I had the pleasure of participating in this webinar with a midwife and lactation consultant, and we talked about how parents can get breastfeeding off to a great start in the hospital and beyond. Stay tuned for Part 2 later this month.

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​Most lactation consultants, including those working in outpatient hospital clinics, have switched exclusively to virtual modes (video and phone) as a way of protecting everyone during the COVID-19 outbreak. You may be wondering if it’s possible to get good lactation support without sitting in the same room as a lactation consultant, and the answer is definitely YES! During a video consult, I can still:

• Offer reassurance, empathy, and emotional support (always important, now more than ever)
• Take a complete history
• Visually assess breasts and nipples
• Visually assess baby’s mouth and latch
• Help with positioning
• Help with pumping
• Help with bottle-feeding
• Advise on breast and nipple care
• Answer questions about feeding and general newborn behavior
• Talk with partner/support person about how they can help
• Provide a written care plan to keep baby well-fed and maximize milk supply

My support doesn’t end after we hang up! Following all consults, I still:

• Send an email summary about our session, including useful videos and information
• Share my clinical notes with your family’s health care providers (pediatrician, midwife, and/or obstetrician)
• Provide two weeks of unlimited follow-up communication by email and text

To make the most of our virtual lactation consult:

• Hold off feeding your baby for 60-90+ minutes beforehand.
• Set up yourself and your baby in a place with adequate lighting.
• If possible, have a support person available to hold your electronic device and point the camera.
• If you need help with pumping, have your pump set up nearby.
• Don’t worry about cleaning your house or looking “camera ready”!

Weight checks

I bring my sensitive pediatric scale to all home visits, and weight checks and measurements of milk intake at the breast are helpful for assessing your baby’s well-being and feeding skills. If we meet virtually, I can’t weigh your baby, but I will ask you lots of questions to guide my assessment. Please keep track of:

• Your baby’s last recorded weight, including the date
• The number of times your baby feeds each day by breast and bottle
• The general length of feedings
• Diaper changes, including color and consistency of stools

 
If you have concerns about weight and milk intake, regular visits and weight checks with your baby’s pediatrician are recommended. Another option is to rent or purchase a baby scale, and I can guide you through checking your baby’s weight and milk intake during our session.
 
Some of my clients have bought this $55 scale on Amazon and found that it is adequate for regular weight checks but not sensitive enough to measure milk intake during breastfeeding. The Hatch changing pad and baby scale is also popular among my clients and is $150. I have done side-by-side weight comparisons with my pediatric scale and found it to be accurate within an ounce or two.
 
Payment and insurance

I am offering my virtual services at a discount since I do not spend any time driving or paying for gas or parking. As of this writing, I understand that telehealth services are being covered by most insurance carriers. I am billing Aetna and Meritain for my services as usual. If you have another insurance carrier, you may prepay for your session when you book an appointment, and I will provide you with a SuperBill to submit to insurance for any reimbursement you qualify for.

“So, how does the latch look?”

I get this question a lot. Many new moms tell me that the hospital nurse or lactation consultant talked with them about what to look for when baby is latching: baby’s wide-open mouth and smooth cheeks (no dimpling), upper and lower lips flanged out, a generous amount of the areola in baby’s mouth, no clicking noises or loss of suction, a round and elongated nipple after breastfeeding, and no pain. Often, moms are tripped up by the last item on the list. If the latch looks good, why is it still painful?

Because in breastfeeding, looks aren't everything.

Pain is a signal that something needs adjustment, whether it’s the baby’s position or the breastfeeding pair’s emotional state or the way the baby is sucking. Sometimes the adjustment is as simple as manually flipping a baby’s bottom lip out, which can be hard to see when that little chin is deeply buried in the breast. Flipping out the upper lip may help, too, but there is evidence that this is not as critical for a deep, comfortable latch as was once believed.

If a baby’s mouth is not wide open when latched, I find that pushing down on a baby’s chin typically doesn’t help. Instead, I recommend moving the whole baby! Often I see babies being brought to breast with their chins tucked into their chests, so pushing on the chin is futile if baby is curled up in this way. The snuggle and slide move is very useful in these cases.

When breastfeeding has been stressful, I find that moms and babies are often holding tension in their bodies as they attempt positioning and latching. Relaxed babies tend to open wider, and relaxed mothers tend to feel less pain. I like to look for ways to help the pair relax together, particularly the mom since her baby will take cues from her. Often a few deep breaths and some measures to soothe the baby, such as skin-to-skin holding, make for a much better experience initiating breastfeeding.

I also encourage moms to take a few moments to let baby relax into a latch. If baby came to the breast very hungry or fussy, her mouth is likely to be tighter, and she may need a minute or two to settle in. Rather than unlatching baby immediately to get a “correct” latch, I ask mom to see what happens if she waits a short time. Does baby open wider? How does the latch feel now? Often, the improvement comes quickly, and without the frustration of baby going on and off the breast several times until she gets it “right” (which can lead to more soreness for some moms).

It’s also possible that have a baby who is latching well and to have some lingering nipple soreness, especially if there were wounds in the early days. As those wounds heal, it’s normal to continue feeling some discomfort, particularly in the first 30-60 seconds of the latch. If the pain subsides, that is an encouraging sign that baby is not continuing to latch in a way that is causing further damage.

If, despite these adjustments, pain continues and breastfeeding feels unsustainable, there may be other factors at play. A full assessment with a lactation consult, who may loop in mom and baby’s doctors, can be useful to determine the cause of the pain and possible treatments. 

A lot of families contact me with the goal of transitioning from bottle-feeding to breastfeeding or chestfeeding. In the vast majority of cases, the families originally intended to exclusively breastfeed, and their plan was derailed by early feeding challenges. Baby may be breastfeeding some of the time but need extra milk if the family is still working on increasing milk supply, or if baby has trouble breastfeeding effectively.

Guilt, shame, and disappointment are common emotions that come up for new parents who haven't yet reached their feeding goals. One of my most important roles as a lactation consultant is to validate parents' feelings. In our competitive and impatient culture, it's easy to feel less-than when our efforts don't immediately lead to the results we seek. I invite parents to step back and recognize it will likely take some time to figure everything out. In the meantime, focusing on The Three Keeps from The Womanly Art of Breastfeeding (La Leche League International, 2010) is very helpful.

1. Keep your baby fed.
I call this Rule #1. Parents who are using bottles, formula, or donor milk often feel bad about it, and I always praise them for keeping their babies well-fed. Babies who are getting enough food are typically more alert and thus easier to feed by any method, especially breastfeeding. Families who are supplementing their babies' feedings with extra milk should be working closely with their health care providers (lactation consultant, pediatrician) and getting regular weight checks to ensure that they are feeding appropriate amounts.

2. Keep your baby close.
Babies who spend a lot of time in close physical contact with their lactating parents typically return to the breast sooner. Skin-to-skin contact is important for helping babies to orient to the breast, so I encourage families to do as much of this as they can. Babies need to return to the breast on their own terms. If the breast has become a battleground, with baby actively resisting breastfeeding, then it's time to work on creating positive associations. A great starting point is lots of snuggling without any attempts at breastfeeding. Parent and baby may enjoy a warm bath together (with parent getting into the tub first and having partner hand over baby). Sleeping together also helps, as long as the family is following safe bedsharing guidelines.

3. Keep your milk flowing.
​Some babies are part-time breastfeeders as parents work on building a full milk supply with pumping and hand expression for added breast stimulation. In other cases, the lactating parent is only pumping and hand expressing, and all feeds are given by bottle. In either case, consistent and effective milk remove is critical! I see the best results when there are at least 8 breast drainings per day. I also talk to parents about the importance of avoiding long stretches in which milk just sits in the breasts; 4 hours is about the maximum amount of time anyone should go without removing milk as they're trying to boost supply.

Babies who have difficulty latching will likely need some extra support, and this is something that I do all the time. Often a few adjustments to positioning make a big difference. There may be a physical issue that we need to address, such as a tongue tie. Some babies do well with the assistance of a nipple shield for a brief time, and this is definitely a tool that should be introduced with help from a lactation consultant.

A parting thought: babies are born to breastfeed, and this instinct stays with them for many months. I have heard of cases in which an older baby of 8 or 9 months was adopted and breastfed for the very first time! It often takes patience, persistence, and good support to get a baby back to breast, but it can absolutely be done.

​Need help getting your baby back to breast? Book an appointment.