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Certified Lactation Counselor
QUESTIONS AND ANSWERS. ALREADY
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Predominant Breastfeeding - CORRECT ANSWER -Babies who receive
breastmilk and other liquids (e.g. water, minerals, vitamins, oral meds).
Breastfeeding - CORRECT ANSWER -Baby receives human milk, as well as
other foods or fluids, including formula.
Complementary Feeding - CORRECT ANSWER -Process starts when BM alone
or infant formula alone is no longer sufficient to meet nutritional requirements of infants, therefore other foods or liquids are introduced. Typically child is between 6-23 months
3 strategies for increasing BF initiation and duration - CORRECT ANSWER -
Promotion, Protection, Support
Promotion - CORRECT ANSWER -Focuses on advantages of BF on a personal,
community, country, or global level. BF to the community.
Protection - CORRECT ANSWER -Focuses on government, manufacturer, and
social responsibility to assure BF ability to compete with commercial interests. Includes state, local, an national laws regarding BF.
International Code of Marketing of Breast-milk Subsitutes - CORRECT
ANSWER -Addresses improper marketing practices by formula companies. It is not
currently a law in the US.
What does the International Code Prohibit? - CORRECT ANSWER -Distributing
free formula Giving coupons for formula
What did the AAP resolution state in regards to the International Code? - CORRECT
ANSWER -No distributing formula, discharge bags, industry written handouts.
Support - CORRECT ANSWER -Focuses on interaction of helpers with family, as
well as program development and implementation.
10 steps to successful BF - CORRECT ANSWER -1. Written BF policy. Skin to
Skin immediately after birth.
- Train healthcare staff
- Inform pregnant women about benefits and management of BF
- Help all mothers initiate BF within 1 hour after birth
- Show mother's how to BF and maintain lactation
- Exclusive breast milk only
- Practice rooming in 24 hours a day
- Encourage BF on demand
- No artificial teats or pacifiers
- Establishment of BF support groups Healthcare staff responsibility for working with lactating mothers include what? -
CORRECT ANSWER -1. Training
- Minimum of 20 hours of training
- 3 hours of competency verification What are the indications for providing supplementation other than breast milk? -
CORRECT ANSWER -1. Medical condition
- Parents request after being informed of consequences
Protocol for calculating Baby's daily needs - CORRECT ANSWER -Baby's weight
x 2.5 (2.7 or 3.0 if Baby needs to catch up weight) = daily ounces. PCP decides what the multiplier is!!!
What should be assessed 3-5 days after birth by PCP? - CORRECT ANSWER -
Hydration (elimination patterns) Body weight (no more than 7% loss) Observe Feeding Maternal or infant issues
What is a CLC? - CORRECT ANSWER -Nationally recognized designation
awarded by the ALPP. Practice parameters are designated by professional scope of practice.
How many stools per day should a breast fed newborn have? - CORRECT
ANSWER -4, some yellow by day 4.
When should a baby be back to birth weight? - CORRECT ANSWER -12-
days post birth
How much weight should a baby gain daily? - CORRECT ANSWER -
Approximately 1 ounce
myoepithelial cells - CORRECT ANSWER -contract in response to stimulation by
sympathetic nervous system and squeeze milk up the duct
Montgomery glands - CORRECT ANSWER -Bumps on breasts (Look like
goosebumps) Produce a unique blend of milk and sebum (skin oil)
Modern study of the structure of the breast reveals what? - CORRECT
ANSWER --Fat is mixed throughout the breast
-Uneven spacing of the ducts -3-5 functioning nipple pores (May have 5-9, but not all work) -No lactiferous sinus
What are the 2 hormones pathways that control lactation? - CORRECT
ANSWER -Prolactin and Oxytocin
Prolactin (4 details related to milk production) - CORRECT ANSWER -1. is
triggered by touch (pregnant and non pregnant women). Higher levels when stimulating breast/nipples vs breast alone.
- Lengthening time between feeding leads to lower baseline levels. (Weaning)
- levels go down between nursings and rise during nursing.
- Infrequent nursing leads to lowering of this hormone
Average number of feeds in a day? - CORRECT ANSWER -8-
What produces colostrum? - CORRECT ANSWER -Progesterone in the receptor
sites
What produces more mature milk? - CORRECT ANSWER -Prolactin in the
receptor sites
What happened when infants suckled in the first 2 hours of birth? - CORRECT
ANSWER -Ingested significantly more milk on day 4
What happened to mother of preemies who initiated milk expression within 1 hour of
birth? - CORRECT ANSWER -Had significantly more milk when measured on
days 7 and 42. Better to stimulate breasts throughout the day right after birth to continue to stimulate production.
Oxytocin - CORRECT ANSWER -A hormone released by the posterior pituitary
that stimulates uterine contractions during childbirth and milk ejection during breastfeeding.
What 3 things can trigger Oxytocin? - CORRECT ANSWER -1. Conditioned
response
- Nipple stretching
- Hand massage
Conditioned Response from Milk Ejection (Let down) - CORRECT ANSWER --
Example- Mother lets down when not near baby, but hears a baby cry. -Conditioned over time -Faster for women who have BF in the past -To condition the response can use any sense-smell, touch, sound
Nipple stretching - CORRECT ANSWER -Only happens with a proper latch
Hand massage: Baby - CORRECT ANSWER -When we allow babies to be more
hands on they can help control flow rate by how they massage the breast.
How many triggers does Oxytocin have? Can it be triggered by stress. - CORRECT
ANSWER -3 triggers. Yes.
What is hormone is triggered by stimulation? - CORRECT ANSWER -Prolactin
What 3 emotional/behavioral function do the hormones of lactation have besides
making milk? - CORRECT ANSWER -1. Aggression
- Protection
- Bonding/trust
What is special about the composition of milk? - CORRECT ANSWER -1.
Mammal species with higher water content milk feed more frequently.
- Prolactin triggers production of lactose in the mammary cells. What are the different care patterns of mammalian mother's and their babies? -
CORRECT ANSWER -1. Nest (eg. puppies, cats) OR cache (deer, rabbit)
- Carry (monkey), follow (giraffe, bison), or hibernate (bear)
What kind of milk has the highest lactose of all mammalian milk? - CORRECT
ANSWER -Human milk: high in water, low in protein and fat.
When does paracellular transport occur? - CORRECT ANSWER -1. In the first
few days after birth
- Mother with low prolactin levels
Does a mother need to nurse both breasts in one feed? - CORRECT ANSWER -
No. Some babies do better on one breast per feeding.
Who regulates the fat intake when feeding? - CORRECT ANSWER -The baby
can regulate his fat intake quickly.
When is fat content higher? - CORRECT ANSWER -When the flow is faster.
Can milk fat be different if the baby is male or female? - CORRECT ANSWER -
Yes.. Mother's seem to produce milk that is 25% higher in fat content for males.
galactorrhea - CORRECT ANSWER -abnormal discharge of milk.
Ex: Men make milk, due to brain tumors or drug side effects (haldol, Thorazine).
Reasons why BF protects babies from diarrhea? - CORRECT ANSWER -1. pH
of the gut is lower. Bifidus factor promotes growth of friendly bacteria which maintains lower pH in the gut.
- Low iron in the gut. Organisms need iron to survive! Lactoferrin deprives bacteria of iron.
- Hormones and growth factors stimulate growth, development, and motility of the gut.
- Antibodies (e.g. Secretory IgA [SIgA] which bind to microbes in the digestive tract and prevent them from being absorbed.
- WBC kill microbes (e.g. B and T lymphocytes)
- Cell wall disrupters that kill microbes by destroying the cell walls
- B12 binding factor. Same result as iron.
- Mucous also wall protectors which keep bacteria from attaching to the cell wall.
- Microbes (bacteria from the mother's intestine) from the mother's skin transferred to baby.
- Absense of exposure to contaminants (e.g. bottle, water, teat)
- Exposure to mother's immunize system.
- Cells from the babies mouth go into the mother's breast. Antibodies are made in the breast.
Does feeding a baby formula occasionally make a difference? - CORRECT
ANSWER -Yes, even just one bottle can impact the pH of the babies gut.
Gut of exclusive BF baby is lower (more acidic), while gut of formula fed baby is more neutral
What bacteria do formula fed babies have an over abundance of? - CORRECT
ANSWER -C Diff
Vagal nerves (parasympathetic) - CORRECT ANSWER -Stimulates peristalsis
and secretion not the GI tract
splanchnic nerves - CORRECT ANSWER -Inhibits peristalsis and secretion.
Adrenal gland increases secretion of adrenaline and noradrenaline.
Somatostatin - CORRECT ANSWER -hormone that inhibits release of growth
hormone and insulin What promotes glucose induced insulin release and exert trophies effects of the gut? -
CORRECT ANSWER -Gastrin & CCK (cholecystokinin)
What increases gastrin and decreases somatostatin in babies? - CORRECT
ANSWER -1. Sucking
- Own species milk
- Decreased stress
- Wellness
- Touch
When do babies start to suck? - CORRECT ANSWER -27 weeks.
What happens when babies suck? - CORRECT ANSWER -Sucking activates
cutaneous receptors in the babies mouth, causing the baby's parasympathetic nervous system to trigger release of gastrin and decreased somatostatin. This makes us feel sleepy and full.
Are mother's GI hormones impacted by sucking and skin contact? - CORRECT
ANSWER -Yes, it activates the parasympathetic nervous system. Increases in
gastrin, CCK, and insulin have been observed.
How much weight loss is acceptable in a neonate after birth? - CORRECT
ANSWER -No greater than 7% from birth & no loss after day 5.
What would cause an increase lose of weight in the first postpartum days? -
CORRECT ANSWER -1. Labor meds used
- Interpartum fluids used
- No labor prior to cesarean
Hypernatremia - CORRECT ANSWER -High concentration of sodium in the
blood
Why would a baby develop hyperetremia or malnutrition - CORRECT ANSWER -
- Not feeding frequently enough (e.g. q3-6 hours/day 5-10min/side=60-120 min/day)
- Babies too sleepy (likely due to lack of nutrition)
- Physical objects
What could cause pressure on the milk-making cells? - CORRECT ANSWER -1.
Vascular, lymphatic, and third-spacing forces
- Secretory activation - Lactogenesis II
What are some characteristics of the normal breast? - CORRECT ANSWER --
Soft -Normal body temp -Mother feels well -Breasts may be hot -Nipple graspable
What are some characteristics of the engorged breast? - CORRECT ANSWER --
Hard -Temp normal + -Mother feels discomfort -Breast hot, shiny -Nipple is hard to grasp/latch
When do symptoms of engorgement occur? - CORRECT ANSWER --Between
days 3- -Moms with a lot of IV fluids, may have swelling up to day 9 -Women who have had a c-section experience it 24-48 hours later.
What happens to the engorged breast? - CORRECT ANSWER -- As pressure
increases, milk production decreases.
What causes pressure in the breast (engorgement)? 4 things... - CORRECT
ANSWER -1. Milk left post feed
- Missed feedings
- Restrictive bras and clothing
- Breast implants (storage capacity is less)
What concerns are there with surgery and BF? - CORRECT ANSWER --Damage
to nerves -Damage to ducts -The periareolar incision is associated with lactation insufficiency.
What are some anatomical concerns (red flags?) - CORRECT ANSWER -1.
Absence of breast changes in pregnancy or just after birth
- No postpartum fullness or change from colostrum to mature milk
- Unilateral underdeveloped breasts
- One implant placed. Things to consider when counseling mother's regarding changes to breast. -
CORRECT ANSWER -1. Assure privacy
- Ask questions about surgery/improvements (when alone)
- Determine innervation/sensation What 4 questions should you ask yourself when counseling a mother about changes to
her breasts. - CORRECT ANSWER -- are the ducts and nipple pores patent?
-are there signs of hormonal connection? -are there concerns for weight gain? -Is there adequate pediatric supervision?
Can a woman BF if she has a flat or inverted nipple? - CORRECT ANSWER -
Yes! -Baby's don't need a nipple to latch, they form the teat. -Many nipples evert from sucking, some don't. -If the nipple does not evert, the baby's weight gain will need to be followed closely.
What is a grade 1 inverted nipple? - CORRECT ANSWER -Easily pulled out
What is a grade 2 inverted nipple? - CORRECT ANSWER -Can be pulled out,
but don't maintain their projection
What is a grade 3 inverted nipple? - CORRECT ANSWER -Nipples are difficult or
impossible to pull out. What do we need to consider when counseling a woman with inverted nipples? -
CORRECT ANSWER -1. Ask her if and when her nipple everts
- Watch for nipple eversion after a feed.
- If no eversion, then intensive f/u is likely needed.
- Consider expression
- Assure adequate infant nutrition
- Check for FDA approval for devices used to evert the nipple.
Do women with inverted nipples produce less milk? - CORRECT ANSWER -Yes,
research shows.
What aspects of physiology impact milk supply? - CORRECT ANSWER --Iron
deficiency anemia -inadequate O2 to milk cells -exhaustion or depression
What about pacifiers and milk production? - CORRECT ANSWER --Studies
contradict each other. -Some research suggests that pacifiers reduce BF as early as 2-4 months. -Pacifer is an indicator that the parents need extra help (sore nipples, hunger, crying?)
What are some public health implications of pacifier use? - CORRECT
ANSWER -1. Increased diarrhea in the first 3 years
- Increased instances of ear infections
What does the AAP say regarding pacifier and SIDS? - CORRECT ANSWER -
Delay intro until BF is firmly established (3-4 weeks of age)
Who should have pacifiers? - CORRECT ANSWER -Preemies- earlier hospital
d/c, improved physiologic/behavioral responses, reduced time for oral feeding.
What are the concerns related to nipple shield. - CORRECT ANSWER -1.
Uncertain of effects on milk supply
- 3x risk of not exclusively breastfeeding
- Increased risk for infant weight loss and dehydration
- Increased risk of early weaning
- There is limited research
- Can have fungal biofilm exposure (must use a scrub brush to remove bacteria)
- Difficulty weaning from the shield
Why is water dangerous? - CORRECT ANSWER -1. Can cause water
intoxication
- More likely to need formula supplementation
How does confidence impact BF? - CORRECT ANSWER -Discontinuation at 2
weeks is linked to lack of confidence on day 1 or 2.
Counseling implications for women with fears about milk supply - CORRECT
ANSWER -1. Give facts, not inappropriate reassurance
- Complete an evaluation including history and feeding assessment
- Provide adequate postpartum support
- Establish a community wide system eliminating the "zone of professional unavailability"- especially days 3- What are the 5 main categories that women fall into regarding how women learn? -
CORRECT ANSWER -Silence
Received Subjective
Procedural Constructed
How women learn: Silence - CORRECT ANSWER --Feel voiceless, powerless,
and mindless -Sometimes in abusive relationships -May be afraid of words -Feel dependent on others -Don't trust selves -Have little awareness of their intellectual abilities
How do you develop a relationship with women in silence? - CORRECT
ANSWER --Keep message simple, use few words
-Short, easy, comfortable messages -Nothing to remember -May need an advocate
How women learn: Knowledge - CORRECT ANSWER --Believe all authorities tell
the truth -Like to learn the right answer and repeat to the teacher -Don't like ambiguity -Want to talk to "leader/authority".
How do you develop a relationship with women receiving knowledge? - CORRECT
ANSWER --Project authority
-Avoid ambiguity -Make advantages concrete -Provide demonstration and return demonstration of the "right" way
How women learn: Subjective Knower - CORRECT ANSWER --Believe knowing
is personal, private, and based on intuition. -Believe experience drives knowledge -Sense of authority arises from the power of the group -Trust own intuition -Inner voice guides them -Distrusts male experts -Trust women with similar experiences -Support groups are helpful -Like natural things like BF. -Want to be helped by someone who has BF. How do you develop a relationship with women who are subjective knowers? -
CORRECT ANSWER --Create time for them to talk about themselves and their
thoughts on BF
-NEC
-Increased risk of SIDS
Women who not BF are at greater risk for what cancers? - CORRECT
ANSWER -Breast, Endometrial, Ovarian
-The longer, the more protected against cancer.
Hierarchy of Infant feeding choices for the Term Baby (WHO) - CORRECT
ANSWER -1. Breast
- Milk Expression
- Milk from Human Milk Banking Association of North America or State Licensed Milk Bank
- Cow Formula
- Soy Formula
Milk Expression by Hand - CORRECT ANSWER --always available
-higher fat content -promotes continued BF -cleanest way to collect milk
Benefits of donor milk - CORRECT ANSWER --Preventative
-Cost Effective -Safe
Is informal milk sharing recommended in the US? - CORRECT ANSWER -No.
Concerns are raised with Wet nursing or borrowing/buying milk from a non-licensed donor (e.g. HMBANA member or local licensed milk bank). Increased risk of contamination. It is illegal to distribute milk if mom knows she is ineligible as a milk bank donor.
Women who do not BF are at risk for what other diseases? - CORRECT
ANSWER -Type 2 Diabetes
Myocardial Infarction Metabolic Syndrome Hypertension Hyperlipidemia
PPAD Postpartum adjustment disorder - CORRECT ANSWER -85% of women
experience mood changes with hormonal changes, lack of support, and many life changes
Weight loss and BF - CORRECT ANSWER -Not significant. Research shows
women who BF loss approximately 3lbs more after 6 months of EBF
Research regarding Babies who have been BF indicate: - CORRECT ANSWER -
- Increase odds of upward mobility
- Higher IQ's, more years of education, high income at age 30
How does breastmilk impact the NICU? - CORRECT ANSWER --Chances of
sepsis decreased by 19% (10mL/day of human milk) -NICU costs lower -Lower risk of getting NEC -Better scores on the Bayley
Do milk banks heat treat milk? - CORRECT ANSWER -Yes, Destroys
bacteria/viruses (e.g. HIV, Herpes, CMV). Retains 90% of nutrients
What are some problems with using formula? - CORRECT ANSWER --
Sometimes they are recalled -Can be contaminated (e.g. Botulism)
What are other routes for contamination? - CORRECT ANSWER --Contaminated
breast pumps -Water used to dilute formula -Additives such as melamine -Contaminated bottles -Dirty bottle nipples
What other feeding issues are associated with formula feeding? - CORRECT
ANSWER --Reflux (can be due to mechanics, food, and/or physiologic immaturity)
-Colic (3 hours of inconsolable crying for 3 days between 3 weeks and 3 months of age) May be related to microbiome. -Anaphylaxis (relented to cow's milk based formula) -Allergies (to soy or cow's milk based formulas). Can cause gut bleeding. -Formula intolerance What are some marketing claims that the formula companies use to increase sales? -
CORRECT ANSWER -Adding Long Chain Polyunsaturated Fatty Acids
(LCPUFAs) to formula
What about homemade formulas? - CORRECT ANSWER -Animal milks and
plant-based drinks. Can cause electrolyte imbalances, scurvy, and other problems.
Contraindication to BF or feeding EBM - CORRECT ANSWER --Infant diagnosed
with galactosemia. -Mother has HIV
What 9 stages do babies go through during the first hour after birth? - CORRECT
ANSWER -Birth Cry
Relaxation Awakening Activity Rest Crawling/Sliding (35 min after birth) Familiarization (40 min after birth) Suckling (60 min after birth) Sleeping(1.5-2 hours after birth) If you are going to introduce the 10 steps in your hospital... what step should you start
on? - CORRECT ANSWER -Step 4: Skin to Skin (S2S) within the first hour
What are some advantages of skin to skin (S2S)? - CORRECT ANSWER --
Decreased rate of postpartum hemorrhage -Faster expulsion of the placenta -Correct suckling -Less crying, more calm -Warmth (Babies are warmer) -Less separation -Improved BF
What does exposure to the mother's odor do for a baby? - CORRECT
ANSWER --facilitate baby's adaption
-attract and guide newborns to the food source -calm newborns during painful procedures
What states are best to initiate feedings? - CORRECT ANSWER --Light Sleep
-Quiet Alert -Active Alert (may be difficult!)
What are some common feeding cues? - CORRECT ANSWER --rooting
-hand to mouth -mouthing/sucking motions -REM -body movements
What happens when cues are missed? - CORRECT ANSWER --infants fret
-sleep at the breast
What's the solution for when feeding cues are missed? - CORRECT ANSWER -
S2S and re-teach feeding cues
Describe the optimal position for baby while breast feeding? - CORRECT
ANSWER --Baby tummy to tummy or chest to breast
-Hips flexed -Shoulders and hips should align -Arms and hands around the breast
What are the hallmarks of a good latch? - CORRECT ANSWER --Nose opposite
nipple to start -Baby opens mouth wide -Room for Baby's head to tilt as he moves closure to mother's breast -Nipple fills the upper half of the mouth -Angle of mouth opening greater than 140 degrees -Top and bottom lip sealed -Rounded cheek line -2:1 or 1:1 ratio -Asymmetric latch -Rocker jaw motion
What are some hallmarks of a satisfied feeding? - CORRECT ANSWER --Baby
released nipple -Soft, relaxed body tone, relaxed hands -Nipple similar to pre-feeding shape What does a suck-suck-suck-suck-suck-suck-swallow pattern that occurs throughout an
entire feed indicate? - CORRECT ANSWER -Baby is not getting enough milk.
Needing to suck a lot to get enough milk to create a bolus.
Where do we see motion when Baby is sucking in a rocker motion? - CORRECT
ANSWER -Closer to the cheek/ear
How can you tell when a Baby might want to continue to feed? - CORRECT
ANSWER -If you notice tenseness in the Baby's body. (E.g. 1 arm is in a fist, other
relaxed. OR both in a fist)
What can happen if the latch is not good? - CORRECT ANSWER -Pain in the
nipple
Do CLC's assess tongue tie? - CORRECT ANSWER -No. Assess and give
suggestions to optimize latch. Then refer onward for diagnosis.
