Experts Give Mothers, Nature a Hand : Babies: Lactation specialists pioneer a new health-care field, offering moms advice on how to successfully breast-feed reluctant infants.
Lidia Abbasi of Reseda cradled her dozing, 3-day-old baby and sighed.
“You should have seen us this morning,” she said. “She was screaming and I was crying. I’m just worried she’s not getting enough milk.”
Enter Ellen Petok, a certified lactation consultant called in by the staff at AMI Tarzana Regional Medical Center. As Abbasi spoke, Petok nodded sympathetically, then donned a white medical gown and set to her task of making breast-feeding work.
Trained lactation consultants are pioneers in a relatively new health-care field aimed at helping mothers who don’t know where to turn when breast-feeding problems arise. Petok, an actress before she took two years of lactation training at UCLA, is one of about half a dozen lactation consultants in private practice in the San Fernando Valley.
Petok explained to Abbasi that she was not alone; many mothers of premature babies such as the 4-pound, 12-ounce Larissa have difficulties nursing at first.
Forty minutes later, after an examination of the baby’s suckling reflexes, repositioning of pillows, baby and mother, and four unsuccessful attempts to nurse, Lidia breast-fed her daughter. Throughout the process, tiny Larissa squeaked a pathetic, frustrated cry, or groggily moaned at being awakened. Finally, exhausted, she began to drink her mother’s milk in quiet, measured gulps.
This was not breast-feeding as shown on the covers of paperbacks on parenting, where the blissful mother is always dressed in white lace, and the baby is inevitably plump and happy.
“They say breast-feeding is the most natural thing,” Abbasi said, laughing. “Look at me. I’ve got a machine, a lactation consultant and four hands trying to make this work. Really natural.”
Problems with breast-feeding were practically unheard of during the 1950s because breast-feeding was practically unheard of: Fewer than 5% of American mothers nursed their babies. A large turnaround occurred after the American Academy of Pediatrics in 1979 stated that, ideally, all infants should be breast-fed for the first four to six months of life because of the nutritional and protective qualities in human milk that cannot be duplicated in formula. In California, 85% of babies are breast-fed, compared to slightly more than 50% nationally.
When women were abruptly told that breast-feeding was better for their babies than bottle-feeding, it was assumed that women instinctively knew how to breast-feed, said Carol Ann Friedman, a certified lactation consultant. But lactation can be a complicated process, dependent on many structures and functions working properly in both mother and baby. And while scientific studies proliferated documenting benefits of the properties of breast milk--medical journal studies show that breast-fed babies suffer fewer respiratory and ear infections, and are less prone to allergies and digestive disorders--few researchers looked at the problems in the breast-feeding process until very recently, Friedman said.
“People think breast-feeding is natural, which it is. Suckling is a natural reflex,” Friedman said. “What is not natural--a learned skill--is how to put the baby onto the breast.”
Before there were lactation consultants, modern experts who understood all of the components of the complex breast-feeding equation were hard to find, Friedman said.
Medical schools teach little or nothing about breast-feeding, said obstetrician Steven Hartford of Glendale. “They teach the structure and function of the breast but absolutely nothing about the interaction between mother and baby.” Most of Hartford’s knowledge about the problems of breast-feeding came when his wife nursed their children, not through his professional training, he said.
Burbank pediatrician Kenneth Stoller said he learned about breast-feeding during his residency because the hospital’s nutritionist was a lactation consultant. Although Stoller said he often can diagnose the problem when breast-feeding isn’t going well, he prefers to refer patients to a breast-feeding consultant, he said.
“As a really busy pediatrician, I may know what to do, but I don’t have the time to do the hand-holding and the encouragement a mother needs to keep going,” Stoller said.
Dr. Harold Maller, a Van Nuys pediatrician, said he often sends patients to Petok because of the results she achieves.
“She teaches babies good techniques: Many babies just don’t breast-feed well at all without someone to give them lessons,” Maller said. “She also is very good at straightening out all sorts of bad advice moms have been given by friends or family, even doctors and nurses who really don’t know what they’re talking about.”
The lactation consultant movement was started in the mid-1970s by people who sensed the need for training based on scientific knowledge that went beyond the emotional and practical support offered by lay groups such as La Leche League. In Encino, Chele Marmet and Ellen Shell founded the Lactation Institute and Breastfeeding Clinic in 1977, and today draw nurses, doctors and therapists from around the world who want to know more about the basics of breast-feeding or more difficult subjects--how to teach adoptive mothers to nurse, how to help babies with Down’s syndrome, cleft palates or cleft lips.
Since 1982, lactation consultants have also been trained and certified through the UCLA Extension. Petok was an early graduate, as was Lois Marquis, a nurse who developed an interest in lactation problems when she had difficulty nursing her own baby 13 years ago.
Friedman received training in both programs, which, like a handful of others around the country, sought feedback from their graduates as they developed curricula for the new allied health field of lactation consultation.
The International Lactation Consultant Assn. was established in 1984, and examinations were given to consultants who wanted to become board certified through the International Board of Lactation Consultant Examiners, beginning in 1985. They now number more than 1,500 nationally and undergo years of training in the physiology, chemistry and physics of lactation.
Some, like Petok, who recently opened an office in Woodland Hills, went into private practice. Friedman, a registered nurse, worked in obstetricians’ and pediatricians’ offices at first, then went on to attain medical staff privileges at Verdugo Hills Hospital, and now has a private practice in Glendale. Marquis, a mother of three, has always worked out of her home in Sherman Oaks, although she, like the others, makes house calls and consults in hospitals.
The lactation consultants said they are hard-pressed to define a typical day. Usually, they spend a few hours each week teaching pregnant women what to expect from breast-feeding, and how to avoid trouble. Then a phone call from a distraught mother or a concerned pediatrician will prompt a consultation, usually lasting two hours or more, in which they ask detailed questions about the nursing problem, examine mother and baby and watch the infant nurse. The most common cases involve mothers with sore, bleeding or inverted nipples, babies who have trouble sucking or lack the coordination to latch properly onto the breast, and newborns who are not gaining enough weight.
Sometimes problems are complex: Stephanie Akers Cohen of Van Nuys went to Marquis to rent a breast pump when her daughter was 3 weeks old, crying constantly and gaining no weight. She had tried supplementing baby Georgina’s feedings with formula, and using a pacifier to soothe her, but nothing worked.
“I was freaking out,” Akers Cohen said.
Marquis found that the baby had a weak suck, and taught Akers Cohen how to exercise her baby by having her suck on a finger placed on the roof of the baby’s mouth. She also helped her sort out the baby’s hunger cries from the screams of colic. Soon the baby was sucking more efficiently and thereby triggering the production of more milk.
“She started gaining weight and eventually outgrew the colic, and I finally relaxed,” said Akers Cohen, whose baby is now a healthy 6-month-old. “I’m so glad that we just stuck it out.”
Marquis said she considers the case one of her nicer success stories, although working through Akers Cohen’s problems took quite a bit of time.
“You have to really see it as a passion more than a job,” she said. “When people need to see you, it’s a crisis. You can get consumed by it, seeing patients six days a week, having them call you at two in the morning.”
Because it is a new, relatively unknown profession and insurance companies only reimburse about half the time, Petok said trying to break into the field of lactation consultation is difficult.
“The hardest part for me is the business aspect,” Marquis said. “I am not a businesswoman. Most nurses are nurturers, and it’s really hard for someone like me to say, well, now it’s time to get reimbursed.”
The average rate for a breast-feeding consultation is between $50 and $60 per session, with home and hospital visits costing about $30 more. But lactation consultants say each paid consultation is usually followed by hours of unreimbursed telephone advice to the new mother. Providing rental electrical breast pumps, which is supposed to help offset the costs of the business, becomes time-consuming because consultants end up giving mini-consultations to women who need help with the pumps or the logistics of collecting milk for a baby’s later use, Marquis said. (Electric pumps rent for between $1 and $2 a day, depending on how long a mother wants to use them.)
Friedman saw patients for free for a year while she tried to establish her reputation and hone her skills.
Breaking into hospital work was most challenging, Friedman said, because she had to gain the trust and respect of doctors, and even more important, nurses in maternity wards.
“I thought they would welcome me with open arms,” she said. “What nurse has an hour to spend with a new mom who is having breast-feeding problems, and what nurse has this kind of training in lactation?”
But even though she was a nurse, Friedman found herself as the “outsider, the unknown.” Sometimes mothers would call her after hospital consultations, confused because a nurse had contradicted everything Friedman had just told her. One nurse didn’t speak to Friedman for a year after Friedman insisted that the staff stop trying to feed a troubled baby by bottle until a program of exercises and regular breast-feeding had been tried.
Over time, though, barriers are being broken. Friedman said she recently chalked up a victory when 38 nurses from Verdugo Hills Hospital enrolled for a course she is teaching on breast-feeding techniques.
Meanwhile, some lactation consultants have faced criticism from another corner: the minority of well-meaning but untrained breast-feeding advocates who believe formula is akin to poison and want to believe every problem can be solved by what Marquis called “marathon nursing.”
All three lactation consultants agreed that there are times, albeit rare, when babies must be supplemented by formula feedings because mothers cannot produce enough milk, or their infants, for some developmental reason, cannot consume enough to grow and thrive.
More often, mothers who could breast-feed ultimately give up, frustrated by their nursing difficulties and facing pressure from families who urge them to choose the “easier” alternative of bottle-feeding.
Lactation consultants count such cases among their failures, particularly when the mother had a strong desire to nurse.
But for every such memory, there are many more success stories, Petok said.
As an example, she recalled the case of a mother who initially decided not to nurse her premature baby who had Down’s syndrome, but changed her mind later, after her milk had dried up. By using a nursing supplementer that fit around the mother’s neck, Petok was able to ensure that the baby received nourishment from formula while stimulating the mother’s breasts to produce milk, she said.
“After nursing for the first time, the baby pulled away and just smiled,” Petok said. “Those are the kinds of intimate and intense times that I realize why I love this work so much.”
