Certified Lactation Counselor Questions and Answers (2023) (Graded A+)

weaning - ANSWER the addition of adding other foods to a diet, but not completely stopping or ceasing breastfeeding when did breastfeeding rates start to initially decline (i.e. in Britain), particularly among the wealthy population? - ANSWER 16th-17th century and through the 18th century which month did women historically think was the most important to breastfeed during? - ANSWER the summer (due to food spoilage) what three ingredients made up the first commercial formula? (early 1800's/19th century) - ANSWER -wheat flour -cows milk -sugar what was, and still is today, one of the biggest reasons why mothers quit breastfeeding? - ANSWER mothers report not producing enough milk when did bottle feeding become the "new norm", thus, causing breastfeeding rates to continue to decline? - ANSWER 20th century (particularly, mid 1900's) (1950's-1970's) what is the WHO code? - ANSWER an attempt to prevent excessive marketing of ABM (artificial baby milk) and to bring awareness of benefits of breastfeeding (although this code is not law in many countries as it interferes with marketing & freedom) *breastfeeding education to pubic is critical!* what are some other breastfeeding barriers mothers have? - ANSWER -sexual vs functional aspects of breasts -women in the workplace -"im not producing enough milk" -lack of support from medical profession where are the breasts specifically located on the body? - ANSWER -between 2nd & 6th rib -from sternum to mid axillary line -only gland in not fully functioning at birth *may contain hair, sweat, and oil glands hypoplastic breasts - ANSWER -insufficient glandular tissues -usually only extend from 3rd to 5th rib -typically have more spacing between breasts (1.5 inches or more) montgomery glands/tubercles - ANSWER "small bumps" located around areola that become more prominent (hypertrophy) during pregnancy & are thought to secrete substance during pregnancy/lactation & contain scent glands to help guide infant to nipple, while also helping kill pathogens that try to enter the body areola - ANSWER vary in shape & color; usually circular; become darker during pregnancy and do not return to pre-pregnancy color nipple - ANSWER contain smooth muscle fibers for erectness and graspability; normally found at 4th intercostal space that typically contain between 4-18 openings (9 on average) for milk to be expressed through during lactation nipple/areola complex - ANSWER thought of as one entity; both elongate up to 2-3 times resting length during breastfeeding; areola = most sensitive part of breast nipples = least sensitive everted nipples - ANSWER most common type of nipples; protrudes slightly at rest & everts well with stimulation flat nipples - ANSWER soft, but pliable & graspable pseudo-inverted nipples - ANSWER appear to be inverted but will evert with stimulation or compression retracted nipples - ANSWER type of inverted nipples that appear to be graspable but retracts, rather than everts, with compression inverted nipples/nipple inversion - ANSWER retracted nipples that occur with retracted both with rest and stimualtion what are some techniques for flat/inverted nipples that may help to evert nipples? - ANSWER -inverted syringe -supple cups -breast shells -avent nipplette -"pinch test" in last trimester of pregnancy supernumerary nipples - ANSWER "3rd nipple" or "accessory nipple" found along line of glandular tissue what is breast tissue composed of? - ANSWER 2/3 glandular tissue 1/3 adipose tissue suspensory ligaments - ANSWER aka cooper's ligaments; heavy fibrous bands that divide adipose and glandular tissue of breasts into segments describe breast innervation - ANSWER breasts and areola are high innervated by 4th-6th intercostal nerves (greatest amount of innervation from 4th intercostal nerve) to bring sensation from behind from spine along ribs to chest and breasts how to properly perform breast assessment: - ANSWER -examine bilaterally at same time -observe shape, size, symmetry, elasticity -look for bumps, edema, engorgement, scars, anything abnormal what are the internal features of the breasts? - ANSWER -4 sections called quadrants -lactocytes (cells that make milk) fill each alveoli -- alveoli fill lobes of breasts -- lobes surround areola of breasts -- breast milk secreted into lumen of alveolus -- from center of alveolus, milk moves into small channel (ductile) (many of these, delicate) -- each ductile drains into large lactiferous or mammary duct -- ducts terminate at the nipple **AKA: lactocytes -- alevoli -- small ductile -- mammary duct -- larger mammary ducts -- nipple opening what is the "foundation" of milk production? - ANSWER lactocytes (milk producing cells) what is witch's milk? - ANSWER breast buds/neonatal engorgement in full term infants that may be mistaken for baby acne; self resolve by 4 weeks pp why is it critical to ask mothers about breast changes during pregnancy when completing an assessment - ANSWER different hormones cause breast changes during pregnancy which are critical in assisting with breastfeeding in the pp period; examples: -estrogen: cause ductile system to proliferate -progesterone: promotes and increases the size of breast lobes and alveoli -serum prolactin: nipple growth -serum placental lactogen: areolar growth Lactogenesis I - ANSWER occurs between 16-20 weeks of pregnancy until milk surges, or comes in, after birth breast size increases differentiation between alveolar cells into secretory cells occur hormone prolactin stimulates mammary secretory epithelial cells to produce milk *endocrine (hormonal) control* Lactogenesis II - ANSWER occurs between PP day 3-8 where there is a rapid increase in milk volume for 2-5 days, then abruptly levels off; this is the onset of copious milk supply triggered by rapid drop in progesterone levels after placenta is delivered will feel fullness and warmth in breasts *now switches from endocrine to autocrine control* galactopoiesis - ANSWER maintenance of the established milk production under autocrine control works on a supply & demand basis breasts will decrease slightly by 6-9 months pp involution - ANSWER the process of weaning slowly over 3 months or longer when FIL (feedback inhibitors of lactation) in breastmilk suppress lactation if milk is not removed from the breasts describe colostrum - ANSWER -"first milk" -starts about 16-20 weeks gestation and mom may or may not leak this during pregnancy (which is normal, nothing to worry about); -clear to golden yellow in color, but may be greenish or brownish due to old blood -very dense and thick, gel-like; present in small aounts -acts as "gut primer" or "closure"; helps block out pathogens and clear meconium out of gut -physiologic capacity of stomach: only 20 mls at birth (note: anatomic capacity is much larger, do not go by this) transitional milk - ANSWER milk produced between colostrum and mature milk; occurs by 3 days PP occurs when "milk comes in" or when "milk comes to volume"; sensation of fullness occurs during lactogenesis II caused by rise in lactose in cells which draw water into secretion by osmosis and enhances milk volume; can be sped up by increasing frequency of breast emptying in first few days pp mature milk - ANSWER occurs between days 10-14 and onward the longer the breastfeed, the higher the fat (caloric) content of milk (in both one feed and longevity of feedings); fat content higher at end of feedings and the longer one breastfeeds for in total not all breastmilk is 20 cal/ounce milk in second year of lactation has significantly increased fat & calories Describe the differences between colostrum & mature milk in terms of composition - ANSWER Colostrum: higher protein, higher cholesterol, high IgA antibodies Mature milk: higher energy (calories), higher lactose, higher fat (the emptier the breast, the higher the fat content in the milk because there is more fat toward the end of breastfeeding) what is the average caloric value of breastmilk (per ounce)? - ANSWER First 3 weeks of life: 20.2 - 28.2 kcal 6 months: 22.5 - 36.25 kcal 9 months: 22.9 - 32.4 kcal 12 months: 19.4 - 34.6 kcal *Essentially, it ranges from 18-23 kcal/oz What volume of milk approximately should mom be pumping and should be used to supplement if needed during first 5 days of life? - ANSWER Day 1: 5 ml/feed Day 2: 15 ml/feed Day 3: 30 ml/feed Day 4: 45 ml/feed Day 5: 60 ml/feed By one month of age, moms will get approximately 750-800 ml/day More is usually produced in right breast over left side Rusty-Pipe Syndrome - ANSWER Capillaries in breast tissues are traumatized resulting in blood leaking into breast milk, often due to rapid breast growth during pregnancy; can turn colostrum brown; continue breastfeeding if this happens What factors affect breast milk volumes AND composition in mothers? - ANSWER -genetic individuality -maternal nutritional status -stage of gestation & lactation -high weight gain in pregnancy = higher milk fat -parity -diet (for fatty acids & vitamins) what is the sugar in all mammalian milks called? - ANSWER lactose (carbohydrates) oligosaccharides (carbohydrates) - ANSWER non-digestible; ferments in the colon promoting further growth of probiotics; blocks pathogens from attaching to intestines by enticing bacteria to bind to the HMO for excretion by feces, and thus, acts as a prebiotic in infant's gut fats (lipids) - ANSWER the most variable constituent in human milk over a feed, between breasts, and over time; inhibits growth of pathogenic bacteria while allowing beneficial species to survive related to fullness or emptiness of breast; the emptier the breast, the higher the fat content and vice versa proteins (i.e. whey, casein, lactoferrin, lysozyme, SIgA) - ANSWER concentration in breast milk decreases over first few months of life more whey found in breast milk than casein, but vice versa in formula -whey can help kill of different cancerous cells; -casein can cause behavioral issues what are the "big three" proteins that contribute to the bacteriostatic and bactericidal properties of human milk? - ANSWER -lactoferrin -lysozyme -SIgA *These are: anti-inflammatory, protect against diarrhea (aid in digestion), and have immunological factors/antibodies what are some micronutrients that are commonly found in breastmilk? - ANSWER -iron -calcium, phosphorous, magnesium -Vitamins A, D, E, K -low levels of electrolytes what is the difference breast milk directly from breast and EBM in bottle/syringe/etc.? - ANSWER baby's saliva enters breast when feeding directly on breast, so there is an increase in antibody production specific to each baby's need fat variation also is more specific to each baby's needs, thus, decreasing amount baby needs to take from breast remember: breast milk is _____________, while formula is _________________ - ANSWER alive; dead what things should be assessed in the breastfeeding infant, which may affect how well infant feeds or show effectiveness of breasfeeding? - ANSWER -gestational age (term infants feed best) -birth hx (long 2nd stage, forcep/vacuum use, position in utero, meconium aspiration, AGAR scores, resuscitation efforts -baby's ability to breastfeed (is anything out of the NORM) -oral assessment/exam (tongue tie? thrush? cleft lip/palate? moist or dry mucous membranes?) -alertness levels (feeding cues, stress signals) -muscle tone (normal extremity flexion? resistance when undressing or wet noodle? head lag when in sitting position?) ----------------------------------------------------- *-I&O: * 1 void/day of life until day 5-6, then several a day = normal (excessive voiding in first 12-24 hours of life can be due to excessive maternal fluids during labor; if baby loses more than 10% of weight but is feeding well with many many pees & poops--DONT WORRY) 3 "scoopable" stools or more a day by day 4= normal -Weights: All infants will lose weight; Infant should be back to birth weight by day 10 pp & one ounce weight gain per day until 3 mos old; normal weight loss = no more than 6.6% **What is considered the norm when assessing an infant? - ANSWER healthy, vigorous, full term infants what infant stage of behavior do infants feed best in? - ANSWER quiet alert stage what are some hunger cues and infant might display, which tells the mother she should put infant to breast immediately? - ANSWER -mouthing (rooting) -hand to mouth -hand swipes to mouth -sucking on hand -tonguing -head bobbing what is the best intervention of under or over-aroused infants to help get them to feed? - ANSWER skin to skin what is the Dancer Hand Position? - ANSWER position mothers can use during breastfeeding to help support the breast and the infant's jaw simultaneously during a feed *very useful for hypotonic babies (i.e. LPT, Downs, preterm, mandibular asymmetry)` what is the best way to know that breastfeeding is going well? - ANSWER *PAIN FREE WEIGHT GAIN* What is the best way to identify sick infants, which need further assessment and intervention - ANSWER Infants that dont want to eat: -baby refuses to nurse 2x in a row -3 poor feedings in a row, after good feedings have been established *Baby's physician needs to be contacted what is another name for mongolian spots? - ANSWER gray slate nevus can a mother breastfeed an infant with galactosemia? - ANSWER NO Common traits in Down Syndrome: - ANSWER -low muscle tone* -flat facial features -upward slant to eyes -low set ears -enlarged tongue -super flexible -single crease in palm of hand -excessive spacing between toes -congenital heart conditions Is it okay to breastfeeding during a pregnancy? - ANSWER Yes, unless mother has hx of preterm labor What are the best practices to exhibit when counseling breastfeeding women? - ANSWER -provide small, tidbits of information at various times so as not to overwhelm mother -counsel women AT LEAST 4x for best outcomes -face to face counsel sessions -get on same eye level as mother (ex. sit knee-to-knee) -eye contact -be conscious of: tone of voice, body language, and facial expressions -interact with mothers to allows them to participate in learning/counseling (ask questions, etc.) -address/focus on mother's needs & concerns TOP THREE: 1. Ask OPEN-ENDED questions 2. Affirm feelings 3. Educate What is the most important goal in helping breastfeeding mothers achieve for success? - ANSWER CONFIDENCE which hormone helps keep milk production under control until after delivery? - ANSWER Progesterone--levels drop after delivery of placenta & milk production begins in earnest prolactin - ANSWER hormone that builds up during pregnancy to get ready to make milk by acting on lactoycytes; manufactures in hypothalamus and stored in anterior pituitary gland what is the role of prolactin? - ANSWER prolactin receptors develop early in lactation and remain constant after that, so increasing prolactin levels are not needed *it is permissive rather than regulatory* when is it important to establish good feeding techniques? - ANSWER In the first two weeks; *early and often* what is the purpose of Feedback Inhibitor of Lactation? (FIL) - ANSWER the concept that you must remove milk to make milk; supply & demand, which helps to protect supply ensures amounts of milk in excess of infant's needs are not produced under autocrine control the more FIL, the less milk production; vice versa oxytocin - ANSWER manufactures in hypothalamus; stored in posterior pituitary gland produced when breasts are stimulated, to then, elicit the let down reflex (or milk ejection reflex) for milk transfer when breastfeeding this hormone moves milk from lactocytes alveoli ducts nipple and beyond for baby contracts mothers uterus can cause mothers to feel thirsty what are signs that the let-down reflex is occuring? - ANSWER -*leaking from opposite breast than feeding on* -nausea -intestinal colic -headaches -infant may feed faster with each let down during a feed what does the let-down reflex/milk ejection reflex feel like to most mothers? - ANSWER -tingling -"rushing down" feeling -"drawing" -sometimes pins & needles *what are some effects of oxytocin on mothers and babies? - ANSWER -promotes attachment -eases stress -solidifies relationships -reduces drug cravings -triggers protective instincts -calming, tranquil, and loving (also sleepy) -generosity what interferes with oxytocin and can shut down the let down reflex? - ANSWER adrenaline & noradrenaline (stress/fear); make sure moms are calm and safe what are some findings of NORMAL breastfeeding? - ANSWER -good first feed after birth -poor feedings/sleepy baby for rest of 24 hours -1 sided feeds & short in duration in first 24 hours -difficulty latching first 24 hours -improvement in frequency & duration in second day -*skin to skin* -babies "ready" to eat; showing cues (do not wake baby) -*Remember: 8 or more in 24* (number of feedings/day, except for possibly first 24 hours) -some cluster feeding, some longer intervals in between -good, quality sucking: more about quality than quantity (not all about the length of feedings) -rhythmical sucking with swallowing (audible) & breathing: *suck/swallow/breathe pattern* -several sucking bursts accompanied by occasional pausing -baby's mouth wide open -deep, ASYMMETRICAL latch (jaw pressed to breast, nose up and out) -mother reports: fatigue, thirst, cramping -nose & toes of infant pointing same direction -ears, shoulders, hips of infant lined up Once milk comes in: -infant should appear sleepy after feeds -1.5-2 hour intervals between feeds - Describe normal infant stools: - ANSWER Mec: First 2-3 days Transitional (greenish): Days 3-4 Yellow/seedy: By Day 5 *Remember, 3 scoopable (good sized) poops/day by day 4* what is cholecystekinin (CCK) - ANSWER a GI hormone that enhances digestion & causes sedation and feeling of well being; is released to both mother and baby within 10-30 mins of end of feed what is important to remember when promoting breastfeeding? - ANSWER -*breastfeeding is normal, not sexual* -every feed counts (do not focus on rules/exclusivity) -engagement/education (early) in pregnancy is important -*help mothers feel confident with breastfeeding* -tell the truth about BF: it can be challenging -encouraging partner support & education for support person -health care providers need to support BF -breastfeeding classes, prenatal classes, etc. List the 11 steps to SUCCESSFUL breastfeeding? - ANSWER 1A. Comply full with International Code of Marketing & WHA resolutions 1B. Have a written evidence-based breastfeeding policy that is routinely communicated to ALL health care staff (keep short & simple so they are implementable) 1C. Establish ongoing monitoring and data-management systems in your facility (TJC req.) 2. Educate staff- Ensure they have sufficient knowledge, competence, and skills to support breastfeeding (this includes ALL interdisciplinary team members in a facility) & evaluate staff attitudes towards BF 3. Prenatal education- discuss importance & management of BF with pregnant women and and their families at prenatal visits and classes/tours 4. Skin to skin- immediately & uninterrupted for at least 60 minutes 5. Maintain lactation & essential education- positioning & latching, prevention of sore nipples & engorgement, how to tell infant is "getting something", nutritional concerns 6. Breastfeed Exlusively- nothing other than breast milk unless medically indicated 7. Rooming in- remain together 24 hours a day, decrease interruptions on PP unit (cluster cares) 8. Breastfeed on cue- recognize hunger cues & respond, do not feed "according to a clock" 9. No bottles/pacis- prevent nipple and/or flow confusion 10. Support groups & follow ups- discharge planning for follow-up, breastfeeding support groups & resources within 3 weeks or less 11. Interventions- decrease the use of interventions during the labor process; honor & support mother's wishes & birth plan & offer nonpharm pain relief methods when possible What baby-friendly practices & initiatives can help initiate & protect against early termination of breastfeeding? - ANSWER -Breastfeed within first hour -Give only breast milk (exclusive breastfeeding) -Rooming in -Breastfeed on demand -No pacifier use -Provide info on BF support on discharge What are some birthing practices that HCPs and CLS's can delay to promote bonding and breastfeeding between mothers & infants? - ANSWER -infant physical exam in L&D -infant weight -suctioning -eyes (after first feed) & thighs (within 4 hrs) -painful procedures -swaddling -maternal-infant separation Are L&D interventions for mothers, such as IVs, EFM, pitocin, and eating/drinking restrictions evidence-based? - ANSWER No! Often they are encouraged by HCPs because L&D is associated with risk and danger. What is the trouble with epidurals in labor? - ANSWER -often cause a cascade of events which can impact ease of breastfeeding -change mother's muscular status, which makes delivery harder and increases length of second stage of labor -lead to lower oxytocin levels during and following labor -pain meds (ie fentanyl) significantly decrease likelihood of baby suckling while skin to skin during first hour -epidural medications CAN get into baby via blood, etc. what are some negative effects of using synthetic oxytocin (pitocin) during labor? - ANSWER -antidiuretic effect: edema in moms breasts causing latch issues due to firm nipples (babies also retain water weight from IV therapy during labor causing inaccurate birth weight, and often excessive diuresis in first 12-24 hours) -lower apgar scores -unexpected NICU admissions -neonatal jaundice -*the longer epidural medications & pitocicin runs with inductions, pp, etc., the lower the moms own endogenous oxytocin levels during breastfeeding, causing difficulties with establishing BF*