Breastfeeding Medicine

Physicians blogging about breastfeeding

Archive for the ‘Protocols’ Category

Newly Published! ABM Clinical Protocol #1: Guidelines for Blood Glucose Monitoring and Treatment of Hypoglycemia in Term and Late-Preterm Neonates, Revised 2014

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It is with great excitement that I announce that the long awaited publication of the 2014 Revision of the Academy of Breastfeeding Medicine Protocol #1 Hypoglycemia in Breastfeeding Medicine Volume 9, Number 4, 2014! The previous version was released in 2006. The authors, Nancy Wight MD, IBCLC, FABM and Kathleen Marinelli MD, IBCLC, FABM remain the same.

There have not been any earth shattering changes in the field since the last protocol was published. Importantly in fact there has been no progress in the definition of clinically relevant “hypoglycemia.” An expert panel convened in 2008 by the U.S. National Institutes of Health concluded that there has been no substantial evidence-based progress in defining what constitutes clinically important neonatal hypoglycemia, particularly regarding how it relates to brain injury, which is what concerns us all the most. We reiterate that the literature continues to support that transient, single, brief periods of hypoglycemia are unlikely to cause permanent neurologic damage. Therefore, the monitoring of blood glucose concentrations in healthy, term, appropriately grown neonates is unnecessary and potentially harmful to parental wellbeing and the successful establishment of breastfeeding. Read the rest of this entry »

Written by kmarinellimd

June 9, 2014 at 3:01 pm

How ABM enables mothers and babies to breastfeed

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We know that in the first six months of life infant nutrition is very important for growth and development, but it doesn’t just end there. These early decisions about how babies are fed have an ongoing impact throughout childhood and into adulthood. Therefore, finding opportunities to optimize infant feeding during this period is crucial to ensure infants are able to reach their potential.

Exclusive breastfeeding for the first six months of life is the most appropriate method of infant feeding, yet many babies are not exclusively breastfed at all, or only for a limited time. This is in spite of the fact that most mothers are aware that breastfeeding is the best option for their babies, and the majority initiate breastfeeding immediately after birth.

Mothers who have the support of family, physicians, nurses and health workers are more likely to continue to breastfeed when they run into unexpected breastfeeding problems or are uncertain of what they should do. If these problems are complex, or the mother has specific medical issues, having a physician with breastfeeding knowledge and expertise is even more important. However, many physicians have not had the training or experience to provide the help and assistance mothers need. Read the rest of this entry »

Written by wbrodribb

March 21, 2014 at 6:13 am

Newest ABM Protocol Released from the International Meeting in Miami Today: Allergic Proctocolitis in the Exclusively Breastfed Infant

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We are here in sunny Miami at the 16th Annual International Meeting of the Academy of Breastfeeding Medicine–our “Sweet Sixteenth” birthday party!  What better way for me, a member of the Board of Directors and the Chair of the Protocol Committee to celebrate the accomplishments of our organization than to see the e-pub release today, live from the meeting, of our newest clinical protocol, #24: Allergic Proctocolitis in the Exclusively Breastfed Infant?
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Written by kmarinellimd

November 5, 2011 at 7:16 am

Announcing our Newest Protocol: ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant (34 0/7 to 36 6/7 Weeks Gestation) (First Revision June 2011)

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I am pleased to announce our newest protocol has been published in Breastfeeding Medicine: ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant (34 0/7 to 36 6/7 Weeks Gestation) (First Revision June 2011).  This is a revision of the previously entitled ABM Clinical Protocol #10: ‘‘Breastfeeding the Near-Term Infant (35 to 37 Weeks Gestation)”.  As this protocol starts out explaining:

“At the time this protocol was first written ‘‘near-term’’ infant was commonly used to describe infants born in the few weeks before the 37th week of gestation. In July 2005 a panel of experts assembled by National Institute of Child Health and Human Development designated infants born between 34 0/7 to 36 6/7 weeks of gestation as late preterm to emphasize the fact they are really ‘‘preterm’’ and not ‘‘almost term’’ and establish a uniform designation for this group of infants.  This definition, however, includes infants born 1 week more premature (34 0/7–34 6/7 weeks) than the previous Academy of Breastfeeding Medicine protocol for the ‘‘near term infant’’ that encompassed infants born at 35 0/7 weeks to 36 6/7 weeks. In addition, infants born at 37 0/7–37 6/7 weeks may be at risk for breastfeeding problems and associated risks, and, therefore, the following guidelines may be applicable to these infants as well”.   Breastfeeding Medicine 2001; 6(3):151-156.

This protocol is the perfect example of what we as the Protocol Committee hope can happen as we update and revise our Clinical Protocols on a 5 year basis.  Unless the evidence has changed dramatically, the plan is to attempt to update the references and the data in such a way as to follow the general outline of the original protocol.  The reasoning is that those of you who are used to using a particular protocol will think everything is changed if you see a completely differenct document, when maybe only one or two things have actually been changed.  If the format remains generally the same, you will be able to easily see what has been updated and what has changed since the last version, and easily be able to update your own practice.  Sometimes this is not possible if either practice really has changed extensively, or author styles and interpretation of the data are so different that there is just no way around it.  But this protocol is an excellent example of how some of the evidence has changed, starting with the basic definition of the population, and there are many more references available ( 13 cited in 2004 versus 52 in 2011) but the basic outline has been followed, enhanced, and expanded to make an even better protocol than the original was.

As the ABM Protocol Chair, I speak for my Committee and for the ABM Board of Directors when I say we are very proud of these Clinical Protocols and our Statements, all of which can be found on our website.  The Clinical Protocols are also accepted and published by the National Guidelines Clearinghouse, sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health & Human Services, which has very stringent requirements for acceptance to their website.

So please check out this newest protocol, and keep your eye open for our next one, the brand new Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant!

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by kmarinellimd

June 6, 2011 at 7:45 am

ABM Protocol and Statement Updates!

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Today I wear my dual hats as ABM Protocol Chair and ABM Blogger.  It came to the attention of the Protocol Committee that there were typos/errors in a couple of our ABM protocols after publication.  Two protocols have been corrected in the on-line copies for Breastfeeding Medicine previously, and have now been updated on the ABM website as of today. 

Here are the corrections that have been made:

1.  Protocol #3—Supplementation—Volume 4, Number 3:

  Table 3, page 178  under “Time” the second line was originally printed 24-28 hours; correction is 24-48 hours.

2.  Protocol #7—Model Hospital Policy—Volume 5, Number 4:

  Page 176 and in the listing of the Ten Steps.  Step #6: only the US version require that hospitals purchase their formula.  The original published text stated: 

   6.  Give newborn infants no food or drink other than breast milk, unless medically indicated. (A hospital must pay fair market price for all formula and infant feeding supplies that it uses and cannot accept free or heavily discounted formula and supplies.)

Now it correctly and in keeping with the original, international Ten Steps says:

  6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

I will let you know if any future changes occur in published protocols or statements. 

And by the way, the just published issue of Breastfeeding Medicine contains ABM’s second Statement, Educational Objectives and Skills for the Physician with Respect to Breastfeeding.  Check it out in the latest Journal (Breastfeeding Medicine. April 2011, 6(2): 99-105).  Our first ABM Statement, Position on Breastfeeding (Breastfeeding Medicine 2008;3(4):267-270), can be found under the “About Us” tab on our web page right now.  As we now have two statements, and several more on the way, we are setting up a “Statements” section on our Protocol page to make them easy to find all in one place.  Please be a little patient with us!  Our newest statement will be on our website soon!

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by kmarinellimd

April 11, 2011 at 5:04 pm

New Galactogogue Protocol–New Attitude??

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Today a new ABM protocol was published in Breastfeeding Medicine: ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting the Rate of Maternal Milk Secretion (First Revision January 2011).    I am posting today having my hat on as ABM Protocol Committee Chairperson.  When we wrote the first version of this protocol in 2004, the basic message of the document was that galactagogues were a definite second-tier therapy for increasing milk supply, after all the mechanical and physical and otherwise treatable etiologies were investigated and adequately treated. That they are second-tier has not changed in this newest version.

What has subtly shifted is the attitude toward the use of the galactogogues themselves.  In 2004 there was an almost laissezfaire attitude—if the mechanical changes and medical work-up did not yield the hoped-for increased results in milk production, then galactogogues were effective, and thus should be, and were, used.  Although one should think (briefly) about potential side-effects, they were really quite rare, and the use of galactogogues were essentially (although not definitively stated as such) standard of care.  The protocol proceeded to tell us how to use them. Read the rest of this entry »

Written by kmarinellimd

February 22, 2011 at 1:30 pm

Breastfeeding–Preventive Medicine for Pain?

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Somewhere during the excitement and preparations for all the many holidays that occur in November and December, culminating with the global ringing in of the New Year, a new issue of Breastfeeding Medicine was published, the last of 2010.  As always it contains a number of articles that are timely, interesting and on the forefront of lactation research.  It also has the newest ABM Clinical Protocol to be added to our slowly, but ever-growing list, Clinical Protocol #23: Non-Pharmacologic Management of Procedure-Related Pain in the Breastfeeding Infant.  Long title.  Important concept.

It wasn’t that long ago that the medical profession did not think babies even felt pain.  What a horribly painful thought.  Having had personal experience with chronic excruciating pain, I cannot fathom that thought.  “Minor” procedures were done with no anesthesia or analgesia—non-ritual circumcisions (we could go off on a tangent here about whether or not that even should be done, but I promise to stay on task…) being the most well-known.  But so were “major” procedures.

I am definitely not a young chickadee any longer, as my teenage daughters will readily tell you, but I am not headed for the nursing home any time soon either I don’t think.  True story—when I was a second year resident in Pediatrics, in charge and alone covering all of pediatrics one night–the floor (ward), emergency room full of asthmatics getting epi shots, theophylline drips and bronchodilator aerosols (I think that dates me) and the delivery room at an “out-lying” affiliated hospital to my Pediatric residency primary Children’s hospital (we are talking major metropolitan area in the United States, not out in the wilderness) a pediatric surgeon came barreling in the middle of the night after the unexpected delivery of a baby with a diaphragmatic hernia (yes Virginia, those things used to happen in the days before “routine” ultrasounds) and right there to my and the nurses horror, he performed an emergent  laparotomy with no anesthesia, no analgesia on the open warmer I was slaving over to stabilize the baby, to pull the intestines out of the chest before transport…. A sight I have NEVER forgotten.

So, as the saying goes, we’ve come a long way baby.  We recognize pain in even our most immature babies (I hope), and try our best to prevent or alleviate it.  Anyone who has worked in a neonatal intensive care unit has seen and heard of the use of narcotics (which will relieve pain) and sedatives and anxiolytics (which we must remember don’t relieve pain, but often settle the baby down and make it easier to control the pain with narcotics, or at least we believe so).  And that makes sense for major pain, like intubation and incisions and chest tubes and of course, surgery.

But what about the countless other things we do to babies, both sick and premature, and well and term that are noxious and painful—heel sticks for blood draws, Vitamin K injections, numerous immunizations, and yes, circumcisions being at the top of the list. We know from the literature that pain can have long-term detrimental consequences and that pain-reduction therapies are under-utilized in this age group.  We also know there is a growing body of evidence that non-pharmacological means of pain reduction not only exist, but are effective.  And guess what?  The safest, most cost-effective, natural and supportive of the breastfeeding relationship is—you guessed it—Breastfeeding!

This new ABM protocol, which can be found on our website at, under the Protocols tab, is worth taking a good look at.  It presents the data on pain relief we have now in 2011 on breastfeeding as an entire act; the various components seperately—the milk, the sugar, skin-to-skin; the use of sucrose and pacifiers; in term babies; preterm babies; and what we know of older babies.  And it points out as always where the literature is lacking, where we need further research.

This protocol, like all others before it, is a long, thoughtful, extensive review of the literature and comments by experts in the field, which undergoes multiple reviews and re-writes before publication.  It is the state of the art and the science as we know it at the time of publication.  Pain is not something I would wish on anyone.  If I was not already so immersed in lactation at the time of the accident that has caused me so many years of chronic pain, I would have put my efforts into the study of pain.  I learned quickly that the medical profession knows little about pain and its management in adults, and the consequences of that management.  The worst issues with the narcotics are not necessarily the worries about addiction, but in my view, all the other side effects associated with their use.  And in pain treatment, we have ignored our youngest even more.  The information included in this protocol is a great first step in educating us toward non-pharmacologic means of pain reduction in neonates.  We should all be familiar with it, and use it in our practices.  And we should also use it to realize how much more work there is to be done.  Pain is no fun.  It cannot have any positive outcomes past letting us know something is wrong and needs attention, even if it is the sting of an injection to a baby who cannot comprehend why those she trusts to protect her are doing this to her.  She deserves to be comforted and to have her attention brought elsewhere, so her memory is not of the pain, but of the warmth, and comfort and love.  After all, isn’t that how we are all trying to bring our babies and children into contact with our world?

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by kmarinellimd

January 6, 2011 at 8:50 am