Newsletter #47: What an IBCLC Will Never Say

By BMSG Editorial Committee

Editor’s Note: This article is meant to help mothers recognise errant or misconceived breastfeeding advice that they may receive from individuals who claim to be breastfeeding professionals. Ultimately, we hope this article empowers mothers to discern between well-meaning and problematic advice.

What is a Lactation Consultant?

If you are a breastfeeding mother, chances are, you might have been asked to contact a lactation consultant or LC for short. This is usually the case when a breastfeeding mother is facing challenges that go beyond what a peer counsellor or lactation nurse is able to help with. 

In such situations, mothers are strongly encouraged to seek help from a certified lactation consultant. Currently, International Board Certified Lactation Consultants (IBCLCs) are the only breastfeeding professionals who can provide mothers with assistance to more serious breastfeeding issues such as oral restrictions and latching difficulties. IBCLC is also the highest qualification standards for lactation certification globally.

Unfortunately, the term “Lactation Consultants” are not exactly protected. Anyone can call themselves a “lactation consultant” but to become an IBCLC, one would have completed the requirements to be eligible to sit for and passed a rigorous exam, prove continuing education every year and accumulated relevant number of hours before they can legally use the term.

You may need to see a Lactation Consultant if you have breastfeeding-related queries that are of a more serious nature. It is important to find one who is knowledgeable and makes you feel safe. [Stock Photo]

Recognise the Alarm Bells

So if you are meeting someone who claims she is a lactation consultant or a lactation specialist, paying attention to this list of errant comments may help you to decide if the advice you are receiving from the individual is sound:

1) “Your milk is too thin and of poor quality.”

Breastmilk is made up of many components and unlike commercialised milk or milk powders, breastmilk will separate into many layers when settled. At the start of a feed after a letdown, milk that is expressed from the breast may take a watery texture. It may be natural for anyone who is uninformed to conclude that this is a sign of poor milk quality. But once we understand that milk is made up of part water and part fat, both of which are important as these help to quench a baby’s thirst AND keep them full all in one feed, the appearance of a mother’s milk rarely is any cause for concern.  This is akin to the appetiser-main course-dessert analogy where breastmilk fulfils all the necessary nutritional needs for babies.

If you were to place a bottle of expressed breastmilk and let it stand for a while, you will notice that the breastmilk will separate into layers. The fattier layers will climb to the top (characterised by a layer of fat or oils) and the watery layers will sink to the bottom.

2) “Your baby is too lazy to latch.”

It must be heart-breaking to know that your baby has been labelled “lazy” at such a young age! Such advice can never be further from the truth. The fact is that a percentage of babies may face some difficulties or challenges to latch, either due to an oral obstruction (tongue ties, lip ties, missing palate etc.) or due to interventions that affect baby’s ability to latch (e.g. using a bottle before breastfeeding is well-established, using a nipple shield or a pacifier very early on in baby’s life, or mum having taken epidural in labour).

A baby is never lazy! But they can be taught to latch and if they have oral conditions that prevents them from latching well, their situation can be improved with medical interventions. After all, especially for a newborn, breastfeeding requires practice. Some babies may have very small mouths that may need them to put in considerable effort to latch on mummies’ breasts.

A baby who has trouble latching is not lazy; something is preventing them from latching well. [Stock Photo]

3) “You need to pump to see how much milk you are making.”

Pumping to check your supply is inaccurate as a pump is never able to extract as much milk as a baby can latch. The best way to check your supply is to monitor your baby’s wet and dirty diapers, weight gain as well as level of activity. Pumping too early can also trigger an onset of problems such as oversupply in the early days, which can inevitably lead to complications such as blocked ducts and mastitis.

4) “You must introduce bottles at 3 weeks to prevent bottle rejection.”

This is not true. Early introduction of bottles (anytime before 4 to 6 weeks) can interfere with a baby’s ability to latch at the breast. Parents should wait before introducing bottles because babies may develop a preference for the fast flow of the bottle. They may also experience nipple confusion where they are unable to latch at the breast or become too impatient to wait for a letdown at the breast. While it is true that breastfed babies can reject the bottle, there are other ways to provide expressed breastmilk (EBM) to babies when the time comes such as when mothers return to work. Alternatives such as cup, spoon, syringe and straw feedings have worked with many babies. Babies can also receive EBM through age-appropriate sippy cups.

5) “Pump after latching to prevent blocked ducts.”

There is no need to pump after each time you latch your baby. If your baby has emptied your breast during the session, you can continue to offer your baby the other breast at the next feeding session. Pumping unnecessarily after each latch can signal to your body to make more milk than what your baby is actually receiving. This can lead to complications such as oversupply and subsequently blocked ducts and mastitis. If you still feel that your breast is not fully empty after a feed, use breast compressions during the feed to activate the milk flow once you sense it has slowed down. This can be seen when baby falls asleep at the breast. Baby will automatically unlatch or fall into a deep sleep once he or she has received enough milk. Some mothers also hand express the excess milk and store them for later use. As long as your baby is feeding efficiently, there is no need to pump after every latch.

Giving baby full access to the breast without time limits means allowing baby to receiving a full feed from the breast. This will also be helpful for your supply as an empty breast signals the brain to produce more milk. [Stock Photo]

6) “Feed baby on both sides for 15 minutes each.”

The time that baby takes to feed from the breasts is not important. Latch on demand and allow baby to drink from the breast for as long as he or she wants. Limiting time at the breast (or unlatching too quickly) may prevent baby from getting a full feed from the breast, which may consequently mean preventing baby from getting the fattier part of the milk which is present towards the end of a feed (i.e. an emptier breast). An empty breast also stimulates the brain to urge the body to produce more milk, hence helping to maintain your supply.

Knowledge is Power

With all that has been said, at the end of the day, it would be helpful for mothers to seek evidence-based information and to talk to as individuals as possible before making important decisions for your breastfeeding journey. It can be overwhelming and also demoralising to receive comments that may be far from accurate but knowing how to sieve out errant information and to seek opinions from different sources will greatly help you to decide what is best for yourself and your baby.

A lot of times, advice can be well-meaning. It can also be problematic if it is actually misinformation or does not help you to make a well-informed decision. It is therefore highly important that parents understand the techniques behind breastfeeding and do some fact-checking before arriving at a decision. A wrong move can greatly impact what happens subsequently.

Newsletter #45: How Has Covid-19 Affected Mothers?

By BMSG Editorial Team

The presence of Covid-19 in our lives has been hugely unexpected. For mothers, it brings about multiple reasons to cause anxiety and worry. Over the past months, we have read many stories in the news about how mothers have been affected by Covid-19. From mothers who could not send their milk home to their babies living overseas back home, to new mothers who face isolation and lack of family support with a newborn in hand – the challenges seem endless.

The fear is real and the struggle is even more. We highlight other struggles that mothers have faced based on a survey that we conducted in early 2020 as well as from our interactions with mothers who have reached out to us via our social media platforms.

Fear of Being Separated from Baby if Mum Gets Infected

From the very beginning, what is probably on every mother’s mind is what happens when she or her baby gets infected with the virus. For some mothers, the worry of being separated especially when baby is breastfeeding is a terrifying thought. Applie Wan, a mother of two, had a wake-up call when a member of her family had become infected early this year. The breastfeeding counsellor, who has a young baby and toddler, was concerned about having enough breastmilk for her baby in the event that she has to be warded or isolated from the family. 

Separating from a breastfeeding baby, especially if baby is very young, can be stressful for mothers. [Stock Photo]

“There is a constant worry about whether I will be separated from my three-month-old baby if ever I was to contract the virus, and whether I am still able to breastfeed her because of that,” said Applie. She also started to pump extra breastmilk if she had to be separated from her child suddenly. “I’m also motivated to have a bit of oversupply to provide my toddler with breastmilk, too, to try and boost her immunity,” she added.

It is understood that one parent is able to accompany a child who gets infected with the virus. However, not much information is available on the arrangement when a breastfeeding mum is the one who catches the virus. According to KK Women’s and Children’s Hospital, in a letter responding to BMSG’s queries on the matter above, each hospital adopts individual protocols to suit the needs of patients best. It is still not clear if a lactating mother is allowed to have her nursing baby with her if she is to be under isolation or warded at the hospital, especially since no visitors are allowed to see patients who contract the illness.

Challenges for Mums who want Urgent Lactation Care

For some mothers, receiving urgent lactation services from lactation consultants has proven to be challenging. 

Two mothers whom we interviewed had faced difficulties in trying to receive care for mastitis. One mother, Marissa Lee (not her real name) who developed mastitis when her two week-old son had been warded at a hospital for high fever, was turned down from the same hospital when she presented herself at the A&E department.

“It was disappointing to be turned away when I was already having a high fever and pain in my breast. Because I was not a mother who had given birth at that hospital, I was not able to receive emergency lactation care right away. I was, in fact, redirected to a nearby hospital, which did not have any lactation service,” she said.

After being discharged when her fever subsided, Marissa decided to go to another hospital when her fever returned on the same day. Thankfully, it offered her outpatient lactation service through a lactation consultant and helped her resolve her mastitis. Unfortunately, due to having a long separation from her son and coupled with the complications of mastitis, the mother eventually had to resort to exclusively pumping as her baby had developed a preference for bottle feeding. She has not had her issue completely resolved and has had to depend on breastfeeding support groups and advice from fellow mums to resolve her recurring milk duct. “It has been such a long and emotional rollercoaster ride,” she said.

Mothers who need professional lactation care may find themselves having to wait till CB ends before securing an appointment due to social distancing measures. [Stock Photo]

For another mother Shena Ng (not her real name), Circuit Breaker (CB) measures had made it impossible for her to reach lactation consultants and a paediatric dentist when she sensed something was amiss with her newborn’s latch. As CB measures were already put into place by then, she was disappointed to discover that lactation consultants were no longer allowed to conduct home visits. “I desperately wanted to seek expert advice regarding my daughter’s latching. Breastfeeding has been painful and unbearable,” she said. 

While Shena attempted to return to the hospital she birthed at to set an appointment with a lactation consultant, she was gently turned away as they had discovered that her baby was taking the bottle, possibly due to hospitals wanting to prevent seemingly unnecessary visits. “The lactation consultant had been really helpful and contacting me via phone calls. She said the hospital has been very strict about setting appointments for lactation care. I’m still trying to latch my baby on and off, but I really want to see a paediatric dentist or anyone who can tell me what is going on with my baby,” she said.

A Challenging Time to Give Birth

In the same survey, four pregnant mothers shared their concerns about precautions in the hospital, particularly in the delivery suites.

With limitations on visitors at the hospitals, pregnant mothers are anxious to know if their partners will be allowed to enter the delivery suite during labour. Wen Xiu, a pregnant mother of two, shared her real worries: “I am most worried that my husband will not be allowed in the delivery suite.”

Some expecting mothers are anxious about giving birth during the Covid-19 season while some are worried about having their partner around during labour. [Stock Photo]

According to Shaheeraa Khan, a doula and EXCO member of Doulas of Singapore, such anxieties are valid. “Having a support person to be there with the laboring mother is essential for her needs. Thankfully, all hospitals in Singapore do allow husbands or an immediate family member  into the delivery suite,” said Shaheera. All accompanying partners or family members must also not have been issued a SHN or be under quarantine orders. They must also comply with safety measures imposed by the hospital.

Unfortunately, for mothers who desire to have a doula with them during labour, doula services have been suspended across all hospitals except for Thomson Medical Centre.  

This has not dampened the spirit of doulas and clients alike; many doulas continue to provide prenatal support virtually or on mobile to parents. “Doulas can still be part of your birth team. Prenatally,  the doula will work with both parents to prepare them for their birth; go through comfort measures, types of pain relief and address any other concerns which the parents may have to guide them to have (a) positive birth.”  

According to Shaheera, from the 37th week onwards (although this may vary from doula to doula), the doula will still be on standby remotely to answer any questions which the parents may have.  During labor, she will support the labouring mother closely via phone. “We will help in answering any questions the couple has, encourage the mother and advising the father on what to do and ensuring that everything is going well while not physically being there. She will guide the father on what to say or what not to say and how to offer comfort measures. She is also there to offer encouragement,  advice and really holding the space virtually to encourage the mother to have a pleasant birthing experience,” said Shaheeraa.

Mothers who give birth in the season of Covid-19 have had to adapt and recalibrate their expectations of the postpartum period. [Stock Photo]

Babies Not Allowed in Other Hospital Wards

For mothers who are hospitalised for other medical reasons, such as an illness, having baby be with mother has proven to be impossible. We spoke to Emma Bell, who recently gave birth to her second baby, on her harrowing experience when she had to be hospitalised for post-birth complications. Emma had to be hospitalised when she developed a fever due to a womb infection. As she was a breastfeeding mother, she expected to be able to have baby with her at the hospital so that she could latch baby on demand.

She was warded at two hospitals, the first being just before CB was implemented. “They allowed baby in during visiting hours (at the first hospital) but not at night, so I pumped at night,” said Emma, whose husband brought baby to the hospital daily so that she could nurse her.

However, when she decided to transfer to another hospital, CB had just been implemented on the same day. Unlike at the first hospital, this time, baby could not join her at all. “They did not allow (my) baby in at all. My husband brought her in the first day but the nurses insisted that she leave and couldn’t come back so I didn’t see her again until I was home. I pumped the whole time I was there,” said Emma, who decided to go home after six days at the hospital so that she can rejoin her baby.

For a new mother, being totally separated from baby is extremely distressing. While Emma is now back home with her baby, she has not fully recovered and is facing the struggles of managing a newborn while trying to recuperate.

Extended Confinement

The confinement period can also be taxing on mothers during this CB period. An earlier article by TODAY Online interviewed many new mothers who had to struggle and make do with a lack of family support especially for those whose parents or family were not living in the same household.

Mothers who are recuperating for postpartum may feel frustrated and stifled when their freedom is restricted because of CB measures. Not being able to visit postpartum care professionals can also affect their emotional health. [Stock Photos]

For another mother we interviewed, the start of the CB coincided with the end of her confinement period. Having looked forward to being able to leave the house to get some fresh air and spend time with her husband and baby outdoors, she has had to deal with isolation and negative emotions of being confined at home instead.

“I took awhile to decide to visit the psychological services available at the hospital I gave birth at. I managed to book my initial appointment and had been looking to see a psychologist for some issues that I am currently facing,” she said. However, with the new CB measures in place, such services have not been able to be carried out and she has had to halt her visits. 

Many care services for mothers and babies have had to cease due to CB measures. Some mothers have voiced their disappointment at these because they see them as crucial for their and their babies’ well-being. [Stock Photo]

No Access to Other Services: Antenatal Classes, Masseuse, Confinement Nannies & Alternative Therapies

Mothers also reported that many things that they had planned for their pregnancy and postpartum during their pregnancies were now out of the question. 

One mother who had been looking forward to antenatal classes at the hospital she is due to give birth at has been sorely disappointed that these classes have been cancelled. A few mothers also lamented that postpartum masseuse services were regrettably unavailable since home visits are not allowed. As reported earlier this month, confinement nannies were also difficult to obtain as a lot of them hail from Malaysia; with the extended lockdown in Malaysia, and subsequently Singapore, mothers have had no choice but to grin and bear it during confinement.

Some mothers also mentioned their disappointment at the closure of alternative medicine and therapies such as osteopathy and chiropractic clinics.  

Mothers need to seek support as it is even more crucial during this period. Focus on connecting in other ways even though physical interactions are impossible. Confide in your partner, a trusted confidante or connect with other mothers in support groups and make new friends. [Stock Photo]

Seek Whatever Support is Available

With the extension of another month of CB, things may look bleak for mothers. However, we would like to offer some tips that can help you achieve some self-care and to constantly remain connected to services that would be of benefit to you:

  1. Take advantage of virtual support – consultations, support groups, helplines

    It may be easy to slip into an abyss of helplessness, but looking out for online platforms to connect with professionals and other mothers are imperative for your mental health at this point.

    Here are a list of helplines and online consults that may be useful for mothers:
  • General Support Hotlines:
    • National Care Hotline (24 hour) – 6202-6868 – emotional support for anyone who is in need
    • Samaritans of Singapore (SOS) – 1800-221 4444 / Email befriending:
    • HEAR4U (set up by CARE Singapore for Singaporeans to have a space to seek advice and express their concerns arising from the current COVID-19 situation) – WhatsApp 6978 2728
Be assured that this period is not permanent and it will back to business as usual, with our family and friends, before you know it. [Stock Photo]
  1. Know that CB is temporary; you are doing your part by staying at home
    • Speak to your partner or trusted family member about your struggles
    • Have regular virtual meetups with other friends, mummy confidantes, and family members to find solidarity and support
    • Avoid being alone for long periods of time; seek human connection at least once a day
  2. Prioritise your health and well-being
    • Have complete meals and eat nourishing foods
    • Stay away from self-destructive thoughts – focus on positive affirmations (e.g. I am a good mother, I am enough, I can do this no matter how long it takes)
    • Find a hobby or do something that you like for at least an hour every day

We know that with pregnancy or with a baby in tow can be isolating and frustrating, but taking stock of your feelings and taking the proper steps to remain calm and in control can help you manage these challenging times.

If you need help, seek them early and inform your spouse or family members.

We are all in this together! We support you mummies, and we have your backs!