Tongue- Tie Tale

True Story:
this was this week
Mother's nipples hurt during latch of newborn and ended up pointy like a lipstick.
Nurses told mother that the baby looked tongue-tied. They recommended checking with the IBCLC.  ((Yay, for the nurses!))

IBCLC confirmed the tongue-tie. Referred her to me. ((Right-on!))
PEDIATRICIAN even confirmed it was tongue-tie!! He referred to ENT!
ENT AGREED!!

ENT scheduled baby to have frenotomy relaeased in out-patient center. :(
Mom's nipples still hurt.
Out-patient surgery center notified parents that they don't take newborns. Either they can re-schedule at 6 months or go to the operating room.

Waiting won't help breastfeeding TODAY.
Anesthesia is not necessary.

Mom came to me. Determined to breastfeed.
She explained all this to me. Showed me the baby's tongue and her lipstick shaped nipple after latching.

A very simple snip in the office released the frenulum.
The baby went to breast.
No pain.
No lipstick shape to the nipple.
Everyone Lived Happily Ever After.
The end.

Milk Sharing (My Statement)

Addendum1/22/12 : I have been sent updated links and comments in response to this post.  My post is outdated. Until I can update, read through the comments. As I have found out there ARE guidelines from LLL. Not too many people are aware that leaders can discuss the pros and cons of milk-sharing when it is brought up. Per the guidelines it is very appropriate for a leader to refer to a health care professional for a discussion of medical pros/cons of informal milk sharing. That is where I would come in. I want to evaluate why the mother can not meet the needs of her baby (low supply or medication exposure or other reason), can it be corrected and if not discuss the options of what to supplement with (donated milk, home-made formula, commercial formula, cow's milk, goat's milk, or vegan mylks with and how to supplement it (bottle vs supplemental system, etc..). Human Milk 4 Human Babies is a commerce free site on facebook to offer your extra milk or seek potential donors. Look for the global network and your regional group.

From my attendance at the recent conferences it is apparent that even some of the breastfeeding doctors can be adamantly opposed to milk sharing. La Leche League does not support informal milk sharing either.

It would be very reasonable to support milk sharing amongst friends who have known blood tests and are obviously healthy.

If the mother is feeding milk to their own baby, and recipient knows both the donor mother and the baby, it sounds responsible for a breastfeeding group to support informal milk sharing. Then go on to clarify if you must that if you don't know the mother and the baby that carries risks of the unknown.

There is VERY little that makes milk bad. I'd be afraid of the risks of formula and increased illness.

 If you don't know the donor you can get to know them.

The only reason I once heard for La Leche League not supporting the use of donor milk was desiring credibility to new-comers and the public.

There is much more awareness now on the benefits of milk-sharing, it is time to update policy and make a huge positive impact.

I could also accept if a new policy stated that both mothers and both babies be monitored for good health through out the donation period. The donor mother's prenatal labs with HIV should suffice (HIV is a topic for another post). A donor baby who is healthy and growing, labs are not necessary. We just want to see that the baby won't be compromised if mother shares milk. The recipient mother should have an evaluation on why she can't produce enough milk and optimize her own production.

Doctors get blamed for making decisions based on pharmaceutical and financial interest. I have wondered if the hold out for breastfeeding groups to accept donor milk has something to do with collaboration and survival of milk banks.  I don't know if this is fact, so don't quote me. It's just a thought.

Pasteurized milk serve a special community: the preemie babies and research. It is not easy to get pasteurized milk out to the communities healthy babies.

I will take this one step furthur. I have been a Raw food advocate. The same principle applies to breastmilk. While pasteurized breastmilk is much better than formula. Minimally processed breastmilk has the  LIVE enzymes. I also support the use of minimizing the handling of fresh milk.

If anyone has milk to share at this time, I can probably find a home for it.

Finally,

I do not support buying milk from Craig's List and Social Media.

Miami Physician's Breastfeeding Summit

 Like a geek, I sat in the front row of this physician's meeting on breastfeeding in Miami. I wanted to make sure I heard EVERYTHING. I didn't even know about this conference til about a week ago. 

I get patients from Miami and when I heard about the meeting, I felt like I should now what is going on there. 

Who's at the table:

Grisel Garcia MD from Miami

Joan Meek MD from Orlando

Julie Kelogg MD from Jacksonville

Liz Westwater from Baby Friendly

Lourdes Forester MD from Miami

Alberto Dominguez-Bali MD from Miami

So Miami has 14 hospitals and 12 are working towards Baby Friendly! Part of becoming Baby Friendly is that your physicians must have 3 hours of formal training in breastfeeding. Attending this meeting was physicians and other staff trying to meet this requirement. How do you get a physician at a meeting on a Saturday morning, on breastfeeding.  FREE CME, FREE breakfast and lunch, and a mug.... the good view of the harbor was a bonus. It got me there!

This was not a lecture to the choir!

Joint Commission a group that hospital quality control has a campaign directed towards mothers to "Speak Up".

That's how the meeting started-- by showing the brochure. What does it mean when your mother speaks up and asks for skin-to-skin. ((It never entered my mind that a physician might not know what skin-to-skin was.)) This was a good non-threatening starting place to reach the participants. Dr. Bali showed a video of attachment after birth and the phases in detail. He emphasized touch, touch, touch... and he was quite passionate about it. He said, if the mother couldn't do skin-to-skin immediately, partner or grandma should. 

He said we forgot something very basic-- WE ARE MAMMALS! No other species survives without breastfeeding. 

We talked about removing warmers from the delivery room

Talked about how damaging suctioning is because it cause aversions, stresses baby, changes the flora.

We talked about how WE interfere with breastfeeding. We ((doctors)) and our policies interfere. 

But the good news is how a little education and a little encouragement form the physician GOES a long way.

The speakers told the other doctors to tell their patients:

"As your doctor, "I want you to know I support your breastfeeding."

A point was made that if you tell mothers this, you should remove the formula display from your waiting room which undermines a mother's confidence in herself and you.

In the hospital, anticpate the baby will be up all night.  The hospitals are implementing a no procedure, restful period from 1-3 o'clock in the afternoon. We talked about how society prepares mother that everything will go back to normal. We need to support mother better.

It was noted that in one area no one came to the breastfeeding support group, but they changed the name and  many came to massage class (and they spoke about breastfeeding).

When the hospital got an estimate to purchase formula, the formula company inflated the estimate.  There was several reasons that actual usage didn't meet the estimated purchase cost. For example- staff passed out extra formula because it was free. As time went on and they used less formula, they purchased less.

We talked about delaying procedures, growth curve, reflux, hepatitis, glucose, jaundice, starting solids. 

The participants got to ask Questions at the end. I thought this three hours was excellent for Physician Breastfeeding 101.

The AAP is coming out with a new breastfeeding statement this year emphasizing the physicians role in management.

At the end Liz from Baby Friendly encouraged the doctors and said that surveys use to come back with negative about the doctors being the barrier, but in more recent years, the surveys come back as the doctors being the one who moved it forward!

I see mothers from Miami for tongue-tie (frenotomy was not discussed) and alternative vaccine schedules (discussed briefly, if any of the speakers supported an alternative schedule I didn't here it). Also, most of my Miami consults have had out-of-hospital births. This meeting should have a positive impact on what is going on in the hospital! A good start has lasting effects!!

What's New Here at Permission to Mother

Over the New Year's Weekend in my blog reader, I noticed a lot of blog authors reposting their favorite blog post of the year. It made me realize how long it has been since I have added anything here. My kids don't like me taking their photos and they like more privacy. I get that. Although I do plan to update about their homeschooling and other activities very relevant, I am not using this so much to update family and friends. I will use it for birth, breastfeeding, and homeschooling mostly.

I've been actively following a facebook group for the La Leche League of the Treasure Coast. We have over 200 enthusiastic mothers standing up for their breastfeeding and asking tons of questions to make good choices. I love seeing so many involved mothers in one place!

I've been to two breastfeeding conferences this fall. I am planning to attend a morning conference in Miami geared towards baby-friendly and physicians this weekend.

I've been going to some local LLL meetings and events. I have an events tab up above on my blog. I like meeting you and seeing your babies out of the office, so hope to see you there!

In my office we have moved from paper charts to EMR (electronic medical records). This continues to be a big transition.

I frequently get e-mail like this:

I received your name from a local IBCLC after being horrified by my current ped's advice. After taking a look at your website, I really hope you can make room for my baby and I in your practice. Here is our situation...


We exclusively breastfeed, cloth diaper, and babywear, and I consider myself very knowledgeable in all 3 areas. Breastfeeding is extremely important to us and I plan on doing baby led weaning.

Now at 6 months, she hasn't gained anything since 4 months. We question vaccines. We'd like to have an opinion from someone else on vaccines, weight gain, etc...

PLEASE be our new doctor!!! 

I carefully keep tabs of the amount of active patients in my practice. I leave space each week to offer appointments to those moms who share the same beliefs as I. I hope to fill ALL those spaces with moms and babies who need well visits or consults.

Another question I get asked:

We don't go to the doctors much, but it would be nice to establish with a doctor just in case something comes up. Can my family come to you without getting caught up with vaccine schedules and other demands.



I am very flexible. I know there are many families who take good care of themselves. I know that they don't get sick much and have remedies they use before calling a doctor. That is the goal! You take care of yourself. I only make recommendations and/or support you your choices. As long as we have good communication and what kind of situations you may need medical care, I find this flexibility works. 




So despite the blog being quiet, I've have not been.   One more thing... I don't know why I have problems with fonts and laying out photos. It doesn't make it fun to blog. When the fonts and spacing  are no longer easy to deal with. I can easily kill a lot of time figuring out what is wrong with the spacing, but I am going to hit publish now...Sigh.

Administrative Q about Network Blogs

I set up Network Blogs with my old facebook account that got hacked using my active email address. To make  a new facebook profile I had to make a new email address. Network Blogs didn't get hacked. Since then I have 70 followers on network blogs (THANK YOU for your interest). Network Blogs no longer recognizes me as author with a new address. Do any of you know how I can claim this blog on Network Blogs. If you leave a comment on facebook I will see it (I think). I would like to have this blog fully functioning and update-able.

Gut Integrity- NEC

Gut integrity -- nothing in the gut except breastmilk for 6 months. The thought amazes me. The life LONG benefits of optimizing sealing your baby's gut with nothing but breastmilk so the intestinal lining seals and matures.  Sealing your gut would promote natural flora and keep proteins from being absorbed that shouldn't get absorbed by the gut. In turning possibly causing digestive problems and inflammation.

I am not sure many of our full-term healthy babies get nothing BUT BREASTMILK for this long. There is too many tempting tastes, religious customs, grandma's treats, tylenol for vaccines and fevers, Vitamins, and early use and misused formula given. I don't know that a drop of something that is absorbed in the mouth ruins gut integrity, but you get the idea.

I believe in gut integrity. I trust that if we keep doing research we will one day have all the Science to back it this up- NOTHING BUT BREASTMILK.

Neonatologist at the conference don't agree on what to supplement the NICU micropremie with. I say UNPASTURIZED mother's own milk is best without supplement if it's available. Someone else's premie milk is second best. Third best is donated milk from the bank regardless of age. I actually like the idea of unpasteurized milk even if it's screened donor, but it is assumed that all milk from a donor will be pasteurized. I am bothered by the thought that the live enzymes needed to seal and protect the gut are going to be killed... but better than formula. Formula offers know immunity.

The current practice in most places is using a cow protein based fortifier. Adding fortifier to milk is better than the worst option (just formula).  There is some research being done on human milk fortifier. This is an all human product being added to mother's milk. But why add it? just give breast milk. In general, the studies  show the more breastmilk / the less fortifer the less NEC (necrotizing enterocolitis- the problem that keeps neonatologist up at night in the NICU). This is a serious bowel ischemia. Think about it. Nothing belongs in the gut but mother's breastmilk. Of course these little premies should still be protected by the placenta in the womb, but why put cow's milk protein or anything but mother's milk in the premies intestines? Just to fatten them up quicker and make them "look good."

Despite all the time and energy on  research being done on fortifier use in the premie, it is going to take me a lot of convincing that any fortifier is necessary.

Vitamin D in Florida

I "absorbed" everything I could about Vit D at the conference, met the authors, and bought the book with all the research
I really want to show that we don't all need to supplement our baby in Florida, however, almost everyone, all ages, I test is sub-optimal.  I hope to get it set up soon that I can do Vitamin D testing by fingerstick. That way I can check more babies.


The current recommendation is that we begin to supplement our babies with 400 iu shortly after birth.
If  you are going to choose not to give your baby a Vit D supplement. This is what you can do yourself. With my current clinical experience I believe this would be effective.


Get Sunshine, both mom and baby
Take 4000 iu while pregnant
Take 6400 iu during lactation. This is the amount it takes to get 400 iu into the breastmilk daily. 
Take surf lessons. :)


For darker skinned women in Florida this is especially important. Perhaps over time and with increase awareness we can redefine what is best for all women and babies and minimize supplement exposure.


I have not seen Ricket's. Vitamin D is a powerful antioxidant and anti-inflammatory. If you want to boost your immunity Vit D is important.


I also believe in gut integrity. I want nothing in the babies gut but breastmilk. I want the gut to seal off and mature with several months of exclusive breastfeeding whenever possible.  The "seal" has benefits long beyond the duration of breastfeeding. I really hope to reconcile the need for D and maintaining gut integrity.


With awareness preconception and during pregnancy, I hope we can keep our D levels up.


_________________


New Insights Into Vitamin D: During Pregnancy, lactation & Early Infancy
Wagner, Taylor, Hollis

Learning from Moms: Babies with Down's Syndrome

I have just got back from The Academy of Breastfeeding Medicine Conference. It was in Miami and I was there 2 1/2 days for 22 continuing education hours. With lots of thoughts, I'll probably frequently blogging over the next few days about breastfeeding.

I was very touched by a Platform Presentation on Down's Syndrome presented by Barbara Phillips MD. Mother's of who breastfed babies were surveyed.  Here is some of their responses that I had jotted down during the presentation:

"Never considered that DS would even have affect."
"I didn't know that low tone, meant I couldn't breastfeed, I just breastfed."
"The diagnosis of DS made me even more determined to breastfeed because I knew he was at a disadvantage in so many other way. I wanted to give him this benefit."
"Slowing down to nurse, was beneficial  to me in that it made me slow down."

Do you feel touched? I thought moms of babies with DS would be discouraged like everyone else from breasrfeeding. I am sure many are.

The title of this presentation was Learning from the Moms. It was shown with support these mom can do quite well breastfeeding.

I love the title. I learn from moms all the time. I enjoy being on our local LLL facebook page because there is so much to learn. I know I was at a big physician meeting and I learned a lot. I know what the Academy wants us to know from around the world, but the experts are right here local-- the voice of the collective moms. No matter how much I post, I learn more from you.

Not all sessions were emotionally/maternally moving. Some were quite political and academic, but I realized how important being around  breastfeeding moms is for new moms. It's more than just receiving and exchanging information and support, but there must be something about being around other lactating moms that helps your instincts and milk flow, miss your baby, want to cuddle and hold your baby. I know mothers past lactation have said the get a sensation years after they wean... seems to be the same idea.

Vitamin D update

I have tested 7 lactating mothers who have babies between 6 weeks and one year.

So far all the mothers have sub-optimal Vitamin D levels.

All live here in the Treasure Coast (or are close). (This is South Florida, in case you don't know). All are involved in La Leche League and educated on this controversy about giving Vit D supplements to  babies.

I do not have any fully breastfed babies tested yet.... Veins to small, don't want to put a healthy baby through that, and other reasons, it's not getting done.

I have one supplemented baby who tested adequate who also takes Vitamin D.

I have been testing a lot of adults who are not lactating. Many come back low.

I am not making any scientific or clinical conclusion yet. I think we all need an Rx to go to the beach this weekend!

Adoption Protocol for Breastfeeding

I have recently had a cluster of consults for induced lactation for adopting a newborn. I want to lay out some thoughts.
I follow the protocols from asklenore.com
Here is a link to the regular protocol.

There is no typical "adoption."
Everyone's situation is so uniquely different.

Not all women are adopting because they are infertile. Some want to expand their family both biologically and through adoption.

I often asked the adopting parents to consider how they feel about approaching the healthy birthing mom to express some colostrum or provide breastmilk. One of the most recent mothers found out about induced lactation because the birthing mother told about induced lactation. Some birthing moms are even willing to let the baby latch and suckle. This would be the best for the baby. Some people raise concern that the birthing mom will experience strong attachment and change her mind. I don't know if this concern is founded.

I learned from another mom, that her adopted child nursed better than her biologic children! This mom is planning a twins adoption now and starting the protocol again.

Some moms don't mess with herbs or prescriptions and just put the baby to breast with a supplemental nursing system. They may have had not enough time or just don't want the medication. Even if you used the protocol, it is still a good idea, to be familiar with this option to meet the babies full nutrient needs in case your supply isn't fully in. Medela makes a supplemental nursing system and lact-aid.com. ( I do have the supplies of both systems in stock, if you like to look at them.)

What to supplement a newborn with if you can't bring in your own full supply?
Birthing mom's milk, donated milk, make your own formula, commercially prepared formula.

Most moms don't know the ways to get breastmilk.
1)Once involved in a local breastfeeding support group many woman find other local moms with extra stored. 2)Facebook has a group with Human Milk for Human Babies (this is Florida, you can search for your region) where those in need can find those with donations. 3)There are pasteurized milk banks (expensive and not enough of them, mostly serving the needs of a hospitalized preemies, special situations, and research), and 4)For-profit milk banks (I do't know enough about these). I am biased towards the first two choices.

Get yourself a sling or babywrap to promote bonding and milk production. It's a great idea to attend a LLL meeting and have the support of an IBCLC lined up.

If you have a medical condition or concern, I may also be able to help you with approaches that won't interrupt breastfeeding.

Feedback From a Midwife

"Your book is the most borrowed book in my library."


I know women in my area enjoy Permission to Mother because they get to know my practice and family better and read stories about mothers they recognize, but that I appreciated her feedback knowing that it has been a good resource in her area, too.


"I live in a very conservative area and these women were sometimes surprised at first by the book's candid approach (as well as mine) but I've enjoyed the various "reviews" when they return the book:  


"Sure does make you think"


"It helped me to laugh about everything instead of being as worried," 


and 


"It's about time someone said it like it really is."

Julia Swart, LM, CPM

Southwest Idaho

Dr. Punger's Informal Vitamin D Study on Breastfed Babies, Toddlers, and Children

"The American Academy of Pediatrics is recommending 400IU of Vitamin D to breastfed babies starting soon after birth. Breastfeeding is the ideal form of infant feeding, but supplementation with Vitamin D, starting soon after birth, is recommended because breastfed infants generally do not obtain adequate Vitamin D from other sources.  Pediatricians should encourage parents of infants who are either breastfed or consuming less than 1 liter (just under 1 quart, or 33.8 ounces) of infant formula per day to give their infants an oral Vitamin D supplement to meet the current AAP recommendation."

Vitamin D is a hot topic. It's a potent anti inflammatory and antioxidant. Up  to this point, I have not routinely recommended Vitamin D supplementation of the exclusively breastfed baby living in South Florida. I would prefer that babies consume only breastmilk to protect the optimal development of a healthy sealed gut and natural flora. I have been making recommendations to get indirect sunlight in the morning and late afternoon.

Are we giving our babies, toddlers, and children enough sunlight?

With the enthusiasm and interest of a diverse group of mothers I would like to check Vitamin D levels  in mother and baby (toddler and children).

Your participation is voluntary. I can give you a the script to get you and your breastfed child's levels checked. Results will be kept anonymous, but will be made available to other mothers via Internet and possibly formal research. I will ask each participant to fill out a brief questionnaire regarding ethnic background, diet (vegan, vegetarian, wholefoods, junk food)  and 
supplements.


The lab test will be at your lab and you will responsible for for any portion not covered by insurance. I will provide you with the best diagnosis codes and results of your test.


I am looking for self-motivated, volunteers(mothers and breastfed baby), enthusiastic about furthering our understanding about Vitamin D deficiency in South Florida.




References
AAP
Sunlight
Kelly Mom

Starting Thursday AM, if you have contacted me to participate, you can pick up your script for lab work.
You may contact me here to express interest: email Use Vitamin D as your subject.
I will confirmed that your lab requisition is ready before picking it up from my office.

An example of how I may share anonymous results on my blog would be:

1. 2 month old Latin male exclusively breastfed -- suboptimal levels.

World breastfeeding Week Schedule

This schedule of WIC/LLL events are awesome. I wish I could be at everything, like a weeks vacation. Looks like so much fun! I didn't realize that WIC was having so many activities. Facebook is a great way to reach out (there is an event page for each activity) and I hope their is lots of attendance at all the events.

 

Tuesday, August 2nd, at WIC office on Avenue C from 11 am to 1 pm Babywearing Fashion Show.

Wednesday, August 3rd, at WIC office 531 Lake Whitney Place, SLW. 11 am Permission to Mother. Dr. Punger will answer your breastfeeding questions.
Wednesday, August 3rd, at WIC Office 531 Lake Whitney Pl, SLW 2:30 - 3 and 3 - 3:30 Yoga classes by Jenn Cohen.

Thursday, August 4th, at WIC office 531 Lake Whitney Pl, SLW 11:30 - 12 and 12 - 12:30 Yoga classes by Jenn Cohen

Friday, August 5th, at WIC office 531 Lake Whitney PL, SLW 11 am to 1 pm Babywearing Fashion Show.

culminating in the www.LATCHonPALOOZA.org  extravaganza on Saturday morning
....and the following week be sure to hit Panera Bread in Vero, 2nd wed of the month La Leche League meeting,  where you can meet our newest Leader!!!

What's your favorite nursing bra?

I wore playtex for many years (do they still make bras?). After I found medela, I realized my playtex bras fell apart quickly and gave them up. I tried bravado, but found they lacked the support I need (13 years ago, things might have changed). I have one from motherwear... this was before I had medela and I was feeling huge. It was the best support ever for heavy pp breast. Once my first son was born, I wear a bra 24/7. I am not comfortable without one, ever. I still wear my medela sleep bra around the house and at night. The tanks didn't come out till after my third. After a few months pp I was comfortable in a tank without a bra. If I wear my tanks now to exercise, I put a sports bra underneath. I wear them around the house without a separate bra. The first time I bought nursing bras, I thought to myself, "Do I really need this? I'll only need it a short time!" haha-14 years of maternity and nursing bras...that's a short time... my size has changed through the years with pregnancy and weight management issues. I've had quite a collection. Makeshift- sports bras were not comfortable to me. I have never worn a target, k-mart, or off brand bra... I need support. The latch on playtex I could release and put back with one hand. Medela can be released with one hand, but I need two hands to put it back.


Now for what I don't like... I never wore one, but it must be popular. I see it a lot. Not sure what it's called and if more than one company makes it... but I don't like when the cup is thick and "molded." What I observe is that it is hard to pull it truly out of the way so that the breast position is not distorted. Your breast should be in the natural position when the flaps are moved out of the way. If you can't get your cup out of the way, either get it out of the way, or consider another style. Newborns need your breast and nipple to be in natural position and no fabric in the way of learning to latch.




Disclaimer: I currently sell Medela bras in my office. When I run out of inventory I am not stocking up again. It's too much to keep up with all the different styles, colors, and sizes. I don't have space for the inventory. I am not paid for this review.