A Case Study from LA County…
It is one of the most challenging and misunderstood moments for hospital staff: what to do when a mother calls for help in the middle of the night with a screaming baby who is having trouble breastfeeding. People who know Kittie Frantz will not be surprised to hear that she has some strong feelings on this subject.
Kittie is a well-known breastfeeding expert and Baby-Friendly champion who helped drive the transformation of maternity practice in one of the country’s most demanding settings – at the Los Angeles County + USC Medical Center (“LAC+USC”).
From Ms. Frantz’s perspective, it is crystal clear what should happen in this situation.
“The nurse assigned to the mother at night should have the knowledge and skills to be able to help the mother soothe the baby and assist her in successfully getting the baby to the breast,” says Frantz. “Too many nurses abdicate this responsibility to the lactation consultant the next day, but that’s not how we do it here.”
“When we decided to pursue Baby-Friendly designation back in 2005, I said to the committee that this is only going to work if we train all the nurses in the skills that they need and tell them that you are responsible for the lactation care for your patient,” she recalls.
Frantz (fourth from left) with the Baby-Friendly Initiation Committee at LAC+USC Medical Center in 2011
“We’re a county hospital. At that time, we didn’t have the budget for a lactation consultant – and even if we did, we knew we would only be able to have one during the day. So this was the model we chose, which meant we had to seriously educate our nurses.”
Frantz and her colleagues created an intense 20-hour-long course, consisting of all of the topics outlined in the Baby-Friendly Guidelines and Evaluation Criteria to train the staff themselves. That program is a standard component of training for all new maternity unit staff at her facility, as well as at their sister facilities, Harbor-UCLA Medical Center and LAC Olive View-UCLA Medical Center. Since 2010, over 1,000 nurses have taken the class, creating consistency of care across all three facilities.
“In some ways, this is a classic case of the old saying that ‘necessity is the mother of invention,’” says Baby-Friendly USA CEO Trish MacEnroe. “Lack of resources forced the hospital to consider a different approach. And yet, what they did is fully consistent with Step 2 of the Ten Steps to Successful Breastfeeding. The nurse-to-patient ratio is always greater than the lactation consultant-to-patient ratio and a mother requires immediate help when a problem occurs and cannot wait for the lactation consultant the next day.”
That very scenario was used to cast Baby-Friendly in a negative light in a recent article on Huffpost.com.1 Here’s the situation presented by the author of this article:
- The mother was enthusiastic about breastfeeding her new infant at a Baby-Friendly facility.
- After birth, she had skin-to-skin contact with her daughter and saw a hospital lactation consultant who helped her with the infant’s latch.
- Then in the middle of the night, the baby woke, had trouble latching and screamed inconsolably.
- The mother called the nurse and asked for “a bit of formula to tide them over until they could get a better handle on breastfeeding.”
- The nurse told her that this would require a doctor’s order.
- Because it took so long to get the doctor’s order, the mother asked her husband to sneak some formula into the hospital.
The author goes on to argue that mothers should not be pressured to breastfeed.
“We completely agree that mothers should not be pressured to breastfeed,” says MacEnroe. “That’s not what Baby-Friendly is about. Baby-Friendly is about having conversations with mothers and helping them to overcome difficulties so that they can achieve their own infant feeding goals.”
What Should Have Happened
“The problem in this case was not that this mom was unduly pressured to breastfeed,” says MacEnroe. “It’s that she didn’t get the help and support she needed – help that is fundamental to Baby-Friendly practice standards. A screaming baby in the middle of the night should be basic nursing care.”
“The nurse assigned to that mother at night should have been in there helping her, validating her concerns, empathizing with her distress, and collaborating with her on solution,” says Frantz.
There are many things she and the mom could try, according to Frantz. The first thing that should have happened was for the nurse to help her soothe her baby. It might be as simple as burping the baby. Once the baby is calmer, she can then work with the mom on positioning.
“In this case, the lactation consultant had already worked with her on positioning,” she says. “In a perfect world, the lactation consultant has left a note in the chart that provides information about what she and the mom worked on and the night nurse has already seen that note. Then the nurse can go in and say, ‘let’s try again what the lactation consultant helped you with.’ It’s all about communication, compassion, encouragement and support.”
Frantz and MacEnroe agree that by collaborating with the mom and giving her the help and support she needs when she needs it under the skilled eye of a professional, the nurse is giving the mom the opportunity to acquire some skills, learn her baby’s cues, and understand what works for her baby. Then the next night if the same thing happens or another challenge arises, she’s better equipped to deal with it.
While supplementing at that moment might have achieved the immediate goal of settling down the baby, in the long run it might have undermined the whole process of lactation and thus the mother’s goal of breastfeeding her infant.
“The whole premise of Step 2 in the Ten Steps – train all health care staff in the skills necessary to implement the facility’s breastfeeding policy – is that nurses should have the skills, knowledge and confidence to help a mother in this situation,” says MacEnroe. “Lactation consultants are there for more difficult challenges, as well as updating the nurses’ skills.”
“The whole point of Baby-Friendly is to give providers who are at the point of care the tools and the skills to be able to provide the proper support to help moms achieve their goals,” says Frantz.
Frantz also believes a key to supporting mothers in situations like this is to use a technique called “laid-back, baby-led breastfeeding.” This means leaning the mother’s body back at a 45-degree angle, placing the baby skin-to-skin, and letting the baby take his or her time to find the breast.
“The mother gets incredibly comfortable,” says Frantz. “And she’s more willing to let the baby to take his or her time to nurse because she’s not sitting up in a chair hunched over with the baby on a pillow with neck strain. And it’s better for the baby because with the mother’s body back at 45 degrees, the baby can lie on the mom’s chest, so he or she is more comfortable too and more likely to want to explore in a natural position .”
“Our moms love it,” she says. “It’s the perfect position for a good latch and it feels so natural. They let the baby stay on the breast as long as they want.”
“Our providers love it because the moms love it, and it saves them time,” she continues. “No more hovering over each mom to teach her how to latch the baby. They figure it out together.”
And best of all, once they fully implemented laid-back, baby-fed positioning at LAC-USC, the staff there realized it had some unintended benefits. For one thing, they observed moms tended to breastfeed for much longer in this position because it’s so comfortable – often as long as 45-60 minutes. As a result, mom’s milk tended to come in sooner, often before 48 hours. In addition, this resulted in a reduction in the number of moms experiencing engorgement and sore nipples.
“We have a policy that dad or grandma needs to stay awake and sit by mom to watch the baby if mom dozes off. It works really well,” says Frantz.
Frantz believes this technique would have helped the nurse with the screaming baby in the middle of the night. “What our nurses would have likely done is first to listen to the mother’s concerns, acknowledge her request, and then suggest we let the baby and mom go skin-to-skin in a laid-back baby-led position,” she says. “Often the baby will calm down, find the breast and all is well.”
Success with a High-Risk Population
What’s perhaps most impressive about the Baby-Friendly effort at LAC+USC is that they’ve been able to achieve remarkable results with the high-risk population found in a county hospital. One of the largest public hospitals in the country, LAC+USC serves a high proportion of patients with chronic health conditions and also serves as the facility for much of the county’s prison population. Yet, they’ve been able to achieve a 66% exclusive breastfeeding rate.
“It’s a remarkable achievement,” says MacEnroe.
“I’m very proud of what we’ve accomplished,” says Frantz. “I don’t think any of this would have happened if we weren’t on the trail of becoming Baby-Friendly. And none of the good results would have happened if we had relied on someone else to train our nurses because we could tailor our training to our unique patient population.”