IBCLC Detailed Content Outline: Pathology Focused CERPs - Section III

Low milk supply is a common reason for breastfeeding mothers to seek care from their obstetric provider. Causes are multifactorial, including chronic disease, endocrine dysregulation, and environmental factors. Learn more about the latest updates and research on the causes of low milk supply and identifiable risk factors during pregnancy that may predict low milk supply. Updates on diagnostic workup and management of low milk supply will be discussed.

Although human milk confers important health promotion benefits to all infants, vulnerable babies admitted to an NICU stand to benefit even more. Their parents are typically strongly motivated to provide their own milk, although for a variety of reasons, such as parental ill health and stress (often complicated by the pandemic), parents may not have a full volume of their own milk. In this case, donor milk is the recommended supplement to bridge until parent’s milk is available. There is strong research evidence to support the use of human donor milk in preterm infants to prevent necrotizing enterocolitis, while there is less available evidence for the use of donor milk in late preterm infants. There are important differences between parent’s milk and donor milk with respect to their nutrient and non-nutrient components which may be secondary to processing techniques used in creating batches of donor milk. It is important to understand these differences and be able to interpret nutritional labelling on donor milk. Newer techniques in pasteurization may address some of the losses of bioactive molecules in human milk.

Unless access to clean water and appropriate infant formula is reliable, the World Health Organization does not recommend HIV-infected mothers stop breastfeeding. Remarkably, only about 15% of babies exclusively breastfed by their HIV-infected mothers become infected with HIV. This suggests that although breast milk is a vehicle for HIV transmission, the milk itself exhibits a strong protective effect against infection. Breastfed babies ingest 100,000 - 100,000,000 maternal cells every day via breast milk; what remains largely unclear is the contribution of these cells to the milk’s anti-viral qualities. A large study has been undertaken to isolate cells from human milk in order to measure the ability of these cells to engulf and destroy HIV by a mechanism known as phagocytosis. Over 50 samples of breast milk obtained from healthy women have been analyzed. Phagocytosis of HIV was detected in all samples. Activity did not appear to correlate with stage of lactation. Various cell types known for phagocytic capacity were identified and measured, including granulocytes, monocytes, macrophages, and dendritic cells. All samples exhibited strong granulocyte activity.These data further demonstrate that phagocytosis of HIV by immune cells from breast milk can be measured. This information will be critical for design of therapeutic vaccines capable of reducing the likelihood of mother-to-child transmission of HIV in areas where breastfeeding is essential.

New mothers experience the milk ejection reflex, or “letdown,” in various ways. While some feel no physical symptoms, others experience a tingling sensation and some even have significant pain or sadness. Babies also have different experiences, from the overactive “drink from the firehose” to frustratingly long waiting at feeding time. This presentation explores the multitude of influences on letdown, from internal hormones and chemical signaling pathways to the research related to such external influences as diet, alcohol, stress, and the use of synthetic oxytocin.

Many moms believe that they either do not produce sufficient milk or need a quicker, more effective letdown. Suggestions to deal with these issues range from drinking beer to adding different nutritional supplements to the diet, from hypnosis to oxytocin nasal spray. We will explore the research and unravel the best practices and recommendations we can give to clients related to their concerns about the milk ejection reflex.

Preterm infants are at increased risk for impaired neurodevelopmental outcomes (Stoll et al, 2010). There is evidence supporting the differences in outcomes related to how we provide care to preterm infants and the effects of the environment in which the care takes place. One of the most effective ways to reduce impaired infant outcomes is inviting parents to actively participate in care activities and provide Kangaroo Care (Boundy et al., 2016; Charpak et al., 2017). Despite international recommendations, empirical evidence, and an implementation science project focused on strengthening Kangaroo Care in neonatal intensive care units in British Columbia, Canada, implementation has been slow due to various barriers to uptake (Charpak et al., 2020; Coutts et al., 2021; WHO, 2020). A ‘one size fits all’ approach cannot guide Kangaroo Care implementation as it is a complex intervention and each NICU presents unique barriers and enablers. The uptake of Kangaroo Care relies on the involvement of parents and healthcare providers and their understanding and commitment to the evolving paradigm shift in neonatal care. This transition requires environmental and social supports, systems level change of philosophies of care, and assistance for healthcare providers to recognize their changing role.

Carol will explain how the sources of tongue and oral dysfunction aren’t always in the mouth. Sometimes the gold is buried elsewhere. She will discuss torques and twists in the body that extend into the floor of the mouth and express themselves as a lack of tongue mobility. She will discuss how fetal lie and restricted fetal mobility cause babies to grow in ways that negatively impact their breastfeeding. These things may masquerade as and/or exacerbate tongue mobility issues disguised as short frenula. Carol will also explain the CST treatment approach for these babies.

Regulation of the autonomic nervous system is critical for the successful breastfeeding relationship of the dyad. This 1 hour lecture will first, review the anatomy and physiology of the Vagus Nerve (Cranial Nerve X) as it might potentially influence breastfeeding. It will then explore the myriad of ways that the presence of ankyloglossia could potentially influence dysregulation of vagal tone resulting in a myriad of complaints often seen in both members of the dyad when the neonate has ankyloglossia.

As a health professional you may find yourself supporting a mother who is breastfeeding or requires support to breastfeed her baby with Down syndrome. Babies with Down syndrome can often have additional health needs, which may affect how successful they are with breastfeeding. Down syndrome or trisomy 21 is the most common genetic cause of intellectual disability for around 1 in 700 births worldwide. People with Down syndrome are not all the same but may have similar characteristic physical features, health and developmental challenges and some level of intellectual disability. Research has shown many benefits associated with breastfeeding a baby with Down syndrome. It contributes to establishing long term skill development, particularly with speech and feeding skills, as well as aiding brain growth. It also provides an opportunity for mother baby bonding during stressful periods after learning of their baby’s diagnosis. Regardless of these known benefits, some mothers may nevertheless be told their baby will not be able breastfeed. This presentation will explore some of the common challenges mothers may face when breastfeeding a baby with Down syndrome and tips on how to address these for the mother and baby. The material presented will also assist health professionals to support mothers with babies who may have similar health/developmental needs.

Many preterm infants remain vulnerable following discharge from the neonatal intensive care unit (NICU). Health challenges persist beyond the NICU including respiratory illness, breastfeeding progression, bottle feeding incoordination, behavior and development issues, impaired growth, infrequent stooling, and gastroesophageal reflux. Preterm infants are up to two times more likely than full term infants to be hospitalized in the first year of life. Parents are challenged to transition their premature baby home and to keep them home!

Community-based, specialized follow-up services following NICU discharge have a powerful impact. The Neonatal Transition Team in Calgary, Alberta, Canada provides post-NICU follow-up for very-low-birth-weight infants and their families. The team consists of community health registered nurses with advanced skill in premature infant outcomes, feeding and neurodevelopmental assessment, and a consultation partnership with nutritional and feeding specialists. While home visits have been the backbone of this service, the team questioned the feasibility and acceptance of virtual care and completed a three month quality improvement pilot. This virtual care pilot demonstrated optimization of health-care resources by providing safe, high-quality care at a reduced operational cost. The pilot was instrumental in the team’s management during the SARS-COVID-19 pandemic. Virtual care has been fully operationalized into the service delivery model and expanded to serve other newborns with feeding or growth challenges.