Official Journal of the United States Lactation ... - Clinical Lactation

March 2012, Vol. 3, Issue 1
Print ISSN: 2158-0782
Online ISSN: 2158-0537
Official Journal of the
United States Lactation Consultant Association

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International Lactation Consultant Association
2012 Conference & Annual Meeting
July 25-29, 2012
JW Marriott Orlando Grande Lakes | Orlando, Florida, USA
Featuring
Stephen Buescher, MD
on Human milk
and immunizations,
Human milk
cells, and Infant formula
Louise
Dumas, RN,
MSN, PhD on
Skin-to-skin
care as a safe
transition for mothers and babies
Martin Ward
Platt, MD on
Breastfeeding
and blood
glucose and
Mothers and babies –
The mysteries of the night
Michael
Woolridge,
DPhil on Fresh
ultrasound studies
on the mechanics of
breastfeeding and bottle-feeding
➤ Full day of Spanish presentations
➤ Workshops on global advocacy, research
and health promotion
➤ Popular clinical skills rotation – fills up early!
➤ 4-Hour Exam Prep Workshop with key
concepts, clinical slides, practice questions
and test-taking tips
➤ Tracks on empowering breastfeeding
families and high-risk infants
www.ILCA.org
Email: info@ilca.org | Phone: +1 919 861 5577 | Tollfree in US and Canada: +1 888 ILCA IS U (452 2478)

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Begin anytime. Work at your own pace.
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Program Director Vergie Hughes RN MS IBCLC FILCA RLC
(443) 607-8898 phone | (410) 648-2570 fax | programdirector@lactationtraining.com
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Table of Contents
9 “Don’t Sleep with Big Knives”: Interesting (and Promising)
Developments in the Mother-Infant Sleep Debate
Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA
13 Working with Families of Different Cultures I: Lessons Learned
Jeanette Panchula BSW, RN, PHN, IBCLC, RLC
16 Working with Families of Different Cultures II: Improving our
Communication Skills
Jeanette Panchula BSW, RN, PHN, IBCLC, RLC
21 The Nutritional Adequacy of Infant Formula
George Kent, Ph.D.
26 Clinical Decision Making: When to Consider Using a Nipple Shield
Diane C. Powers, BA, IBCLC, RLC
Vicki Bodley Tapia, BS, IBCLC, RLC
30 Clinical Tips: Caring for Breast Pump Parts
Kathleen Chiu, IBCLC, RLC
32 Blog Watch: Dangers of “Crying It Out”: Damaging Children and
Their Relationships for the Long-term
Darcia Narvaez, Ph.D.
36 Media Reviews
Kathleen A. Marinelli MD, IBCLC, RLC, FABM
39 Marketing via the Web and Social Media
Kathleen Lopez

Call for Papers
Clinical Lactation is a peer-reviewed journal summarizing
recent advances in clinical care in the field of human
lactation, and is the official journal of the United States
Lactation Consultant Association. The aim of the journal
is to advance clinical practice for lactation specialists
who work in a variety of settings: hospital, private
practice, WIC, and mother–to–mother–support organizations.
The articles being solicited for Clinical Lactation
are concise, readable reports that summarize issues
related to clinical care, treatment innovations and applications.
All articles should contain specific implications
and suggestions for clinical practice. Suitable topics for
submission include, but are not restricted to:
Treatment innovation
Treatment dilemmas
Case presentations
Implementation of specific programs
Outcomes of policies or programs
Papers should be consistent with the current evidence
base (if applicable), and should constitute a substantive
contribution to the professional literature on clinical lactation.
All articles can be hyperlinked to videos, websites,
PowerPoint slides, or other ancillary sources of
information.
Types of Contributions
Articles on Clinical Practice. These articles include process
and program descriptions, clinical audit and
outcome studies, and the presentation and description
of original clinical practice ideas. These articles should
generally not exceed 2,000 words (approximately 8 pages
of double-spaced text), not including references, and
should be written in a readable, user-friendly style.
Brief Reports of Research Findings. Brief reports of
research findings are concise reports of new research.
These articles are limited to 2,000 words, not including
references and must have direct clinical relevance. These
reports can be hyperlinked to other documents or websites
with additional information.
Brief Literature Reviews. Brief literature reviews are
concise articles on a highly specific topic related to clinical
practice, ending with applications for practice. These
manuscripts are also limited to 2,000 words (8 pages of
double-spaced text).
Case Reports. Case reports offer clinicians a forum to
share an interesting case, with the implications for
broader clinical practice. These reports will typically
range from 3–5 manuscript pages (750–1250 words).
Letters to the Editor. Letters and responses pertaining
to articles published in Clinical Lactation or on issues relevant
to the field, brief and to the point, should be
prepared in the same style as other manuscripts (250–
300 words).
Submission Requirements
All manuscripts submitted should adhere to the
format delineated in the Publication Manual of the
American Psychological Association, 6th Edition. Go
to ClinicalLactation.org for submission instructions.
Please also contact the editor if you have questions about
a possible submission (kkendallt@aol.com).
This journal is published by
1712 N. Forest • Amarillo, Texas • T: 806.376.9900 F: 806.376.9901
www.ibreastfeeding.com

Editor–in–Chief
Kathleen Kendall–Tackett, Ph.D., IBCLC, RLC, FAPA
Associate Editors
Catherine Watson Genna, BS, IBCLC, RLC Barbara Robertson, BA, MA, IBCLC, RLC
Shera Jackson, M.S., IBCLC, RLC, CPST
Editorial Assistant
Olga Evans, BA
Book Review Editor
Kathleen A. Marinelli, MD, IBCLC, RLC, FABM, FAAP
Copy Editors
Jaye Simpson, IBCLC, RLC, CIIM
Tricia Elbl, LLLL
Monique Jones, IBCLC, RLC
Laura Goodwin-Wright, MS, IBCLC, RLC
Editorial Review Board
Jo Ann Allen, RN, MSN, IBCLC, RLC
Denise Altman, RN, IBCLC, RLC, LCCE
Jan Barger, RN, MA, IBCLC, RLC, FILCA
Elizabeth Brooks, JD, IBCLC,RLC, FILCA
Jan Ellen Brown, BS, IBCLC, RLC
Suzanne Colson, RGM, RM, Ph.D.
Judith Dodge, BS, IBCLC, RLC
Nancy Franklin, LCSW, LMFT
Lawrence Gartner, MD, FAAP
Karen Kerkhoff Gromada, MSN, RN, IBCLC, FILCA
Thomas Hale, R.Ph., Ph.D.
Alison Hazelbaker, Ph.D., IBCLC, RLC, FILCA
Robin Hirth, BS, M.Ed., IBCLC, RLC
Kay Hoover, M.Ed., IBCLC, RLC, FILCA
Jarold (Tom) Johnston, MSN, CNM, IBCLC, RLC
Makeda Kamara, CNM, MPH, M.Ed.
Miriam Labbok, MD, MPH, IBCLC, RLC, FACPM, FABM
Judith Lauwers, BA, IBCLC, RLC, FILCA
Lisa Marasco, MA, IBCLC, RLC, FILCA
Kathleen Marinelli, MD, IBCLC, RLC, FABM, FAAP
Anne Montgomery, MD, IBCLC, RLC, FAAFP, FABM
Nancy Mohrbacher, IBCLC, RLC, FILCA
James Murphy, MD, IBCLC, RLC, FABM
Paula Oliveira, RN, IBCLC, RLC
Jeanette Panchula, BASW, RN, PHN, IBCLC, RLC
Kathy Parkes, BSPsy, RN, IBCLC, RLC, FILCA
Sherry Payne, RN, MSN, CBE
Molly Pessl, BSN, IBCLC, RLC
Karen Peters, MBA, RD, IBCLC, RLC
Linda Smith, BSE, FACCE, IBCLC, RLC, FILCA
Christina Smillie, MD, FAAP, IBCLC, RLC, FABM
Jeanne Tate, RN, IBCLC, RLC
Ann Twiggs, RD, LD, IBCLC, RLC
Marsha Walker, RN, IBCLC, RLC
Diana West, BA, IBCLC, RLC
Nancy Williams, LMFT, IBCLC, RLC
Barbara Wilson–Clay, BSEd, IBCLC, RLC, FILCA
Marilee Woodworth, BS, IBCLC, RLC

USLCA is organized and shall be operated exclusively for the educational, charitable, and scientific purposes as contemplated
by 501(c)(3) the United States Internal Revenue Code. More specifically, the purposes of USLCA are to:
2.1.1 To protect the public by advocating for the U.S. Lactation Professional in the United States of America, to promote
recognition of the U.S. Lactation Professional within the healthcare community, continued improvement in skills
related to lactation care, expansion of the literature relevant to lactation consultants and such other activities as
may hereafter be brought under the auspices of USLCA for such purposes;
2.1.2 To provide for education opportunities for the IBCLC and other healthcare workers concerned with breastfeeding
and related issues;
2.1.3 To heighten recognition of the consequences of artificial feeding of infants and children;
2.1.4 To cooperate with other organizations whose aims and objectives, in whole or in part, are similar to those of the
Association;
2.1.5 To foster communication, networking and mutual support amongst USLCA members;
2.1.6 To advocate for USLCA members and advise relevant authorities on issues of concern to the Association’s
members;
2.1.7 To uphold high standards of professional practice;
2.1.8 To foster awareness of breastfeeding and human milk feeding as important measures for health promotion and
disease prevention;
2.1.9 To encourage research in all aspects of human lactation; and
2.1.10 To support the worldwide implementation of the International Code of Marketing of Breast-milk Substitutes and
other subsequent World Health Assembly resolutions that are consistent with the goals and objectives of USLCA.
USLCA Board Of Directors
USLCA President
Laurie Beck, RN, MSN, IBCLC, RLC
Texas
USLCA Secretary
Karen Querna, RN, BSN, IBCLC, RLC
Washington
Director of External Affairs, Hospital Position Statement
Alisa Sanders, RN, IBCLC, RLC, CCE
Texas
Director Of Marketing
Debi Ferrarello, RN, MS, IBCLC, RLC
Pennsylvania
Director of Members Services–Chapters, Membership, Newsletter
Regina Camillieri, IBCLC, RLC
New York
Director of Professional Development
Barbara Robertson, BA, MA, IBCLC, RLC
Michigan
Director of Public Policy–Licensure and Reimbursement
Marsha Walker, RN, IBCLC, RLC
Massachusetts
Executive Director
Scott Sherwood
North Carolina
If you are interested in joining USLCA or learning more, go to USLCA.org.

“Don’t Sleep with Big Knives”
Interesting (and Promising) Developments in the Mother-Infant Sleep Debate
Share this:
Editorial
The city of Milwaukee launches their most recent infant sleep campaign.
On November 9, 2011, amid much fanfare and media
attention, the city of Milwaukee unveiled their latest
campaign to promote safe infant sleep. The images are
disturbing to say the least—they were designed that way.
“Co-sleeping deaths are the most preventable form
of infant death in this community,” Barrett said.
“Is it shocking Is it provocative” asked Baker, the
health commissioner. “Yes. But what is even more
shocking and provocative is that 30 developed
and underdeveloped countries have better (infant
death) rates than Milwaukee.”
A campaign such as this has a noble goal: to prevent
infants from dying. But does this type of campaign keep
infants safe The tragic answer is “no.” In less than two
months after this campaign was launched, two more
infants had died in Milwaukee in what the press
described as “cosleeping deaths.” http://www.jsonline.
com/news/milwaukee/ad-campaign-unveiled-asanother-cosleeping-death-is-announced-s030073-133552808.html
On January 3, 2012, WITI-TV, the affiliate Fox News in
Milwa-ukee reported this:
One-Month-Old Infant Dies in Co-Sleeping
Incident
Medical Examiner’s Report Says Baby Was Sleeping On
Floor with Three Other Children
The second death was of a 10-day-old infant who had
died while sleeping with three other children on an adult
bed. Neither of these infant sleep locations was safe and
should not be classified as “bedsharing deaths.” The sad
take-away we can learn from these cases is that “simple
messages,” may be headline‐grabbing. But in the end,
they do not communicate what parents need to know to
keep their infants safe while sleeping.
In the same month as the Milwaukee campaign was
launched, the American Academy of Pediatrics issued
their new policy statement and follow-up technical
© 2012 United States Lactation Consultant Association 9

eport (American Academy of Pediatrics & Task Force
on Sudden Infant Death Syndrome, 2011a, 2011b) on
infant sleep-related deaths. In their press release, they
stated that they were “expanding [the AAP guidelines]
on safe sleep for babies, with additional information for
parents on creating a safe environment for their babies
to sleep.” http://aappolicy.aappublications.org/cgi/
content/full/pediatrics;105/3/650
When I first read through this statement, it didn’t seem
to differ all that much from previous statements, particularly
on the issue many of us are interested in—namely,
their recommendations regarding bedsharing. That recommendation
did not really change. But in reading the
full statement, there were some interesting, and dare I
say hopeful, developments.
The AAP Policy Statement (2011a) lists their Levels A, B,
and C recommendations. A-Level recommendations are
those with the strongest evidence. Number 3 of their
Level-A Recommendations is that parents and infants
room share, but not bedshare (p. 1031). They based their
recommendation on the results of a new meta-analysis
of 11 studies comparing 2,404 cases where infants died
(28.8% of whom bedshared) with 6,495 healthy controls
(13.3% of whom bedshared). They calculated the odds
ratio and found that it was 2.89 (95% CI, 1,99-4.18). 1
Based on their calculation, bedsharing increased the risk
of SIDS by almost three times. But wait…..The authors
noted that there was “some heterogeneity in the analysis”
(p. 45). The heterogeneity in question referred to the
fact that several of the studies included infant deaths that took
place on a chair or couch (a situation that greatly increases
the risk of infant death), not just those that took place in
an adult bed with a non-smoking, non-impaired parent.
This issue has, of course, dogged the bedsharing debate
for more than a decade. The authors themselves acknowledged
that this was a difficulty (Vennemann et al., 2012).
Only recent studies have disentangled infants
sleeping with adults in a parental bed from infants
sleeping with an adult on a sofa. This is certainly
a limitation of the individual studies and hence of
the meta-analysis (p. 47).
Hopeful sign number 1: the AAP statement specifically
differentiates between bedsharing and the broader term,
“cosleeping,” which often includes all deaths that
1
An odds ratio of 1.0 indicates no increased risk. Above 1.0 means increased
risk. The higher the number, the worse the risk.
take place outside of a crib. I hope that this distinction
will trickle down into future research studies.
And there’s more. Vennemann et al. (2012) noted that
bedsharing was much more hazardous with a smoking
mother (OR=6.27; 95% CI, 3.94-9.99) than a non-smoking
mother (OR=1.66; 95% CI, 0.91-3.01). So there was
still some increased risk if an infant slept with a nonsmoking
mother. But remember that this analysis
included studies where babies died on couches and
chairs. The next analysis was by age of infant. For infants

precisely the point. There needs to be some recognition
of, and planning for, that contingency. But other than
that, I am happy to see this recommendation included.
The final point that I would like discuss is the role
of breastfeeding in SIDS prevention, and how bedsharing
has a role in sustaining breastfeeding. For example,
Helen Ball (2007) found, in her longitudinal study of 97
initially breastfed infants, that breastfeeding for at least a
month was significantly associated with regular
bedsharing.
We, in the breastfeeding world, have been saying this for
a very long time (Academy of Breastfeeding Medicine,
2008; McKenna & McDade, 2005; McKenna & Volpe,
2007). But now the SIDS researchers are saying it too. For
example, Vennemann et al. (2009) found that breastfeeding
reduced the risk of SIDS by 50%. (Yes, this is the
same Vennemann whose meta-analysis was cited above.)
Regarding breastfeeding, Vennemann et al. (2009) said
the following.
We recommend including the advice to breastfeed
through 6 months of age in sudden infant death
syndrome risk-reduction messages (p. e406).
Peter Blair and colleagues (Blair, Heron, & Fleming,
2010) went further and highlighted the role of bedsharing
in maintaining breastfeeding. (Peter Blair is also a
co-author on Vennemann et al., 2012.)
Advice on whether bed sharing should be discouraged
needs to take into account the important
relationship with breastfeeding (p. 1119).
So I am hopeful that we may be reaching a possible
accord on this issue. While the AAP will probably never
come straight out and recommend bedsharing, it would
be helpful if they acknowledged that it will likely
continue, and that our role is to help all parents sleep as
safely as possible—either with or near their infants. Such
a statement is possible. I’d like to close with the words
from the Canadian Paediatric Society (Canadian
Paediatric Society & Committee, 2004/2011).
Based on the available scientific evidence, the
Canadian Paediatric Society recommends that for
the first year of life, the safest place for babies to
sleep is in their own crib, and in the parent’s room
for the first six months. However, the Canadian
Paediatric Society also acknowledges that some
parents will, nonetheless, choose to share a bed
with their child…..
The recommended practice of independent
sleeping will likely continue to be the preferred
sleeping arrangement for infants in Canada, but a
significant proportion of families will still elect to
sleep together…….
The risk of suffocation and entrapment in adult
beds or unsafe cribs will need to be addressed for
both practices to achieve any reduction in this devastating
adverse event (emphasis added).
References
Academy of Breastfeeding Medicine. (2008). ABM clinical protocol
#6: Guideline on co-sleeping and breastfeeding. Breastfeeding
Medicine, 3(1), 38-43.
American Academy of Pediatrics, & Task Force on Sudden Infant
Death Syndrome. (2011a). Policy Statement: SIDS and other
sleep-related deaths: Expansion of recommendations for a safe
infant sleeping environment. Pediatrics, 128(5), 1030-1039.
American Academy of Pediatrics, & Task Force on Sudden Infant
Death Syndrome. (2011b). Technical Report: SIDS and other
sleep-related deaths: Expansion of recommendations for a safe
infant sleeping environment. Pediatrics, 128(5), e1-e27.
Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA is a health psychologist,
IBCLC, and Fellow of the American Psychological Association. Dr.
Kendall-Tackett is Editor-in-Chief of Clinical Lactation, clinical associate
professor of pediatrics at Texas Tech University Health Sciences Center,
and owner of Praeclarus Press. More information on the mother-infant
sleep debate can be found at http://praeclaruspress.com/sense-sensibility.html
© 2012 United States Lactation Consultant Association 11

Ball, H. L. (2007). Bed-sharing practices of initially breastfed infants
in the first 6 months of life. Infant & Child Development, 16, 387-
401.
Blair, P. S., Heron, J., & Fleming, P. J. (2010). Relationship between
bed sharing and breastfeeding: Longitudinal, population-based
analysis. Pediatrics, 126(5), e1119-e1126.
Canadian Paediatric Society, & Committee, C. P. (2004/2011).
Recommendations for safe sleeping environments for infants
and children. Retrieved from http://www.cps.ca/english/statements/cp/cp04-02.htm#Recommendations
Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2010). Motherinfant
sleep locations and nighttime feeding behavior: U.S. data
from the Survey of Mothers’ Sleep and Fatigue. Clinical Lactation,
1(1), 27-30.
McKenna, J. J., & McDade, T. W. (2005). Why babies should never
sleep alone: A review of the co-sleeping controversy in relation
to SIDS, bedsharing, and breastfeeding. Paediatric Respiratory
Reviews, 6, 134-152.
McKenna, J. J., & Volpe, L. E. (2007). Sleeping with baby: An
internet-based sampling of parental experiences, choices, perceptions,
and interpretations in a Western Industrialized context.
Infant & Child Development, 16, 359-386.
Vennemann, M. M., Bajanowski, T., Brinkmann, B., Jorch, G.,
Yucesan, K., Sauerland, C.,...the GeSID Study Group. (2009).
Does breastfeeding reduce the risk of sudden infant death syndrome.
Pediatrics, 123, e406-e410.
Vennemann, M. M., Hense, H.-W., Bajanowski, T., Blair, P. S.,
Complojer, C., Moon, R. Y., & Kiechl-Kohlendorfer, U. (2012).
Bedsharing and the risk of sudden infant death syndrome: Can
we resolve the debate Journal of Pediatrics, 160, 44-48.
New WHO Report on Reducing Maternal and Newborn Deaths
The World Health Organization (WHO) has just released its document, Essential
Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health.
This global consensus outlines 56 essential interventions to be used by health care workers
and communities to significantly reduce the risk for death of mothers, infants, and children.
Among the recommendations on essential interventions for newborns, skin-to-skin
care and breastfeeding in the first hour are listed at the top.
Although the primary target audience for this study is decision-makers in low- and middleincome
countries, the recommendations are best practices suitable for all communities.
This new document is another excellent reference for IBCLCs and other health professionals
seeking to build and retain lactation services in hospital, clinic, and community
settings. The document can be at http://www.who.int/pmnch/topics/part_publications/201112_essential_interventions/en/index.html
12 Clinical Lactation 2012, Vol. 3-1

Working with Families of Different Cultures I
Lessons Learned
Share this:
Jeanette Panchula BSW, RN, PHN, IBCLC, RLC 1
The Code of Professional Conduct for IBCLCs states that an IBCLC must “Provide care to
meet clients’ individual needs that is culturally appropriate and informed by the best available
evidence.” IBCLCs must not only have knowledge that will help a mother breastfeed. They must
also have the skill to help her to discern the best solution for her situation. The ability to communicate
with clients does not necessarily mean learning “everything there is to know” about
their culture. Rather, it means learning the basis for the mothers’ beliefs and actions.
Keywords: Breastfeeding support, ethnic-group differences, cultural competence
Clinical Lactation, 2012, Vol. 3-1, 13-15
Looking back on 26 years as an IBCLC, and 36 years as
a La Leche League Leader, I cannot imagine a more exciting,
awe-inspiring, frustrating, and worthwhile career. I
was raised in a multigenerational, bicultural, and bilingual
household and city, San Juan, Puerto Rico. In San
Juan, people of many different socioeconomic groups
mixed in the market, the stores, and schools. As a result,
I have always been comfortable with a variety of accents,
beliefs, and ways of life.
The concept that there is only one way—the way “I” was
raised—was truly never expressed or taught to me.
In fact, as a small child, I asked a nice man who was walking
right by my porch: “¿Por qué tu eres tan negro”
[Why are you so black]. Without missing a beat, he
answered: “Porque estoy mucho al sol.” [Because I am in the
sun a lot.]
That was the only education I received about race or
skin color, as my parents did not believe it was an
issue that I needed to be concerned with. It was only
when a TV arrived in my home, and I saw horrible
actions of others in the southern areas of the U.S. that I
learned why my father would not move back to the
U.S. with his dark-skinned Puerto Rican wife, and
very light‐skinned (unless I spent a lot of time in the sun)
daughter.
When I lived in St. Louis in the 80s with my own children,
husband, and mother (she lived with us for 25
years)—I did experience how sales clerks and others
“assumed” my mother was my maid. This preface is an
explanation of why and how I arrived at the philosophy
1 jeanette.panchula@sbcglobal.net
that I continue to practice today: All humans are different.
All humans have their own story to tell. You cannot
look at them and assume you know anything about them.
You have to ask.
Assumption: Father is not involved/
interested.
You go into a hospital room, and you see a mother in
the bed trying to breastfeed. She has a scarf over her
head, keeping the hair out of her eyes as she works, and
works at trying to get the baby on “right.” She is frustrated
and worried. Her husband is on the other side of
the curtain, at times reading a book, at times speaking to
her, urging her to “try this” or “try that.” Then he goes
back to reading.
Fact: Mom and dad are practicing orthodox Jews. Her
head is covered as she should during the period that she
is bleeding. She is untouchable at this time, and her husband
is following strictly the instructions that he must
not look at his wife’s body during this time.
Actions: I stand in a location that allows both mother
and father to see me. I use a doll to demonstrate positioning
to both (this is prior to Biological Nurturing®).
We then discuss how the father can help his wife by
identifying where she can sit and be comfortable, what
pillows she may need, what foods are comforting to her,
and how to burp and change the baby. He was so relieved
to know that he could do something instead of being
vilified as an uninterested or demanding jerk.
How did we get there By my asking: Can you tell me
what you need What are your concerns What help will
© 2012 United States Lactation Consultant Association 13

you be getting at home This was the key. Both let
me know about their beliefs: not the beliefs of “the
Orthodox Jewish,” but theirs.) I have worked with people
of many different religions, and know that what they do
isn’t just because they’re Jewish or Catholic or Muslim
or Protestant. What they do is because of how they practice
their beliefs.
Assumption: “They” won’t accept
information or instructions offered by
someone of a different culture.
I made a home visit with a Public-Health Nurse. We
knew the mother was from Ethiopia and was Muslim. As
the nurse was Jewish and I was Catholic, we both put the
symbols we usually wear around our necks inside our
blouses. No need to stress the mother with an obvious
sign that may increase her concern about dealing with
Americans!
Fact: When we arrived, she was already breastfeeding. It
was obvious she was in pain and her baby was damaging
her nipple. We also could see that he was very straight:
unable to curve against her body in any way. Upon
undressing the baby to weigh him, we found a very, very,
very long piece of fabric had been wound around his
torso from hips to under his arms.
Actions: We asked about this fabric, commenting that
the colors and patterns were interesting. She said her
mother had sent it to her from her country with instructions
to wrap it around him to keep his back straight. We
asked how she felt about it. She said she was not sure it
was needed, but she didn’t know whether she would be
hurting her baby if she did not use it. We asked if it
would be OK to not wrap the baby after weighing, and to
try a different way to put the baby to the breast (again
this was before BN). She looked relieved: “anything
would be better than what I’m going through!” A muchbetter
latch was achieved. And we provided additional
information related to the value of allowing baby’s own
muscles and bones to achieve the desired straight back.
During all follow-up visits it was evident the fabric was
never used again.
How did we get there By asking, being attentive to verbal
and non-verbal cues, and then truthfully replying
with information.
Assumption: African American mothers
don’t breastfeed.
A mother delivered her baby in a local hospital. Nurses
on the floor did not go in to ask about her breastfeeding:
after all, she was African American. However, the IBCLC
came on the floor and decided to ask them how they
were doing.
Fact: They were doing very well. The mother, the grandmother,
and the father had all attended a six-session
training offered in their church for free. And they were
all Peer Counselors for the A More Excellent Way
Program (www.mewpeers.org).
Action: None needed, except educating the staff that
yes, African American mothers do breastfeed when provided
the right rationale at the right time with the right
information and resources—and they have a family and
community that supports them.
Question: Is that not the same for all mothers
Assumption: Hispanic mothers do not
exclusively breastfeed.
Fact: Mothers in hospitals sometimes ask for formula.
When the mother is Hispanic, many of the staff just
sigh, often do not take the time to get on a translation
line, or try to locate someone who speaks Spanish to provide
information and education about the importance
and value of exclusive breastfeeding… because “they”
always supplement.
Fact: Carol Melcher, RNC, CLE, MPH, together with
the Perinatal Services Network of Loma Linda University
in California, developed a program called Birth and
Beyond (now evolved to Soft Hospital—www.softhospital.com
). She was often told that some hospitals would
never be able to achieve high exclusive breastfeeding
rates because they had large Hispanic populations. The
Birth and Beyond team created collaborations that
resulted in 10 hospitals becoming Baby Friendly. This
included hospitals primarily serving the Hispanic community.
Part of the project included adding staff to help
gather data and provide additional services. In this case,
they hired someone who was knowledgeable about
breastfeeding, and fluent in Spanish. She could then
explain to parents the importance of early skin to skin,
avoiding pacifiers and bottles, and all the other policies
that were part of their hospital’s maternity services in
their own language. The outcome: hospitals serving
14 Clinical Lactation 2012, Vol. 3-1

primarily Hispanic mothers had exclusive breastfeeding
rates that rose in the same way as hospitals serving non-
Hispanic mothers.
Fact: Jane Heinig, Ph.D., IBCLC, and her team from the
Human Lactation Center at UC Davis (http://lactation.
ucdavis.edu/aboutus/index.html ), led focus groups of
Hispanic mothers as a part of their research of infant
feeding practices in the WIC program. She reported in
the first California Breastfeeding Summit (2011) that not
one mother in the focus groups stated that they requested
formula “because my culture does it.” All mothers
reported the same fears, concerns, insecurities, and frustrations
that have been listed since research on the
perceived barriers to breastfeeding began:
••
I don’t think I’m doing it right.
••
He wants to eat all the time.
••
I don’t have enough milk.
Action: Asking a mother—Hispanic, Asian, African
American or from anywhere—why she wants formula
usually leads to identifying concerns common to all
mothers.
Ideally staff should be fluent and able to dialogue with
the mother. However, many hospitals have limited number
of staff fluent in Spanish (or the many other
languages of the mothers they serve, especially in
California). They may be able to communicate the basic
information in a few sentences. But mothers who have
concerns need more. They need to hear that “this is a
very common worry mothers have,” and “we have people
here and after discharge that can help you,” and “let me
come by in a few minutes after you’ve tried xxx.”
When mothers are provided support by people who
speak their language, they will accept the information.
How this is done can vary.
••
Improving the knowledge about breastfeeding
support to the staff that is fluent in other languages.
••
Collaborating with local programs, such as WIC,
to provide staff and/or peer counselors to support
breastfeeding mothers in and out of the hospital.
••
Linking mothers to groups and agencies that have
staff that speak her language.
••
Local community agency staff to any breastfeeding
trainings offered in hospitals or community centers.
You can find more specific information on communication
skills in working with families from different
cultures in Panchula (2012b).
Reference
Panchula, J. (2012b). Working with families of different cultures II:
Improving our communication skills. Clinical Lactation, 3(1),
16-20
Resources for Further Studies
Journal of Transcultural Nursing, Thousand Oaks, CA: Sage Publications
Health Resources and Services Administration (HRSA):
Indicators of cultural competence in health care delivery organizations:
An organizational cultural competence assessment profile. Retrieved
from: www.hrsa.gov/culturalcompetence/healthdlvr.pdf The
providers’ guide to quality and culture. Retrieved from: http://erc.
msh.org/mainpage.cfmfile=1.0.htm&module=provider&langu
age=English
American Academy of Family Physicians
Cultural proficiency resources. Retrieved from: www.aafp.org/online/
en/home/clinical/publichealth/culturalprof.html
American Academy of Pediatrics
Cultural competency (starter kit for community preceptors). Retrieved
from: http://practice.aap.org/content.aspxaID=1757
Motivational interviewing. Retrieved from: http://www.motivationalinterview.org/
Practicing cross-cultural communication: Ongoing, free online training
course of the New York/ New Jersey Public Health Training Center.
Retrieved from: http://e2ma.net/go/7353886294/208749487/
226815425/1407815/goto:http://www.nynj-phtc.org/pccc.cfm>
Multicultural health in public health practice. Retrieved from: http://
www.njphtc.org/
Jeanette Panchula has been a La Leche League Leader since 1975,
an IBCLC since 1985 and most recently worked as a Senior Public
Health Nurse in California. She works part-time as a consultant for
the Maternal, Child and Adolescent Health Divisions of the state
of California and Solano County. She enjoys speaking/teaching about breastfeeding
and communication to hospital staff and peer counselors alike.
© 2012 United States Lactation Consultant Association 15

Working with Families of Different Cultures II
Improving our Communication Skills
Jeanette Panchula BSW, RN, PHN, IBCLC, RLC 1
Share this:
Working with families from different cultures requires self-awareness, the desire to understand the
goals of our clients, and the ability to collaborate with them to achieve the outcome they are
seeking. Primarily this is achieved through asking open-ended questions, listening not just to the
words, but the feelings that are being communicated, sharing with her that what she has stated
is understood, and then helping her identify an option that will work for her, her baby, and her
family. Using this method maintains respect for the client’s beliefs and culture, and increases the
likelihood of a successful outcome—and possibly creating a new breastfeeding expert and advocate
in the process.
Keywords: Breastfeeding, cultural competence, communication skills
Clinical Lactation, 2012, Vol. 3-1, 16-20
As an IBCLC, it is essential that we not only have knowledge
of the information that will help a mother
breastfeed. We also have to know how to impart that
knowledge. Below are some suggestions I’ve compiled
from my backgrounds in Social Work, La Leche League
Leadership, and local, state, and national WIC projects.
I have helped mothers breastfeed in Puerto Rico, and
five different U.S. states.
The Code of Professional Conduct for IBCLCs states:
1.2 Provide care to meet clients’ individual needs that
is culturally appropriate and informed by the best
available evidence.
In order to accomplish this, we must take responsibility
to understand the families we serve. We can increase our
knowledge just as we do for other aspects of our work as
IBCLCs.
If you do a web search of “cultural competence,” you will
find lists of courses available from many sources. Often
these courses and books provide lists of what “they”
believe. Although interesting and possibly a way to help
the IBCLC know what questions to ask, these can also
lead us to assume that we “know” what this mother
believes; a concept that is, in my opinion, as useless as
knowing what “Americans” or “Southerners” believe.
The publication of an essay about “Cultural Humility”
better reflects the need to develop a lifelong skill, and
1
jeanette.panchula@sbcglobal.net
the ability to learn and discern appropriate care for our
clients, as described in the website by California Health
Advocates: Are you practicing cultural humility The key
to success in cultural competence. www.cahealthadvocates.org/news/disparities/2007/are-you.html
Dr. Melanie Tervalon and Jann Murray-Garcia describe
cultural humility as a lifelong process of self-reflection
and self-critique. The starting point for such an approach
is not an examination of the client’s belief system, but
rather having health care/service providers give careful
consideration to their assumptions and beliefs that are
embedded in their own understandings and goals of
their encounters with clients.
An IBCLC can increase his/her skill by:
Reading books, such as Women’s Ways of Knowing
(Belenky et al., 1997), or this article by Monica
Roosa Ordway (2008). http://jhl.sagepub.com/
content/24/2/135.full.pdf+html
Attending webinars such as:
Promoting breastfeeding in minority communities and in
the workplace. www.albany.edu/sph/coned/bfgr/
bfgr04.htm
Communicate to make a difference series: exploring cross
cultural communication. New York/New Jersey Public
Health Training Center http://www.lowernysphtc.
org/trainingcatalog
But most of all work towards increasing our knowledge
16 Clinical Lactation 2012, Vol. 3-1

through a variety of experiences. I encourage all IBCLCs
who work in hospitals or private clinics to connect with
professionals in public health, especially public-health
nursing. Making home visits, and seeing what mothers
will be facing when they go home is one of the best ways
to develop a better understanding of the “landscape” of
our clients, including their culture.
••
Be aware of this attitude.
••
Identify others who enjoy working with teens and
provide them with the knowledge of how to support
these young breastfeeding moms.
••
If there is no one else, we must be very aware of our
communication, especially non-verbal. Below will be
some steps that will help.
Similar to when we lack knowledge about how to deal
with mothers with different physical characteristics or
situations from our own (e.g., larger breasts, twins), we
must increase our ability to communicate with mothers
with experiences we may not have had (e.g., poverty,
racism).
IBCLCs spend a lot of time and effort preparing for the
exam, and continue to take courses to maintain their
certification. I believe, that like CPR and ethics, communication
skills should also be a requirement for
re-certifications. Often we “forget” what steps to follow
when communicating with our clients. Of course, there
is no “one way.” Below are some points I believe will
help. Without developing the skills to communicate
with our clients, there is much less likelihood that we
will have met our client’s needs, leading to frustration
for both the IBCLC and the mother.
Self-Awareness
My first degree was Social Work. The training offered
was related to using our own personalities to help
improve communication with our clients. This required
an awareness not only of our clients’ needs, but also of
ourselves. It is essential that we be aware of our own preconceived
notions. This is the first step in working with
our clients/patients.
What if we are in a situation where we cannot avoid
working with mothers who make us feel
uncomfortable
We need to acknowledge to ourselves that this is the case,
in order to avoid placing the burden of communication
on our clients.
••
We need to be very attuned to both their body
language and tone of voice, and our own.
••
An example: Perhaps we find teens annoying knowit-alls,
difficult to communicate with, and unwilling
to listen. What can we do
You may wonder why I chose to use “teens” as an example
in this article about “Working with mothers of
different cultures” I did this quite purposefully. I have
found that when we consider “teens” a different culture,
rather than as “unfinished adults” who “have no business
being mothers,” and address them with similar
respect as we would a mother from Bangladesh or Cuba
or Laos, we are more successful in developing rapport,
identifying their barriers, and developing a plan that will
work in THEIR culture/landscapes.
Avoid Prescribing
Once we have become self-aware, we can more easily
address the needs of our client. However, we need to
have a “barrier to our lips” when we first meet with a
mother. We need to avoid walking in with “this is what
you need to do” or “I understand you’re having ____
and it’s best if you ___.
…even when we were given a written chart with clear documentation
of what is troubling this mother…
…even when we talked to her on the telephone and she
told us what she needed…
…even when a fellow IBCLC has described clearly what
issues are…
Some basic steps highlighted below can help us discover
a mother’s issues and solutions. (In WIC it is called the
Three Steps. In other programs, there are more.)
As experts, we often move into a “fixing” mode, and
then are frustrated when the mother “doesn’t do it.”
Mothers need to know, in their deepest self, that you
have “heard” them: that you are not just giving them
information and answers based on what you believe but
on what they are experiencing.
Clarify the Information
We must know what this mother is reporting, in her own
© 2012 United States Lactation Consultant Association 17

words. Yes, it seems like a “waste of time.” But we accomplish
two very important goals.
1. A mother will get to know us and develop a sense
of being heard and understood. Thus, we avoid
the trap of assuming we know what is truly her
concern.
2. We will hear symptoms in her words rather than
interpretations by others, which can often lead to
a different plan, and save us a great deal of time
in the long run.
We accomplish this through the use of what we have
learned through many different venues and professional
courses: Ask open-ended questions.
If we ask: Does it hurt We get a “yes or no” answer. In
contrast, if we ask: “What does it feel like,” or “What
was the last feeding like,” or “Can you describe your day
to me,” we get a much richer description, which often
leads to additional questions.
Continue to Clarify
After we have some ideas of what is going on, describe
back what you heard and make sure you heard it correctly,
or that you did not misinterpret a term. This is
especially important. Terms and language mean different
words to different cultural groups. For example, you
may assume you understand what “Hispanics” mean.
But if you are talking to a Puerto Rican, “ahorita” means
“in the near future.” To a Mexican mom, it means “right
now.” This misunderstanding can cause big problems in
terms of scheduling a visit, starting a treatment, or
arranging for a referral.
An African American mother may say to you that her
baby is “greedy.” Does that mean the baby is too demanding
Or does it mean that her baby is strong, knows what
he wants, and goes for it
Another important clarifying question: What have you
tried
Asking this shows respect for the mother. She must have
tried something if her baby was crying, or too sleepy, or
not latching on correctly. Listening to the mother can
often reduce the frustration often felt by IBCLCs who
say, “she refuses to try anything I suggest!” Some may say:
Asking all these questions will take tooo long!
In my experience, without asking questions and getting
a full picture, a lot of time is wasted, teaching what has
already been tried, or worse: providing education on
what is not the real problem. For example, a mother
calls and says her nipples are sore. Until we ask questions
about the age of the baby, when this started, what
happens and when, what it looks like, we could be giving
information about positioning when the issue is that the
baby bit her.
Reflect Feelings and Validate
After asking questions and clarifying information, many
IBCLCs launch into the “teaching” mode: “What you
need to do is: ….” Or “Let’s get the baby going…” Or “I
need to refer you to…” However, if a mother does not
sense that we understand what they have been through,
she often will just repeat a description of her problem, at
times almost verbatim, again. They seem to give us a
“broken record” report, stating over and over their issues.
For example:
••
“No one listened.”
••
“They didn’t help me.”
••
“The labor was horrible.”
••
“When the baby latches on it, feels like crushed glass.”
I’ve found that mothers need to know we “heard” them
and understand what they feel, and what has upset them.
It is hard at times to remember to take this step. We
want to get going on the “fixing” stage. However, when
working with mothers of our own, or of different cultures,
and especially with mothers for whom English is
not the first language, it is one of the best ways to establish
a feeling of trust and understanding. Choose words
you are comfortable with, and be specific so the mother
knows you care.
••
“It sounds like you’ve been very frustrated with
different solutions given to you.”
••
“How frightened you must have felt when you learned
your baby was losing weight.”
••
“You’re feeling guilty about not wanting to breastfeed.
But it hurts too much!”
It is important to use different and specific feeling words.
We don’t have to fear getting it “wrong”; mothers will
usually correct us if we didn’t get it “right” (e.g., “No,
I’m not frightened. I’m ANGRY.” ). Doing this gives us
18 Clinical Lactation 2012, Vol. 3-1

time to really listen, think the solution through for this
breastfeeding dyad, rather than running headlong into
the “education mode.”In my experience, when mothers
sense that we DO understand and are “with” them in
their feelings, they more easily move on to the next step:
addressing their issues and problem-solving with us.
Targeted Education
Whatever culture or language, mothers of young babies
and mothers under stress are not ready to hear a large
number of instructions. Our education must be targeted
to the problem at hand, and what mother is ready to
hear.
This can be difficult for us. We want her to know… so
much more.
••
What her baby needs at 1 day, at 7 days, at 2 months,
etc.
••
Babies need to be “babied.”
••
This period of total dependence is really very short
in the “big picture.”
••
Breastfeeding will make a huge difference in
their relationship with their babies, and their
babies’ health.
The reality is the mom is not ready to hear so many messages.
We must concentrate on her question, her
priorities, and her concerns. We need to identify what
she feels she needs to know, answer her questions by giving
her various options—even those you would rather
she not take, and then be open to listening to her
decision. 1
CAUTION:
If there is fear for the baby’s health, such as when a mother demands that she
MUST exclusively breastfeed, we must be aware of our obligations. If, despite
attempts to establish rapport and communicate with her effectively, there is
still concern that her choice may put her baby at risk, it is essential that we
communicate our concerns with the baby’s health care provider. (Code of
Professional Conduct for IBCLCs; 4.2 (www.iblce.org/upload/downloads/
CodeOfProfessionalConduct.pdf)
For example, a mother has decided her nipples hurt too
much, even though she was able to latch the baby to the
breast with little pain while you were there, she wants to
pump. This is not the time to disagree with her. It is the
time to let her know you respect her decision, and will
be available to address other options when she is ready.
Provide e-mail, telephone, and web contact information
that she can use to access you or someone who can translate
if she cannot communicate directly with you.
Following Up
Maintaining contact with mothers of different cultures
and languages can be difficult. Whenever possible follow-up
the visit with a text or an e-mail (even mothers
who are poor now have access to the Internet) with links
to information in their language to send a follow-up
e-mail. Some sources are:
••
La Leche League International (www.lalecheleague.
org)
••
Medline: www.nlm.nih.gov/medlineplus/languages/
breastfeeding.html
••
The Baby Friendly Initiative, UK www.unicef.org.
uk/BabyFriendly/Resources/Resources-in-otherlanguages/
Having used the steps above often leads to a continuing
relationship with mothers, giving us opportunities to
add to our own knowledge of their culture and beliefs.
This will also allow us to develop the skills of someone
who will someday be able to provide information and
support to her friends and neighbors—in their own language.
In my experience, this is one of the most rewarding
aspects of my job as an IBCLC: meeting a mother who is
breastfeeding and learning from her that a mother I
helped years ago, helped her. I can see a network of
knowledgeable and multicultural experts growing, as
these mothers become Peer Counselors and IBCLCs!
Hope to see some of you at ILCA, 2012. I plan to
improve my own skills, and expand my network by
attending the Spanish Track, and the full conference.
Bibliography
Airhihenbuwa, C.O. (1995). Health and culture-beyond the western
paradigm. Thousand Oaks, CA: Sage Publications.
Beasley, A. (1991). Breastfeeding studies: Culture, biomedicine, and
methodology. Journal of Human Lactation: 7; 7.
Belenky, M.F. et al. (1997). Women’s ways of knowing: The development
of self, voice, and mind. New York City, Basic Books
Bodo, K., & Gibson, N. (1999). Childbirth customs in Orthodox
Jewish traditions. Canadian Family Physician. 45, 682–686.
Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2328400/page=1
Chiu, S.H., Anderson, G.C., & Burkhammer, M.D. (2008). Skin-toskin
contact for culturally diverse women having breastfeeding
difficulties during the early postpartum. Breastfeeding Medicine,
3(4), 231–237
© 2012 United States Lactation Consultant Association 19

Good Mojab, C. (2000). The cultural art of breastfeeding. Leaven,
36(5), 87–91.
Hunt, L.M. (2001). Beyond cultural competence applying humility to
clinical settings. Up front. Retrieved from: http://www.parkridgecenter.org/Page1882.html
Kiselica, M. S. (1995). Multicultural counseling with teenage fathers.
Thousand Oaks, CA: Sage Publications.
Lauwers. J., & Swisher, A. (2005). Counseling the nursing mother, 4 th
ed. Sudbury, MA: Jones and Bartlett.
Lu, M.C., & Halfon, M. (2003). Racial and ethnic disparities in
birth outcomes: A life-course perspective. Maternal and Child
Health Journal, 7(1), 13–30
Mohrbacker, N(2010). Breastfeeding answers made simple. Amarillo,
TX: Hale Publishing.
Ordway, M.R. (2008). Synthesizing breastfeeding research: A commentary
on the use of Women’s ways of knowing. Journal of Human
Lactation, 24, 135-138.
Riordan, J., (2010). Breastfeeding and human lactation, 5 th Ed.. Sudbury,
MA: Jones and Bartlett.
Scott, J.A., & Mostyn, T. (2003). Women’s experiences of breastfeeding
in a bottle-feeding culture. Journal of Human Lactation,
19, 270.
Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus
cultural competence: A critical distinction in defining physician
training outcomes in multicultural education. Journal of Health
Care for the Poor and Underserved, 9(2), 117.
Thulier, D. (2009). Breastfeeding in America: A history of influencing
factors. Journal of Human Lactation, 25, 85.
Zimmerman, G.L., Olsen, C.G., & Bosworth, M.F. (2000). A
“Stages of Change” approach to helping patients change behavior.
American Family Physician. Retrieved from: http://www.aafp.
org/afp/20000301/1409.html
Jeanette Panchula has been a La Leche League Leader
since 1975, an IBCLC since 1985 and most recently
worked as a Senior Public Health Nurse in California.
She works part-time as a consultant for the Maternal,
Child and Adolescent Health Divisions of the state
of California and Solano County. She enjoys speaking/
teaching about breastfeeding and communication to hospital
staff and peer counselors alike.
20 Clinical Lactation 2012, Vol. 3-1

The Nutritional Adequacy of Infant Formula
Share this:
George Kent, Ph.D.
Government agencies that regulate infant formula have been concerned about its safety, worrying
about things like contamination with bacteria and insect parts. Questionable formula has been
subject to government-ordered recalls. This attention reinforces people’s confidence that national
governments are ensuring the quality of infant formula. However, national regulatory agencies
generally just assume that various versions of infant formula and other foods are safe for children
(Kent, 2011).
While many others have commented on safety issues relating to infant formula, few have paid
attention to another important point. Safety is about ensuring that the product does not cause
direct harm—but that is not enough. There are things infant formula is supposed to do. The quality
of infant formula depends not only on its safety, but also on its nutritional adequacy.
Keywords: Infant formula, safety, nutritional adequacy, Codex Alimentarius
Clinical Lactation, 2012, Vol. 3-1, 21-25
The Regulatory Context
At the global level, the primary agency concerned with
food quality is the Codex Alimentarius Commission,
created by the Food and Agriculture Organization, and
the World Health Organization in 1963. It issues nonbinding
guidelines regarding food composition and
safety. In 1976, at its 11 th session, the Codex Alimentarius
Commission issued a Statement on Infant Feeding. It said:
…it is necessary to encourage breastfeeding by
all possible means in order to prevent that the
decline in breastfeeding, which seems to be actually
occurring, does not lead to artificial methods
of infant feeding, which could be inadequate or
could have an adverse effect on the health of the
infant (Codex Alimentarius Commission, 1976).
At this session the Commission also adopted a Codex
Standard for Infant Formula. The standard, designated
as CODEX STAN 72-1981, includes a list of required
ingredients and various required quality-control measures.
In 1983, the 15th Session adopted amendments
to the sections on Food Additives and Labeling. A further
amendment to the Labeling section was adopted in
1985 by the 16th Session. Amendments to the vitamin
D and B12 amounts were adopted by the 17th (1986)
and 22nd (1997) sessions respectively (Codex
Alimentarius, 2007).
This core statement of the required ingredients for
infant formula is generally accepted throughout the
world. The permitted nutrient ranges allow a variety of
quite different formulas. The requirements are widely
regarded as a minimum standard. Some countries have
adopted more stringent requirements.
The primary source of binding regulations regarding
foods is national governments. In the United States, the
responsibility for regulating children’s foods, such as
infant formula, is the Food and Drug Administration
(FDA), located in the U.S. Department of Agriculture
(USDA).
The Federal Food, Drug, and Cosmetic Act defines
infant formula in Title 21, Section 321(z) of the United
States Code. It is:
…..a food that purports to be or is represented
for special dietary use solely as a food for infants
by reason of its simulation of human milk or its
suitability as a complete or partial substitute for
human milk (21 U.S. Code 321 (z)).
Section 350a of the act provides specifications regarding
adulteration, quality-factor requirements, manufacturing
regulations, product testing, and record keeping. It
sets out a list of required nutrients and their minimum
and maximum quantities. The list includes protein, fat,
essential fatty acids (only linoleate is in the list), fifteen
different vitamins, and eleven different minerals. The
1 Kent@Hawaii.edu
© 2012 United States Lactation Consultant Association 21

list conforms to the recommendations of the Codex
Alimentarius Commission.
The U.S. Code of Federal Regulations Title 21, Part 106
specifies infant formula quality- control procedures. Last
revised in 2009, it is mainly about quality control during
the manufacturing process, and not directly about the
quality of the product that emerges from that process
(U.S. Code of Federal Regulations (21CFR106) 2009).
Part 107, last revised in 2003, states the nutrient requirements
and other rules regarding labeling, recalls, etc.
(U.S. Code of Federal Regulations (21CFR107) 2003).
U.S. rules have been summarized as follows:
Infant formula, like no other food, is regulated
by its own law, the Infant Formula Act of 1980
as amended in 1986. The act sets lower limits on
29 nutrients (so-called “table nutrients” because
they appear in table form. U.S. Code of Federal
Regulations 21 CFR 107.100). . . . Manufacturers
are required to follow “good manufacturing
practice,” but no requirement for sterility is specified.
. . . Powdered formula is not guaranteed
nor required to be free of pathogenic organisms
(Baker, 2002).
Nutritional Adequacy
Infant formula is not officially a pharmaceutical product,
though in many cases the manufacturers are
pharmaceutical companies. If infant formula were to be
categorized as a pharmaceutical, under U.S. law it would
have to be assessed for both its safety and its effectiveness.
Safety is about ensuring the product does no harm
in the short term, while effectiveness is about ensuring
that it does what it is supposed to do: its functionality.
In dealing with pharmaceuticals, for example, if a claim
is made that a product will reduce fever, it should be
demonstrated scientifically that it does in fact accomplish
that. For infant formula, effectiveness can be
understood as equivalent to nutritional adequacy. Does
infant formula do what it is supposed to do with regard
to infants’ nutrition
The only thing the FDA does to ensure nutritional adequacy
is to require that all varieties of infant formula
conform to the list of required ingredients that was
worked out in the 1980s, with a few modifications since
then. The FDA usually takes the manufacturers’ word
on whether they have, in fact, met those requirements.
The underlying assumption is that any infant formula
that includes the specified ingredients in the required
amounts is both safe and nutritionally adequate.
This is a simplistic, reductionist approach, treating
something very complex as if it were the same as the sum
of its components. It is a bit like suggesting there is no
difference between a nice meal based on a variety of
fresh and natural ingredients, and what would be
obtained by putting a few roughly comparable ingredients
into a mixer. To suggest that one can approximate
breast milk by putting a few ingredients into a mixer is to
grossly underestimate it.
If any infant formula that conforms to the list of required
ingredients is nutritionally adequate, how would we
explain why so many different infant formula products
are available on the market
In the United Kingdom, for example, one can obtain:
••
Infant milks suitable from birth (cows’-milk based),
••
Infant milks marketed for hungrier babies, suitable
from birth (cows’-milk based),
••
Thickened infant milks suitable from birth,
••
Soy-protein-based infant milks suitable from birth,
••
Lactose-free infant milks suitable from birth, and
••
Partially hydrolysed infant milks suitable from birth.
For older infants one can obtain:
••
Follow-on formula suitable from six months of age,
••
Partially hydrolysed follow-on formula suitable from
six months of age,
••
Goodnight milks and food drinks,
••
Goodnight milks,
••
Food drink, and
••
Growing-up milks and toddler milks (Crawley, 2011).
Many new varieties are offered all the time, including
versions with a bewildering variety of additives. There
are reasons to suspect that the many variations increase
profitability for the manufacturers, but offer few significant
benefits in terms of children’s health (Kent, 2011).
This reductionist approach has dangerous consequences.
As nutritionist Carlos Monteiro explains:
Nutrition science is taught and practiced as a biochemical
discipline. Practically all nutritionists
22 Clinical Lactation 2012, Vol. 3-1

now categorise food in terms of its chemical
composition, as do most lay writers. This almost
universal perception of nutrition is evident in textbooks
and scientific journals, and on food labels,
journalism, and “diet books.” The identification
of food with its chemistry is a defining characteristic
of modern nutrition science, as invented in
the early 19th century. Seeing food in terms of
its chemistry has enabled the industrialization of
food systems. In particular, it has made possible
the formulation of ultra-processed products from
“refined” or “purified” chemical constituents of
foods-oils, proteins, carbohydrates, and their fractions—together
with “micronutrients”—vitamins
and minerals (Monteiro, 2011).
He summarizes: “Identification of food mainly with its
chemical constituents at best has limited value, and in
general has proved to be unhelpful, misleading, and
harmful to public health.”
The Codex Statement on Infant Formula of 1976 said,
“Numerous formulae have been produced which offer a
nutritionally adequate food for infants . . .” (Codex
Alimentarius, 1976). That depends on how one understands
“nutritionally adequate.” Elsewhere the Codex
Alimentarius Commission said:
The nutritional adequacy of a product can be
defined in terms of protein quality and quantity,
and content of minerals and vitamins.
Such a product should be considered nutritionally
equivalent if:
i. its protein quality is not less than that of the
original product or is equivalent to that of
casein, and
ii.
it contains the equivalent quantity of protein
(N=6.25) and those vitamins and minerals
which are present in significant amounts
in the original animal products (Codex
Alimentarius Commission, 1989).
This is difficult to understand. A food’s nutritional adequacy
should be assessed in terms of its results, not its
ingredients. Infant formula should be viewed as nutritionally
adequate only if it is proven to be as good for
children as breastfeeding. Any other definition shortchanges
children.
The overall quality of infant-formula products should be
assessed on the basis of their safety and their nutritional
adequacy. Assessing infant formulas only on the basis of
their safety and their composition (as in Crawley, 2011)
is a serious error. Studying the composition of infant
formula is of little help in assessing the risks involved in
its use.
There is value to checking the composition of infant formula
because it can deteriorate over time, it may be
manufactured improperly, and it may be contaminated
in various ways. However, that is not the same as checking
for nutritional adequacy. Even perfect adherence to
imperfect recipes for infant formula puts infants at risk.
The main function of infant food and the associated
feeding process is to ensure long-term health—including
not only body-building, but also protection against infections
and allergies, and facilitating cognitive as well as
physical development. The only way to ensure that feeding
with any breast-milk substitute is equivalent to
breastfeeding would be to compare the health of children
who are breastfed with the health of those who use
the substitute, not only in the short term, but also in the
long term.
In 1981, the Codex Alimentarius Commission said:
Infant formula means a breast-milk substitute
specially manufactured to satisfy, by itself, the
nutritional requirements of infants during the first
months of life up to the introduction of appropriate
complementary feeding (Codex Alimentarius
Commission 2007, Section 2.1.1).
If we assess formula by its results, rather than by whether
its ingredients matched a specific list, we would have to
conclude that there has never been an infant formula
that would “satisfy, by itself, the nutritional requirements
of infants during the first months of life.”
Contrary to Codex’s 1976 claim that, “Numerous formulae
have been produced which offer a nutritionally
adequate food for infants” (Codex Alimentarius, 1976),
there has never been any infant formula that is nutritionally
adequate.
The European Union said, “Infant formula is the only
processed foodstuff which wholly satisfies the nutritional
requirements of infants during the first months of
life until the introduction of appropriate complementary
feeding” (EUR-Lex 2011, para 4; also see Article 2(c)
© 2012 United States Lactation Consultant Association 23

and Article 3). The statement should be rejected. If
infant formula wholly satisfied infants’ requirements,
there would not be a regular pattern of worse health outcomes
for infants who use it.
The industry’s lobbying group based in the U.S., the
Infant Formula Council, says, “Iron-fortified infant formula
is the only safe and effective alternative to breast
milk, providing complete nutrition to meet the unique
needs of growing infants” (Infant Formula Council
2011). One possible interpretation of “complete nutrition”
is that the formulas comply with the list of required
ingredients under the law. If they are complete, why do
the manufacturers offer additives beyond those required
by the law If nutritionally adequate infant formula had
already been developed by the 1980s, why has there been
a steady stream of modifications since then
Perhaps the Infant Formula Council means to say that
the formulas are complete in the sense that they meet all
infants’ nutritional needs. If that is their position, then
how would they explain the consistently worse health
outcomes with formula feeding when compared with
breastfeeding Either way, the claim that infant formulas
are “nutritionally complete” is misleading.
The Infant Nutrition Council based in Australia makes
a claim similar to the one by the Infant Formula Council
in the U.S.: “Infant formula has been specifically developed
to contain all the necessary ingredients needed to
meet an infant’s nutritional requirements” (Infant
Nutrition Council, 2011). If formula has all the ingredients
needed to meet nutritional requirements, why add
things And how would they explain the fact that formula
feeding leads to worse health outcomes than
breastfeeding
Nutritional Adequacy Should Be Judged
By Results
While nutritional adequacy in the sense of functionality
(results) is not covered explicitly in current standards for
infant formula, it has been considered. In the discussion
leading up to the adoption of the rules relating to infant
formula in the U.S. (21 CFR Parts 106 and 107), rules
were proposed that would have required that “formula
will support optimal infant growth and health” (U.S.
Federal Register, 1996).
The proposal said, “the FDA has tentatively concluded,
therefore that an evaluation of the ability of a formula to
support healthy growth must be made under its most
demanding conditions of use, i.e., when it is used as the
sole source of nutrition.” It also said, “the determination
of physical growth rate is the most valuable component
of the clinical evaluation of infant formulas.” However,
this recognition of the importance of physical growth
did not carry over into the rules that were finally adopted.
Although there are issues regarding the precise relationship
between infant growth and health (Burger &
Newman, 2011; De Onis et al., 2004; Fomon, 2004;
Garza & de Onis, 1999), there is clear consensus that
healthy infants grow rapidly (but not too rapidly), and
have low rates of morbidity and mortality. International
agencies have worked out clear standards for normal
growth rates of infants and young children.
When the World Health Organization investigated the
adequacy of exclusive breastfeeding during the first six
months of infants’ lives, their study focused not on the
composition of the diet, but on its results.
In evaluating the nutrient adequacy of exclusive
breastfeeding, infant nutrient requirements are
assessed in terms of relevant functional outcomes.
Nutrient adequacy is most commonly evaluated in
terms of growth, but other functional outcomes,
e.g. immune response and neurodevelopment, are
also considered to the extent that available data
permit...
In determining the optimal duration of exclusive
breastfeeding in specific contexts, it is important
that functional outcomes, e.g., infant morbidity
and mortality, also are taken into consideration
(Butte et al., 2002, p. vii).
Various feeding methods could be studied by examining
their impacts on these outcome indicators. The common
standards would make it possible to compare the
nutritional adequacy of different methods of feeding.
Though people may believe that agencies, such as the
Codex Alimentarius Commission, and the FDA actively
work to ensure the nutritional adequacy of infant formula,
they do not. In fact, the FDA explicitly states that
it does not approve functional claims for foods (U.S.
Department of Health and Human Services, 2011). It
does not address claims that particular infant formulas
help infants to grow or to have good eyesight. There is no
agency that ensures the functional quality of infant formula.
24 Clinical Lactation 2012, Vol. 3-1

So long as feeding with infant formula consistently produces
worse health outcomes, formula should not be
viewed as nutritionally adequate. Feeding with formula
might be claimed to be adequate in the sense that it can
keep a child alive. But it should never be implied to be as
good, or nearly as good, as breastfeeding.
References
Baker, R.D. (2002). Commentary: Infant formula safety. Pediatrics.
110(4), 833-835. http://pediatrics.aappublications.org/cgi/content/full/110/4/833
Burger, S.E., & Newman, S.D. (2011). Can lactation consultants
find appropriate uses for the World Health Organization
Growth Curves” Clinical Lactation, 2(2), 14-19.
Butte, N. F., Lopez-Alarcon, M.G., & Garza, C. (2002). Nutrient adequacy
of exclusive breastfeeding for the term infant during the first six
months of life. Geneva, Switzerland: World Health Organization.
Retrieved from: http://www.who.int/entity/nutrition/publications/infantfeeding/9241562110/en/
Codex Alimentarius Commission. (1976). Statement on infant feeding,
CAC/MISC-2-1976. Retrieved from: http://www.codexalimentarius.net/download/standards/301/CXA_002e.pdf
Codex Alimentarius Commission. (1989). Codex general guidelines
for the utilization of vegetable protein products (VPP) in foods. CAC/
GL 4-1989. Retrieved from: http://www.codexalimentarius.net/
download/standards/326/CXG_004e.pdf
Codex Alimentarius Commission. (2007). Standards for infant
formula and formulas for special medical purposes intended for infants.
CODEX STAN 72-108. [Formerly CAC/RS 72-1972. Adopted
as a world-wide Standard 1981.Amended 1983, 1985,1987. Revision
2007] Retrieved from: http://www.codexalimentarius.net/
download/standards/288/CXS_072e.pdf
Crawley, H., & Westland, S. (2011). Infant milks in the UK. Abbots
Langley, United Kingdom: Caroline Walker Trust. Retrieved from:
http://www.cwt.org.uk/pdfs/infantsmilk_web.pdf
De Onis, M., Garza, C., Victora, C.G., Bhan, M. K., & Norum,
K.R. (2004). The WHO Multicentre Growth Reference Study
(MGRS): Rationale, planning, and implementation. Food and
Nutrition Bulletin, 25(1). Retrieved from: http://www.inffoundation.org/FNB/FNBindexNEW.html
EUR-Lex. (2011). Commission directive 2006/141/EC of 22
December 2006 on infant formulae and follow-on formulae and amending
Directive 1999/21/EC (1). Official Journal of the European
Union. EUR-Lex: Access to European Union Law. Retrieved
from: http://eur-lex.europa.eu/JOHtml.douri=OJ:L:2006:401:
SOM:EN:HTML
Fomon, S.J. (2004). Assessment of growth of formula-fed infants:
Evolutionary considerations. Pediatrics, 113(2), 389-393.
Retrieved from: http://pediatrics.aappublications.org/cgi/content/full/113/2/389
Garza, C., & de Onis, M. (1999). A new international growth reference
for young children. American Journal of Clinical Nutrition,
70(1), 169S-172S. Retrieved from: http://www.ajcn.org/cgi/
content/full/70/1/169Smaxtoshow=&HITS=10&hits=10&R
ESULTFORMA
Infant Formula Council. (2011). What nutrients are present in infant
formula and why are they included IFC. Retrieved from: http://
www.infantformula.org/faqs
Infant Nutrition Council. (2011). Infant formula information. INC.
Retrieved from: http://infantnutritioncouncil.com/formulainformation/
Kent, G. (2011). Regulating infant formula. Amarillo, Texas: Hale
Publishing.
Monteiro, C. (2011). The big issue is ultra-processing. “Carbs”: The
answer. World Nutrition, 2(2), 86-97. Retrieved from: http://
wphna.org/2011_feb_wn4_cam5.htm
U.S. Code of Federal Regulations. Title 21 Part 107 (21CFR107).
(2003). Retrieved from: http://www.access.gpo.gov/nara/
cfr/waisidx_03/21cfr107_03.html
U.S. Department of Health and Human Services. (2011). Is it really
FDA approved Washington, D.C.: USDHHS. Food and Drug
Administration. Retrieved from: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm047470.htm
U.S. Federal Register. (1996). Proposed rules for 21 CFR Parts 106 and
107 . . . for the production of infant formula 61:132 (July 9). U.S.
Federal Register. Retrieved from: http://www.fda.gov/Food/Food-
Safety/Product-SpecificInformation/InfantFormula/Guidance-
RegulatoryInformation/RegulationsFederalRegisterDocuments/
ucm106557.htm
George Kent, Ph.D. is Professor Emeritus, Department of Political
Science, University of Hawaii, and currently teaches online for the
University of Sydney in Australia and Saybrook University in San
Francisco. This article is adapted from his most-recentbook: Kent, G.
(2011). Regulating infant formula. Amarillo, TX: Hale Publishing.
© 2012 United States Lactation Consultant Association 25

Clinical Decision Making
When to Consider Using a Nipple Shield
Diane C. Powers, BA, IBCLC, RLC 1
Vicki Bodley Tapia, BS, IBCLC, RLC 2
Share this:
Nipple shields have a long and somewhat controversial history. Nearly every published article in
recent years reports positive breastfeeding outcomes for mother/baby dyads who used a nipple
shield. Its use may be warranted if infants have sucking difficulties, or are having problems latching
to flat or inverted nipples. In addition, they can be useful for mothers who dread breastfeeding
because of nipple pain, are experiencing hyperlactation, or have histories of sexual abuse. It is
time to recognize the possible uses for nipple shields that can help create favorable results for
breastfeeding couplets.
Keywords: Nipple shields, tongue-tie, receding jaw, cephalhematoma, prematurity, sore
nipples, flat/inverted nipples, hyperlactation, sexual abuse
Clinical Lactation, 2012, Vol. 3-1, 26-29
Although the nipple shield has existed, in one form or
another, for centuries, attitudes toward its use as a breastfeeding
tool have been mixed. In recent years, some
lactation consultants have reported being belittled by
colleagues in their work settings for using nipple shields
as an intervention in challenging breastfeeding situations.
As recently as the Fall of 2010 in the authors’ city,
WIC contracted with a traveling lactation education
group to provide breastfeeding teaching to WIC personnel.
The women who attended this educational offering
reported to the authors that they were cautioned to
never use a nipple shield, being admonished that only
inferior lactation consultants resorted to offering nipple
shields to breastfeeding mothers.
Descriptions of the device appeared in medical papers in
Europe around 1550. Written records show that during
that century nipple shields were devised from glass, pewter,
tin, horn, or bone (Riordan & Auerbach, 2005). It is
difficult to imagine how nipple shields made from these
materials were helpful, since they block the suckling
stimulus to nerve receptors in the areola, which causes
oxytocin release from the pituitary, which provides the
neurological underpinning of lactation. Knowing the
history of nipple shields allows us to understand that
poor suck, flat or inverted nipples, and sore nipples have
impacted women’s experiences of breastfeeding for hundreds
of years.
Nipple shields have evolved through the centuries.
1 Billings Clinic, dpowers@billingsclinic.org
2 Children’s Clinic, victorialee37@gmail.com
Around 1850, nipple shields began to be made of rubber,
and around 1950, latex nipple shields became
available. Latex is a stabilized rubber that can be made
much thinner than earlier rubber products. Latex nipple
shields were probably still too thick for most infants to
be able to stimulate the areola sufficiently to send appropriate
signals via the breast-brain nerve pathway. Thus,
infants using these devices did not always gain suitably.
In 1983, silicone nipple shields appeared on the market.
Silicone shields are thinner, extremely pliable, and more
malleable than other substances used previously for nipple
shields. The introduction of silicone nipple shields
provided a tool that could help sustain “at the breast”
feeding without causing a decrease in maternal milk
supply.
Paula Meier and colleagues published research (Meier,
no date; Meier et al., 2006) that showed premature
infants with feeding difficulties were able to transfer four
times as much milk when a mother used a silicone nipple
shield during a feeding, as compared to not using a
nipple shield. This was validated with experiments done
at two different NICUs in two different states using preand
post-feed weights of the premature infants. If
premature infants are able to sustain sucking and transfer
milk better with a nipple shield, then it is reasonable
to hypothesize that other infants with suckling difficulties
can have a similar result.
Two articles published in the Journal of Human Lactation
studied nipple-shield use. In the case report, all babies
gained the appropriate amount of weight, or better, at
26 Clinical Lactation 2012, Vol. 3-1

three weeks, two months, and four months (Bodley &
Powers, 1996). In the 2004 study, 88% of the 200 women
interviewed felt the nipple shield helped them breastfeed,
and 98% stated they would use the nipple shield
again with subsequent children if needed (Powers &
Bodley Tapia, 2004). Nipple shields can be used in several
different situations.
Situations That May Warrant the Use of
Nipple Shield
Infants with Inadequacies in Their Suck Due
To Tongue-Tie, a Receding Jaw, Painful
Cephalhematoma, or Prematurity
Infants with these issues often transfer an ounce or less,
as measured by a pre- and post-feed weight on an electronic
scale designed for test weighing. Usually, their
weight is already trending downward, with more than a
10% loss from their birth weight. A nipple shield may be
used for the next feeding attempt, with pre- and postfeed
weights to identify any improvement in milk transfer
using the nipple shield. If the infant transfers more milk
with the shield, the shield can be used until the infant is
able to transfer adequate milk without it. This generally
happens as the infant takes in more calories, often
improving the sucking coordination and strength. There
is no timetable for the infant’s readiness.
Painful Nipples Where the Mother Says She
Dreads Every Feeding
By covering the damaged nipple, the shield may reduce
further injury, thereby speeding healing. Remind the
mother that even with the shield, the first minute or two
of breastfeeding might still be painful, but after that the
pain should subside. When using the nipple shield for
abraded nipples, the mother uses the shield until the
nipples have healed, with occasional use thereafter as
needed. When nipples have been severely damaged, it is
imperative to address the underlying cause of the soreness,
most often incorrect latch and/or positioning of
the infant, so that when the shield is discontinued, abrasion
to the tender nipple skin is not repeated.
For Women Who Have Very Flat Nipples or
Inverted Nipples
If women are aware prior to delivery that this anatomical
situation might prevent the infant from maintaining a
latch, they may have been wearing breast shells for the
last four weeks of pregnancy, providing there was no history
of pre-term labor. Based on the authors’ study of
200 breastfeeding women, breast shells helped to evert
nipples approximately 50% of the time prior to the
infant’s birth (Powers & Bodley Tapia, 2004).
Many pregnant women are not aware of the importance
of nipple anatomy for ease of breastfeeding until they
have difficulty and seek assistance after delivery. This
mother may need a nipple shield until the nipples are
more easily graspable by the infant, or the infant develops
greater sucking strength and coordination to
maintain a latch on nipples with less-than-ideal
elasticity.
For Women with Hyperlactation
If the mother produces a copious amount of milk, it can
cause a newborn infant to choke, sputter, and pull away
from the breast, sometimes turning red and struggling to
breathe. This phenomenon is alarming to the mother
and infant. Depending upon the child’s disposition,
some infants will even go on a nursing strike when faced
with too rapid a milk flow. A mother may find using a
nipple shield will slow the flow of the milk into a more
manageable quantity for the infant, since there are only
four holes in the nipple shield rather than a spray of
milk from approximately 7 to 15 nipple pores. The nipple
shield is thus used to keep the baby breastfeeding
with ease while the mother simultaneously downregulates
her milk supply.
Infants may handle high milk flow better if fed in an
upright position, straddling the mother’s thigh, or prone
on a mom lying flat on her back. Milk production can be
reduced by breastfeeding on one breast only per feed. If
these techniques are insufficient to improve feeding
within several days, the mother may increase the amount
of hours spent breastfeeding on alternating sides. Some
mothers find if they feed the infant on just one breast
per feeding, for as many as 12 hours, alternating with the
other breast, they will successfully diminish the milk supply
within several days. A mother might also take the
original Sudafed containing pseudoephedrine, as
directed, for a couple of days to help downregulate her
supply. (Note: This is an off-label use of a medication
that is non-prescription, but kept behind the counter of
pharmacies. It should not be used by women with hypertension,
heart disease, or who are taking an MAOI
antidepressant, or are allergic to any of the ingredients.)
Once the milk supply decreases, the mother would no
longer need a nipple shield to manage the milk flow.
© 2012 United States Lactation Consultant Association 27

For Women with a History of Sexual Abuse
These women may manifest a myriad of breastfeeding
outcomes (Bernshaw & Johnson, 1997). Some absolutely
can’t face breastfeeding, while others share that
they are not going to let their perpetrator do further
harm by not allowing them to provide the very best nourishment
for their infants. Still others find that having
the infant on the bare breast is intolerable, even with
distraction. But if a nipple shield is used as a barrier
between the breast and the infant’s mouth, they are able
to sustain breastfeeding. For other mothers, this barrier
is insufficient and they choose to pump and bottle-feed
their milk.
How to Fit a Nipple Shield
According to a widely used nipple-shield manufacturer’s
instructions, “The shield should be placed over the
breast so that your nipple fits into the nipple chamber of
the shield.”
It has been our experience that many premature babies
with small mouths are able to open their mouths wide
enough to attach to the 24 mm nipple shield. We recommend
that the nipple shield be fitted to the size of the
mother’s nipples, not the size of the baby’s mouth.
Certainly the smaller diameter nipple shields (16 mm or
20 mm) are suitable for women with smaller nipples. If,
however, one attempts to only fit the shield to a baby’s
mouth, and the diameter of that mother’s nipples is
wider than the teat of the nipple shield, the nipple cannot
fully descend into the teat, resulting in less milk
transferred. This is not unlike when one pinches a straw
and then attempts to suck through it: there is less flow
through the crimped straw. The mother’s nipples are
also at risk for abrasion from the friction caused by rubbing
against the interior of the teat that is too small.
Conclusion
References
Bodley, V., & Powers, D. (1996). Long-term nipple shield use—A
positive perspective. Journal of Human Lactation, 12, 301-304.
Brigham, M. (1996). Mothers’ reports of the outcome of nipple
shield use. Journal of Human Lactation, 12, 291-297.
Chertok, IR. (2009). Reexamination of ultra-thin nipple shield use,
infant growth, and maternal satisfaction. Journal of Clinical Nursing,
18, 2949-2955.
Chertok, I.R., Schneider, J., & Blackburn, S. (2006). A pilot study
of maternal and term infant outcomes associated with ultra-thin
nipple shield use. Journal Obstetrics Gynecology Neonatal Nursing,
35(2), 265-72.
Meier, P., Brown, L., Hurst, N., et al. (2006). Nipple shields for preterm
infants: Effect on milk transfer and duration of breastfeeding.
Journal of Human Lactation, 16, 106-114.
Meier P. (no date). Breastfeeding your premature baby using a nipple
shield. Rush-Presbyterian St. Luke’s Medical Center, Rush
Mothers’ Milk Club Special Care Nursery. http://www.medelabreastfeedingus.com/tips-and-solutions/132/breastfeeding-yourpremature-baby-using-a-nipple-shield
Powers, D., & Bodley Tapia, V. (2004). Women’s experiences using
a nipple shield. Journal of Human Lactation, 20(3), 327-334.
Riordan, J., & Auerbach, K. (2005). Breastfeeding and human lactation,
2nd ed. Sudbury, MA: Jones & Bartlett Publishers.
Wilson-Clay, B. (1996). Clinical use of silicone nipple shields. Journal
of Human Lactation, 12, 279-285.
For Further Reading
Clum, D., & Primono, J. (1996). Use of a silicone nipple shield
with premature infants. Journal of Human Lactation, 12, 287-290.
Drazin, P. (1998). Taking nipple shields out of the closet. Birth
Issues, 7, 2.
Elliott, C. (1996). Using a silicone nipple shield to assist a baby unable
to latch. Journal of Human Lactation, 12, 309-313.
Sealy, C. (1996). Rethinking the use of nipple shields. Journal of Human
Lactation, 12, 299-300.
Woodworth, M., & Frank, E. (1996). Transitioning to the breast at
six weeks: Use of a nipple shield. Journal of Human Lactation, 12,
305-307.
There have been 14 articles published regarding nipple
shield use since 1990. Thirteen of these articles contained
information that supported use of thin silicone
nipple shields as an effective clinical intervention in certain
situations, also commenting that most women
appreciated having this tool in order to keep their infant
feeding at the breast (Brigham, 1996; Chertok et al.,
2006; Chertok, 2009; Wilson-Clay, 1996). The thin silicone
nipple shield has been available to new mothers for
the last quarter century. It is time to recognize the possible
uses for nipple shields that can help create positive
outcomes for breastfeeding couplets.
28 Clinical Lactation 2012, Vol. 3-1

Diane Powers, BA, IBCLC, RLC, is a lactation consultant and former
La Leche League leader. For the past 23 years, she has worked with
approximately 700 new mother/baby pairs per year, both in-patient and
outpatient. She has completed two research projects and had numerous
articles published. She lectures nationally and internationally.
Vicki Bodley Tapia, B.S., IBCLC., RLC, is a former La Leche League
Leader, and has been in private practice as a lactation consultant since
1987, published numerous articles, and lectures both nationally and
internationally.
© 2012 United States Lactation Consultant Association 29

Clinical Tips
Caring for Breast Pump Parts
Kathleen Chiu, IBCLC, RLC 1
Cleaning Breast Pump Parts
Unless the kit is sterile, a member of the baby’s household
should clean kit parts before the first use.(“Home
germs are best germs.”) The pieces that should normally
be washed include the milk storage containers (bottles),
the flanges or breast shields, and the valves/
membranes.
Pump tubing only requires washing if it gets wet inside.
Filters should not be washed either. They are meant to
shut-down if wet to stop fluid from getting inside the
pump and/or motor, and causing contamination and
mold growth. This protects both mother and baby, and
the pump. A wet filter may need several hours to dry, or
may need to be replaced.
For healthy, full-term babies the pump parts are:
••
Washed in hot, soapy water.
••
Rinsed in hot water.
••
Laid out to air dry on a clean towel.
••
Covered with another clean towel.
In addition:
A bottle brush may be used on the milk-storage
containers.
••
NEVER use a nipple brush on the valves/membranes.
º º Be gentle with this part. They often have thin
edges that are easily torn, frayed, or otherwise
damaged by sharp objects, including fingernails.
Swish tubular (duckbill) valves in soapy water,
and gently rub flat-valve membranes with the
fingertips, like cleaning a contact lens.
••
NEVER put the valves/membranes on “pegs” (like
on a bottle/nipple drying rack) to air dry.
º º The valves or membranes are sensitive pieces,
and poking things in or through them can warp
or tear them.
1 amcbe@comcast.net
º º Vulnerable (preterm, small for gestational age,
ill) babies may require that the pump parts be
sterilized in addition to washing.
Sterilizing Pump Parts
Start the water boiling first without placing anything else
in the pot. Put sufficient water in the pot to allow the
pump pieces to be covered by several inches of water
once they are submerged.
••
Once the water is boiling, lower the heat until the
water is boiling softly.
••
Pad the inside of the pot with a cotton dish towel,
washcloth, or diaper. This will prevent the pump
parts from warping or melting from touching the
hot metal. The pad will also singe before the plastic,
if the boiling pump parts are “forgotten,” and all the
water boils away.
••
Put the pump parts in, on top of your cotton-cloth
padding, so that they are completely immersed in the
boiling water.
••
SET A TIMER. It needs to be a loud, repetitive alarm
(new parents are often overtired and forgetful).
••
When the timer alarm goes off, shut off the heat
and allow the water and parts to cool off to a safe
temperature.
••
Use a set of tongs to remove the pump parts from
the water.
••
Lay them out to air dry on a clean towel.
••
Cover them with a clean towel.
••
Once dry, parts can be stored in gallon zipper-top
plastic bags.
Common Concerns
Dishwashers
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Pump parts can be cleaned in the dishwasher, but should
not routinely be washed in one. Dishwashers use very
harsh chemicals and very hot water, plus heat to dry, all
of which will shorten the life of pump parts, especially
the sensitive valves/membranes. Mothers who value convenience
over money may want to use the dishwasher
30 Clinical Lactation 2012, Vol. 3-1

anyway. But those who are dependent on their pump
may want to avoid using the dishwasher.
Sterilizing Bags
The use of microwave sterilizing bags can cause extra
extreme wear on pump parts over time. Microwave sterilizing
bags should be reserved for when a stove and pot
are unavailable.
Cleaning Tubing
••
If tubing becomes wet, it must be washed and
dried before attaching it to the pump. Otherwise,
fluid can be drawn into the motor area and cause
mold growth, or contact the filter and shut down
the pump. Immerse the tubing completely in clean,
hot, soapy water. Run that soapy water through the
tubing several times.
••
Rinse by running a stream of hot, clean water
through the tubing.
Drying the Tubing
••
You can “whip” the tubing in the air like a lariat.
Make sure you are holding the end with any hard
plastic adapter on it, and that the free end is soft.
Hold the tubing away from your body to avoid being
hit.
••
Roll the tubing back and forth on a table with the
palms of your hands, like rolling dough for pretzels,
or making snakes out of modeling clay. Rolling the
tubing like this pulls the fluid out each of the ends.
••
Blow out the fluid with a hair dryer or can of
compressed air through a funnel made from a small
piece of paper inserted into the larger end of the
tubing. Some canned air has that little red tube,
which can also be used on your pump tubing.
••
You can use isopropyl alcohol. Put a few drops down
the tubing and allow it to evaporate, along with the
fluid.
In the last 25 years, Kat has held positions as LC in a pediatrics
practice, a private practice, a group LC practice, as well as
both postpartum and the NICU. Kat has also worked in the
breast pump industry as a lactation consultant, sales manager,
product manager and a marketing resource for almost 10 years.
© 2012 United States Lactation Consultant Association 31

Blog Watch
Dangers of “Crying It Out”: Damaging Children and Their Relationships for the Long-term 1
Darcia Narvaez, Ph.D. 1
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Letting babies “cry it out” is an idea that has been around
since at least the 1880s, when the field of medicine was
in a hullaballoo about germs and transmitting infection,
and so took to the notion that babies should rarely be
touched (see Blum, 2002, for a great review of this time
period and attitudes towards childrearing).
In the 20th century, behaviorist John Watson (1928),
interested in making psychology a hard science, took up
the crusade against affection as president of the
American Psychological Association. He applied the
mechanistic paradigm of behaviorism to childrearing,
warning about the dangers of too much mother love.
The 20th century was the time when “men of science”
were assumed to know better than mothers, grandmothers,
and families about how to raise a child. Too much
kindness to a baby would result in a whiney, dependent,
failed human being. Funny how “the experts” got away
with this with no evidence to back it up! Instead there is
evidence all around (then and now) showing the opposite
to be true.
A government pamphlet from the time recommended
that “mothering meant holding the baby quietly, in tranquility-inducing
positions,” and that “the mother should
stop immediately if her arms feel tired” because “the
baby is never to inconvenience the adult.” Babies older
than six months “should be taught to sit silently in the
crib; otherwise, he might need to be constantly watched
and entertained by the mother, a serious waste of time.”
(See Blum, 2002.)
Don’t these attitudes sound familiar A parent reported
to me recently that he was encouraged to let his baby cry
herself to sleep so he “could get his life back.”
With neuroscience, we can confirm what our ancestors
took for granted: that letting babies get distressed is a
practice that can damage children and their relational
capacities in many ways for the long term. We know now
that leaving babies to cry is a good way to make a less
1 Published on December 11, 2011 by Darcia Narvaez, Ph.D. in Moral Landscapes
www.psychologytoday.com/blog/moral-landscapes/201112/dangerscrying-it-out,
dnarvaez@nd.edu
intelligent, less healthy but more anxious, uncooperative
and alienated person who can pass the same—or worse—
traits on to the next generation.
The discredited view sees the baby as an interloper into
the life of the parents, an intrusion who must be controlled
by various means so the adults can live their lives
without too much bother. Perhaps we can excuse this
attitude and ignorance because at the time extended
families were being broken up, and new parents had to
figure out how to deal with babies on their own, an
unnatural condition for humanity: we have heretofore
raised children in extended families. The parents always
shared care with multiple adult relatives.
According to this discredited view completely ignorant
of human development, the child “has to be taught to be
independent.” We can confirm now that forcing “independence”
on a baby leads to greater dependence.
Instead, giving babies what they need leads to greater
independence later. In anthropological reports of smallband
hunter-gatherers, parents took care of every need
of babies and young children. Toddlers felt confident
enough (and so did their parents) to walk into the bush
on their own (see Hunter-Gatherer Childhoods, edited by
Hewlett & Lamb, 2005).
Ignorant advisors then—and now—encourage parents to
condition the baby to expect needs NOT to be met on
demand, whether feeding or comforting. It’s assumed
that the adults should “be in charge” of the relationship.
Certainly this might foster a child that doesn’t ask for as
much help and attention (withdrawing into depression
and going into stasis or even wasting away), but it is more
likely to foster a whiney, unhappy, aggressive and/or
demanding child: one who has learned that one must
scream to get needs met. A deep sense of insecurity is
likely to stay with them for the rest of their lives.
The fact is that caregivers who habitually respond to the
needs of the baby before the baby gets distressed, preventing
crying, are more likely to have children who are
independent than the opposite (e.g., Stein & Newcomb,
1994). Soothing care is best from the outset. Once patterns
get established, it’s much harder to change them.
32 Clinical Lactation 2012, Vol. 3-1

Rats are often used to study how mammalian brains
work, and many effects are similar in human brains. In
studies of rats with high- or low-nurturing mothers, there
is a critical period for turning on genes that control anxiety
for the rest of life. If in the first 10 days of life you
have a low-nurturing rat mother (the equivalent of the
first six months of life in a human), the gene never gets
turned on. The rat is anxious towards new situations for
the rest of its life, unless drugs are administered to alleviate
the anxiety. These researchers say that there are
hundreds of genes affected by nurturance. Similar mechanisms
are found in human brains—caregiver behavior
matters for turning genes on and off. (e.g., Meaney,
2001).
We should understand the mother and child as a mutually
responsive dyad. They are a symbiotic unit that
make each other healthier and happier in mutual
responsiveness. This expands to other caregivers too.
One strangely popular notion still around today is to
let babies “cry it out” when they are left alone, isolated
in cribs or other devices. This comes from a misunderstanding
of child and brain development.
••
Babies grow from being held. Their bodies get
dysregulated when they are physically separated from
caregivers.
••
Babies indicate a need through gesture and eventually,
if necessary, through crying. Just as adults reach for
liquid when thirsty, children search for what they
need in the moment. Just as adults become calm
once the need is met, so do babies.
••
There are many long-term effects of under care or
need-neglect in babies (e.g., Dawson et al., 2000).
What does “crying it out” actually do to the baby and
to the dyad
Neurons die. When the baby is stressed, the toxic hormone
cortisol is released. It’s a neuron killer. A full-term
baby (40 to 42 weeks), with only 25% of its brain developed,
is undergoing rapid brain growth. The brain
grows, on average, three times as large by the end of the
first year (and head size growth in the first year is a sign
of intelligence, e.g., Gale et al., 2006). Who knows what
neurons are not being connected or being wiped out
during times of extreme stress What deficits might show
up years later from such regular distressful experience
(See my addendum below.)
Disordered stress reactivity can be established as a pattern
for life not only in the brain with the stress-response
system, but also in the body through the vagus nerve, a
nerve that affects functioning in multiple systems (e.g.,
digestion). For example, prolonged distress in early life,
resulting in a poorly functioning vagus nerve, is related
to disorders, such as irritable bowel syndrome (Stam et
al, 1997). (See more about how early stress is toxic for
lifelong health from the recent Harvard report, The
Foundations of Lifelong Health are Built in Early
Childhood).
Self-regulation is undermined. The baby is absolutely
dependent on caregivers for learning how to self-regulate.
Responsive care—-meeting the baby’s needs before
he gets distressed—-tunes the body and brain up for calmness.
When a baby gets scared, and a parent holds and
comforts him, the baby builds expectations for soothing,
which get integrated into the ability to self-comfort.
Babies don’t self-comfort in isolation. If they are left to
cry alone, they learn to shut down in face of extensive
distress—stop growing, stop feeling, stop trusting (Henry
& Wang, 1998).
Trust is undermined. As Erik Erikson pointed out, the
first year of life is a sensitive period for establishing a
sense of trust in the world, the world of caregiver, and
the world of self. When a baby’s needs are met without
distress, the child learns that the world is a trustworthy
place, that relationships are supportive, and that the self
is a positive entity that can get its needs met. When a
baby’s needs are dismissed or ignored, the child develops
a sense of mistrust of relationships and the world. And
self-confidence is undermined. The child may spend a
lifetime trying to fill the inner emptiness.
Caregiver sensitivity may be harmed. A caregiver who
learns to ignore baby crying will likely learn to ignore the
more subtle signaling of the child’s needs. Secondguessing
intuitions to stop child distress, the adult who
ignores baby needs practices and increasingly learns to
“harden the heart.” The reciprocity between caregiver
and baby is broken by the adult, but cannot be repaired
by the young child. The baby is helpless.
Caregiver responsiveness to the needs of the baby is
related to most—if not all—positive child outcomes. In
our work, caregiver responsiveness is related to intelligence,
empathy, lack of aggression or depression,
self-regulation, and social competence. Because responsiveness
is so powerful, we have to control for it in our
© 2012 United States Lactation Consultant Association 33

studies of other parenting practices and child outcomes.
The importance of caregiver responsiveness is common
knowledge in developmental psychology. Lack of responsiveness,
which “crying it out” represents, can result in
the opposite of the aforementioned positive outcomes.
The “cry it out” approach seems to have arisen as a solution
to the dissolution of extended family life in the 20th
century. The vast wisdom of grandmothers was lost in
the distance between households with children, and
those with the experience and expertise about how to
raise them well. The wisdom of keeping babies happy
was lost between generations.
But isn’t it normal for babies to cry
No. A crying baby in our ancestral environment would
have signaled predators to tasty morsels. So our evolved
parenting practices alleviated baby distress and precluded
crying except in emergencies. Babies are built to
expect the equivalent of an “external womb” after birth
(see Allan Schore, specific references below). What is the
external womb—being held constantly, breastfed on
demand, needs met quickly (I have numerous posts on
these things). These practices are known to facilitate
good brain and body development (discussed with references
in other posts, some links below). When babies
display discomfort, it signals that a need is not getting
met, a need of their rapidly growing systems.
What does extensive baby crying signal
It shows the lack of experience, knowledge and/or support
of the baby’s caregivers. To remedy a lack of
information in us all, below is a good set of articles about
all the things that a baby’s cry can signal. We can all educate
ourselves about what babies need and the practices
that alleviate baby crying. We can help one another to
keep it from happening as much as possible.
Check these out:
How to soothe babies:
http://www.babycenter.com/0_12-reasons-babies-cryand-how-to-soothe-them_9790.bcpage=2
Soothing babies crying “for no reason”:
http://www.babycenter.com/0_what-to-do-whenyour-baby-cries-for-no-reason_10320516.bc
Soothing babies who have “colic”:
http://www.babycenter.com/0_colic-how-tocope_1369745.bc
Science of Parenting, an inexpensive, photo-filled,
easy-to-read book for parents by Margot Sunderland,
has much more detail and references on these matters.
I keep copies on hand to give to new parents.
Here is a terrific post on co-sleeping (the abandoned
practice that is behind notions of leaving babies to cry
it out) by my esteemed colleague, Peter Gray. Much
more about co-sleeping research is here at the website
of my colleague, James McKenna.
More on babies’ and children’s needs here, here, here.
Giving babies what they need is really a basic right of
babies.
See here for more rights I think babies should expect.
And see here for a new book by Eileen Johnson on the
emotional rights of babies.
ADDENDUM: I was raised in a middle-class family
with a depressed mother, harsh father, and overall emotionally
unsupportive environment—not unlike others
raised in the U.S. I have only recently realized from
extensive reading about the effects of early parenting on
body and brain development that I show the signs of
under care—poor memory (cortisol released during distress
harms hippocampus development), irritable bowel
and other poor vagal tone issues, and high social anxiety.
The U.S. has epidemics of poor physical and mental
health (e.g., UNICEF, 2007; USDHSS, 1999; WHO/
WONCA, 2008). The connection between the lack of
ancestral parenting practices and poor health outcomes
has been documented for touch, responsiveness, breastfeeding,
and more (Narvaez et al., in press). If we want a
strong country and people, we’ve got to pay attention to
what children need for optimal development.
34 Clinical Lactation 2012, Vol. 3-1

For Further Reading
Blum, D. (2002). Love at Goon Park: Harry Harlow and the science of
affection. New York: Berkeley Publishing (Penguin).
Dawson, G., et al. (2000). The role of early experience in shaping
behavioral and brain development and its implications for social
policy. Development and Psychopathology, 12(4), 695-712.
Gale, C.R., O’Callaghan, F.J., Bredow, M., Martyn, C.N., and the
Avon Longitudinal Study of Parents and Children Study Team.
(2006). The influence of head growth in fetal life, infancy, and
childhood on intelligence at the ages of 4 and 8 years. Pediatrics,
118(4), 1486-1492. Retrieved from: http://pediatrics.aappublications.org/cgi/content/short/118/4/1486.
Henry, J.P., & Wang, S. (1998). Effects of early stress on adult affiliative
behavior. Psychoneuroendocrinology, 23(8), 863-875.
Hewlett, B., & Lamb, M. (2005). Hunter-gatherer childhoods. New
York: Aldine.
Meaney, M.J. (2001). Maternal care, gene expression, and the
transmission of individual differences in stress reactivity across
generations. Annual Review of Neuroscience, 24, 1161-1192.
Narvaez, D., Panksepp, J., Schore, A., & Gleason, T. (Eds.) (in
press). Evolution, early experience and human development: From
research to practice and policy. New York: Oxford University Press.
Schore, A.N. (1997). Early organization of the nonlinear right brain
and development of a predisposition to psychiatric disorders.
Development and Psychopathology, 9, 595-631.
Schore, A.N. (2000). Attachment and the regulation of the right
brain. Attachment & Human Development, 2, 23-47.
Schore, A.N. (2001). The effects of early relational trauma on right
brain development, affect regulation, and infant mental health.
Infant Mental Health Journal, 22, 201-269.
Stein, J. A., & Newcomb, M. D. (1994). Children’s internalizing
and externalizing behaviors and maternal health problems.
Journal of Pediatric Psychology, 19(5), 571-593.
UNICEF (2007). Child poverty in perspective: An overview of child
well-being in rich countries, a comprehensive assessment of the lives and
well-being of children and adolescents in the economically advanced
nations, Report Card 7. Florence, Italy: United Nations Children’s
Fund Innocenti Research Centre.
U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration. (1999). Mental
health: A report of the Surgeon General. Rockville, MD: Center for
Mental Health Services, National Institutes of Health, National
Institute of Mental Health.
Watson, J. B. (1928). Psychological care of infant and child. New York:
W. W. Norton Company.
WHO/WONCA (2008). Integrating mental health into primary care: A
global perspective. Geneva and London: World Health Organization
and World Organization of Family Doctors.
Darcia Narvaez, Ph.D. is an Associate Professor of Psychology, and Director
of the Collaborative for Ethical Education at the University of Notre Dame.
Her research explores questions of moral cognition, moral development,
and moral character education. She has developed several integrative theories:
Adaptive Ethical Expertise, Integrative Ethical Education, and Triune
Ethics Theory. She spoke at the White House’s conference on Character
and Community. She is author or editor of three award-winning books:
Postconventional Moral Thinking; Moral Development, Self and Identity; and The
Handbook of Moral and Character Education.
© 2012 United States Lactation Consultant Association 35

Media Reviews
Reviews by Kathleen A. Marinelli MD, IBCLC, RLC, FABM 1
BabyBabyOhBaby
Nurturing Your Gorgeous
and Growing Baby by
Breastfeeding
© 2011 Stark
Productions Inc,
$26.00 USD
28 minute DVD
http://store.llli.org/public/profile/544
Share this:
early milk, colostrum, how it helps the immune system
and the intestines. It also describes how the milk changes
over time to provide exactly what an individual baby
needs at that particular time. She discusses oxytocin, the
“cuddle hormone,” and a mother emotionally says, “I
am the only person who grew her and can sustain her!”
The narrator tells us that the key is comfort: calm, snuggles,
present in mind, body, and spirit. Refreshingly, we
are told that the best position is—whichever works best!
The baby is already an expert most of the time. So just let
them do their thing.
This beautifully composed DVD is a must-see for all! It is
meant for mothers and families who are either contemplating
breastfeeding, or may have already made the
decision, but still have doubts. Professionals should view
it as well. It is a practical, real-world guide to breastfeeding.
The experts are real mothers and babies who let you
into their breastfeeding lives, tell you honestly what to
expect, and want to share the joy they have found in
breastfeeding. They are not necessarily demonstrating
perfect technique. But they are all successfully breastfeeding.
As is stated on the cover:
Much more than a how-to film, BabyBabyOhBaby:
Breastfeeding, is a heart-felt, honest, and reliable
introduction to one of the very best parts of
motherhood.
The entire DVD is visually and auditorily calming and
soothing. It begins with mothers talking about the wonderment
of pregnancy, babies, and breastfeeding while
showing beautiful photographs of mothers and their
babies. Gentle music plays in the background as the narrator
speaks: “Breastfeeding is the heart of mothering.
The way nature wants you to take care of your baby.”
The miracle of a woman’s body growing a cell to a baby
to a person leads to the importance of the first hour—
”skin to skin and heart to heart,” a time to relax,
recuperate, and begin the bond of a lifetime.
The next section is the breast crawl, and beautifully
shows video of babies finding their way to the breast,
and baby-led breastfeeding. The narrator talks about the
The mothers are of all ages, ethnicities, and one has tattoos:
in other words, normal moms. Breastfeeding is
depicted as “on the job training.” There is no right or
wrong—as long as mom is comfortable, the baby is getting
milk, and it becomes second nature. If things don’t
seem to be going well, first thing to do is to go back to
the beginning: laid-back breastfeeding. Mothers are also
told that if they need help, they should contact their
local La Leche League, their health care provider, or an
internationally board certified lactation consultant.
The second-most important job in the world is that of
the mother’s partner. It is the partner’s job to nurture
mom so she can nurture the baby. But it is also important
for the baby and partner to have special bonding
time as well.
A section on questions and answers addresses the following,
all visually and verbally by mothers and babies:
••
How do I know my baby is hungry
••
What is a feeding cue
••
How do I know my baby is getting enough
••
My breasts are too big/small. Can I still breastfeed
••
This is not working. What do I do
Mothers’ groups are suggested as a great idea for support,
talking over questions, and watching other mothers
and babies interact. Then going back to work or school
is discussed, showing mothers expressing milk with a
variety of types of pumps, and even hand expressing into
a bottle. The last topic is weaning, with a reminder that
1
Kathleen.marinelli@cox.net
36 Clinical Lactation 2012, Vol. 3-1

the American Academy of Pediatrics recommends exclusive
breastfeeding for six months, and at least one year of
continued breastfeeding.
This is truly a beautiful DVD, and I highly recommend
it to all pregnant mothers and their partners. As a health
care provider, I also recommend it to all of us who counsel
mothers about breastfeeding. This critical subject is
presented in the most gentle, beautiful, calm way I have
ever seen, and I think we would all learn from this
approach. I can certainly see this video playing in waiting
rooms where pregnant mothers are waiting for health
care. What a beautiful picture to come away with!
New Insights into Vitamin
D during Pregnancy,
Lactation and Early Infancy
Carol L. Wagner, MD, with
Sarah N. Taylor, MD, and Bruce
W. Hollis, Ph.D. © 2010 Hale
Publishing LP., Amarillo, TX,
$24.95 USD
www.ibreastfeeding.com
Vitamin D is certainly a hot topic these days; no pun
intended. We hear about it everywhere, from medical
practice to the daily news. It has been a controversial
issue in breastfeeding for the last several decades—to supplement
or not to supplement—is that the question
As so eloquently elucidated in the book, New Insights Into
Vitamin D During Pregnancy, Lactation, and Early Infancy,
Drs. Wagner, Taylor, and Hollis take us on a journey of
our past, and current knowledge and understanding of
vitamin D, which is actually not a vitamin at all. As they
explain, vitamin D is a preprohormone that has profound
effects on metabolism and immune function
extending far beyond purely bone and calcium metabolism.
As they state in the summary:
Vitamin D is the substrate precursor to one of the
most powerful hormones in the body—1,25-dihydroxy-vitamin
D, which has profound effects on
metabolism and immune function that extend
far beyond the traditional thinking of bone and
calcium metabolism. We are only just beginning
to understand its effects on various organ systems
throughout the body—from epidemiological studies
to its action at the cellular level. Vitamin D
had been linked to inflammatory and long-latency
diseases, such as multiple sclerosis, rheumatoid
arthritis, lupus, tuberculosis, diabetes, cardiovascular
disease, and various cancers, to name a few.
How can such a simple “vitamin” be involved
in such diverse groups of diseases What is the
mechanism What does it mean to you as the individual,
as the practitioner, or as the public policy
maker (p. 7)
They pack a tremendous amount of information into
this 164-page soft-cover book. We begin the journey with
the history of vitamin D, its relationship to rickets, and
its discovery as the active rickets-preventing component
in cod liver oil. We are then taken through the lifestyle
changes that have led to widespread vitamin D deficiency
throughout most populations, leading to one of
the largest nutrient deficiencies beginning in the late
20 th century. As they tell this “story,” it is fascinating to
learn how we compounded this effect by our lack of
knowledge of the metabolism and function of this compound,
thus setting forth recommendations that have
now been associated with furthering the vitamin-D-deficiency
state. Chapters are spent elucidating the
metabolism of vitamin D, its functions, and importantly,
defining vitamin D sufficiency. This is accomplished
using scientific data and research studies, pointing out
those of quality and those with flaws that influenced our
views—and thus our use, and misuse of vitamin D. And
although some of the writing is quite technical, it is done
in such a way that those among us without technical or
chemistry backgrounds can easily follow and understand.
Thus it bridges both worlds quite nicely: the
scientific-minded and those with interest, but possibly
without the scientific background. As an MD, I “should”
understand the science. But I must admit that when I
start reading chemical formulations, I can easily drift off.
This book kept me riveted, focused, and interested as it
is so well written.
They go on to discuss vitamin D in the context of its
various functions—bone mineralization, immune function—and
how that knowledge influences our views on
vitamin D requirements. We then go on to learn about
the effects of deficiency during pregnancy, lactation, and
implications for early childhood and later adult life.
There is a comprehensive discussion of the current controversies
surrounding vitamin D supplementation, and
what can be done by health care professionals and public
health officials to impact health care to prevent further
vitamin D deficiency.
The final three chapters detail, with evidence presented
© 2012 United States Lactation Consultant Association 37

from the scientific studies done to date, vitamin D
requirements during pregnancy and lactation, and the
vitamin D recommendations for the pregnant and lactating
woman and her infant. These chapters are
extremely important to the work we do, but must be
understood in the context of the information gleaned
from the preceding chapters. In other words, I highly recommend
that one reads this book from start to finish,
and not just jump to the last chapter and the table of
recommended doses of vitamin D. Only in that way, can
one understand how they are derived, and where, as further
large-scale randomized trials that are mentioned
(and will soon be completed) are going. These authors
are leaders in this research. They are the ones I want to
hear from about how to supplement lactating women in
order to ensure sufficiency in their nursing infants,
when the data are in.
Finally, this book is extremely well-referenced. There are
over 500 full references at the end. So if you are interested
in looking into any aspect of this subject more
fully, you have the information right at hand. New
Insights into Vitamin D is a well-woven story encompassing
the science, the history, the humanity, the mistakes,
and the current research in a fascinating look into one of
the most controversial subjects in the field of not only
human lactation, but pediatric and adult medicine. It is
a far-ranging subject, and I enthusiastically recommend
this book to view it in a concise and remarkable way.
Kathleen Marinelli MD, IBCLC, FABM, FAAP an expert in the field
of Human Lactation, is an Associate Professor of Pediatrics at the
University of Connecticut School of Medicine, and a neonatologist
and directs Lactation Support Services at Connecticut Children’s
Medical Center, Hartford, CT. She serves on the Board of the
Academy of Breastfeeding Medicine and as Chair of its Protocol
Committee, on the United States Breastfeeding Committee, the
American Academy of Pediatrics (AAP) Section on Breastfeeding, is
the founding Medical Director of the Mothers’ Milk Bank of New
England and currently is co-Medical Director of the Mothers’ Milk
Bank of the Western Great Lakes. She has written chapter, monographs,
research articles, and ABM protocols. Her research interests
center on breastfeeding and the use of human milk in the neonatal
intensive care unit, cup feeding, donor milk and donor milk banking,
and the education of medical professionals. She has lectured
extensively in the United States, and abroad.
38 Clinical Lactation 2012, Vol. 3-1

Marketing via the Web and Social Media
Share this:
More than ever before, the world is truly at our fingertips.
“Let your fingers do the walking” no longer refers to
that giant book that immediately makes its way to the
recycling bin, but to the world of always-on information
that is available to us with a click of the mouse and the
touch of a pad.
As lactation consultants, we have the unique opportunity
to use online and social-media channels to both
reach and support our clients. While there are many
breastfeeding issues that require an in-person consultation,
there are also many that do not. The use of the
Web and social media in an IBCLC’s practice should
serve to consolidate the accurate, reliable, and current
information on breastfeeding. Used wisely, social media
can act as a valuable back-up assistant.
What is “Social Media”
The term “social media” refers to the use of Web-based
and mobile technologies to turn communication into an
interactive dialogue. For IBCLCs, it’s a way to use these
technologies and channels to engage directly with clients,
as well as other lactation professionals and
maternity-care providers. It is dynamic, existing in real
time, and is constantly updated, just like an ongoing
conversation. It’s also extremely popular: a 2009 Pew
study examining how people access the Web specifically
for health-related information showed that up to 42% of
adults searching for this information online say that
they, or someone they know, have been helped once
they’ve followed medical advice found on the internet.
This number is almost double the same statistic from
just three years earlier, and as of this writing, Facebook
alone has over 800 million active users.
What does this have to do with my practice as
an IBCLC
According to Scott Public Research, Generation X and
Generation Y women tend to rely on the Web and peer
contact for their information needs. Scott also shows
that the younger adult generation simply does not pay
attention to more traditional forms of health marketing
1 Kathleen Lopez is a student lactation consultant and aspiring IBCLC
Kathleen Lopez 1
promotion. Women who use social media on a daily
basis often turn to it as their first line of defense. Perhaps
more importantly, these generations are often doubtful
of advice that comes to them from outside their realm of
social contact. Younger, socially savvy mothers may be
more willing to listen to their peers than seek the advice
of an (older, more experienced) lactation professional.
So where do I start
Let’s take a quick quiz. Where do you look first when
seeking information or professional services Draw a
mental circle around all that apply, and then think about
where your clients or other local new mothers might be
looking for information and support. It may be very different
than what you think!
Word of
mouth
Phone book
Internet
search
Facebook Twitter Blog posts
Telephone
hotline
YouTube
videos
SMS text
messaging
Reference
book/
magazine
Chat rooms
or instant
messaging
iPhone/iPad
or
Android app
Journal
publications
Message
boards
Webinar
Is the list longer than you thought Did some of the
items surprise you It is interesting to note that more than
421 hospitals have YouTube channels, and that companies
that make products for the mothers you serve are on
Twitter, Facebook, or have blogs.
Consider the amount of time it takes for a mother to get
the information or support she needs. Without quick
turnaround, a mother may feel unsupported. Those
lonely, isolated overnight hours can leave a new mother
feeling especially vulnerable. And more and more, they
are using iPads or laptops to find information and support
that they need.
If your clients can “reach” a part of you after hours,
© 2012 United States Lactation Consultant Association 39

chances are they will feel a deeper connection to you and
your practice, and as a result will feel more supported.
Don’t forget, that to a new mother with breastfeeding
issues, every question can feel like an emergency. Waiting
even three or four hours for an answer can be an eternity.
Through the use of online channels, such as
Facebook and Twitter, or dedicated informational Web
pages and apps, IBCLCs can provide searchable answers
or have quick, direct engagement that takes less time
than a phone call or office visit.
Perhaps most importantly, we can disseminate information,
gain visibility for the IBCLC credential, and add
commentary to (and sometimes even correct) information
that already exists. While the ever-changing
landscape of technology can at times seem overwhelming,
it is important to remember that reaching new
mothers is most effective when we engage them in the
places where they are asking questions.
Clinical Lactation is on Facebook
Visit to:
• Make comments,
• Send us a message, or
• Recommend us to your friends.
For Further Information
http://en.wikipedia.org/wiki/social_media
http://www.pewinternet.org/reports/2009/8-thesocial-life-of-health-information/01-summary-of-findings.aspx
Electronic Submissions
Clinical Lactation is pleased to announce
our new electronic submission portal at
http://www.clinicallactation.org.
http://www.facebook.com/press/info.phpstatistics
World AIDS Day Statement from WABA
In recognition of World AIDS Day on December 1, the World Alliance for Breastfeeding
Action (WABA) released a statement, Getting to Zero: Zero New HIV Infections, Zero
Discrimination, Zero AIDS‐Related Deaths—Making GETTING TO ZERO a Reality for HIV-
Infected Mothers and Their Children. The Statement brings critical updated information on
this complex issue of HIV and infant feeding policy guidelines and decision making, and
the important role of exclusive breastfeeding in HIV intervention and child survival.
WABA has also recently updated their pamphlet, What Women Need to Know on HIV and
Infant Feeding. It guides women in understanding this complex issue better, and helps them
make informed decisions on needed treatment, and infant feeding for both maternal
health and prevention of HIV transmission to infants.
You can access both documents at the WABA Website, www.waba.org.my
40 Clinical Lactation 2012, Vol. 3-1

The California Maternal Quality Care Collaborative is pleased to
announce the release of a new White Paper.
Cesarean Deliveries, Outcomes, and Opportunities for Change in California:
Toward a Public Agenda for Maternity Care Safety and Quality
[Executive Summary only]
Elliott Main, MD, Christine Morton, Ph.D., David Hopkins, Ph.D.,
Giovanna Giuliani, MBA, MPH, Kathryn Melsop, MS, and Jeffrey Gould,
MD, MPH
The MCH Navigator
The Maternal and Child Health Bureau, HRSA, is excited to announce the availability of
a new resource for MCH professionals working in state agencies and at the community
level who seek to advance their learning and skills mastery. The MCH Navigator is a
learning portal that links individuals to existing open-access training, organized in areas
consistent with nationally endorsed public health and MCH leadership competencies.
Online training resources, such as archived webcasts and webinars, instructional modules,
and self-guided short courses have undergone academic review and have been
handpicked for, and vetted by, MCH audiences. Those seeking more complete information
about the overall MCH Navigator project can find a short video presentation at
http://navigator.mchtraining.net/wp-content/blogs.dir/5/files/PPT_Navigator/
© 2012 United States Lactation Consultant Association 41

Need help remembering the 10 Steps to Successful Breastfeeding
Here are some HANDY reminders from Christine Gibson.
http://www.youtube.com/watchv=JRr1QK_saa4
Handy Reminders for the 10 Steps to Successful Breastfeeding
Breastfeeding Education & Communication Skills
What to say, How to say it, and When to say it
Part 1 A 45 Hour 5–Day Professional Breastfeeding Course
Offered by Barbara Robertson, MA, IBCLC, RLC
The Breastfeeding Center of Ann Arbor
April 11–15, 2012 and September 19–23, 2012
Wednesday–Sunday 8 am–5:30 pm
at The Center For The Childbearing Year
Part 2 of this comprehensive 90 hour
course will be offered on
June 27–July 1 and October 10–14, 2012
It is not required that you take both parts.
Your Investment = $650 ($215 in 3 monthly payments)or
$590 paid in full by April 1 or September 1
http://bfcaa.ticketleap.com/45lactationcourse/
Who should take this course
••
IBCLCs or anyone qualifying and preparing for
the IBCLC exam
••
Nurses
••
Doulas
••
Midwives
••
Breastfeeding Peer Counselors
••
Anyone interested in knowing more
about breastfeeding
What makes this class unique
Everything! You will not sit for 45 hours and just listen to PowerPoint
lectures. This is an extremely interactive course focusing on what
we know about adult learners. In order to truly learn something, the
learner has to use the skill or practice in some way, not just hear
it. To learn more visit http://bfcaa.com/new-45-hour-lactationprofessional-course/
This unique course is limited to 20 attendees and will provide much needed clinical experiences.

To see more of our books and order online, please visit our website at
www.ibreastfeeding.com

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