lactationconnectioninoz

Am I having a good time or what??? Today I went back to the Breastfeeding Day stay clinic at the RWH for a second day of observation. Pam and Heather have been most welcoming, and the whole experience has been very enlightening. Morning discussions were about hands free pumping, a new design of bra to help that, and then I asked if people saw it as important to belong to their professional organisations, but most of them said it was expensive and they didn't think there was anything much in it for them. But judging by the amount of recognition and supprot the IBCLCs get in Melbourne, that may not be surprising. I got to follow Heather for the day, with a couple of visit through the clinic to see Marg's mums.

First up today was a mother who had been up most of the night with a 5 day old, who was concerned he was waking because he was hungry. She was using nipple shields but was not at the clinic because she wanted to wean from them, and expressed no desire to wean from them at all. Baby had a great feed, followed by breast compressions, which were just like you always hope they will be. Baby stops sucking, mum compresses, baby swallows and swallows again, stops, mum compresses a different part of the breast, baby swallows again etc. This happened for about 5 minutes at the end of one side and again at the end of the other. Baby then conked out completely and slept for the next 5 hours!! All the time he was in the clinic and the mum got to recline with a blanket and catch up on some sleep herself. Probably he was having his night! Anyway mother wants his nights to improve within the next 2 weeks or she wants to come back in again....

That reminds me, "sleep schools" are everywhere. Typical ads read:
Expert help for settling/sleeping/feeding problems
Learn sleeping/settling/feeding strategies)...note that feeding does not come first.
Infant sleep management programs
Establishing routines
Manage/control your child's routines
How to manage reflux/colic
Names like Sweet Dreams, Sleep Rescue Home Visiting Service, the Baby whisperer.
For older kids, one ad reads "How To Get Your Child To Beg To Go To Bed"!!
There are "teaching" centres for just about any developmental milestone you can imagine. It is really an eye-opener. People have strayed so far from the biological norm....

Back to my day at the clinic.
The second mother was a Japanese mum who had not had a good time in the hospital as all the midwives told her different things to do. Baby was having trouble only on the left. She was relieved to be able to speak Japanese to someone (me) and her friend had come with her for support. Her friend was wonderful with a 4m old baby of her own there too. She had gone to the clinic to sort out her challenges when he was a week old. Mother had reported to friend when they had been having lunch in a restaurant the day before (baby was 7 days old) that she thought all the patrons in the restaurant were midwives and they were all talking about her. Friend was understandably worried about this. During the day in the clinic, mum pumped lots of milk, which was good for her confidence, and baby got a little better at attaching to the left. But most of all, she could see that baby had what was called a "positional turn", probably from the way he was lying in utero, and he really did have trouble when he was lying on his right side, making left side harder to latch on to. So she got some exercises to do with the baby to help him strengthen the weaker side, lying on his tummy, legs flat, and putting gentle pressure with your hand on baby's bottom to encourage him to lift his head, also shaking a rattle on each side to get him to turn his head more completely etc. After he had fed earlier in the day he was quiet and alert and she just put him in his bed and ignored him, so I got her to get him out and showed her how he can interact with her, making faces, chatting to him etc. She had no idea he could see, nor do such things and was so pleased to see how clever he was. Her friend is off to get Sue Cox's book in Japanese,possibly also Akane's, and they have the llljapan.com website. I also suggested they start a Japanese mother/baby playgroup and they were very keen on that idea, and said they already knew 4 mothers who could be the founding members. I was like, GO for it! I hope they do.

Next up was a baby who I first observed noisily drinking a bottle of EBM after he first came in. Heather explained he has a soft palate cleft, and the bottle was a Haberman feeder. Mum has a super dooper supply, and Heather is really impressed at how far this little baby has come, now breastfeeding some feeds directly from the breast. Mum has to compress the breast for the whole feed, and sometimes use dancer hand position for stability, but baby can get some milk there, and then when he gets tired he swaps over to the Haberman. It is tiring because he can't maintain enough negative pressure in his mouth to extract the milk, so he has to work doubly hard for it. Heather herself is in the process of making a video about feeding cleft babies, that is her specialty. She has been around a LONG time, held every position imaginable, now just retiring from the National Board of ALCA.

While I was observing the cleft baby, Lisa Amir walked in and said Ohayo gozaimasu to me! She is back from her 10 days in Japan, where she got to observe an Oketani midwife demonstrate breast massage. The Japanese doctor she was with said she has only seen one case of mastitis in all her years of practice. Was this a comment on a (questionably) low rate of mastitis in Japan, the competence of the doctor, the effectiveness of the massage technique or something more sinister?

Lisa was there to assess a 5 day old with tongue tie. Yup! I felt so lucky! The baby was unable to latch onto the breast and suck at all. The frenulum under the tongue was assessed on a special score chart to be significantly short with very little range of movement and quite inelastic, which required it to be clipped. Lisa gloved up, got the sterile scissors, explained it all to the parents who were keen for this to be done, asked if there was any family hisory of tongue tie (NO) explained a few more details to me, and I got to hold the light while baby's tongue was clipped, taking about 30 seconds total. Baby gave one cry out, Dad held it (Mum had conveniently gone to the bathroom) and then baby was fine. 2 or 3 drops of blood, that was all. Lisa had explained that it may not make a sudden improvement in breastfeeding, it could take a few days, and in this case, the baby had never latched before so it looked like it would still take a while. Plus mum had flat nipples. Marg the LC suggested the mum spend a lot of time poking her tongue out at the baby, and when mum poked her tongue out, I could see she had a tight frenulum under her tongue, pulling it at the tip and not much range of movement! Didn't think I should say anything. This mum had been fully cup feeding EBM for the 5 days since birth, but changed to a bottle and also nipple shields while at the clinic. Baby still couldn't latch onto the nipple shields, but maybe after a few days on a bottle, it will get the idea.

In between seeing mothers the staff at the clinic have to be sure that all equipment is in order, and I helped with and learnt about putting bottles together (because I never have!) and which bits need to go with which for Habermans etc. All good practice. The hospital sterilises everything for them, all the pumps, shields, finger feeders, SNSs (mothers buy their own tubing)etc. So far I have not seen anyone encouraged to use an SNS, all just expressing, cups and syringes, then directly from the breast.

Another mother was in for a repeat visit with a 6 week old, and asked so many questions about problems she didn't even have. Heather was very patient with her, but I started to detect a note in her voice a bit later on in the day. The mother thought she had position and latch problems, but all looked and felt fine, so she launched into a "Well now that I am here can I just ask you..." and her questions were amazing. So worried about what might happen. Heather asked her what she did before her baby was born and I said to myself "accountant" and SURE enough she was an accountant. How did I get that right? But we showed her some other positions at her request, and how to nurse lying down, and all she could worry about was how will I know if position and latch are OK. Heather said if it feels OK and baby is sucking and swallowing OK then IT IS OK. She must have said it 10 times. I told her later, baby will be able to stand on one leg and nurse eventually and she thought I was kidding! I thought she was someone who would benefit from a mother-to-mother group like her local ABA.

I got to observe all the paper work of a Day stay clinic, masses of records required by the hospital, as there is a baby set and a mother set, all have to be signed off. Then there were discussions about how to keep more accurate stats for their clinic, and how to keep them in line with BFH, and I found that if a mother gets followed up with a call, this is classifiedas HITH, hospital in the home, and is worth heaps of money/funding to the clinic, so they do like to book mothers into HITH and then call them. But more papers are required to transfer mums to HITH!

I found there are at least 3 more seminars while I am here, one with Rebecca Glover and Denise Fisher, one with Pam Heselev from the Day stay clinic and a pediatric physio (that one is a 2 day practical workshop with case studies, and Pam tells me I will learn heaps beacuse she is teaching it!) and one in Geelong which Pam tells me will be good and they always have nice food in Geelong! Costs a fair amount to attend these things. Then there is also the link group for the College of LCs and Marg is getting me the details on that. That one is a lunch hour thing.

So all in all a very exciting an educational day for me at the clinic, and maybe I can go back another day too. Pam and Heather are waiting for their invitations to come and speak in Japan. They would be good on position and latch etc. We should think about that! They are very relaxed, very funny girls, who have maintained their total commitment to this work through thick and thin. Inspiring!

Chronological order is proving impossible here, I will go back and fix it later! Now I want to tell you about the day I spent at The Royal Women's Hospital Breastfeeding and Education Support Service (BESS). I was introduced to the girls there by Karen Clements from Lactnet, and I was there from 8am till 4pm. The clinic is across the road from the hospital, the largest hospital for birth in Melbourne and a Baby Friendly Hospital. They have already delivered over 2000 babies this year to date.

The clinic itself is basically 2 flats/apartments joined together, filled with comfy chairs and pillows for the mums to use. It is a day stay clinic, where the mothers and babies come in the morning and stay until baby has had at least 2 feeds or it is 2.30 whichever they prefer. There are 3 IBCLCs who handle 9 mothers and babies, all sitting round like in a big lounge room, and the mums all chat and have lunch provided by the hospital there too. They have access to the kitchen for drinks, and it is all very relaxed and friendly. The amazing thing is that this is all paid for by Medicare, the national health care system. Another IBCLC does the hospital rounds, seeing mothers on the wards who have challenges that the midwives can't handle.

So I got to go on the hospital rounds with an IBCLC Marion who, as fate would have it, was employed as an LC by my sister many years ago when Heide was the Unit Manager at Mitcham Private Hospital, and Marion could remember when Heide came to London for Isamu's birth! Several of the staff knew Heide. Had a lovely day following her round.
For those of you like me, with minimal hospital experience, here is what happens. First when you go to do rounds, you get to view all the records for the mother in the office. There is a computer generated printout of labor and delivery information, where you can see how many weeks gestation, how long labor was, any interventions (they all seem to use drugs, very unusual to have a drug-free birth) and the condition of the baby, APGARs etc. Then there is a breastfeeding report form, which shows the details of the first feed, when it occurred, how it went, and then subsequent feeds are noted and a code is used to identify if midwife latched baby on or mother herself latched baby on, and a scale of how the latch was. In theory these records are great, but the reality is very busy staff, who don't fill it in, or who fill it in incorrectly, and apparently everyone seems to over rate the baby's latch, saying it was very good even when mum's nipples are very sore after! Then if an LC has already seen the mother there will be her report and what her recomendations were included in the notes too.

So armed with a certain amount of info, we headed off to see the mothers. First mum had difficulty with latch, and was expressing and syringe/cup feeding the baby EBM. This is what everyone does here. The LC showed her how to use the Medela handpump (actually just a bottle with the piston from the electric pump attached, the reasoning being if she needs to rent a pump after she goes home, at least she has a compatible system and doesn't incur additional expense. ) Mothers are also given the info about the day stay clinic and asked to make an appointment. They find that if the mother calls herself she will turn up, but if they book her in, she may not turn up at all.
After seeing this mother, we went to the other ward, where all kinds of interventions have occurred because mothers had GD or some other high risk setup or had emergency C sections etc.
The mothers there seemed to have similar issues with latch, and the "fix" seemed to be get the supply up and running with regular expression, feed the baby some alternate means, and then try to work on the baby breastfeeding from the breast. Sore nipples were rested till they healed and baby fed by cup/syringe. The LC did not spend much time trying to fix baby's latch, as it is mainly the midwives who are supposed to do most of that. The day stay clinic is like a back up where they can go the week after discharge, and spend a whole day relaxing and being helped by the IBCLCs if they haven't got it together quicker.
One mother was interesting. She had already been feeding significant quantities of formula because she reported she had "no milk". In that situation, she has to sign an informed consent paper, setting out that the staff had told her the benefits of breast milk, and that breastfeeding may be compromised by her choice to formula feed, and that she must provide her own formula and bottles to the hospital. (Wouldn't that be a dream come true in Japan??) I thought it most interesting that this mother was not Australian, and wondered if there was a cultural side to this formula thing. But when we saw her, she had masses of milk, and was encouraged to express it and feed that instead of formula, but she still wanted to feed it by bottle. The LC doesn't argue with that, because she says it is better that the baby gets EBM by a method the mum is comfortable with than none at all.

Another quite young mother had a very unhappy baby, and the father was struggling to get it dressed into some outfit I felt it probably really didn't need to have on. The LC took the baby and tried to latch it, and it just conked right out as soon as it was there, not even one suck. After lots of skin to skin, baby still wasn't really doing anything, so mother was referred to the clinic. Then Dad decided (why?)he needed to dress the baby again, woke it up and poor thing started screaming again. Later we walked past again and Dad was changing the baby AGAIN, with baby screaming blue murder.
One baby we saw just before lunch was under lights for elevated bili, assessed by pinprick. He was being finger fed by syringe by mum, who was very chatty. A lovely Greek/Indian couple who were planning that baby would speak 4 or 5 languages! I asked if baby looked more yellow becasue Dad was Indian, but they said bili is assessed via blood. The baby was under the lights right beside Mum's bed, so she could see if he was hungry. LC said skin to skin is so important with these babies too, because they spend a lot of time away from mum.

After lunch in Carlton, I spent the afternoon at the day stay clinic, hearing how things are run and chatting with the mums. Most of them had confidence issues, and one had a baby who cried every waking minute if it was not feeding, and I could see her just shutting down from the stress of it. Another Greek chatty mother who wanted to talk all about Japan (don't you hate that?!) who was just a bit unsure how it was all going, and then after all the mothers went home, I stayed with the 3 IBCLCs and asked lots of questions. They invited me back next week and also would like me to speak to the staff in the hospital about BF in Japan. It should be pretty embarrassing telling all the things we deal with from hospitals in Tokyo, considering mothers and babies are never separated at this BFH, and hospital breastfeeding protocols are even available online.

So at the end of the day in the clinic, the staff then call back all the people who have left messages, just like a telephone counselling line...well just like what WE do! Then they debrief with the other IBCLCs, and everyone heads home about 4pm. Apparently many of the hospitals offer this sort of service.

Off topic here, but because RWH is so big and central, they get lots of different nationalities of women there, lots of immigrants, and have a variety of interpreting services/cultural support services available where needed. They even have a special protocol for women from countries where FGM occurs. I confess I did not know this abbreviation, but it was a very enlightening page to read. Just take a look.

Dates are all over the place, as I am posting details from the ILCA Conference weekend

Thursday July 31st 2003
Warning: Serious pathological but enjoyable namedropping follows. Scroll down if
a) You are not interested,
b) you are sickened by my pathetic adoration as a groupie of these "rock stars" of lactation or
c) you are just plain jealous...


The zoo sessions of the pre-conference were incredible, discussions of mammalian lactation, comparisons between humans and wallabies, higher order primates and so on, with a discussion of what we can learn from each other. The big word of the day was olfaction....very important even for human babies. With all our cleansing procedures associated with birth and postpartum, we take away so many of the important smells that babies can rely on for orientation to our world and their subsequent acclimatization.
The wallabies actually spend 364 days of every year pregnant, which is amazing. They deliver the 5 mm baby one day, and the baby crawls up to the pouch, latches on to the teat and stays permanently latched for a number of months. The next day after birth, fertility returns and they mate and fall pregnant the same day, and the blastocyst sits there dormant until the just born baby grows big enough and finally releases the teat, some months later. Then the blastocyst kicks back in and the next baby grows. Wouldn’t giving birth be a breeze if the baby were only 5mm???
I had the good fortune to meet quite a lot of lactation people at the zoo, as we had very long tea and lunch breaks. I met Lisa Amir (Candidiasis expert and doctor, now doing her PhD on mastitis) before things even began in the morning and found she is off to Tokyo (actually near Nikko is more accurate) next week to teach a course for Melbourne Univ. on Women’s Health, which, while not strictly about lactation, piqued Tomoko Seo’s interest (JALC) and I left them trying to work out a meeting with an IBCLC while Lisa is in Japan. Lisa remembers meeting up with Akane Kanamori some time ago in Melbourne.

Lisa was sitting with Kay Hoover (Breastfeeding Atlas), who told me she spent a day at Lisa’s clinic in Melbourne and got to witness 3 tongue-ties being clipped, and my invitation to observe any Friday I liked followed shortly thereafter. (See me punching the air here) Yes!! I also met Gillian Opie, a neonatologist IBCLC whom I actually knew from my university days in Ormond College, and she has said I can visit her Level 3 NICU in Melbourne anytime too! I felt like the invitation collector. But having a name tag that said I was from Japan when I so clearly didn't look like it, was a great conversation starter, and helped people remember who I was! On the zoo day there were 450 or so participants so this was indeed a good thing!

Lunch was with Jean Cotterman of Reverse Pressure Softening fame, and we discussed getting her material translated into Japanese. I wandered around the zoo, admiring the view and the beautiful weather more than the exhibits, which was mainly because a lot was under construction. The gorillas and their baby were cute and the giraffes and elephants had quite nice enclosures. The hardest thing of all was staying alert and awake during the presentations, which were really interesting but sitting still all day is not really my thing, especially after all the nice food and not enough sleep!

More later

I decided to create a separate blog for my different experiences in lactation here in Australia for fear of boring the general readers of tokyokidsinoz to tears with my constant babble about breastfeeding related things. This way, those of you who really want to read about it can choose to do so, and those who don't want to don't have to. I will soon post with ILCA conference stuff.
By the way, the way things happen in Japan is so different, some of my comments will be coloured by that. And some things I will have never seen before just because I never work in a hospital.