Breastfeeding Management: It’s so much more than just the latch

Breastfeeding initiation and the period of the first month after birth for the mother and infant can often be complicated by medical and psychosocial challenges which may be difficult for lactation specialists alone to address. In a published article in March 2014 in the Journal of Human Lactation, we describe an integrated mental health approach which we have coined the ‘Trifecta†Approach’ as a model of breastfeeding management. († We borrow the term Trifecta which is a betting term for predicting 1st , 2nd and 3rd places in a horse race. It is also synonymous with the likes of winning an Oscar award for a movie). Our breastfeeding consultation clinic developed a multidisciplinary team comprised of : 1) a pediatrician specializing in breastfeeding medicine (myself), 2) a lactation consultant (nurse with IBCLC), and 3) a clinical psychologist specializing in infant mental health and child development.

The Trifecta Conceptual Model

The lactation consultant and I take the detailed history on mother and baby together, and try to include a pre- and post- feeding weight and assist with latch and positioning.
Since breastfeeding often gets the blame if the baby is not growing well, we occasionally need to obtain other laboratory studies (e.g. Vitamin D levels) or pulse oximetry monitoring (e.g. low oxygen levels due to snorty breathing helped detect a congenital laryngeal problem that required surgery).

We also offer practical advice about ‘simplifying your life’ in the first week and recognizing the reality of having a new baby:

• Minimizing hosting ‘afternoon teas’ (or even dinners) for visitors to admire the new baby
• Enlisting help with meals i.e. simplified meal plans, creative with take-out meals and use of paper plates
• Taking a break from laundry, cleaning, chores and running errands
• Getting much needed rest with having someone take the ‘baby out of the building’ so that mother can sleep in a quiet house

After we complete our assessment and make plans for follow-up, our psychologist goes in for a debrief of sorts and reviews the Edinburgh Postpartum Depression Screen (EPDS) score. Our psychologist is able to get more information about previous mental health issues and provide more advice about self-care. We find that most families need help with the dramatic change that happens in their partnership after baby and the shock that for most this is ‘not the warm fuzzy Downy TV commercial’ they expected!!

Having a psychologist on the team has been helpful in that she can often loop back to us about any lingering issues. For example, for mothers who are stressed about milk supply, we recommend that they take a few days and just rest at home and stay in pajamas, watch movies and focus on feeding. Some comments have included: ‘Does that mean that I can’t go and put in a load of laundry or go for a run?” or “My husband needs me to be to get some things done on my leave and meet with the sprinkler guy”.
As with most clinical experiences, the more you ask, the more surprising information you can get. We are able to get so much more information on how to best support moms by designating this counseling time immediately after the clinic consult.

Some new mothers also have issues of lost expectations. If they have a sick baby or one born early, they face additional challenges with sleepiness at breast or oxygen tubing– not being able to nurse their baby only adds to their grief. If couples have struggled with infertility, then when breastfeeding does not work it brings back feelings of past losses or failures.

I often find that just when we are helping mothers get over the hurdle of establishing milk supply at the 3 week mark, babies start with normal fussiness. Unfortunately so many myths are perpetuated and the mother is left feeling that there must be something in her diet or something else she should be doing. Convincing families that fussiness and the associated increased crying is just a phase and that breastfeeding is a process that can be difficult to control are often the most challenging cases.

I know we all do some degree of this support and advice to new mothers. I find this a tremendous privilege as a pediatrician to work with such a great Trifecta team. I firmly believe that if we have a chance at making our culture one where breastfeeding is the norm, we need to make this holistic approach standard practice. This type of ‘right here, right now’ integrated mental health consultation will hopefully have an increased presence in health care systems as reimbursement for psychologists and innovative models of care continue to emerge.

Maya Bunik, MD, MSPH is an Associate Professor of Pediatrics at University of Colorado, Children’s Hospital Colorado. She sees patients in both primary care and breastfeeding consultation and has published a book Breastfeeding Telephone Triage and Advice. She is a Fellow of the Academy of Breastfeeding Medicine and serves as the Protocol Committee Co-Chair.

For more information:

Bunik M, Dunn DM, Watkins L, Talmi A. Trifecta Approach to Breastfeeding: Clinical Care in the Integrated Mental Health Model. J Hum Lact. 2014 Mar 4