Moms struggling with breastfeeding problems left adrift during COVID

“You are your baby’s immune system.”

That’s the message Emily Pease, charge nurse for Swedish Medical Center Lactation Services, wants lactating parents to receive.

Lactation consultants have another message: There is support for nursing parents — even as the COVID-19 pandemic surges again.

Still, like most health and wellness services, the availability of lactation support has evolved with the pandemic.

First wave: Loss of breastfeeding wraparound care

In the first months following Washington Gov. Jay Inslee’s “Stay Home, Stay Healthy” order, lactation services outside hospitals all but shut down. Community-based wraparound services like professionally led in-person lactation groups and parent-to-parent support groups seemingly disappeared overnight, and hospital-based services experienced gaps in care.

“Early in the pandemic, we were hearing about patients being discharged as soon as possible to minimize exposures, with some not getting direct lactation support,” says Pease.

Betsy Hoffmeister, a certified lactation consultant and owner of Betsy’s Baby Services in Seattle, is more blunt. In spring and early summer 2020, she says, new families were sent home from the hospital “as fast as humanly possible” as facilities sought to reduce everyone’s COVID-19 exposure.

Such quick dispatch may have left parents feeling lost and overwhelmed by minor breastfeeding problems and setbacks, even if they had lactation consultations before discharge. Moreover, in the effort to limit exposure to COVID, follow-up visits have felt rushed, Hoffmeister’s clients report.

The pandemic has thrust new parents “out into the void with no way to get family or community support, no wraparound care,” says Hoffmeister. Many local birth professionals echo Hoffmeister’s assessment.

That is, if those professionals are getting calls from expectant or newly parenting families about breastfeeding problems.

As the pandemic continues, doulas, lactation consultants, and other in-home newborn care experts say new parents remain fearful, and calls for support are lower than expected compared to this time last year. Parents, they say, tell them they are afraid of spending too much time in the hospital but feel worried about the possible added exposure of having a lactation consultant or doula spend hours in their homes. Thus, says Hoffmeister, nursing parents are largely still alone as the pandemic rages on and as they try to suss out normal versus abnormal baby feeding routines or to manage breastfeeding problems such as discomfort and pain.

Such isolation could lead to serious health concerns for babies as well as plummeting parent confidence.

“I’m seeing huge anxiety, a spike in babies just not eating enough, more failure to thrive than usual, and parents who have absolutely no concept of normal,” she says. She points to one parent who thought pumping 17 ounces of breastmilk at one sitting was a normal nursing occurrence. (It is not). Another parent in Hoffmeister’s care was certain it was abnormal for a baby to nurse for less than 10 minutes and be satisfied, a scenario well within normal feeding patterns.

On the good side, expectant and new parents no longer have to weed through misinformation about the safety and efficacy of nursing when a lactating parent has COVID-19.

“In the early days of the pandemic, information was changing daily,” says Catherine Fenner of Nurture New Life, a certified lactation consultant. “Scientists were working as quickly as they could to learn more and pass that on to the public. It was a painful, confusing time. Parents were separated from their babies in an abundance of caution, but also at great cost.”

Fenner points out that today research points to breastmilk as “an important line of prevention,” against COVID-19, just as it is known to be with other diseases. Still, research about disease spread within the nursing dyad continues.

“The immune support properties of human milk are incredible,” says Fenner. “Depending on which sources you look at, U.S. or international, the guidance is more encouraging or more cautious of breastfeeding. Parents need to read the guidance, and look for the middle ground.”

Today, the World Health Organization and the Centers for Disease Control and Prevention both recommend infected parents remain with their newborns and continue to nurse as long as possible using simple precautions.

Still, some consultants feel conflicting messaging between health authorities may mean more babies are getting formula than usual as a result of the pandemic.

“With people being frantic about getting food, parents may have stocked up on formula just in case breastfeeding didn’t work out,” says Sarah Tyrack at Babe N’ You, a registered nurse and certified lactation consultant, reflecting on the mass grocery store runs that were common at the start of the pandemic. “Then we had the situation where there’s already formula in the house, breastfeeding is hard, they didn’t know they could get help, and so they gave up and used the formula,” Tyrack says.

So far, research hasn’t addressed this theory.

Pease says that uncertainty continues to be a common thread among lactating parents, both before and after birth, as COVID-19 continues its run.

“We have noticed an increase in anxiety and isolation among our families,” she says. “Many of our patients have questions about general baby care in addition to lactation. This has always been true, but they look to us for more information as most of them have much less family support.” She adds that International Board Certified Lactation Consultant referrals to inpatient therapists and the medical center’s Center for Perinatal Bonding and Support have increased.

As lactation consultants both inside and outside hospitals learn to reach more families in need, most agree that the reduction or outright loss of wraparound support across the city to address breastfeeding problems has been a significant hit for nursing parents.

“These services were an affordable way to help multiple people at once and help folks who may not need a full private visit or had financial barriers to lactation help,” Pease says.

The pandemic has led to the cancellation of most in-person breastfeeding classes and groups. Swedish has ceased in-person breastfeeding classes and support groups. UW Medicine – Northwest Hospital’s popular Tuesday/Thursday breastfeeding support drop-in group was an early casualty of the pandemic.

Local meetings of La Leche League’s peer-to-peer support groups have moved to a less than ideal online format that could fail to provide the kind of intimacy that would allow parents to connect and honestly share their struggles and breastfeeding problems. The region’s popular Program for Early Parent Support (PEPS) groups, where new parents share challenges and solutions on all things new parenthood, are also meeting online at the moment.

“My biggest concern is social isolation and lack of wraparound care,” says Hoffmeister. “More than ever, I am seeing people falling between the cracks in healthcare because they are not out in public, seeing other parents with normal babies acting normally — like at a La Leche meeting or PEPS or story time — or even just a relative visiting. They are not getting that usual reality check.”

Hoffmeister and other lactation experts place high value on such parent-to-parent opportunities.

“‘My baby nurses for 90 minutes at a time and is never satisfied,’ is something that any La Leche leader is going to pick up on,” Hoffmeister explains. “Or at a La Leche meeting, you look around the room and see that all the other babies in your cohort have double chins, but your baby has sunken cheeks, and someone pulls you aside and says ‘Hey I think you need to get checked out.’”

Both hospital and community lactation experts say they don’t know the full biological impact of high anxiety on breastfeeding, but expect there is an effect.

“Stress seems to be at an all time high,” says Fenner. “That sure can affect milk supply.”

New ways of getting care for breastfeeding problems

Hospital lactation consultants are grateful that, after an initial drop due to COVID-19 safety precautions, calls for support started to surge in late summer. Both the UWMC and Swedish lactation departments have returned to pre-COVID levels of in-person face-to-face visits with families, even as private lactation consultants say in-person home visit requests remain low.

But regardless of caseloads, all breastfeeding experts in the region say they have needed to employ trial and error to figure out how to deliver care effectively and safely.

“We tried tele-visits [telephone consultations] for about six weeks, but immediately realized how limited lactation [consultation] by phone is,” says Pease.

Swedish ultimately implemented new safety regimens, including a double health screening and social distancing protocols, to bring back in-person outpatient lactation visits.

Other hospital departments are using telehealth technology successfully to allow them to meet virtually with parents via HIPAA-secure phone calls or video chat.

Virginia Wall, a registered nurse and certified lactation consultant, is the UW Medical Center Lactation Services coordinator. She says UW lactation consultants don’t see every baby before discharge, but nurses offer all parents basic breastfeeding help, and consultants see those having breastfeeding problems or who request a consultant visit. Her department focuses on linking parents to nursing support at either a baby’s first pediatric visit or the first obstetrical follow-up. But, she admits, support in these clinic settings can be spotty. So, parents are always invited to call Wall’s department to set up an in-person or telehealth visit.

Wall says getting the hang of telehealth has been a learning curve for her staff since great lactation support relies so heavily on touch and close-up viewing to solve breastfeeding problems. But, it has been very valuable for her department — and for parents who want the intimacy of in-person care but are wary of taking a baby into the hospital.

“Mothers adore it,” Wall says. “They feel at ease in their own home during visits. It helps if there’s a partner to hold the phone camera during the visit, and I have to say I’m impressed most of the time that I don’t even have to tell them where I want them to move the camera. It really works — we can check the latch, hear swallowing, see sore nipples or engorgement.”

The more intimate connection of face-to-face interaction, whether virtual or in person, seems to inspire parents to open up about the joys and travails of new parenthood in the midst of isolation. Wall says in her new normal she spends a lot of time just listening to new parents and allowing them to process their experiences.

“They are so alone, and they really, really need to talk,” she says.

Telehealth visits have also been an invaluable tool for community-based lactation consultants when addressing parents’ breastfeeding problems. With so few offering home visits at this juncture, many IBCLC-certified experts are relying on this technology to stay in business, serve parents and keep themselves safe.

Says Tyrack: “Are there times when I know if I was there in person, I could just show her myself? Sure. But this works just fine and it’s fun and challenging for me. I think the results are just as good.”

“More lactation consultants will be offering in-home consultations,” adds Fenner, who has returned to home visits using standard COVID precautions. “But I think telehealth services are here to stay. There is room for both methods of care. It may make our services even more efficient and effective.”

For those community-based lactation experts who have resumed home visits, COVID precautions are key. The CDC dictates that all providers should take their temperature before entering a home, wear a mask, and, if possible, wear gloves. They should wash their hands before donning gloves or touching a parent or baby. But home-visit safety is a two-way street, they stress.

“I get asked all the time what I will do for a family in terms of COVID precautions,” says one postpartum doula who preferred that her name not be used. “But the truth is, I’ve gone into a lot of homes where Mom or Dad or both aren’t wearing a mask and don’t put one on unless I ask — even if they can see I am wearing double masks. We are all in this together. I want to help but I also want to keep myself safe.”

Hoffmeister too has been in uncomfortable situations.

“I [had one] incredibly stressful experience where a dad was overtly hostile to me after I asked him to mask up,” she says. “The dad doesn’t like to have to wear a mask in his own home. He made me feel so unsafe and I came home crying and then changed my website to make my COVID rules very strict.”

The upshot of Hoffmeister’s rules for hands-on support, which are echoed by many other birth or postpartum care providers these days, are simple: No mask, no support. Visit over.

Wrapping around a parent

As Washington and the rest of the country continue to lean into a third wave of high COVID-19 transmission, breastfeeding advocates worry more newly lactating parents will fall through the cracks.

Pease says, “I’m concerned that people won’t know they can get help or will delay getting help out of fear of coming to the hospital. I’m concerned about families and nursing parents being more isolated than ever before and the effects on mental health and community.”

Without community groups to help them through, parents have turned to calling hospitals for minor breastfeeding concerns. That’s fine, says Wall, but it takes staff away from hands-on care for those who need it most.

“We are getting calls for the little ‘Is this OK?’ sorts of questions that are not real issues,” says Wall. “These are the things that are easily addressed in a group.”

Both UWMC and Swedish leaders say they are looking at safe ways to re-establish breastfeeding support groups, but it will take time.

And, as the Supreme Court begins its review of the nation’s health care act (Obamacare), local lactation consultants not affiliated with hospitals fear parents will become confused about coverage, or worse, have to pay out of pocket to receive in-home IBCLC-led care.

“I’m concerned there isn’t access to enough affordable lactation care,” she says, citing spotty insurance coverage for certified lactation consultants in Washington.

“Parents need the care, and expect that their health insurance will cover it,” Fenner says. “They are surprised when it’s not [covered]. That means they ration their own care, lowering the chance of reaching their breastfeeding goals.”

Cheryl Murfin is a certified doula, lactation educator and postpartum doula. She’s the owner of Nesting Instincts Perinatal Services in Seattle.