A Day in the Life of a Lactation Consultant
Gina Arias chokes back tears as she strokes the hair of her owl-eyed baby boy, Khalil. "Do you think there's any chance for us?" she asks Jan Wenk. "I don't know," Wenk replies softly. "I just don't know." "Well, at least that's not a no," says Gina, catching her breath.
If I'd just walked in on this conversation, I would have thought Khalil's life was in grave danger. And as far as Gina is concerned, it is. She contacted Wenk, a professional lactation consultant in Manhattan, because she isn't producing enough breast milk. Gina's had to supplement with formula, and she's devastated: "Formula ... you don't really know what's in it."
Well, actually, you do. Formula may not be breast milk, but it's not toxic waste, either. But try telling that to women like Gina, who fervently believe, as the informal motto of the passionately pro-breastfeeding La Leche League International puts it, "Breast milk is liquid gold, and it's yours to give!"
The number of American women who breastfeed is on the rise. In 2000, 68% were at least partially nursing when they left the hospital, compared to 27% in 1970, according to a study by Abbott Laboratories, a maker of infant formulas. With this increase, women have been turning to lactation consultants in record numbers. Teaching breastfeeding as a profession began only 17 years ago, but since 1995 the number of consultants accredited in the U.S. by the International Board of Lactation Consultant Examiners has doubled, to more than 7,000. Many are nurses or other health professionals, and to get board certification they must complete anywhere from 900 to 8,000 hours of field work.
Eight thousand hours on breastfeeding? Like many women who didn't nurse (I had twins, spent every day of the pregnancy throwing up, and wanted my body to myself as soon as they were out of me, thankyouverymuch), I wondered: What's there to study? If breastfeeding doesn't come immediately, why should it come at all? I was also cranky about breastfeeding's fashionability, typified by the singer Brandy, who, when pregnant with her first child, had said, "I'm going to be a real mommy. I'm going to nurse."
So what are non-nursing women? Faux mommies? Lactation consultants wouldn't go that far. But they do say that breastfeeding gets little support. "Our society makes women believe that if they have to ask for help there's something wrong with them," says Laura Best, president of Wellcare, a lactation consulting firm in Manhattan.
Few can dispute the health advantanges of breast milk -- we know that it passes immune-boosting antibodies from mother to child, reducing a baby's risk of allergies, ear infections, and stomach problems. There are benefits for mothers as well, from helping them take off surplus pregnancy weight (the process of turning yourself into food burns up a lot of calories) to reducing the lifetime risk of breast and ovarian cancer by as much as 25%. In fact, the American Academy of Pediatrics recommends that mothers nurse their babies for at least six months, with a year being the ideal.
But just because nursing is healthy and natural doesn't mean it comes naturally. And since breastfeeding plummeted in popularity in the '50s and '60s, many women who choose to nurse now weren't breastfed themselves and can't turn to their own mothers for advice. Hence, perhaps, the rise of the breastfeeding expert. When Americans are a little unsure of ourselves, we like to leave the decisions to the professionals.
Perhaps I shouldn't have been surprised, then, by the eagerness-bordering-on-desperation I encountered while following Manhattan-based lactation consultant Emily Pease on her appointed rounds one day. Pease, 45, developed a fascination with breastfeeding when nursing her own children. She still breastfeeds her youngest daughter, Ruby, now 3. "If children are allowed to self-wean, they'll do it between the ages of 3 and 7," Pease says. Still, she doesn't let Ruby nurse on the subway anymore. "Ours is not a culture that loves breastfeeding," she says. "You get some looks."
For most of her patients, the thrill of new motherhood is in conflict with the fear of doing something wrong. "This isn't a light subject," she says. "Moms feel distressed and overwhelmed -- and they worry that their babies aren't getting enough food."
Dealing With Nursing Pain
Jessica Freiser, a 31-year-old art gallery owner, prides herself on being somewhat of a stoic. But when she began experiencing "unbearable" pain while nursing her
3-week-old son, Jack, she decided to call Emily Pease. On this, her second visit with Jessica, Pease covers her finger with a condom and places it in Jack's mouth to test the strength of his suckling. "He's got a better seal than last time," she says. "There's a lot more vigor." Then she watches approvingly as Jessica places Jack in the position for optimum latching on: not held close to the breast with his head tilted forward, as many mothers think, but with his head slightly hyperextended, his forehead tipping backward. This allows the baby to open his jaw wide so he can compress as much of the areola as possible, rather than just clamping down on the nipple. It's the sacs behind the areola, not the nipple, that contain milk ducts, Pease explains. Babies can cause their mothers pain if they latch on only to the nipple, which is exquisitely sensitive.
"Women are told they have to toughen their nipples," Pease says. "Some of them use Brillo pads. It's ridiculous. Nipples are really made of the same tissue as the penis. Would anyone use a Brillo pad on a penis?"
Usually nursing pain is caused by improper latching on, but that's not the case with Jack. So what is it? Jessica mentions a small, tender lump near the 4 o'clock position on her right areola. It's a plugged milk duct, which may occur if the breast isn't fully drained of milk. Pease shows Jessica how to hold Jack in a clutch hold -- kind of like a football -- so his chin points to the area of the plug. As he nurses, his jaw's back-and-forth movement will knead and unplug the duct. But that's apparently not the only problem. Pease notices that Jessica's nipples, once brown, are now a bright pink. She opens Jack's mouth; the upper palate is coated white. "You've got thrush (a fungal infection) and you're passing it back and forth to each other," she explains. "That can really hurt." She tells Jessica to ask her ob-gyn for a particular topical cream that's nontoxic to the baby and also recommends avoiding sweet, processed foods and rinsing her nipples with a vinegar wash.
"So this doesn't have to hurt?" Jessica asks Pease, with some surprise. Pease leaves her with the words that, I will realize later, are her mantra: "I think you're going to be fine."
Finding Time to Breastfeed
We're at the Elizabeth Seton Childbearing Center in Manhattan, where a breastfeeding support group that Pease leads is just getting started. A dozen babies are sucking away noisily at a dozen breasts; their mothers are sitting cross-legged on the floor, nibbling take-out sushi, talking on cell phones, and drinking huge bottles of water. The casualness of the setting, however, belies an undercurrent of anxiety.
Still sleep-deprived, many of the women are worrying about nighttime feedings: Why is it that when their babies eat in the middle of the night, they splutter and spit up more than they do in the daytime? It turns out that the culprit is prolactin: The earliest hours of the morning are the highest for milk production, so nursing during that time is the breastfeeding equivalent of doing a beer bong. Pease demonstrates a position that allows the infants to nurse against the flow of gravity: Mom and baby lie on their sides with the baby's mouth at his mother's breast, his feet at her head.
Pease advises the women not to be worried about the spitting up. "Mothers think babies aren't getting enough nourishment, but most of the time there's really very little milk that comes up -- it's mostly saliva," she says. "I like to say this is a laundry problem, not a health problem. Just remember: Spit happens."
The most common concern here today? Going back to work. "I'm in a panic," says Denise, mother of 4-month-old Milo. "When I go back, how can I keep my milk supply from going down?" Pease recommends that Denise pump once for every three hours she's away from the baby -- at least twice for an eight-hour day. "You shouldn't feel you have to wean if you go back to work, because ... well, can you imagine the transition for him? You're leaving, and he has to be weaned?" There is a collective shudder.
Pease is there to provide reassurance, but with the subtle pressure she often exerts I suspect she can sometimes cause as much anxiety as she alleviates. Rachel Bachner, for example, is frustrated that her son William seems to take forever to chow down. "I don't want to breastfeed all day long," the 31-year-old mother says.
"Really?" says Pease, archly. A silence descends on the room.
Rachel backpedals wildly. "Well, if he needs it, of course I will!" Pease smiles, and a quiet rumble of relieved laughter passes through the group.
Later, Rachel wonders whether she should bring her son to a wedding she has to go to; she doesn't want to breastfeed there. "Why not?" asks Pease. "It's normal to nurse." "But, I don't want to pull out a boob...." Rachel's voice trails off meekly.
Later, when the class breaks up, I hear Rachel still muttering to herself. "But I don't want to do it at the wedding.... I just don't want to...."
More Feeding Problems
Complications With a Premature Baby
After a day of watching tears and frayed nerves, I am hugely relieved to meet Prudence Carlson and her 6-week-old, Ida. Here, finally, is a new mom suffused with joy. This is ironic, considering that Ida's path into this world was anything but simple. Prudence, 50, a writer, underwent 12 years and untold thousands of dollars' worth of failed infertility treatments before using egg donation to conceive Ida. Then, when she was several months pregnant, doctors found that Prudence had an enlarged aortic stem -- a congenital heart defect that is aggravated by pregnancy and could possibly trigger heart failure. Prudence was advised to terminate the pregnancy. She did not. Now here is Ida, who, genetics be damned, bears an uncanny resemblance to the woman who risked her life to carry her.
Nursing has also been a nightmare. Ida, four weeks premature, simply could not stay awake while feeding for more than a few gulps. She was born at 7 pounds, 15 ounces, but in the first few days of life lost a pound, considerably more than the 6% to 10% weight loss most babies experience right after birth. Though doctors were encouraging Prudence to bottle-feed Ida since getting milk from a bottle demands less energy, she persevered. "I just kind of kept her attached to me all the time," she says. "I jostled her awake and fed her for four hours at a stretch. I didn't sleep, but I figured, hey, I have my whole life ahead of me to sleep."
For the first few weeks,the little girl continued to gain weight, but Prudence was so sleep-deprived she was practically hallucinating. That's when she decided to call the lactation consultant. On Pease's first visit, she put Prudence on a supplemental nursing system, or SNS. With SNS, extracted milk or formula is placed in a feeding canister, which is slung around a mother's neck and connected to the breast via a slim tube taped to the nipple. When the baby suckles, she gets not only the milk in the breast but also the liquid in the tube. So it keeps the flow steadier and feeding easier -- like using a bottle -- but continues to stimulate the mother's own milk production.
Now, four weeks and four visits later, "this is a different baby," Pease enthuses. "She nursed well before, but never for very long. The SNS taught her to stay on the breast and finish the feeding. Look how she's totally into it!" Pease tells Prudence that she's graduated from the SNS and can now nurse without it. Prudence beams.
By the end of Pease's workday I'm exhausted; I feel like a Munch painting, having just absorbed the angst of dozens of hormonally challenged women. And a week later, I'm still worrying: How's Jessica's thrush? What happened to Gina and Khalil -- did more milk come in? Did Rachel end up nursing at the wedding? I manage to wait a few more weeks before calling for status reports.
In turns out that Gina went to Santo Domingo for a month so her mother could help her with Khalil; she found that her milk production increased when she felt less stressed. Jessica's thrush needed stronger treatment -- her doctor prescribed an oral antibiotic that can be used while nursing -- "but when she stopped calling I knew she was okay," says Pease. And Rachel ultimately decided not to bring her baby to the wedding at all. "The baby had fun staying with other people, and it's good for me to know he can survive for two hours without being latched to my breast," she says.
As for Pease, she still greets each day with a sense of wonder, seeing herself as a star player in the soap opera of new motherhood. "You really never know what you'll find when you walk in that door," she tells me.
Before I met Pease, I prided myself on being guilt-free about choosing not to nurse. I would not succumb to the tyranny of breastfeeding fashionability! Then, as I was finishing up this story, a study came out from the American Medical Association saying that adults who had been breastfed as babies had higher IQs than people who hadn't.
That $100 I just spent on Baby Einstein, Baby Shakespeare, and Baby Mozart videotapes? Completely coincidental, I assure you.
Copyright © 2002. Reprinted with permission from the October 2002 issue of Child Magazine.