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Episode 10 - Mechanical vs. Chemical: Spotting the Difference and Making the Difference

Hi and welcome to the Lactation Training Lab Podcast. I'm Christine, an IBCLC and trained childbirth educator based in the US and I help lactation care providers optimize their lactation practice and career through resources, information, and mindset shifts that help them to clarify and reclaim their purpose and mission and lactation. I've been in the lactation field for 20 years now and this podcast is my way of sharing with you what I've learned and what the future holds for those of us supporting families and babies. Whether you are seasoned or studying, I hope this show will make you think and inspires you to act! Let's get started.

Welcome back! Today we’re going to talk about a way that I use and teach to sort through symptoms and issues that parents come to us for help with. This concept I can honestly say I've never read it somewhere that I can recall. It’s not something that I found in a textbook or heard someone say, but I can't 100% guarantee that someone else didn’t say this first. So I’m not necessarily going to take credit for this concept, but it is something that I use that has really helped me personally in my practice to develop ways of thinking through people’s issues. It’s also something that I teach to other people because I think it’s a way that we can take a really important point and clarify something that has become very, very muddled over the years.

If we think back over the time that formula marketing has been a thing, that it’s been something that has been out there that families have to contend with, we also have to remember that while formula marketing obviously on the surface is aimed at the people who would be using infant formula, it also is aimed at the people who would be recommending it. And as this marketing has been propagated throughout the years, one of the things that I think encapsulates the way that formula marketing started out is that the message that was truly the kernel, the message of infant formula marketing was, “yeah breastfeeding is great, but in case there’s not enough milk, there’s formula, too.” And everything around this message was used to plant that seed of doubt. Whether it was the seed of doubt in healthcare providers who began to believe that not everyone really could make enough milk for their babies, which of course is true, not 100% of people can, however, the vast majority of people actually can and that confusion has lasted.

And then even more insidiously, that seed of doubt was planted in families, in expectant parents, and in culture, that breastfeeding is wonderful, but it doesn’t always work out because a lot of times people don’t make enough milk. Many other things have come about to support that thesis and then to fix that problem. And that’s what marketing truly is. It’s identifying a problem, whether or not that problem exists, and then making you think that you need this product in order to solve that problem. This marketing has been highly effective.

I also think that in the past, probably 5 to 10 years, but maybe closer to 5, there’s been a subtle shift in formula marketing to add to that seed of doubt about the volume of milk, adding to that something about the quality of milk. And everything that we see now is truly about the ingredients, it’s about what’s been added, it’s about how they’ve done so much research to figure out what makes formula different from breastmilk and how they can get it infinitesimally closer. I think that that is the premise upon which so many of the problems - the myths, the misperceptions, the inaccurate information that’s out there - I believe that’s where it comes from. It comes from that fundamental seed of doubt that someone can make enough milk for their baby, and that’s what this is really going to address.

The second part of it, the more recent messaging, we’ll save that for another day, but this strategy, this concept I think really speaks to that whole fear of not having enough volume of milk. And I’ll start by again saying that I am not trying to say we all know this is in the science that not every person, not 100% of people can make all of the milk that their babies need. We recognize that there are definitely situations where that is not possible medically, and that’s actually one of the ways that we’re going to look at this.

This concept to me is really about putting problems and issues that families come to us with, that lactating parents are experiencing, putting them into two buckets and then understanding how those buckets are connected. When we understand this truth, this is when we can really start to help people. This is also how we get into the work of utilizing all of the people out there who have training to address these buckets of problems. Utilizing the skills, utilizing the technologies, the devices and tools that are out there, utilizing them appropriately so that more people can get help.

We’ll start with this. Problems - when people come to me with their lactation issues, I see them in two ways: I see mechanical issues and I see chemical issues. We’ll get the chemical issues - the first part of that - out of the way right away. Chemical issues are typically hormonal problems. Almost every problem that creates a situation where a person is not able to make enough milk for a medical reason, this is almost always going to be a hormonal problem. This is a chemical issue in the body. Chemical issues are sometimes able to be resolved through the use of medications and technologies, and sometimes they are not able to be resolved through that and so sometimes people truly do not make enough milk for their babies. This is why we have infant formula and this is why we work to make it as good as it can be, as safe as it can be, and as available and accessible as it can be to everyone so that that is truly how we ensure there is justice so that every family has a healthy developing child.

That’s the chemical side of it. Sometimes chemical issues are visible right away. These are things sometimes that we recognize as risk factors during pregnancy, during birth and early postpartum, sometimes they are not picked up on until a little bit later if there’s not really great attention to what’s going on health-wise and medical-wise for somebody. Chemical issues are going to be more complicated things that are, usually in many cases, require somebody to see somebody with very specialized lactation training. Not just everybody who knows about lactation who has taken a class or a course is, feels confident enough to be able to manage those things or has the skills or the diagnosing ability to be able to manage those things.

However, there are a whole other set of problems. To me, most of the problems that I see are mechanical problems of lactation. And here’s the key that we’re going to keep coming back to: mechanical problems that don’t get resolved lead to chemical problems. You can have a person who has full capacity to make full volume of milk for their baby, but if they’re experiencing mechanical problems that don’t get resolved, they can end up with chemical, hormonal issues making enough milk. And we see this all the time.

When we think of our lactation situations that come from poor latch - that come from dysfunctional latch, pain during latch, dysfunctional sucking, dysfunctional feeding, dysfunctional milk removal, infrequent milk removal by breast pump or by hand expression, the improper use of lactation devices and tools such as having a poorly sized flange on your electric breast pump or a nipple shield that’s not being used properly so that the baby can’t truly get milk through it or empty the breast - when we see these mechanical issues surrounding lactation, all of those, if you’re listening to this and interested in lactation and work in this field, you recognize all of those problems as problems. You hear that and think “oh, that’s definitely a person that needs help.” What sometimes gets skipped over, I believe, is that when we don’t resolve those problems, when we let them go on and on, when we don’t give people the referrals that they need for the assistance that they need, those lead to chemical issues which turn into generally low milk production.

This could be the reason why so many people really buy into that marketing message that they might not make enough milk. And if we can more properly and promptly identify mechanical problems and get them resolved, then we’re going to see that more people do have the capacity to be able to make all of the milk that they need to make.

When we think about how these things compound if we think about one of the most common things that we are going to see especially in the early postpartum period is a poor latch from, say, a poor positioning, and that needs to be resolved as quickly as possible. That doesn’t always happen. Sometimes the suggestions that are given, they don’t work, or the parent is overwhelmed by too many options and they don’t know what to try, or they only try one thing and think that’s the way they have to do it, and those things can result in poor latch which means poor milk intake by baby, poor milk removal from the breast, and then we are leading into an issue - potentially a chemical problem with milk production.

We see that problems that are presented to us, if we think about them as being fundamentally mechanical or chemical, this is a way for us to sort through and figure out “here are the things that are happening or that might be happening that I can address, that I have the skills or the ability to address, and here are the other parts of it which might need somebody else’s help.” Those are going to be mechanical things in a lot of cases. The more skilled we get as lactation care providers in resolving mechanical problems of lactation, the more effective we’re going to be. And truly as we always say there are some people who cannot make enough milk, this is a hormonal medical issue, that is a small percentage of the total population.

Therefore, most of the problems that we see are therefore going to be problems of the management of lactation and mechanical problems that are going on. And those really are the things that we should be working on our skills, that we should be taking trainings on, that we should be talking to our colleagues and gaining skills and knowledge from them, learning how to manage those things because when those things start to compound and become a bigger problem, they become more difficult for lactating parents to manage.

When we can address mechanical issues at the root -this is that same conversation that we keep on having about making sure that we’re addressing the root of a problem. Whether the root of the problem is very poor positioning because we haven’t given enough options for how positioning can work, or we’ve made someone think that they have to do this kind of feeding a certain way, they have to sit a certain a way or they have to lie down or they have to use a pillow or not use a pillow - when we set a lot of rules around things and we don't actually resolve the root of the problem which is that the parent’s not comfortable during feeding, then we can end up leading much bigger problems. I think we all think of positioning as being a problem we can pretty easily solve even when as we’ve learned over the last year with all the virtual work that we’ve done and the telehealth visits and the virtual group support, we’ve seen how all it takes is for us to visually assess somebody with their baby feeding from the body and we can see the things they need to do to make everybody more comfortable, to get the baby in better alignment, to get the parent in better alignment, to get support wherever it needs to be, we can see those things visually very quickly and we think of those things as being very easy to solve.

Things that are more difficult to solve are going to be oral anomalies. They’re going to be babies who are having trouble swallowing because of an anatomical disorder. Babies who have a dysfunctional swallow because of an anatomical disorder. Babies who are potentially tongue tied. Babies who might have an impinged nerve in their cranial nerves. When we think about all of those things there again, we’re looking at a mechanical issue that very likely in many cases is going to involve referral for additional help. What we don’t want to do is give the impression that waiting out a mechanical problem is the way to solve it. Like this is going to get better. And this is that old thing that we hear people say to their friends and acquaintances and coworkers and everyone they know all the time, “well, breastfeeding works, you just have to get through that pain that lasts about a week or two weeks,” or whatever time frame they’re setting around it. That’s not really what is happening for people who experience that, where it was painful for a week then it got better, that’s not really what happened, that’s their impression of what happened. What truly happened, even if they didn’t get any outside help, is that they found a way to get their baby to latch better or get more comfortable during feedings so they weren’t artificially limiting those feedings or ending them too soon because they were really uncomfortable. They found a way to get their nipple problem that happened from one really bad latch, they finally found a way to get it to heal so that it didn’t hurt while they were feeding anymore.

That’s what really happened. It didn’t just resolve because they waited it out. They could have actually gotten external help, there’s other ways that that could have ended but the problem is without that external help, what if they didn’t figure it out? Then they were one of those people who felt that their situation turned into then I started to have problems with engorgement or plugged ducts because my baby wasn’t taking out enough milk or it was hurting and then I found out that my baby wasn’t gaining enough weight.

All of those problems in someone's mind can potentially turn into “my body doesn't make enough milk.” And that’s a situation I feel like it’s pretty common, I’ve talked to a lot of other lactation care providers, when we hear somebody say that, that is one of those things that breaks our hearts. We want to know all the facts - we wish we could go back in time with our special glasses and be a detective and figure out what actually happened, especially if we have the opportunity to help them prevent that from happening again. And I think that if we start to really approach the problems people are coming to us for help, if they’re coming to us for help with these problems and we approach it with “what is the root of this problem, what are the mechanics of it?” and then how is that impacting them chemically, that’s where we can really start to make a difference and start to give people plans that are really going to be effective especially if they're going to be effective quicker than simply waiting it out.

I think we can have a bigger impact by influencing how people are able to proceed as we think of these problems as being mechanical or chemical.

Another example of how things can really compound is that common issue of not having enough milk actually being removed. So for instance, if somebody does not have a really great technique for getting milk out of the breast when they’re using their electric breast pump, they’re not holding their flanges on the breast successfully so they’re breaking suction and seal quite a bit or they’re having pain because perhaps the sizing is off, or they’re not pumping for long enough or - I’ve seen it happen where people are pumping, they haven’t removed the clothing that they have around it so something is digging in somewhere so there is a portion of the breast where milk is not coming out of - all of these things to me when I think about them are mechanical problems, but they can very quickly lead to chemical problems.

When I think of those complications of not removing all the milk that’s available there - I think about engorgement as being both a mechanical issue and a chemical issue because a mechanical issue you have to get it resolved right now. I also think of, and I always teach this, it is one of the only acute problems of lactation. Engorgement: you have to do something about this right now, you have to be working on this. But then, engorgement that is ongoing or recurrent, persistent leads to chemical problems. It leads to that milk being left inside the glands, it’s going to start signalling the brain “don’t make so much milk because we’ve got some problems going on down here.” We have to think about those things together. We can’t think a mechanical problem is going to take some time to resolve and once it resolves everything’s going to be perfect.

This is where the follow-up part really comes in. We have to make sure that we’re setting up plans for people to make sure they both resolve their mechanical issues and continue following up so that we can help them be aware and work through any issues that are going on, if there are any chemical repercussions of those mechanical problems that were happening.

That’s it I mean that’s as simple as I try to make it. What is happening mechanically in this situation, how could that potentially turn into a chemical problem that leads to secondary lactation insufficiency and then how are we going to resolve that, what’s our plan for resolving that. The great thing about the fact that most problems are mechanical is that most 45-hour courses, most 20-hour courses have a high emphasis on content that teaches people who are in these courses how to resolve and how to set people up for better positioning, better latch techniques, having mechanical issues addressed right from the beginning. There are giant groups of people out there - and I like to think about it this way because it’s like there’s so many of these potential flowers that are blooming out there - taking all of these courses and getting all of this knowledge who have the ability to help with most of the common problems that people are having right from the beginning.

We always say most people don’t actually need a specialist but they do need some really great help right from the beginning to not only look for potential problems, but also to be able to help them get the fundamentals settled in right from the start. If we could get all of these lactation care providers who have a fundamental foundation of really great latch mechanics and positioning mechanics to resolve most of these issues, that’s a whole work force right there in itself, that’s a workforce of people who can then say “great, solved this problem, this family is good to go, but this family over here, things did not resolve with this foundational knowledge that I had and my ability, so I’m going to send them on to somebody else who has different skills or send them for a referrals for this issue that I think might be going on.”

We have so much potential. This is not something where nobody knows how to help with these things. There are many healthcare providers who are primarily licensed in another discipline who also have a foundational lactation course under their belt who can do this, who actually have the ability - and they may not even realize it- to help most people with most of their problems.

Thinking about it that way I feel like is not too “pollyanna”, but I like to think of that as being one of the greatest strengths that we have: when people enter this field, when they begin, most people enter using some sort of a foundational course, and those courses are so focused on resolving the most common mechanical problems of lactation. That’s going to help to filter through so that people who have more complex problems are able to be resolved by people who have different skills. But there are so many people out there who have the skills to help with most problems. That would make a really big difference.

The important thing to remember there too with these two buckets, these mechanical and these chemical buckets of issues, is that when we see somebody presenting who is asking right off the bat what can they do to make more milk - that’s kind of the question that when somebody comes to me for help, when that’s their first question I know we’ve got something deep going on because either we have somebody with a medical issue, a primary lactation insufficiency that was never picked up by anyone else and they never got help with it or the information that they needed, or we have something where there’s a root mechanical cause that I can probably help them with. That’s where I get excited, the detective in me loves that part: asking all the questions and looking at all the things visually and physically, that’s what really gets me excited about lactation consults.

But that’s really kind of my favorite question, even though a lot of people say that they dread that question because they feel like the person is looking for an easy answer. I don't think that that's true. I don’t think that parents are looking for easy answers but they are looking for answers. They really enjoy knowing more information about what’s going on for them so that they feel some more power and control over whatever is going on. Even if it doesn’t work out great, to be able to have that story to be able to pro[perly explain what happened in their lactation situation with the power of the information and that they were in control. They could figure out what was going on. They could impact the outcome of it that matters. That helps people feel more satisfaction with their experience regardless of whether or not they met their own goals. I think that’s really important.

I think that we as providers have to always keep in mind that galactagogues don’t help mechanical problems of lactation, so we don’t start there and I think that that's where parents get into groups, they form online groups for supporting one another and there’s often a lot of throwing those things back and forth to one another, “I took this, I used this,” there’s a lot of that. But a lot of people don’t get results from whatever they’re doing until they get their mechanical problems resolved.

That’s where we come in, that’s where the professional help is more important. That's just really the easiest way to think about it. Galactagogues are mostly going to be for when you’re seeing a chemical issue whether it’s a primary lactation insufficiency, a hormonal dysfunction, or whether that's a secondary lactation insufficiency, it came from mechanical problems. Even if you’re not the person who is able to tell or advise them on using galactagogues, using galactagogues alone does not solve the root problems. It does not resolve the mechanical problem. If they don’t resolve that, right back to square one. It’s just going to keep happening because it doesn’t solve the original problem.

This whole conversation has just circled right back to where we started: finding the root cause and knowing that the root cause for most people, with most of their lactation problems is mechanical, not chemical. In a perfect world, anybody with risk factors or where we know that there’s a really high likelihood that they’re going to have a primary lactation insufficiency, in a perfect world that would get picked up during their pregnancy or during their birth process, especially if it happened in a hospital where there were a lot of healthcare providers around. Somebody would be picking up those risk factors and looking for that. And then we would know that most other people are going to be able to get help from people who can address mechanical problems of lactation and prevent a lot of these cases of secondary lactation insufficiency.

This way of sorting through problems, sorting through symptoms and prioritizing them I think can be really helpful. If it speaks to you, please use it. I hope that it will help you. If it doesn’t speak to you, if it makes things seem more confusing let it go. Put it in your pocket and let it go. Maybe come back to it another time.

I think that it can be really helpful though and I think that it speaks to the continued need to advocate for better, more thorough, more comprehensive early postpartum support for lactation and continuity of care as families become, are discharged out into the community and require continued assistance and support with their lactation initiation process as time goes on. Setting up appropriate places that they can contact, resources they can contact for continued lactation support, it matters so much.

If you want one thing to do in the next few days, do something about your local lactation support situation. Here’s a little project for you, here’s a little task you can do in the next few days. Pretend that you are a new parent yourself. Do a very quick search of how to get help with lactation. You can use different words - type this into your internet search, say “how to get help with breastfeeding” in, I live in California so I would say maybe “how to get help in San Francisco” and then also try “how to get help with breast pumps in San Francisco,” or “lactation help in San Francisco,” so just try a couple of those things pretending that you are a new prent. Remind yourself that as a new parent, you have 50 million other things on your mind, not a lot of resources to go through a bunch of stuff or make a bunch of phone calls, how hard is it to figure out how you’re going to get help? Figure that out, find that out for your local community and see if there’s something that you can do to make things clearer or if you’re identifying gaps or if you’re identifying that there are resources available but only to certain people, see what you can learn about that. See what you can figure out about how hard it actually is for people. Ask some of your clients how they found you and how hard it was to find you.

Make sure that people actually have access to lactation support in your community and that they can find it. It’s one thing to be there but the fact is that they have to find it and then they have to actually access it. Especially if it's something that, if you're fortunate to be able to do that in person, then make sure that it is something that they are actually able to access or find out how they can do that.

That’s your little homework assignment for the next few days. Let me know how it goes, what you find. Let me know what you think about my mechanical and chemical buckets, if that makes a difference for you, if that seems like something that would be helpful for you in your work. Let me know! I’d love to hear from you! You can find information about the podcast and more episodes on the Lactation Training Lab website and lots of other information, free resources from me on the website. I’d love to see you there. You can join my email list there and never miss another new episode or anything new that I’m offering. I am really excited to present this information to you. I hope it’s helpful to you and I look forward to seeing you next time on the next episode of the Lactation Training Lab Podcast! Bye for now!


Listen to Episode 10 here!

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