Breast may be best, but sometimes a helping hand is needed

The pale, first-time mother is struggling to nurse her newborn daughter, but she wants to go home.

"I'm not sleeping," she says to lactation consultant Margaret Hynes, and she clearly doesn't want to spend another night on the ward here in Limerick's University Maternity Hospital. Her nipples are sore and she is worried her daughter, born two days previously, is not getting enough milk.

Hynes, one of two clinical midwife specialists working as lactation consultants in the hospital, had been into the ward earlier to put a heat pad on one of this mother’s breasts. Now she is back to help her use an electric breast pump, which doesn’t cause discomfort, unlike the baby’s sucking.

Looking into the mouth of the baby, who is noticeably jaundiced, Hynes can see a “very obvious tongue-tie” – when the cord that stretches under the tongue to the floor of the mouth is short and restricts the tongue’s movement. Affecting up to one in 10 babies, it can, but doesn’t always, cause breast-feeding issues.

While the mother is visibly reassured that she is beginning to express milk with the help of the pump, Hynes recommends she gets something done about the tongue tie if difficulties continue. The cord, or fraenulum, can be divided with scissors in a surgical procedure known as a frenotomy.

In the meantime, after she goes home, it is suggested she tries to express and give the baby that, or formula if necessary, by cup or syringe, to get them both to the point, hopefully, where the supply is increased and the baby is feeding better at the breast.

Over-stretched

Lack of support in over-stretched maternity hospitals is sometimes cited as one of the reasons for Ireland's low breastfeeding rates, with just 57 per cent of mothers breastfeeding on discharge, according to latest HSE figures. It is the lowest rate of 27 high-income countries, a Lancet study found earlier this year.

A mother’s milk can take between three and nine days after birth to come in, following the initial colostrum, yet the average stay in hospital after giving birth in Ireland is just two days. That’s a very short time for maternity units to try to ensure women and their infants are set up, both physically and mentally, to continue breastfeeding at home – if that is what they want to do.

The work of hospital-based lactation consultants, such as Hynes, is key during this time, which is why The Irish Times is shadowing her for a shift to get a glimpse of her varied workload. From helping individual patients on the post-natal wards, to being a "go to" person for referrals and advice for other hospital and community health professionals, she is in great demand.

Hynes, having noted that it is Food Month at The Irish Times, is quick to point out the appropriate timing of our visit, this being all about babies' first food.

The day before we meet, the hospital had a ceremony marking the renewal of its Baby-Friendly Hospital Initiative (BFHI) certificate, a global scheme introduced by the World Health Organisation 25 years ago to implement practices that promote and support breastfeeding. Only nine of the Republic's 18 maternity units/hospitals have been adjudged to meet the strict criteria, which require training of all staff.

Hunger-inducing

For instance, she says, indicating the worker behind the counter in the canteen where we’re sitting having a quick cup of coffee, he needs to know to go over and give any woman breastfeeding here a glass of water and offer to keep her meal warm if necessary. And while patients used not to have access to hospital food after their 5pm tea, because breastfeeding is a hunger-inducing business, they can now order sandwiches later in the evening.

Meanwhile, porters are instructed not to let deliveries of packs of formula milk sit around in public sight, lest they, subliminally even, convey a sense that this is what the hospital endorses as the norm.

A breastfeeding team, including Hynes and her specialist colleague Margaret O’Leary, cover the two post-natal wards during the day, seven days a week. There is also a weekly “drop in” feeding clinic.

When Limerick’s maternity hospital, which has about 4,500 births a year, first signed up for the BFHI certification process in 1998, just 24 per cent of its mothers initiated breastfeeding. By 2000 that had risen to 33 per cent, with 25 per cent still breastfeeding going home, and last year that had more than doubled, with 53.5 per cent of mothers continuing to do so at discharge.

Hynes says it is important to address feeding in ante-natal visits and classes. The hospital used to devote one class in the ante-natal series to breastfeeding, but some people skipped it, so now an element is incorporated in each class.

She finds the best approach to the subject is to ask expectant parents what they know about breastfeeding, rather than ask them how they intend to feed their baby.

“Women want to know how it helps them,” she says, reeling off benefits such as weight loss, contraceptive effect, protection against ovarian cancer. “And it’s cheap.”

Eat well

Expectant women generally eat well during pregnancy to nourish their developing babies, so she suggests they might continue to do so for a few months more after the birth.

Hynes’s second bedside visit of the day is to a mother who sounds like she has had enough of abstinence and there is a “combined” feeding notice on her locker.

“I’m looking forward to a very good night out,” she says frankly, cradling her baby son born less than 24 hours previously. “All I want is cocktails.”

It doesn’t faze Hynes in the slightest. “You deserve a break,” she agrees, advising her to feed beforehand, and express as well if possible. Then the next morning “pump and dump”.

The midwives had tried to get her baby, born at 38 weeks and weighing just over five pounds, to latch on in the delivery ward, but the mother felt she was no use to him that night and was happy for them to give him a bottle.

A sleepyhead, he is still not showing much interest in latching on, despite Hynes’s best efforts to encourage him. She uses a syringe to collect a little of the colostrum and inject it into his mouth “to give him energy”.

Although the mother didn’t breastfeed her two older children, she seems keen to persevere at the moment under guidance. Previously, “I had nobody like you to teach me,” she tells Hynes. “I was left to my own devices.”

After more than an hour working with this mother and baby, Hynes leaves, advising her to use one of the hospital’s breast pumps to stimulate the supply.

Feeding care plan

Back in her small office at the end of the corridor, she has a few minutes to write up an infant feeding care plan for that patient, before attending to Kate Hickey, who has called in by arrangement with her three-week-old son Dean.

Having happily breastfed her first child, Lauren, for 14 months, she hadn’t anticipated having issues second time around. But her son wasn’t latching properly, forcing her into the very time-consuming cycle of expressing milk and then bottle-feeding it to him. It was just about doable while her husband was on paternity leave but, with their daughter to look after as well, near impossible when he had to go back to work. She was on the brink of giving up.

“I will be honest, this day last week I was in ribbons,” she says, seated in a comfortable turquoise leatherette armchair, which was paid for by a member of staff to equip the small, screened-off area at the end of the corridor.

Dean had tongue tie and although the public health nurse didn’t think it was severe enough to be causing the difficulties, she was referred to the regional breastfeeding co-ordinator, who advised having it treated. So at two weeks, Dean had it “snipped” by a consultant and it looks like he is beginning to suck more deeply at last.

However, concerned that he was “screeching” at attempts to feed the previous night and again this morning, Hickey puts him to her breast to show Hynes. There are no histrionics this time.

“I think you have turned the corner,” Hynes remarks as the baby boy nurses. “That’s the best feed he’s ever had.”

Fragile state

Downstairs waiting, there’s another woman who has been referred to Hynes by a public health nurse. Clearly in a fragile state, the mother is worried that the fact that she is still nursing her older child is causing problems for the baby, but she is not prepared to attempt weaning right now. She has also resisted medical advice to express milk and feed with a bottle, fearing that would scupper the breastfeeding as the baby got used to the easier flow.

After hearing that the now 10-day-old baby has started to gain weight, Hynes agrees. “Just keep feeding her,” adding that she should keep in touch.

It’s back to the wards to see a first-time mother who is concerned that her baby doesn’t seem to be latching on one side. But after Hynes’s attention, all seems well and the woman and her husband are reassured.

Although Hynes, who works part-time, is due to leave the hospital for a 2.30pm appointment, this has to be postponed while she sees one more mother who had been at a clinic downstairs and whose baby, the public health nurse thinks, may have tongue tie.

He does but it doesn’t seem to be causing problems, says Hynes, who demonstrates how to latch the baby boy on more deeply and comfortably.

“You’re doing a brilliant job,” she reassures the mother, who beams with relief as her son feeds.

“If he is going like this, we should be fine,” the mother replies.

Before leaving the building more than half an hour behind schedule, Hynes listens to and deals with the messages on her desk phone.

“It’s very busy, isn’t it,” she remarks, reflecting on how the woman she spent the most time with today is the least likely to continue breastfeeding at home. “But,” she adds, with indefatigable enthusiasm, “you never know.”

swayman@irishtimes.com