For the broader O&G Magazine readership, balanced answers to those curly-yet-common questions in obstetrics and gynaecology.

Q: Lactation consultant: what does this role involve?

A: Drs Eliza Hannam, Melody Jackson, Melanie Mapleson and Marisa Nguyen are all GP-Lactation Consultants (GPLCs) practising in NSW. They join us for a Q&A session to explore the role of a GPLC in the care of breastfeeding parents and their babies in the perinatal period.

Q: Melanie, can you tell us a bit about the role of a lactation consultant?

A lactation consultant is a healthcare provider with expertise in the management of breastfeeding and lactation. Lactation consultants come from a variety of different backgrounds, notably midwifery and medicine. The globally recognised title of IBCLC (International Board Certified Lactation Consultant) distinguishes high-level clinical professionals who have undergone extensive study, training and examination.

IBCLCs are relied on by many other health practitioners as an integral part of the parent–baby care team, both on the wards and in the community. IBCLCs are skilful at providing compassionate, hands-on support to parents in need at any stage of their breastfeeding journey (including anticipating difficulties in advance). They also play a very important role in breastfeeding education, advocacy and policy development.

Q: How did each of you come to work as a lactation consultant?

Marisa:

I didn’t realise I was passionate about breastfeeding until my children were born. I had significant feeding challenges with my first two babies and found it extremely difficult to access feeding support. When I did manage to get support, I found that the information from my medical providers and lactation care providers often conflicted – even as a medical professional myself, this was confusing and distressing. I decided the solution was to train in lactation medicine to fill the gap I found in my own care.

Eliza:

My passion to learn more followed my own unexpected difficulties breastfeeding my second baby. I found it difficult to access the right help, including from GPs who were experienced in breastfeeding medicine. I also had not anticipated how much breastfeeding difficulties would affect my mood and overall enjoyment of early parenthood – so I feel passionate about supporting other families going through the same.

Melanie:

I guess one could say I got my calling through misadventure! I went on maternity leave, during the COVID-19 crisis, feeling burnt out and dispirited. After facing significant feeding difficulties myself and being ‘rescued’ by a skilled breastfeeding practitioner, I fell in love with this area of medicine and haven’t looked back. Moving away from regular GP work to practice exclusively in lactation medicine and perinatal care was a big leap into the unknown but it’s proven to be one of my best decisions in life so far.

Melody:

After a challenging experience breastfeeding my first baby, I did what I always do when searching for answers – I went searching high and low for information that would help me. I ended up attending a conference of the Breastfeeding Medicine Network Australia and New Zealand (BMNANZ), which gave me the knowledge, skills, education pathways and colleagues to practice breastfeeding medicine. In 2020, I opened my own parents and baby clinic as a ‘part-time hobby’, but with the need growing rapidly, I stopped general practice soon after and now spend all my clinical life in the world of breastfeeding medicine. I couldn’t be happier.

Q: Melody, what does your medical training add to your lactation consultant work?

I have found that being both a doctor and an IBCLC has placed me in a unique position where I am a bit of a ‘one stop shop’. Doctors possess a strong medical background, enabling them to diagnose and treat various health issues in both breastfeeding parents and babies. In contrast, IBCLCs specialise in lactation and breastfeeding support. They offer in-depth knowledge of breastfeeding techniques, positioning and attachment and milk supply concerns.

The synergy of these two roles creates a holistic approach to healthcare for breastfeeding families. Professionals can offer evidence-based medical advice and intervention while also providing practical, hands-on support for breastfeeding success. This dual qualification ensures that families receive the most well rounded care, and care that can deal with the intersection of breastfeeding with other medical or mental health issues. This integrated approach prevents parents from having to seek out support from many different services. An additional benefit is that patients can access Medicare rebates for doctors that are not available to IBCLCs of a different discipline.

Q: Marisa, can you tell us a little about the most common presentations you see?

The most common presentation I see overall is nipple pain, followed closely by supply concerns and ‘breast refusal’.

Interestingly, all of these presentations are most often caused by a problem with positioning and attachment. While each problem requires a slightly different history and assessment, the starting point is always positioning and attachment.

When I assess positioning, I’m looking for three key elements: first, I want to know that baby has a stable position against the breastfeeding parent to allow comfortable and easy transfer of milk. I’ll also check the attachment to ensure there is a good vacuum seal around the breast allowing a deep latch. Finally, I’ll check that parent and baby are fitting with each other in such a way that the breast can sit comfortably in a natural position. When all these elements are optimised, pain is reduced, and milk transfer is improved – this results in an improvement in most presentations.

The focus of the assessment will change depending on the presentation. With nipple pain, I will focus more on positioning and attachment to minimise nipple trauma. I will also assess for rarer causes of nipple pain such as vasospasm, dermatitis, mastitis and fungal infection. When there are supply issues, I will focus on milk transfer and ensuring frequent removal of milk from the breasts – either by direct feeding or pumping.

Breast refusal can be a challenging presentation. It is often the result of increasing frustration of both parent and baby when there are breastfeeding challenges. When these challenges are left unchecked, both parent and baby start to think of breastfeeding as an unpleasant and frustrating exercise. In these cases, prioritising pleasant time at the breast is key.

Q: Eliza, in a perfect world, when would you like to see breastfeeding parents and babies for lactation advice and/or assessment?

In a perfect world, all expectant parents who intend to breastfeed would have individualised lactation education and advice in pregnancy! Antenatal lactation education can be so valuable, especially for those at increased risk of breastfeeding difficulties. This includes people who have had:

• previous breastfeeding difficulties
• previous breast surgery (including augmentation or reduction)
• medical conditions that can potentially affect supply, such as gestational diabetes, polycystic ovarian syndrome and thyroid conditions
• expected pre-term birth or other known fetal conditions that might affect feeding

Antenatal lactation education appointments include discussions about normal breastmilk production, optimal latch and positioning, management of nipple pain, and when and where to access help if breastfeeding issues arise postpartum. Ideally, antenatal appointments could also include information about normal infant sleep and behaviours and postpartum planning.

Otherwise, for breastfeeding issues that arise in postpartum, early assessment and management is ideal.

In addition to hands-on assistance with latch and positioning, management can include referral for radiology/pathology and prescription of medications such as galactagogues and antimicrobials. Assessment should also consider an infant and parent’s general and mental health. Thus, GPs who are also IBCLCs are perfectly placed to assess and manage breastfeeding issues!

Q: Can each of you share your one ‘hot tip’ for other health professionals working with breastfeeding parents and babies?

Marisa:

If you are seeing a pregnant person who intends to breastfeed, please encourage them to have a dedicated antenatal breastfeeding consult. This will arm them with skills and knowledge they can use to advocate for themself and their baby at the time of delivery. It also means they will have an existing relationship with a lactation expert and know where to turn for help if they experience challenges.

Melanie:

Please don’t dismiss any breastfeeding pain as normal. If you’re not sure how to help or don’t have enough time, refer the parent on (search easily online for an IBCLC through LCANZ or a breastfeeding medicine doctor through BMNANZ). The courage and heroic determination it takes to feed a baby through excruciating pain quickly turns into deep despair if the parent is told to go home and ride it out. Painful breastfeeding isn’t normal and it’s one of the leading preventable causes of early weaning.

Melody:

I would say to always check in on mental health. Sometimes breastfeeding is the problem, but sometimes mental health is the problem, and it is easier to present with a breastfeeding issue. Additionally, sometimes when breastfeeding is really difficult, it overwhelms the parent’s ability to cope.

Eliza:

Management of issues such as low infant weight gain or low maternal milk supply cannot simply involve prescription of formula supplementation without understanding and addressing the underlying breastfeeding issues. Suboptimal latch and positioning can commonly contribute, and therefore hands-on support with an IBCLC is an essential part of management of breastfeeding issues.