Episode 5 - Raising the Bar for Lactation Care of Late Preterm Infants
Hi and welcome to the Lactation Training Lab podcast, a show created to inspire, inform, and engage current and aspiring lactation care providers. So glad you’re here! I’m Christine, an IBCLC and trained childbirth educator based in the U.S. I created the Lactation Training Lab after years of practicing clinical lactation care and providing professional lactation training to other healthcare providers to serve as a resource for learning and connecting overall things lactation related. Whether you’re seasoned or studying, I hope this show will make you think and inspire you to act. Here we go!
Welcome back! This is Episode 5. Believe it or not, we’re on episode 5. If you came across this episode on social media or through an email and you didn’t know there was a podcast- welcome to the family, glad to have you here, and I hope you will go back and hit the subscribe button to make sure you never miss an episode when they come out. And to those of you who have been listening all along and this is your fifth episode, welcome back, glad to have you, so nice of you to continue to join me and if you’ve been listening and you like or dislike or disagree or agree, I’d love to hear about it. Please go back to your podcast provider and give me a review. Do some reviews, send me some feedback, let me know what you think, and give other people the opportunity to see this podcast because when you rate and review it, that means more people can actually see it. More people will see this come up in their list of things they could listen to. That would be really helpful not only for me but for other people as well!
Coming in today I’m going to talk about something that, if you found this episode on social, if you’ve seen anything that I’ve put out in the last week or so, then you’ve heard and probably seen a little cute owl picture and mention of the program called Early Birds, and I wanted to talk a little about Early Birds and how this came about.
Recently I decided to take a deep dive into lactation care for late preterm infants. It’s a topic I’ve always been really interested in and focused on quite a bit when I was [working] in the hospital. As soon as I realized, as soon as I really had that realization, that late preterm infants require a different kind of lactation care, I really struggled to understand why that wasn’t more well-known, why that wasn’t a more popular thing, and one of the things that I found was that I’m not the only person who says that, obviously I’m not, I’m not a unicorn, but it’s still hard to find a lot of courses and trainings and information about late preterm infants and how we should approach their care.
I found through the Lactation Training Lab that (one of the questions you might remember from the free Facebook group The Lactation Training Lab, you would remember that one of the questions I ask when you want to join is: what kind of topics would you like me to cover?) one of the most popular responses to that question is what to do with late preterm infants. I know that people want to know about this. I know people need more than what they can find, and I also get a lot of questions on my masterclass, The First 100 Hours.
A lot of people were looking for something even more dedicated to this particular population so that when they’re working through First 100 Hours with the client, with the family, if that happens to be their situation, they’ve got even more detailed information about how to support things best during that time frame. This entire package of materials is actually going to be included in the Masterclass going forward. Everybody who is in the masterclass, they’re just going to get it uploaded into the module, and then everybody who joins from now on is going to have that in there as part of it.
It’s been really interesting to go through the materials that are out there, and what I did was I went ahead and I got the new Breastfeeding Late Preterm Infants book by Marsha Walker. I ordered that and I took a deep dive into reading that, and looked up how the information in there had been updated. There are a lot of new references in that book. There are a lot of new pieces of information that support everything that the book previously said, but a more robust set of evidence that really supports a lot of the techniques and skills that are discussed in there. I pulled, of course, the Academy of Breastfeeding Medicine protocol for breastfeeding late preterm infants to make sure that everything that I was thinking, everything that I’ve been doing is basically within that framework as well, because that’s one of the ways that I always check to see how my practice and my habits are fitting in with the frameworks of what others are teaching and what we know from the evidence is the best way to handle things. I always want to make sure that what I’m doing fits in there.
It’s always a good way for me to check my new knowledge because those [protocols] are updated every few years. Those have got modern, updated information, and they also have places where, as new information emerges, that information, if we’re applying brand new evidence, if we’re applying brand new research or something that might be a little bit different and out of the mainstream, there’s going to be places in those protocols where there is call for professional judgement. There is room and space for us to make recommendations that might not sit right inside the framework of exactly what the previous evidence said, but adding knowledge and adding professional judgement in there.
So I definitely pulled that and was taking a really deep dive in there. I worked with a lot of people lately who’ve had late preterm infants and read a lot of comments in some different professional Facebook groups with lactation care providers and other birth workers where people were discussing the way that we use the term breastfeeding in current days to indicate more than feeding the baby at the breast or the chest, but everything lactation-related and how that is a way that parents are using that term “breastfeeding.”
*(If we don’t catch up with that, we’re the ones who are not counseling appropriately, we’re the ones who are not teaching to where parents are. We need to be looking at ways that we can be more specific about what we’re discussing. When we’re teaching and counseling, when we’re helping clients dive into their intentions and their plans and what they actually have set for themselves as goals, we have to be using the same language. If we say breastfeed and what we actually mean is exclusively breastfeed and never use a pump and never use a bottle and never use any plastic device, that may not be what the client is thinking, so we really have to be specific about that.)*
Thinking about that in this framework and how those existing materials that I was finding, how those approach that situation and looking through the information that we’ve been working on in the Lactation Training Lab membership, we spent October  really kind of deep-diving into counseling and this sort of a different way than things that we’ve seen before. Looking at different pieces and parts of how counseling works, the difference between empathy and sympathy, and thinking about how our language impacts people when we’re teaching and when we’re supporting them. With that entire mindset, that is where I decided, against my previous decisions, I decided to do another clinical deep-dive kind of course. As you probably know, the previous clinical dive that I have is the First 100 Hours, and the intention had been for that to be the sole clinical pieceeverything else was going to be the supportive structure of the work we do as lactation care providers.
I was not planning to do any more deep dives into clinical topics. I think there are so many incredible people out there who are working on all of the different topics and issues and things that we need to know about as lactation care providers clinically, and I think there are people doing much better sets of research themselves, people who are looking at things from completely different lenses than I ever possibly could, and I didn’t really think that there was much call for me to actually do this, except that I knew what was missing from the First 100 Hours. So as a piece of that program, I couldn’t leave it out anymore. It’s not that it wasn’t mentioned there, but it really needs a spotlight.
I think we’ll talk a little bit here about why it needs a spotlight. So just this morning it’s November 6 , I just read the CDC birth rate information from 2019, and the rates of preterm birth in general are rising. They rose from the previous year, and that includes the rate of late preterm birth. This was true across races. Of course we already knew the preterm birth rate already started out higher for non-white populations, and it did rise for every population group. I think that there’s a lot of frustration for those of us who work in lactation care at the ethics of how parents are generally not receiving adequate information about the specific health risks and feeding challenges of late preterm infants and early term infants.
For the purposes of this work we’re going to do through Early Birds, we’re really going to talk about those health risks and those feeding challenges and to make it simple to refer to these populations we know that it’s not only late preterm babies born between 34 and 0 and 36 and 6 who may have these problems, it can also be those between 37 and 0 through 38 and 6. Just because a baby is 38 weeks, doesn’t mean they’re not going to demonstrate or display some of these late preterm feeding challenges because we know that due dates are estimates. Sometimes your 38 week baby might be 37 or 36, although they also may be 39 or 40. Of course it is also an individual thing, but when we’re looking at a baby who is looking at specific challenges and we’re looking for where the root cause is, sometimes this is where we have to go.
That frustration about people not being given this information - I was really trying to think about why that would be and took me about 2 seconds to circle back to the same answer that we have for so many other questions that frustrate us in this field: it’s really easy to dismiss this if you assume that breastfeeding doesn’t matter, that human milk doesn’t matter, or that parents’ own feeding intentions don’t matter. If you’re looking at this from purely a health standpoint of, well, the baby is healthy and breathing, the baby does not have any health problems for which we need to keep it in the hospital, this baby can go home with its parents so everything’s fine, the baby is normal but just a little bit smaller - if those are the only lenses that we use to look at this Early Bird baby, then yeah, we are going to be able to very easily dismiss breastfeeding, human milk, and parents’ feeding intentions and just let them know that if they have any problems, they can just feed their baby formula and then it’s all solved, right? That just wraps it up with a neat bow.
It feels like that is kind of how it’s been approached in a lot of ways. Typically, what I’ve seen throughout my career is that late preterm babies are not addressed as such unless they go to the NICU. Even then, it’s not always explained in a way to parents that’s really clear, that really defines for them that it is the fact of being late preterm that is causing their feeding problems. It is not because of a different thing - that is the issue, that is the root thing of what’s going on for them.
This whole way that it’s been approached is just another example of the failure of our structural support for lactation. It is not an individual blame game, this is not “oh there’s another person who didn’t try hard enough or failed at breastfeeding,” because those are the narratives that individual parents actually give themselves when they have trouble and when they end up off their own intention path. In the end though, no matter what it is, it's just a failure of that structural support, just like so many of the other things that we don’t do well, in the end it’s the parents that end up feeling like they let their baby down, they lost something in not being able to feed the way they wanted to, or that they just aren’t good at being parents.
How can we go back to the beginning here and really think about what we can do better that’s going to set parents up to have a better feeling of satisfaction and success. It always starts with information, right? We always go back to giving them better information so they can make better choices and feel better about the choices that they make. There are so many things that we can do, there are so many ways that we can approach this, and so much information we can actually give them.
I’m not talking about overloading them with information, I’m talking about giving them context for what’s actually happening with their baby. And I’m going to say this a million times and you’re going to get sick of me saying it, but the context here, when we’re talking about feeding problems with Early Birds is that they are Early Birds. It’s not that they have a tongue tie or that there’s a low milk supply, or they have a poor latch. The context is first and foremost that this is a late preterm. This is a baby who is not mature yet. This is a baby who needs more time, who needs more focused attention on feeding, who needs assistance with feeding.
For years I’ve tried to make this point really clearly with anybody who is studying with me through mentorship and through my courses, that it’s really important that when we have a healthy term baby, we remember that we don’t interfere as much with those babies because we expect that they have the capacity to feed, if they’re fed responsively and they’re fed on demand, they have the capacity to both get enough food and to maintain enough milk production. But we don’t put those burdens and those responsibilities on babies who are born preterm, late preterm, early term. We help them out. We give them the help they need until they reach the point where they have that capacity, and then we let them take it on. We don’t leave milk production to chance and the wind when we have a baby that we know doesn’t have the capacity to get all the milk they need from the breast.
So it’s a matter of putting everything into that context- that it’s being an Early Bird that is creating the feeding difficulties. The other pieces of it, the other symptoms of that that we’re seeing and we’re assessing as lactation care providers, that’s important, and that’s secondary. No matter how many things we fix, we still may not “fix” this whole entire situation until this baby reaches and achieves the maturity and the capacity that they actually need to be able to get enough food by themselves without our help and to be able to maintain and protect milk production on their own without us intervening in that.
We know that Early Birds, even when otherwise healthy, may experience early feeding difficulties and they require special attention to ensure appropriate growth and development. We've talked about “what does this mean?” Late preterm is defined as 34 plus 0 to 36 plus 6, and early term is 37 plus 0 to 38 plus 6. For the intentions and purposes of working through this lactation care framework, I refer to all of those as early birds.
It is completely possible that we may work with a baby that is 37 weeks who has none of these feeding difficulties or challenges and does not need any of this extra attention, and that’s an individual assessment and totally within the skilled lactation provider’s ability to assess that and to make a lactation care plan that takes that into account. But for all intents and purposes, we must begin by assuming. In the same way that we assume that a baby who is born at 29 weeks is not going to have the capacity to do all their feeding on their own, we have to still assume the same thing with these babies, even though they’re bigger.
Even if they had no feeding challenges at all, they still actually do have some health and growth and development needs which aren’t really adequately addressed always by other healthcare workers either. They have a high need for skin to skin care that isn’t addressed very well and isn’t very focused either. We know that some Early Birds are going to be admitted to a NICU or a special care nursery, but some are not. A lot are going to go home with their parents within 24 to 72 hours after they’re born, which, of course, is such a fraught time anyway. It’s a time of rapid hormonal shifts, so many physiological changes, and typically, a lot of fatigue and exhaustion for everybody involved. We know going home at that time, leaving the birth facility can be really a risky proposition to really have to prepare people and let them know what they need to look for and what they need to do if there’s problems.
We know Early Birds have a higher risk of readmission to the hospital within 30 days of their discharge, so their families really deserve accurate information and support to minimize that risk. We don’t want to see them back because of something we could have prevented with better information. We definitely know that continuity of care is huge here. We do not want people wandering around, not knowing what to do if something is going wrong with lactation or assuming that they can get all of their information from the internet about their very special baby who needs very special lactation care and is not like all the other babies of people they know or all the random strangers that they encounter on the internet.
It’s really important that we make this distinction for them, because it’s not a logical or easy distinction to make for a parent if they don’t have any background in this area. We know that really skilled lactation support is very important and one of the ways that this plays out is if parents don’t really understand that their baby does have this special distinction of being an Early Bird and needing this specialized lactation care and intention and if other health workers who are involved in their care (it might be a doula, it might be a midwife, it might be a lactation counsellor, it might be somebody in their lactation support group, it might be their pediatrician) - if they aren’t thinking in that context, if they aren’t putting this situation into that framework of being late preterm and needing this special lactation care, they may blow off some of the recommendations that we as skilled lactation care providers have made.
They may say “you don’t need to be pumping - when you’re starting out with breastfeeding you don’t need to worry about all that stuff, that’s just extra work.” Well, with an Early Bird, that’s not just extra work, that’s actually a really important part of a good lactation care plan that’s going to be able to maintain milk production if this baby isn’t able to do that. That’s just one example of how well-meaning people can not have that context and make one off-handed comment that might really make a huge impact on the potential for continuing lactation.
We know we want to see a proactive approach to providing lactation care in the Early Bird right from the beginning. It’s going to help avoid the need to intervene more. We don’t want to wait for those negative outcomes to be demonstrated. We want to be proactive about giving these babies extra help if they’re feeding at the breast or chest, we want to give them extra food. If they’re not feeding well, we want to protect milk production and not rely on these babies to do it because it’s not within their capacity for that if babies can barely wake up long enough to feed let alone stay on the breast for a long time.
We want to make sure that we can help with our education and counselling of families that we can make clear the importance of human milk feeding including donor milk, including pasteurized donor human milk to optimize growth and development and minimize risk of infection, because this is a more vulnerable population for contracting infection in the community - and also in the hospital - if they’re getting extra care. We want to be able to make that distinction while providing the kind of support and care and information that modern parents need.
We want to make sure that they are being heard, that their preferences are being heard while we’re giving them this information so that they feel like they’re making the best choice for them and that we’re not just approaching this from a “you have to do it all this way so that you will end up in this place.” We want to know what place they want to end up in so that we can tell them how to get there.
That’s what we do. We don’t lead everyone to the same place. It feels like there’s a lot of ways and strategies out there which are designed to get everybody to the same place, and that place is only feeding at the breast or chest and never using any tools or devices, and we’ve even talked a little bit about that on some of the previous podcasts with a different lens and view. But it’s really important when we’re in these counselling situations that we are truly listening so that we can lead people where they want to go, not where we want them to go.
This Early Bird program, it’s really been designed to incorporate that to make sure that we are looking at what parents are looking for and we’re trying to take them there so that we’re not spending time trying to get them practicing skills or techniques that they actually don’t need and at the same time, making sure that they have all of the most accurate information that’s going to keep their baby thriving. We don’t want to dismiss information or leave information out, but we also need to look at what their plans are and what they really need to get there. If they never planned on feeding their baby at the breast or the chest at all anyway, why are we spending time waiting for that to get better?
We need to be working on the skills and techniques that they actually want to have and that they actually are going to use. What has emerged from all of this discovery that I’ve been in and what I’m creating now is the Early Birds Program, a lactation care framework that’s designed to help you, the health worker who is engaged in the care of pregnant, birthing, and lactation people to kind of shift your approach of lactation care for the families of late preterm and early term babies - Early Birds.
This course is going to lay out for you a step-by-step plan for educating and counselling clients with thorough information about feeding their babies. We’re going to help them set up timelines so that they can have appropriate expectations of when different things are going to change for them and get better, and then techniques that they’ll need to help their babies thrive while protecting their own wellbeing. This can be such a challenging time and such a challenging plan for people that we want to make sure that we’re not overlooking the wellbeing and health of the lactating parent and the rest of the family just because we’re trying to get to a certain goal with the baby.
All of our plans, you’ll hear me say this a million times, but our lactation care plans, they always protect the three pillars. The three pillars being we want to see a healthy and thriving baby, we want a healthy and thriving lactating parent, and we want to protect the capacity of lactation for as long as that parent wants to. If we are leaving any parts of that out, then we are not really providing thorough and ethical lactation care. That’s not an appropriate lactation care plan. We have to consider all of those things and if the plan that we’ve made protects only two of them, which part gets left out? We can’t leave any of these things out, we’re looking for thriving relationships, we’re looking for thriving people, health that is always great and improving. We’re not looking for so-so or adequate or “we can just do this and it will be fine.” We’re looking for everyone to be thriving in these situations.
Using this modern look, we’re going to look through these modern eyes to see how today’s parents can navigate these challenges. They’re not new challenges and we’ve known about them, but this program was really created to help you feel more confident and capable in your knowledge and skills so that you feel like you’re doing the best that can be done for these families.. You feel like you have all of the information that you need.
Watch for details on the Lactation Training Lab Facebook page and in the free Facebook group and join the free Facebook group if you haven’t already - just look for Lactation Training Lab. That way you can enroll and begin the program as soon as it begins and it will be starting very soon, probably I am going to put this date out there - I’m going to say November 16 , and I’m really hopeful that that’s the first day that is going to launch. It will be the kind of course that you can access materials on your own time. There will be videos and there will be course materials you can read, there will be downloads that you can print out and keep so that you can interact with this information on your own as well as some opportunities for us to get together online and discuss different issues and topics and do some Q&A’s and work for the information together.
Just want to end here by saying this: raising the bar for lactation care for this really special population, it matters more than ever today with rising rates of late preterm birth and a worldwide pandemic. I know you will want to be part of this movement to raise the bar and I can’t wait to see what we can do together. I look forward to hearing from you on this. I look forward to seeing you in the free Facebook group on the page, look for me on instagram @IBCLCinCA, and of course on my website LactationTrainingLab.com. If you use the “Free” tab on the top you can always find free downloads and free resources that you can use in your practice. I look forward to hearing from you very soon! Have a wonderful day!
Listen to Episode 5 here!