhood is guilt. And, what we want do is support, encourage, and that's actually why I do this job. Because when my kids were born, I had no help. It was very frustrating. And I think it takes someone to bounce your ideas off of. It takes someone that you can trust to tell them what you're thinking could ask for help without feeling judged. And so that's just my take on everything.

Host: I couldn't agree with you more, Laura. I mean, I think that, you know, right after you've given birth, you're in a vulnerable position and you're often very tearful and extremely exhausted. And you know, if nothing else, the having other people who can just be there for you, listen to you, support you, I mean, that's really what we need at that time. So it's a wonderful thing that the clinic can do to be there for these moms.

Laura Christman, BA,RN, IBCLC: Yes, and there nothing more rewarding to finally hear a baby start swallowing milk that wasn't transferring before. It's my favorite sound in the world.

Host: Absolutely, and the Carle Foundation Community Breastfeeding Clinic has a helpline where help is available Monday through Fridays and the phone number is 217-326-2610. And if you leave a message you will be called back by a lactation consultant within usually 24 hours. Isn't that right?

Laura Christman, BA,RN, IBCLC: So actually, I can amend that just a little bit. Our helpline is seven days a week, holidays, weekends, you name it, from about 8:30 to 4:30. And we try to call you back within a couple of hours, actually.

Host: That's amazing. Well, thank you so much for joining us, Dr. Smith and Laura. This has been a great discussion. I know I've even learned a lot. I really appreciate you being here.

Dionne Smith, MD: Thank you for having us.

Laura Christman, BA,RN, IBCLC: Absolutely, I appreciate it.

Host: For more information and to get connected with one of our providers, please visit carle.org. That's C-A-R-L-E dot O-R-G. Or for a listing of Carle providers and to view Carle sponsored educational activities, head on over to our website at carleconnect.com. That wraps up this episode of Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Cori Cross.