The Motherwear Breastfeeding Blog

Health Care Reform regulations require insurance to pay for breastfeeding support

Okay, how did I miss this?

Yesterday's New York Times reported on new rules requiring health insurers to pay for a broad range of preventive health services.  Among them, it noted, was breastfeeding support.

I asked Marsha Walker about this, and she sent me the following section which describes what kind of breastfeeding support is to be covered:

Section 2713:  "Coverage of Preventive Health Services
United States Preventive Services Task Force (USPSTF) recommendations for breastfeeding include: pre and postnatal breastfeeding education, formal breastfeeding evaluations undertaken by trained caregivers in the hospital and out patient care settings, followed by interventions to correct problems as needed

I don't know what "outpatient" covers, here, but I hope it means consults in other medical offices (like pediatricians and OB/GYNs) as well as private lactation consults.  That would be a huge step forward.  Stay tuned for more details!

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The one problem I couldn't solve

During my pregnancy many people pointed out how lucky I am to be a lactation consultant.  "If you run into a breastfeeding problem," they said, "you'll be able to fix it."

That's true for just about every breastfeeding problem, except one.

When my daughter was born last month I assumed that my milk would come in on day 2, or maybe day 3.  It came in on day 3 with my son, and he was born by c-section (which often causes a delay).  Milk usually comes in earlier for second babies, and I had a vaginal birth, so I figured I'd see a change on day 2.

But day 2 came and went, and so did day 3, day 4, and most of day 5, with no change.

I started getting distressed about this.  I was nursing around the clock, and hand expressing after some feedings.  The latch was good, and I could hear plenty of swallowing.  By day 4 my daughter's bilirubin started to climb, and so did my anxiety level.  Milk is officially "late" in coming in if it hasn't appeared by 72 hours (3 days).  I wished I didn't know that.

I ran through the list of birth factors that can cause a delay in "lactogenesis II," as it's known.  Nearly all of them didn't apply, such as cesarean birth, diabetes, obesity, hypertension, postpartum hemorrhage, thyroid problems (more are discussed here).  But a few did:  Labor analgesia.  Check.  Long pushing stage.  Check.  Stress.  Duh.  Retained placental fragments.  Maybe check?  (The OB was able to confirm that there were no retained fragments).

So apart from nursing, skin to skin, and expressing after feedings, there was nothing to do but wait.  And wait.  And finally, on the evening of the fifth day, the milk in the little medicine cups I'd been expressing into started to get a little lighter in color.  I lined them up as if I were doing a junior high school science experiment.  The different shades of yellow were so reassuring.  Soon we were going like gangbusters.

But isn't it fitting that the one thing I couldn't control was the one thing that went wrong?

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Download a free lullaby album from the Every Once Counts breastfeeding campaign

I'm very excited to be in the process of becoming a breastmilk donor (more on this soon).  I'll be donating to the Mothers' Milk Bank of North Texas. 

When I received my donor paperwork I found a wonderful gift - a CD called Sing to Me, produced by the Texas WIC program.  It's an album of songs by some great Texas musicians, including the Dixie Chicks, created as part of the Every Ounce Counts Campaign.

The campaign has radio and TV spots, print ads, and a website with practical nursing information. The songs represent different musical styles, and a few are in Spanish. 

Some, but not all, of the songs on the album have a breastfeeding theme, and I really think you'll enjoy listening to them:

Baby Fuel by M. Melara

Healthy Baby, Healthy Mama by Andrea Perry

Anytime Tameca Jones

Keats Shayna Brown

Despierta S. Sullivan

Cookie Jar Alice Saffer

Best of all, you can download the whole album for free!  You can also view the campaign's TV ads and listen to the radio spots. 

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What happens if you teach doctors about breastfeeding?

A new study in Pediatrics shows what happens when doctors get good training in breastfeeding management.

Everyone bemoans the fact (established in numerous studies) that doctors receive very limited training in breastfeeding care.  In fact, some get more instruction on formula feeding than breastfeeding.  And recent data show that pediatricans' attitudes toward breastfeeding are deteriorating.  But until this study it hadn't been clearly shown that improving training would have an impact on breastfeeding outcomes.

This randomized, controlled study involving over 400 residents at a number of institutions, used a breastfeeding curriculum for residents designed by the American Academy of Pediatrics.

The results?  Infants at the institutions in which the curriculum was implemented were more likely to be exclusively breastfeeding at 6 months.  Residents also showed improvements in knowledge, confidence, and practice patterns than the control group. 

Here's the great thing:  the curriculum used is available for free on the American Academy of Pediatrics website.  Now it's clear that it works.  Let's hope it get used.

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A few things I've learned this month

1)  If you eat a quesadilla while nursing your baby and some oil falls on your baby's new outfit, washing it with Dawn really works. (See picture for outfit - her first dress!)

2)  If you fall asleep while playing Sorry with your 7 year old you may start to move your pieces backwards on the board.  You are unlikely to win this way.

3)  If you get condensation in the tubing of your breastpump it does indeed work to run it for a while with the tubes connected but no pumping pieces at the end.  However, it also works to whip them around like a lasso.  Yee-haw.

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Does your pumped milk smell bad, soapy, or metallic? You could have excess lipase.

As I think more about pumping these days, it reminds me of one of the challenges some moms have:  excess lipase. 

Breastmilk usually smells either sweet or like nothing at all, but for some mothers pumped milk has a funny smell - either an "off" smell or a soapy odor.

If your milk smells like this, you may have higher levels of a normal enzyme called lipase in your milk.  Lipase breaks down the fat in milk, and the more you have of it the faster this process occurs.  

Here are a few things to know about excess lipase:

1) Since mothers have differing amounts of lipase in their milk, some find that the milk starts to smell funny immediately after it's expressed, while others find that it can retain a normal smell for a number of hours or days before it starts to smell bad.  To figure out what your "window" is, pump some milk and smell and/or taste it at regular intervals.

2) The milk is not harmful.  Some babies, however, object to the smell or taste, and won't drink it.  If your baby doesn't care, there's nothing wrong with feeding it to your baby.  It's sometimes the reason why a baby refuses to take a bottle.

3) You can inactivate the process of lipase fat-breakdown by scalding your milk before the smell develops.  To scald it, heat it on the stove until you see little bubbles around the edges of the pot (180 degrees F).  Then cool and store the milk.  Don't bring it to a boil.  Some mothers use a bottle warmer and thermometer to do this.  According to kellymom.com, "scalding the milk will destroy some of the antiinfective properties of the milk and may lower some nutrient levels, but this is not likely to be an issue unless all of the milk that baby is receiving has been heat-treated."  I know of one mother who pumped at work and brought in an electric burner and scalded the milk in her office!

4) There are some good resources online for more information.  A few good ones are kellymom.com and a La Leche League forum thread on excess lipase.

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New CDC guidelines on birth control may jeopardize breastfeeding

I was really disheartened to hear, via the Academy of Breastfeeding Medicine, that new CDC guidelines on the use of birth control in the postpartum period may spell doom for breastfeeding for some women.

The CDC's new guidelines sanction the use of progesterone-only birth control in the immediate postpartum period, and combined progesterone-estrogen birth control starting at 4 weeks postpartum.  Previous CDC policy recommended that progesterone-only birth control not be used prior to six weeks postpartum, and combined birth control not be used until after six months.

Why is this a problem?  Because the trigger for the onset of mature milk ('milk coming in') is the rapid decrease in progesterone which occurs once the placenta is delivered.  Progesterone and prolactin have a kind of inverse relationship.  During pregnancy progesterone keeps our prolactin levels low, and once progesterone levels drop, prolactin levels go up, bringing in our mature milk.  If progesterone birth control is started in the immediate postpartum period, it could keep prolactin levels low, jeopardizing milk supply.  As to the use of combined progesterone-estrogen birth control, I think we all know that estrogen is linked to low milk supply, especially when started early on.

A statement from the Academy of Breastfeeding Medicine notes:

“The new guidelines ignore basic facts about how breastfeeding works,” says Dr. Jerry Calnen, president of the Academy of Breastfeeding Medicine. “Mothers start making milk due to the natural fall in progesterone after birth. An injection of artificial progesterone could completely derail this process.”

Clinically, breastfeeding support providers report a negative impact on breastfeeding when these methods are introduced too early, and one preliminary study found dramatically lower breastfeeding rates at 6 months among mothers who underwent early insertion of progesterone-containing IUDs, compared with insertion at 6-8 weeks postpartum.

“The data are limited,” says Calnen, “but for now, the state of the science suggests that early progesterone exposure undermines breastfeeding.”

The Academy wrote to the CDC about this issue, and received a response stating that the new recommendation reflects “the best interpretation of the existing evidence.”

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