----- Original Message ----- 
From: <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, February 08, 2008 6:23 AM
Subject: [LACTNET] nipple creams and evidence


**Hi Jennifer,

> All of that said, I have immense concern with the idea that we need
> "evidence" in the form of a study to use any intervention..I think
> clinical experience has far more value than any study in almost all
> breastfeeding situations. IMO, it's just one more medicalized buzz-word
> that limits practice--except of course in the case of the medical model
> where lack of evidence is the norm in everything from birth (90% of all
> interventions) to breastfeeding (supplement or wean b/c of anything and
> everything) to well....everything, really. I am just not buying the idea
> of "evidence-based practice" until I see it applied to the medical model.
> Even then, I would trust "intuitive-based practice" first, in a heartbeat.

**I, too, feel ambivalent about this. I like the statement Debbi posted,
about how anecdotal evidence is the beginning of more extensive research to
see if more people could benefit from whatever intervention it was, that
lead to the anecdotal results. I'm one of the editors of our brochure
committee and there is a tendency towards more and more strictness with only
including evidence based information. As a volunteer association, we *don't*
advice, we *inform*. I like this distinction and think every good HCP,
working with sane people, could restrict him-/herself to that. "You broke
your leg. If we leave it like this, it probably won't heal well and function
loss may be a consequence. If we put plaster around it and you give it rest,
it will probably heal without symptoms." This is information; it needs no
advice, it's quite fool proof. If we work like this, we work on increasing
autonomy and foster empowerment. So, first things first, and that always is:
*good latch*, well explained, emphasized, supported and re-explained,
re-emphasized and supported even more.

But how nice it would be, living in an ideal world, where no problems arise,
and if they do, we have all the time and energy and endurance and
encouragement and support we need to overcome them and no whining, tired,
hungry children that distract us from what we are trying to establish. We
don't, however. So, as important as it is to start with the basics, women
may want to use some kind of auxiliary item that they perceive helpful. This
can be a pump (although the baby could empty the breast), a breast shell
(although a better latch would make the pain disappear), an oitment
(although a good latch would make the skin heal in no time), a pain killer
(although going to bed would be wisest), a galactagogue (although increasing
frequency of feeding would be more effective), an antibiotic (although good
management might solve the problem and prevent thrush), a bottle (although
finger feeding might give more improvement in sucking skills) or whatever
else you can think of. If we pretend to have autonomy and empowerment for
women 'high in our banner', as a Dutch saying goes, it is *not* up to us to
say she can't or shouldn't use these items. Again: we explain and emphasize
and support good management, but parents make their own, hopefully informed,
decisions.

So how far should our information go? How much anecdotal 'evidence' we know
of, should we supply the mother with? Can she deal with all the information
we give her? How 'emotionally overflown' is she? Should we sort out options
for her? Is that still allowing an 'informed decision', when we select the
available options? These are hard questions to answer. Practice will prove
that sometimes we do indeed select options, because giving *all* the options
would confuse the mother more than she already is, let alone pain and
exhaustion. But even then, we are partly filling in the blanks, because we
may be wrong about how much energy or motivation she's got left to try
options we leave out. But hey... anecdotal and practical evidence simply
*proves* that overwhelming an already overwhelmed mother may lead to
weaning, so our expertise helps us to decide which road to take with this
individual mom. Making passing references to not-well known suggestions may
be useful (if she picks up on them) or worthless (because she is too tired
to hear what you say). It's not easy; we deal with a strong and often
healthy, but nevertheless vulnerable group, considering hormonal state and
inexperience in the transition to motherhood. We do our best to serve her
well and don't want to bother her too much with our own professional issues,
like Code-violations. But even that doesn't mean we can never ever pay some
attention to that when speaking with a mom. Like Jennifer says: intuition is
not a bad thing. It's societal developments, that have made us believe it is
stupid to go by your gut feeling. Head and heart should be in balance, in
us, as caretakers, and in a mom, getting to know her infant and her role as
a mother. Especially the latter one takes time, though, and I really don't
mind the placebo effect of certain things; if they do not harm, then I
prefer the beneficial placebo effect to letting problems deteriorate. We
could 'sell' placebo's with: "If it makes you feel good, it might give you
some rest and take some pressure away, alongside with working on better
management/improving latch."

Professional reluctance towards nipple creams or pumps or bottles (or
formula!) is okay, as long as it serves the purpose of helping a dyad with
establishing a good bf relationship. It may not be okay, when it prevents a
mom from regaining lost energy, from getting the oxytocin flowing again,
because she can regain her breath. I really have to tell myself this,
because I think I've been in the camp of "only breasts and baby" when it
comes to breastfeeding, for almost always. At the end of the day, I'm kind
of a 'hardliner', or to say it more friendly: I'm very much in favour of
"breastfeeding naturally". (Oh, what a coincidence... this is the name of
the Dutch bf association (30th anniversary this year!) I've been a volunteer
with since 1995; am I *that* brainwashed?!?! hahaha btw, in Dutch, it can
also be read it like this: breastfeeding? naturally!) But the way *I* look
upon things, the way I persist, may be very different from the way a client
thinks or feels.

As for our brochure, I would like to ask a few questions concerning these
issues: Would you call this 'allowable anecdotal experience' or 'evidence
based practice'? Items at hand:
* soft curd cheese compresses with engorgement and beginning mastitis;
* changing feeding position to better empty a blocked part of the breast;
* supporting heavy breasts during feedings to prevent blocked ducts;
* difference between sterile mastitis (inflammation) and bacterial
infection;
* immersing inflamed breasts in warm water to facilitate milk flow;
* applying cold or warmth with milk stasis;
* abscess treatment either with aspiration or with incision;
* homeopathy as an alternative to antibiotics with sterile mastitis.

Anyone who could shed some light on this, I would really like to hear from.
I'm kinda stuck with these items, because it is exactly about what we talked
about: what kind of evidence is important to share with mothers in our role
as bf advocates? Thanks in advance, for any clearance on the issue.

Kindly,

Marianne Vanderveen, Netherlands

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