On Skin-to-Skin Contact, Associative Learning, and Reward-Based Learning

Across the lifespan, the learning of all feeding and drinking skills reflects procedural learning, reinforcement learning, reward-based learning, and associative learning. During associative learning, we learn to predict relationships, such as between two or more stimuli, a stimulus and a response, and between a response and its consequence.

For young newborns, learning milk-feeding skills is supported and hastened by the primitive survival reflexes, pre-adapted movements that are further adapted during sensory-perceptual-motor learning. The crawl reflex enables us to “drive” to nature’s first restaurant, and the rooting reflex further orients us to the dining location. As the infant determines the action (action planning) of moving still closer toward the nipple-areolar complex, a reflexive lunge is displayed by the infant toward the breast, in tandem with a reflexive wide open gape, with the tongue extended over the lower alveolar ridge. When the baby learns how to achieve and sustain the oral grasp, the suck reflex is soon stimulated. In mutuality and reciprocity between both members of the dyad, milk is released via the initial Milk Ejection Reflex (MER) as well as subsequent MERs in the same meal, much like service at a fine dining establishment, as one course at a time is served. Should the flow of milk temporarily overwhelm the young novice, the cough reflex helps us to reorganize our swallowing movements. With the repetition of practice, the baby’s suck reflex becomes increasingly more coordinated with the swallow reflex, in support of increasing motor control for the infant’s effective transfer of milk.

However, the remarkable presence of the primitive survival reflexes does not guarantee the oral grasp and effective sucking for all infant milk-feeding methods all the time. Following a learning experience with an artificial nipple and the subsequent return to the breast, skill decay (decreased speed and accuracy) is often observed for the baby’s oral grasp/latch at the breast, and/or effective sucking for adequate milk transfer, reflecting the cognitive demands of task-switching. These cognitive demands are particularly pronounced during early learning when memories are in their most fragile state, and furthermore, the younger we are, the greater the cognitive demands of task-switching.

When clinicians are called upon to assist the infant in a transfer of learning from artificial nipple to the breast, finger-feeding is often a highly effective technique in helping the infant learn to associate the smell, touch, and taste of the mother or other caregiver’s skin with sucking and receiving milk. In the language of the cognitive sciences, this pairing of associates is critical for learning and re-learning. However, the very first clinical recommendation is often skin-to-skin contact ad lib, also to familiarize the infant with that rich sensory milieu, including the visual field of that feeding location.

Susan Ludington, RN CNM PhD FAAN is the Executive Director of the United States Institute for Kangaroo Care (USIKC). Ludington has been studying skin-to-skin contact via Kangaroo Care since 1988, and offers this extensive annotated bibliography and reference list on the USIKC website. http://www.kangaroocareusa.org/uploads/KCBIB2018.pdf

Associative learning is heavily studied in the cognitive sciences, as is reward-based learning, reinforcement learning, and procedural learning. Some recent studies:

Title: Pavlovian reward learning elicits attentional capture by reward-associated stimuli.

Authors: Mine C, Saiki J.

In: Attention, Perception & Psychophysics 2018 Jul;80(5):1083-1095. doi: 10.3758/s13414-018-1502-2.


Title: I like it by mere association: Conditioning preferences in infants.

Authors: Jenny L Richmond, Jenna Zhao, Gabrielle Weidenmann.

In: Journal of Experimental Child Psychology 2017 September;161:19-31. doi: 10.1016/j.jecp.2017.03.015.


A new meta-analysis on associative word learning and task-switching in infancy:

Title: Associative word learning in infancy: A meta-analysis of the switch task.

Authors: Tsui ASM, Byers-Heinlein K, Fennell CT.

In: Developmental Psychology 2019 Feb 7. doi: 10.1037/dev0000699.


And one more: These authors reviewed neuroimaging studies of cognitive flexibility, with emphasis on set shifting and task switching. 

Title: Demystifying cognitive flexibility: Implications for clinical and developmental neuroscience.

Authors: Dajani DR, Uddin LQ.

In: Trends in Neurosciences 2015 Sep;38(9):571-8. doi: 10.1016/j.tins.2015.07.003.

Full text/author manuscript: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5414037/pdf/nihms709425.pdf

New Human Milk Studies

From Turkey:

Title: Probiotic characteristics of bacteriocin-producing Enterococcus faecium strains isolated from human milk and colostrum.

Authors: Bagci U, Ozmen Togay S, Temiz A, Ay M.

In: Folia Microbiologica (Praha) 2019 Feb 9. doi: 10.1007/s12223-019-00687-2. [Epub ahead of print]

Abstract with references: https://link.springer.com/article/10.1007%2Fs12223-019-00687-2

From Spain:

Title: Concentrations of dioxins and furans in breast milk of women living near a hazardous waste incinerator in Catalonia, Spain.

Authors: Schuhmacher M, Mari M, Nadal M, Domingo JL.

In: Environment International 2019 Feb 7;125:334-341. doi: 10.1016/j.envint.2019.01.074. [Epub ahead of print]

Open access: https://reader.elsevier.com/reader/sd/pii/S0160412018330757?token=62554EDB441C524053B3F9F4349D4927762DDFB02EE6AC9A229CDAB66C76BA7DDC6837BA1CA3DBB825CD75B14AA7E40A

From Germany:

Title: New short-term heat inactivation method of cytomegalovirus (CMV) in breast milk: impact on CMV inactivation, CMV antibodies and enzyme activities.

Authors: Jens Maschmann, Denise Müller, Katrin Lazar, Rangmar Goelz, Klaus Hamprecht.

In: Archives of Disease in Childhood. Fetal and Neonatal Edition. 2019 Feb 6. pii: fetalneonatal-2018-316117. doi: 10.1136/archdischild-2018-316117. [Epub ahead of print]

Abstract: https://fn.bmj.com/content/early/2019/02/06/archdischild-2018-316117

A New Method for Studying Thousands of Human Milk Peptides

Researchers from The Netherlands have utilized an efficient method for studying the peptidome in human milk, allowing them to perform "qualitative and quantitative detection of about 4000 endogenous human milk peptides in a total analysis time of just 18 hours".

Study Title: Toward an efficient workflow for the analysis of the human milk peptidome.

Authors: Dingess KA, van den Toorn HWP, Mank M, Stahl B, Heck AJR.

In: Analytical and Bioanalytical Chemistry  2019 February 2. doi: 10.1007/s00216-018-01566-4.

Full text: https://link.springer.com/article/10.1007%2Fs00216-018-01566-4

On Sleep and Learning

We clinicians often observe youngest newborns who display improved skill (greater speed and accuracy) for the oral grasp and nutritive suckling after a short nap between breasts and after a longer stretch of sleep. Consolidation is a term from the cognitive sciences that refers to the building of memory, including motor memory, into a robust state. Sleep is a critical aspect of memory consolidation. 

As babies become progressively more skilled in milk-feeding, increasingly less sleep is required by the infant. Although sleep is critical in building robust memory, interference in learning can impede memory consolidation, in spite of adequate sleep. In their 1995 paper providing the first formal definition on nipple confusion, authors Mary Ann Neifert, Ruth Lawrence, and Joy Seacat discussed interference as a factor in breastfeeding difficulties that often follow an infant's learning experience with an artificial nipple. 

This fascinating new study from Switzerland was done on adults, looking at whole-night rocking and its impact on sleep and memory. Does frequent rocking also benefit preterm infants, as well as babies in general? There is often an intrinsic need to rock one's infant, and to stand and sway back and forth with the little one. 

Title: Whole-Night Continuous Rocking Entrains Spontaneous Neural Oscillations with Benefits for Sleep and Memory.

In: Current Biology 2019 Jan 11. pii: S0960-9822(18)31662-2. doi: 10.1016/j.cub.2018.12.028. [Epub ahead of print]

Study Authors: Perrault AA, Khani A, Quairiaux C, Kompotis K, Franken P, Muhlethaler M, Schwartz S, Bayer L.


The following 1989 study associated rocking of preterm infants with improved neuromuscular development.

Title: Effects of rocking on neuromuscular development in the premature.

Authors: Clark DL, Cordero L, Goss KC, Manos D.

In: Biology of the Neonate 1989;56(6):306-314.


In Celebration of Carolyn Rovee-Collier (1942 - 2014)

The following treasure of a short YouTube video is of the late Carolyn Rovee-Collier (1942 - 2014), a developmental psychologist who mastered a steep uphill climb in her field.

Early in her career, a powerful but mistaken dogma held that babies could not learn until later in their first year. In that era, behavior in younger infants was perceived as stimulus and response but without actual learning taking place.

Dr. Rovee-Collier authored over 200 papers during her career, although three years transpired before her first paper was accepted for publication on aspects of infant long-term memory. By persevering in the face of much opposition in what was then a male-dominated field, Rovee-Collier succeeded in dismantling the old paradigm.

In 2006, Peter Gerhardstein interviewed Rovee-Collier for The Society of Research in Child Development, who has since made her 30-page oral history available online - another treasure.

After her passing in 2014, The New York Times, The Boston Globe, and other news outlets published her obituary, and moving tributes to Rovee-Collier are also found in various professional publications.

Rovee-Collier's insightful master's thesis was on sucking in puppies.

The 30-page Carolyn Rovee-Collier oral history: 

A short video showing Rovee-Collier in her preferred lab, i.e., visiting babies in their own home environments:


BabyLabs, Cognitive Flexibility, and IBCLCs

Researchers study how babies learn in infant cognition labs around the world, often in graduate programs in developmental psychology. The following link is to the home page of one such lab, located at the University of Essex, a public research university in Essex, England. At the bottom of their home page, a copy of their tweet from November 29, 2018 asks, "Help inform our research by filling out this online survey on #eating behavior and #food preference in childhood @EssexBabylab". https://babylabessex.wordpress.com/

Will this lab and other BabyLabs someday study the sensory-perceptual-motor learning of infant milk-feeding skills with one or more skilled IBCLCs included on their research team? Also important to study is the observable skill decay (motor forgetting) for infant breastfeeding skills that often follows the use of an artificial nipple, particularly during early learning but not only during early learning. The re-acquisition of infant breastfeeding skills is another important aspect for future study. There is already a body of work on the study of infant sucking behaviors in puppies, including the work of the Carolyn Rovee-Collier (1942-2014), a developmental psychologist who is considered the founder of the field of infant long-term memory research. Rovee-Collier completed her insightful master’s thesis on sucking in puppies.

Early memories are fragile, including motor memories, and we commonly face early challenges in learning and remembering a new computer password or a new telephone number. Our human need for task-specific practice is reflected in The Specificity Principle, and the repetition of this task-specific practice is necessary for gradually building robust memory for each of those numerical sequences for our motor performance, as well as our gradual ability to visually identify a particular telephone number, and to correctly state a specific numerical sequence aloud. Another important precept from kinesiology: the greater the difficulty of the task, the greater the need for practice that is specific for the task.

When a new music student begins once-a-week music lessons but does not practice the new music that was awkwardly learned in the last lesson, it is no surprise that little to none of the previous music lesson is recalled at the next lesson. However, when the student becomes motivated enough to engage in the repetition of task-specific practice, and when the student is given appropriate verbal, visual, and manual guidance from the instructor, the voluntary process of task-specific practice is an effective opportunity for building increasingly greater motor control for the task.

The cognitive demands of task switching have been heavily studied for decades, including the well-known switch costs of decreased speed and accuracy for the task. Today’s PubMed search using the term “task switching” yielded 3,185 results. Note that when the search term is hyphenated as “task-switching”, the yield is far fewer at 1,461 results. PubMed searches can be highly specific, even in regard to something as small as the presence or absence of a hyphen!

In helping babies to learn or relearn the oral grasp at the breast following a learning experience with an artificial nipple, finger-feeding is often highly effective, particularly in younger infants. This is reflected in the well-known precept from developmental science termed the exuberant learning of infancy, and the younger the baby, the faster the learning. Forgetting is also rapid in infancy, and thus the frequent observations of skill decay (motor forgetting) for infant breastfeeding skills that often follow one or more learning experiences with an artificial nipple, particularly during early learning but not only during early learning.

In the new review article linked below, the value of associative learning mechanisms is discussed. In the field of infant feeding, finger-feeding provides babies the opportunity to learn to associate the sensory-perceptual-motor learning experience of human touch with sucking and receiving the reward of milk for one’s efforts, also reflecting reward-based learning and reinforcement learning. Infant feeding clinicians such as IBCLCs often observe a heavier weighting of the primitive survival reflexes toward the more recently learned feeding method, and thus task-switching for infant milk-feeding skills is frequently observed to be a challenging experience, particularly during early learning when memories are notably fragile. Similarly, bottle-fed infants often display difficulty with the oral grasp of a new artificial nipple that is different from the previously learned style of artificial nipple, and these difficulties range from mild to moderate to pronounced.

Cognitive flexibility also has a developmental sequence. In infancy, we have the least ability for skillfully switching between tasks, yet as we reach childhood, we display more cognitive flexibility than our younger baby selves. By adolescence, we have achieved even greater cognitive flexibility, and by adulthood, we have reached the pinnacle of cognitive flexibility, yet discerning and differentiating between things that are similar yet different is often cognitively demanding for adults who are otherwise skilled in many areas. Some of us who have first learned to use western utensils may opt to later learn how to use chopsticks, but many of us find that learning to use chopsticks is too confusing, i.e., it is too cognitively demanding, and we may avoid the cognitive demands of any further practice in the use of chopsticks. Others will enjoy the cognitive challenges of learning how to use chopsticks, and will continue the trial-and-error process toward increasingly greater skill over time. (The trajectory is the same for the hand-to-mouth movements involved in using a spoon, fork, and chopsticks, but the learning curve is steep for the novel manual grasp of chopsticks).

The following new review article, “Getting a Grip on Cognitive Flexibility”, is authored by Senne Braem of Ghent University in Belgium and Tobias Egner of Duke University in the U.S.

From their abstract: “Cognitive flexibility refers to the ability to quickly reconfigure our mind, like when we switch between different tasks. This review highlights recent evidence showing that cognitive flexibility can be conditioned by simple incentives typically known to drive lower-level learning, such as stimulus-response associations. Cognitive flexibility can also become associated with, and triggered by, bottom-up contextual cues in our environment, including subliminal cues. Therefore, we suggest that the control functions that mediate cognitive flexibility are grounded in, and guided by, basic associative learning mechanisms, and abide by the same learning principles as more low-level forms of behavior. Such a learning perspective on cognitive flexibility offers new directions and important implications for further research, theory, and applications.”


For more information on the acquisition and re-acquisition of infant breastfeeding skills, please join us for our 3-hour intensive webinar,

MoreThanReflexes: Learning, Forgetting, and Relearning Infant Breastfeeding Skills. http://www.morethanreflexes.org/webinars/

Motor Learning Terms of the Day

motor forgetting Skill decay, or decreased speed and accuracy for the task.

interference theory A theory that forgetting is caused by interference from other learned information/experiences.

Two major theories on forgetting, including motor forgetting or skill decay, are:

  • trace decay (decay of the memory trace) due to lack of practice, whether this lack of practice takes place in good health or due to illness or injury, and

  • trace decay subsequent to an interference effect

A memory trace is a group of neurons, interconnected and encoded for specific memories, including motor memories.

In the 1995 paper by Neifert, Lawrence, and Seacat, “Nipple Confusion: Toward a Formal Definition”, the authors discuss interference as a factor in observable breastfeeding difficulties that often follow an infant’s learning experience with an artificial nipple.

For an intensive discussion on motor learning and motor forgetting (skill decay) within the context of the primitive survival reflexes, please join us for our dynamic webinar,

More Than Reflexes: Learning, Forgetting and Relearning Infant Breastfeeding Skills

Three New Studies on Duration

From Sweden:

Open Access

Title: Breastfeeding and risk for ceasing in mothers of preterm infants—Long‐term follow‐up.

In: Maternal & Child Nutrition 2018 Oct; 14(4): e12618. doi: 10.1111/mcn.12618


Authors: Jenny Ericson, Mats Eriksson, Pat Hoddinott, Lena Hellström-Westas, Renée Flacking.

From the abstract:


“Exclusive breastfeeding at discharge, higher maternal educational level, and shorter length of stay in the neonatal intensive care unit were factors associated with higher breastfeeding prevalence during the preterm infants' first year of life.

The results give insights on long‐term outcomes of breastfeeding in mothers who breastfed their preterm infants at discharge from the neonatal intensive care unit, where 64% of the infants were breastfed at 6 months.

Most infants were fed breast milk directly at the breast; few infants received expressed breast milk by bottle, tube, or cup.”

From Denmark:

Open Access

Title: The role of intention and self-efficacy on the association between breastfeeding of first and second child, a Danish cohort study.

In: BMC Pregnancy and Childbirth (BioMed Central Pregnancy and Childbirth) 2018 Nov 22;18(1):454. doi: 10.1186/s12884-018-2086-5.


Authors: Kronborg H, Foverskov E, Væth M, Mainburg RD.

From the abstract:

“BACKGROUND: The impact of parity on breastfeeding duration may be explained by physiological as well as psychosocial factors. The aim in the present study was to investigate the mediating influence of intention and self-efficacy on the association between the breastfeeding duration of the first and the following child. CONCLUSION: Due to a reinforcing effect of intention and self-efficacy, breastfeeding support should focus on helping the first time mothers to succeed as well as to identify the second time mother with low self-efficacy and additional need for support.”

From Iran:

Open Access

Title: The Association between Household Socioeconomic Status, Breastfeeding, and Infants' Anthropometric Indices.

In: International Journal of Preventive Medicine 2018 Oct 12;9:89. doi: 10.4103/ijpvm.IJPVM_52_17. eCollection 2018.


Authors: Ajami M, Abdollahi M, Salehi F, Oldewage-Theron W, Jamshidi-Naeini Y.

From the abstract:

“BACKGROUND: The growth, learning, and contribution to active life in the communities are better in well-nourished children, and various factors influence infants' feeding. In this study, we assessed whether household socioeconomic status (SES) affects infants' length-for-age, weight-for-age (indicators of health and nutritional status) and breastfeeding (BF) (a necessity for optimal growth and health) status. CONCLUSIONS: Nutritional status, duration of BF, and EBF might be determined by household SES and maternal education. Therefore, these findings can be used to decide how to focus on appropriate target groups in family education planning to improve children's development to its most possible.”

Three New Studies

From Germany:

Open access

Title: Intranasal breast milk for premature infants with severe intraventricular hemorrhage - an observation.

In: European Journal of Pediatrics 2018 Nov 1. doi: 10.1007/s00431-018-3279-7.


Authors: Keller T, Körber F, Oberthuer A, Schafmeyer L, Mehler K, Kuhr K, Kribs A.

Abstract: "For nasal application of neurotrophins and mesenchymal stem cells, successful delivery to the brain and therapeutic effects are known from experimental data in animals. Human breast milk contains neurotrophins and stem cells, but gavage tube feeding in preterm infants bypasses the naso-oropharynx. This is a first exploration on additional nasal breast milk and neuromorphological outcome after severe neonatal brain injury. We present a retrospective summary of 31 very low birth weight preterm infants with intraventricular hemorrhage °3/4 from one third-level neonatal center. All were breast milk fed. Sixteen infants additionally received nasal drops of fresh breast milk daily with informed parental consent for at least 28 days. Cerebral ultrasound courses were reviewed by a pediatric radiologist blinded to the intervention. The main outcome measure was severity of porencephalic defects before discharge. Clinical covariates were comparable in both groups. With nasal breast milk, a trend to a lower incidence for severe porencephalic defects (21% vs. 58%) was detected. Incidences were lower for progressive ventricular dilatation (71% vs. 91%) and surgery for posthemorrhagic hydrocephalus (50% vs. 67%). Conclusion: The hypothesis is generated that early intranasal application of breast milk could have a beneficial effect on neurodevelopment in preterm infants. Controlled investigation is needed. What is Known: • Successful delivery to the brain and therapeutic effects are known for nasal application of neurotrophins and mesenchymal stem cells from experimental data in animal studies. • Human breast milk contains neurotrophins and stem cells, but gavage tube feeding in preterm infants bypasses the naso-oropharynx. What is New: • This is the first report on additional nasal breast milk application in very low birth weight preterm infants with severe brain injury observing a trend for less severe porencephalic defects. • The hypothesis is generated that nasal breast milk might exert neuroprotective effects in preterm infants."

From The Netherlands:

Title: Relationship between socioeconomic status and weight gain during infancy: The BeeBOFT study.

In: PLoS One. 2018 Nov 2;13(11):e0205734. doi: 10.1371/journal.pone.0205734. eCollection 2018.

Authors: Wang L, van Grieken A, Yang-Huang J, Vlasblom E, L'Hoir MP, Boere-Boonekamp MM, Raat H.


Abstract: "BACKGROUND: Increased weight gain during infancy is a risk factor for obesity and related diseases in later life. The aim of the present study was to investigate the association between socioeconomic status (SES) and weight gain during infancy, and to identify the factors mediating the association between SES and infant weight gain. METHODS: Subjects were 2513 parent-child dyads participating in a cluster randomized controlled intervention study. Family SES was indexed by maternal education level. Weight gain in different time windows (infant age 0-3, 0-6, and 6-12 months) was calculated by subtracting the weight for age z-score (WAZ) between the two time-points. Path analysis was performed to examine the mediating pathways linking SES and infant weight gain. RESULTS: On average, infants of low-educated mothers had a lower birth weight and caught-up at approximately 6 months. In the period of 0-6 months, infants with low-educated mothers had an 0.42 (95% CI 0.27-0.57) higher gain in weight for age z-score compared to children with high-educated mothers. The association between maternal education level and increased infant weight gain in the period of 0-6 months can be explained by infant birth weight, gestational age at child birth, duration of breastfeeding, and age at introduction of complementary foods. After adjusting all the mediating factors, there was no association between maternal education level and infant weight gain. CONCLUSION: Infants with lower SES had an increased weight gain during the first 6 months of infancy, and the effect can be explained by infant birth weight, gestational age at child birth, and infant feeding practices.”

From China:

Open access

Title: A Short Message Service Intervention for Improving Infant Feeding Practices in Shanghai, China: Planning, Implementation, and Process Evaluation.

In: JMIR Mhealth Uhealth 2018 Oct 29;6(10):e11039. doi: 10.2196/11039.

Authors: Jiang H, Li M, Wen L, Baur LA, He G, Ma X, Qian X.


Abstract: "BACKGROUND: Although mobile health (mHealth) has been widely applied in health care services, few studies have reported the detailed process of the development and implementation of text messaging (short message service, SMS) interventions. OBJECTIVE: Our study aims to demonstrate the process and lessons learned from a community-based text messaging (SMS) intervention for improving infant feeding in Shanghai, China. METHODS: The intervention included planning and development, implementation, and process evaluation. A 3-phase process was adopted during planning and development: (1) a formative study with expectant and new mothers to explore the barriers of appropriate infant feeding practices; (2) a baseline questionnaire survey to understand potential intervention approaches; and (3) development of the text message bank. The text messaging intervention was delivered via a computer-based platform. A message bank was established before the start of the intervention containing information on the benefits of breastfeeding, preparing for breastfeeding, early initiation of breastfeeding, timely introduction of complementary foods, and establishing appropriate feeding practices, etc. An expert advisory committee oversaw the content and quality of the message bank. Process evaluation was conducted through field records and qualitative interviews with participating mothers. RESULTS: We found that the text messaging intervention was feasible and well received by mothers because of its easy and flexible access. The weekly based message frequency was thought to be appropriate, and the contents were anticipatory and trustworthy. Some mothers had high expectations for timely response to inquiries. Occasionally, the text messages were not delivered due to unstable telecommunication transmission. Mothers suggested that the messages could be more personalized. CONCLUSIONS: This study demonstrates the feasibility and value of text messaging intervention in filling gaps in delivering health care services and promoting healthy infant feeding practices in settings where personal contact is limited."

A Free CME/CE from Medscape: How Does Marijuana Use Affect Lactating Mothers?

Medscape is offering a free 0.25 CME/CE on a new lactation topic (newly released on Medscape on October 19, 2018).

Title: How Does Marijuana Use Affect Lactating Mothers?

One study cited in this short continuing ed module is the new study by Bertrand and colleagues in the journal, Pediatrics: "Marijuana use by breastfeeding mothers and cannabinoid concentrations in breast milk." Pediatrics 2018;142. http://pediatrics.aappublications.org/conte…/142/3/e20181076.

A current clinical report from the AAP on the use of cannabinoids during pregnancy and lactation is also discussed. Ryan SA, Ammerman SD, O'Connor ME; COMMITTEE ON SUBSTANCE USE AND PREVENTION; SECTION ON BREASTFEEDING. Marijuana use during pregnancy and breastfeeding: implications for neonatal and childhood outcomes. Pediatrics. 2018;142. http://pediatrics.aappublications.org/…/08/23/peds.2018-1889.

This continuing education topic and many others are available at no cost on Medscape. http://www.medscape.org

A U.S. Senator and Mother Speaks Out in Support of Family Reunification

U.S. Senator Tammy Duckworth, a nursing mother, speaking at a Washington, D.C. protest today in support of family reunification:  "I wanted to show my support for the folks here today. I could only imagine what it would be like to have my daughter — my breastfeeding child — ripped away from me the way some of these other moms’ babies have been.” http://thehill.com/blogs/blog-briefing-room/news/394723-duckworth-joins-womens-capitol-protest-with-baby

Families Belong Together: USLCA Statement on Family Reunification

I send deep gratitude to the United States Lactation Consultant Association for speaking out on the immediate need for family reunification following the forced separation of infants and children from their parents at the U.S. border.  This is the USLCA Statement on Family Reunification: 

In solidarity with thousands of individuals and many organizations across the United States of America and the world, the U.S. Lactation Consultant Association calls on lawmakers to end immediately the forced separation of children from their parents at the U.S. border. This unnecessary practice is harmful to both adults and their children, and no justification for this practice should be prioritized above the health and well-being of human beings.

As International Board-Certified Lactation Consultants (IBCLCs), we work daily alongside many more breastfeeding advocates and providers of health care to support and ensure optimal health of pregnant people, parents, infants, children, and the general public through education about and assistance with breastfeeding. The IBCLC is an expert in infant feeding and is responsible to uphold scientific, evidence-informed theory and practice that is free from conflict of interest, be it financial, academic, personal, political, or otherwise.

Separation of children from their parents creates barriers to breastfeeding and safe infant feeding, and to our knowledge, no IBCLCs have been contacted with regard to how to appropriately feed infants away from their parents, to support and protect continued lactation in lactating persons who do not have access to their children for breastfeeding, or any general information about infant and young child feeding in national emergencies, natural disasters, or humanitarian crises. It is critical to understand that globally, children breastfeed far beyond infancy and that this practice is important to the health of families and the general public. The abrupt removal of the opportunity to be breastfed or to express breast milk has serious health consequences for infants, toddlers, and their lactating parents, and USLCA firmly opposes this practice in all circumstances. In addition, all major health organizations with policies about infant feeding call for the use of pasteurized donor human milk in all situations where their own parent’s milk is not available; the use of safely prepared infant formula for all children under the age of 12 months is only recommended when neither their own parent’s milk nor pasteurized donor human milk are available.

USLCA calls for the immediate and rapid reunification of families who have been separated from each other, as well as the provision of appropriate health care and support for all persons who have been directly affected by the practice of forced separation. This includes comprehensive health consultation for all facets of physiological and mental health, as well as support for resuming breastfeeding, milk expression, and education and support to ensure safe infant and young child feeding.


In your entire professional experience in healthcare, have you ever advised a bottle-feeding family to alternate different styles of artificial nipples that differ in contour, diameter, length, and/or texture from one feeding to the next or from one day to the next, from week to week, or even on a month-to-month basis, particularly during the infant’s early skill acquisition for bottle-feeding skills?  

In your entire professional experience, have you ever observed such infant feeding advice being given to a family by a physician or nurse? 

If you are a parent who has bottle-fed your infant, have you ever received such professional advice for feeding your infant? 

Have you ever received such advice from family members or friends? 

In regard to the use of a pacifier/soother/dummy, have you ever given or received professional advice to switch pacifier styles from one use to another over the course of a day or from day to day, week to week, or from month to month?  Have you ever received such advice from family members or friends?   

I wholly support The Ten Steps to Successful Breastfeeding, although this post is primarily focused on bottle-fed infants who may be receiving all mother's milk in a bottle, human donor milk by bottle, artificial infant milk by bottle, or a mixture of any of these milks via bottle.  In my long career as a registered nurse and IBCLC, not once have I heard such switching advice given to bottle-feeding families and/or to families who are giving pacifiers/soothers/dummies to their infants. 

What I have occasionally overheard while passing through a hospital’s well-baby nursery or a neonatal intensive care unit (NICU) is an outgoing nurse giving report to an incoming nurse during shift change, stating that Baby Jones “does better” with a particular type of artificial nipple.  Although hospitals do not stock a wide variety of artificial nipples, typically there are at least two to 3 styles of artificial nipples for the nursing staff's selection.   

The departing nurse intends that both the incoming nurse and her small patient will benefit from her observations of how her infant patient fed during her shift.  We can interpret the departing nurse’s phrase, “does better,” as a reference to the infant’s motor learning toward increasingly greater motor control for the oral grasp of a particular artificial nipple, as well as motor learning for effective suckling toward adequate transfer of milk, all while learning how to coordinate suck and swallow with breathing.  “Does better” infers that with consistent practice that is specific to the task, the infant's family, as well as the nursing staff, can expect to observe greater speed and accuracy by the infant for the oral grasp of the artificial nipple, as well as greater motor control for milk transfer from the bottle.  Motor learning is a complex process, and the healthy term infant who is bottle-fed will gradually build robust motor memory for bottle-feeding skills that are associated with a specific design of an artificial nipple, and there may be learning that is specific to the design of a bottle as well.   

Step 9 of the Ten Steps to Successful Breastfeeding reflects the basic need for the newborn to have frequent and consistent task-specific practice for learning breastfeeding skills, toward gradual building of robust motor memory for these skills.       

When a six-month-old infant begins to learn drinking skills from a sippee-cup, we often intuitively give the same style of sippee cup to the baby day after day, in order to provide task-specific practice sessions in sippee-cup drinking.  If we were to offer alternating styles of sippee cups from one day to the next, we would surely observe the infant’s difficulties in task-switching from one style of sippee cup to another.    

A key aspect of our executive functions is our cognitive flexibility, the ability to adapt our thinking and/or behavior in response to changes in the environment.  In the developmental sciences, there is a well-known developmental progression for our cognitive flexibility: 

We possess the least cognitive flexibility in infancy.

We display more cognitive flexibility in childhood than in infancy. 

We display even greater cognitive flexibility in adolescence. 

We possess still greater cognitive flexibility in adulthood, although task-switching often results in decreased speed and/or accuracy for the task, regardless of age.  Consider the expected miserable experience for the serious golfer who forgets her clubs and must use a loaner set in order to participate in a scheduled game or tournament.  

Task-switching is heavily studied in the cognitive sciences, as are the switch costs of decreased speed and accuracy that often occur during task-switching.  Measurement parameters include reaction time (RT), the interval between the presentation of a stimulus and the initiation of a response; movement time (MT), the interval between the initiation of a movement and its completion or termination; response time, the interval from the presentation of a stimulus to the completion of a movement (the sum of reaction time and movement time); and inhibition of return (IOR), the delay in responding to the previously cued (or orienting) stimulus. 

Today’s PubMed search using the term “task-switching” yielded 1,384 search results.  Note that when using the search term “task switching” without a hyphen between “task” and “switching,” the yield is nearly three-fold at 3,018 search results.  

The first of the below publications is a well-known 2005 study from Adele Diamond and Natasha Kirkham on task switching and cognitive flexibility, followed by one new study and one new review paper by Kirkham and colleagues: 

1)     Title: Not Quite As Grown-Up As We Like To Think:  Parallels Between Childhood and Adulthood.

Authors: Adele Diamond, Natasha Kirkham.

In:  Psychological Science 2005 Apr;16(4):291-297.  doi.10.1111/j.0956-7976.2005.01530.x


2)    Title:  Incidental Category Learning and Cognitive Load in a Multisensory Environment Across Childhood.

Authors:  H.J. Broadbent, T. Osborne, M. Rea, A. Peng, D. Mareschal, N.Z. Kirkham.

In:  Developmental Psychology 2018; 54(6), 1020-1028.



3)    Title:  Infant Statistical Learning.

Authors:  Jenny R. Saffran and Natasha Z. Kirkham

In:  Annual Reviews in Psychology 2018 January 04;69:181-203. 



Three Motor Learning Terms of the Day

Motor program:  Abstract representation that, when initiated, results in the production of a coordinated movement sequence. 

Gearshift analogy:  An idea about the learning of motor programs, analogous to learning to shift gears in an automobile.

Sequencing:  An invariant feature of motor programs in which the order of elements is fixed. 

Critical Aspects of Task-Specific Practice and the Home Field Advantage

Nearly all forms of early memory are fragile, with examples of learning the alphabet or a new language, learning a new telephone number or a new computer password, or building motor memory for new motor skills.  To build robust memory, the repetition of task-specific practice is critical. 

At birth, the presence of the primitive survival reflexes hastens our learning for milk-feeding skills in support of our survival.  When a breastfed infant is given a learning experience with an artificial nipple, the fragility of early motor memory is often on display for the infant's oral grasp of the nipple-areolar complex and/or effective suckling, i.e., the primitive survival reflexes are not equally weighted for all infant milk-feeding movements all the time, and a recency effect is often observed for the more recently learned milk-feeding method.  Similarly, when an exclusively bottle-fed infant is given a learning experience with a different style of artificial nipple, immediate task-switching ability by the infant for the oral grasp of the novel artificial nipple, followed by a prompt and competent return to the original artificial nipple is not at all expected.    

In the cognitive sciences, there is a well-known developmental progression of our cognitive flexibility for switching back and forth between tasks.  Cognitive flexibility is most limited in the young, and the younger we are, the more limited our cognitive flexibility.   Children display greater cognitive flexibility than infants, and adolescents display greater cognitive flexibility than children.  Adults possess greatest cognitive flexibility, yet task-switching is often complex and demanding in adulthood as well. 

Another tenet from the field of motor learning: The greater the difficulty of the task, the greater the need for practice that is specific to the task.  A timely example of the critical need for task-specific practice will be in evidence in the U.S. tonight during Game 2 of the National Basketball Association (NBA) finals between the Cleveland Cavaliers and the Golden State Warriors.  These elite athletes will never rehearse for competition with a novel basketball that differs in diameter, texture, weight, and/or bounce, followed by a sudden switch to a regulation-sized basketball for the fierce competition against their opponents.  Furthermore, such a poor and unthinkable practice strategy is never recommended by the teams' coaches.  As it is, these elite players must contend with environmental constraints in regard to changes in their visual field when they are not playing on their home court, and numerous formal studies have indeed shown a home court advantage (1).  

When infants present with a recessed chin, tethered oral tissues, or cleft lip, for example, the task of learning the oral grasp at the breast and/or effective suckling may be more challenging for the infant.  In the field of motor learning, such potential learning challenges are referred to as individual constraintsTask constraints may also be present, such as retracting nipple anatomy; and/or flat nipple anatomy that is not readily protractile; and/or inverted nipple anatomy; and/or and breast engorgement.  These anatomical variations may also present temporary and transient challenges, moderate challenges, or more prolonged challenges for the infant who is learning the oral grasp and/or effective suckling at the breast. 

The above-mentioned tenet is also applicable to newborns who are learning their first feeding skills, in that the greater the difficulty of the task, the greater the need for practice that is specific to the task, i.e., it is particularly important that artificial nipples are avoided in the presence of any possible learning constraints.  This is not at all to say that artificial nipples should be offered to breastfed infants in the absence of any possible learning constraints, nor should it be said that exclusively bottle-fed infants should receive alternating learning experiences with different styles of artificial nipples, regardless of whether possible learning constraints are present.  A reminder:  cognitive flexibility is most limited in the young, and the younger we are, the greater the limitations in our cognitive flexibility.  

The current widespread use of nipple shields in many childbearing settings in the U.S. often follows the infant's learning experience with an artificial nipple whether in non-Baby Friendly or Baby Friendly settings, even when an infant has initially learned the oral grasp at the breast, or when the infant is to become a breastfed infant but has not yet practiced feeding skills at the breast, having first learned bottle-feeding skills.  Until the baby has the opportunities to learn or relearn feeding skills at the breast, a "home field advantage" is a standard recommendation, i.e., the rich sensory milieu of the mother's chest is recommended for the infant via skin-to-skin contact.    

The frequent risks of task-switching are the well-known switch costs of decreased speed and accuracy for the task.  Measurement parameters of motor performance as well as task-switching and switch costs include reaction time (RT), movement time (MT), response time (reaction time + movement time = response time), and the inhibition of return (IOR), the delay in responding to the previously cued (or orienting) stimulus.  All of these parameters are measured in milliseconds (ms).  

Pronounced and prolonged individual constraints may include complete cleft of the lip and palate until surgical repair takes place.  In the absence of pronounced and prolonged learning constraints, many motor skills soon reach an elegant level of performance with effective practice that is specific to the task.  For the infant's acquisition of milk-feeding skills, the baby's increasing expertise is evidenced by the rapid oral grasp, as well as the baby's ability to consistently and effectively transfer adequate volumes of milk over increasingly shorter periods of time.  When the older baby is able to multi-task while nursing, such as reaching for his toes while feeding, or playing with a button on his mother's shirt while suckling, great heights in motor control have been reached.  Such an "elite" level of performance for an infant is not achieved overnight but requires months of practice, even in the absence of any possible learning constraints.   

Jamieson Jeremy P.  The Home Field Advantage in Athletics:  A Meta-Analysis.  Journal of Applied Social Psychology 9 July 2010.  https://doi.org/10.1111/j.1559-1816.2010.00641.x


New Study on the Interactive Influence of Oxytocin and Testosterone

A new open access study from Germany in the journal, Scientific Reports

Title:  Endogenous testosterone and exogenous oxytocin influence the response to baby schema in the female brain.

Authors:  Sarah K. C. Holtfrerich, Roland Pfster, Alexander T. El Gammal, Eugen Bellon & Esther K. Diekhof

Abstract:  "Nurturing behavior may be critically influenced by the interplay of different hormones. The neuropeptide oxytocin is known to promote maternal behavior and its reduction has been associated with postpartum depression risk and child neglect. Contrariwise, the observed decrease in testosterone level during early parenthood may benefit caretaking behavior, whereas increased testosterone may reduce attention to infants. Here we used functional magnetic resonance imaging to investigate the interactive influence of testosterone and oxytocin on selective attention to and neural processing of the baby schema (BS). 57 nulliparous women performed a target detection task with human faces with varying degree of BS following double-blinded placebo-controlled oxytocin administration in a between-subjects design. Our results support the idea that oxytocin enhances attention to the BS. Oxytocin had a positive effect on activation of the inferior frontal junction during identification of infant targets with a high degree of BS that were presented among adult distractors. Further, activation of the putamen was positively correlated with selective attention to the BS, but only in women with high endogenous testosterone who received oxytocin. These findings provide initial evidence for the neural mechanism by which oxytocin may counteract the negative effects of testosterone in the modulation of nurturing behavior."


New Study on Synthetic Oxytocin, Type of Birth, and Duration of Exclusive Breastfeeding

This new study from Spain has been published in the journal, Women and Birth.  Researchers looked at the use of synthetic oxytocin and the type of birth in regard to the duration of exclusive breastfeeding, finding that those in the group of planned cesarean birth (without oxytocin administration) had the highest risk of cessation of exclusive breastfeeding at all three intervals studied (1 month, 3 months, 6 months).  

Title:  Cessation of breastfeeding in association with oxytocin administration and type of birth.

Authors:  Fernández-Cañadas Morillo A, Durán Duque M, Hernández López AB, Muriel Miguel C, Pérez Riveiro P, Salcedo Mariña A, Royuela Vicente A, Casillas Santana ML, Marín Gabriel MA

"BACKGROUND: Some studies have suggested an association between synthetic oxytocin administration and type of birth with the initiation and consolidation of breastfeeding."

"AIM: This study aimed to test whether oxytocin administration and type of birth are associated with cessation of exclusive breastfeeding at different periods. A second objective was to investigate whether the administered oxytocin dose is associated with cessation of exclusive breastfeeding."

"METHODS: We conducted a prospective cohort study (n=529) in a tertiary hospital. Only full-term singleton pregnancies were included. Four groups were established based on the type of birth (vaginal or cesarean) and the intrapartum administration of oxytocin. Follow-up was performed to evaluate the consolidation of exclusive breastfeeding at 1, 3 and 6months."

"FINDINGS: During follow-up, the proportion of exclusive breastfeeding decreased in all groups. After adjusting for confounding variables, the group with cesarean birth without oxytocin (planned cesarean birth) had the highest risk of cessation of exclusive breastfeeding (odds ratio [95% confidence interval], 2.51 [1.53-4.12]). No association was found between the oxytocin dose administered during birth and puerperium period and the cessation of exclusive breastfeeding."

"CONCLUSION: Planned cesarean birth without oxytocin is associated with the cessation of exclusive breastfeeding at 1, 3 and 6months of life. It would be desirable to limit elective cesarean births to essentials as well as to give maximum support to encourage breastfeeding in this group of women. The dose of oxytocin given during birth and puerperium period is not associated with cessation of exclusive breastfeeding."


Dr. Alison Stuebe on Breastfeeding, Advocacy, and Women's Rights

Alison Stuebe MD MSc presented on this topic at the recent Breastfeeding Advocacy Collective (BAC) meeting in Toronto on May 9th.  Dr. Steube is a maternal-fetal medicine physician and president-elect of the Academy of Breastfeeding Medicine.  Dr. Stuebe's following blog post is adapted from her presentation at the recent BAC meeting.  

In June 2015, I heard a fantastic talk by Keith Hansen, Vice President for Human Development at the World BankGroup, at the Academy of Breastfeeding Medicine summit. Hansen spoke eloquently about the importance of breastfeeding for both global health and economic development; he said, “If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics.”

I’d brought my teenage son with me to Washington, and when we met up for lunch, I shared Hansen’s quote. He responded, “If breastfeeding were invented today, there would be an outrage, because of feminism.”

It took me a few seconds to fully process this response, as I began to consider the implications of a newly-discovered practice that would require one half of the population to engage in thousands of hours of unpaid work, at all hours of the day and night, for the greater good. There would, indeed, be an outrage. This disconnect between praise of breastfeeding and practicality of women’s lives is pervasive, and it is reflected in health promotion strategies. Posters list the ingredients of human milk vs. formula, celebrating the product of breast milk without acknowledging the process of breastfeeding.

Breastmilk is described as nature’s “most specific personalized medicine,” rather than celebrating breastfeeding as personalized nurturing. Even our public health goals aim to “increase the proportion of infants who are breastfed,” absenting the mother doing the breastfeeding from consideration. As a physician scientist, I know how easy it is to become fascinated by the science of human milk and the intricacies of oligosaccharides and the gut microbiome – but speaking of “milk as medicine” suggests a resource to be extracted from a passive mother, without regard to her bodily integrity or autonomy. As Benoit, Goldberg and Campbell-Yeo have written:

By placing breastfeeding focus on the biomedical and nutritional benefits of breastmilk, as opposed to maternal experience associated with nursing her infant, health care providers are perpetuating the patriarchal conceptualization of the ‘good mother’ as one who is defined as selflessly giving by nursing her child while asking for nothing in return.

Our excitement over the constituents of human milk reflects the reductionism of modern scientific research, in which the whole can best be understood by breaking it into its parts. And yet, doing so undermines the fundamental nurturing relationship between parent and child; as Van Esterik and O’Connor write in their critically important book, The Dance of Nurture, “Nurture is a relationship not a thing, and relationships cannot be reduced to their parts.”

Our focus on human milk constituents further fails to consider a growing body of evidence linking breastfeeding duration with maternal health. In reproductive physiology, lactation follows pregnancy, and when breastfeeding is disrupted, chronic disease burden for women increases. In observational studies that adjust for multiple confounders, shorter breastfeeding durations are associated with higher maternal risk of breast cancer, ovarian cancer, diabetes, hypertension and cardiovascular disease. Indeed, a recent cost analysis found that the health burden of suboptimal breastfeeding is far greater for mothers than for children. Policies that disrupt breastfeeding impair a woman’s lifelong health.

Given its importance in reproductive physiology and women’s health, breastfeeding is a woman’s reproductive right.  However, Judith Galtry notes that the Convention on the Elimination of Discrimination against Women (CEDAW) barely mentions breastfeeding. The absence of breastfeeding from the human rights discourse when CEDAW was written in the 1970s may reflect the influence of Western feminists who were focused on liberating women from responsibility for child-rearing. In this context, breastfeeding was a chain to be broken, rather than a right to be protected. As Galtry writes, “It did not always occur to policymakers and legislators that many women did not actually have the right to breastfeed.” This focus on “my right to not breastfeed” continues to dominate discussions among professional women in high-income countries, at the expense of recognizing that economic constraints prevent many marginalized women from breastfeeding, regardless of their personal preferences.

Framing breastfeeding as a woman’s right encourages us to address the relative costs and benefits of breastfeeding for each mother and baby. Tully and Ball note that a woman’s investment in sustained breastfeeding reflects tradeoffs, and lowering the personal cost of breastfeeding would support longer durations:

Van Esterik summarizes the need to address the costs to mothers in a 1981 essay on breastfeeding and women’s work:

Breastfeeding may be viewed by some feminists as the epitome of nurturant behavior – restrictive and unappealing, constraining an emancipated woman from employment possibilities. For these women, biologically determined functions may be devalued and, whenever possible, replaced by technological innovations such as bottlefeeding. A more radical feminist might argue instead for a restructuring of society to support women in their productive and reproductive lives.

What if we leveraged the importance of breastfeeding to restructure our society around each woman’s human right to nurture her children as she desires?

As defined by the Officer of the High Commissioner on Human Rights, “Human rights entail both rights and obligations. States assume obligations and duties under international law to respect, to protect and to fulfil human rights.” If breastfeeding is a woman’s right, then it is not sufficient to urge women to breastfeed – we must enact policies that respect, protect and fulfill that right. A human rights framework recognizes that breastfeeding is not a one-woman job – multiple social structures are essential to enable a woman to exercise her human right to nurture her child as she desires.  To that end, the Global Breastfeeding Collective has identified seven key strategies to enable mothers to achieve their infant feeding goals, including funding for breastfeeding support, implementing the WHO Code of Marketing, enacting paid family leave, implementing evidence-based maternity care, improving access to skilled support, strengthening links between health facilities and communities, and strengthening monitoring of processes and outcomes.

The collective has tracked country-level adherence to these recommendations with a Country Scorecard; to date, no country provides the minimum standard for support. Consider paid family leave: the standard for the Score Card is compliance with International Labor Organization conventions for at least 18 weeks of maternity leave and guarantees continuation of previous earnings paid out of compulsory social insurance or public funds. Slightly more than 10% of countries meet this standard; 90% of countries fail to address this fundamental barrier to a woman’s right to nurture her child.

Lack of paid leave is particularly egregious in the United States, where 23% of employed women return to paid work within 10 days of birth. Moreover, in 8 US states, single parent head-of-households with a newborn are not exempt from welfare work requirements. Women living in poverty are effectively punished for nurturing their children. As Burtle and Bezruchka have written:

The lack of policies substantially benefitting early life in the United States constitutes a grave social injustice: those who are already most disadvantaged in our society bear the greatest burden.

Given what we know about the importance of the first months of life for the health and wellbeing of mothers and infants, why haven’t we taken the necessary steps? In The Dance of Nurture, Van Esterik and O’Connor offer an explanation:

…we have not done the things that we need to do to support breastfeeding because these things conflict with deregulated capitalism and complacent consumerism.

Where to, then, from here? Do we conclude that modernity is inimical to breastfeeding, and rely on formula companies to provide “liberation in a can”? Or do we challenge societal structures that do not permit women to use their breasts and their brains at the same time? Feminist scholar Bernice Hausman writes:

Feminists …should be fighting for the right to breastfeed without social censure, loss of economic livelihood, or limitations on women’s freedom…Changing the bottle-feeding culture that we live in is a political enterprise than cannot be accomplished simply by advertising risks to replacement feeding or heralding the medicinal qualities of breast milk.

These are not new challenges, and these are not new ideas. In 1976, when I was 3 years old, Elisabet Helsing wrote:

In a world in which a female labour force is participating more and more, the peculiarities of this labour force have to be borne in mind. Until now, pregnancy and lactation have been strictly private enterprises, and society has not had to bother about how to cater to the newborn–that has always been regarded as the task of a woman… How can society adjust, so that she can remain useful to the society and simultaneously take the necessary care of her offspring?

Real liberation for women would not require us to choose between our professional and reproductive work. The current system incurs costs that reverberate across society by disrupting women’s participation in the paid work force. Indeed, a recent International Labor Organization / Gallup report found that balance between work and family is the number one challenge facing working women worldwide. Moreover, the report notes, “An ILO survey of 1,300 private-sector companies in 39 developing countries confirmed that family responsibilities borne by women was ranked as the No. 1 barrier to women’s leadership.” When societal constraints exclude women from participating in paid work, we all lose. As Gallup CEO Jim Clifton writes:

Our research also concludes that women have every bit as much game-changing talent as entrepreneurs and “builders” as do men. The problem is, millions of potential star women leaders are on the sidelines, and this isn’t good for organizations, societies or countries. Failing to maximize women’s talent to lead, manage and build stunts global economic growth and fails humankind.

It’s time for a feminist outrage that demands we restructure society to support women and men in their productive and reproductive lives. As Van Esterik wrote in 1994:

By enabling women to breastfeed we address women’s rights since the improvement of women’s social and economic status is necessary for supporting breastfeeding. Any violation of women’s right to breastfeed is a violation of women’s human rights.

Dr. Stuebe's entire blog post with graphics: https://bfmed.wordpress.com/2018/05/09/breastfeeding-advocacy-and-womens-rights/

Resources on Medications in Human Milk

Lactation consultants are often asked about the safety of various maternal medications during lactation, which is but one aspect of education and training for the International Board Certified Lactation Consultant (IBCLC).  Since the early 1990s, our profession has often referred to the invaluable text, Hale's Medications and Mothers' Milk by Thomas W. Hale RPh PhD, and on May 28th, the 19th edition of this important volume will be released.  Dr. Hale also founded the InfantRisk Center, which addresses maternal medications during lactation and more about infant health and wellbeing. 

Dr. Frank J. Nice offers the text, Nonprescription Drugs for the Breastfeeding Mother, now in its 2nd edition. 

The U.S. National Institutes of Health's Toxicology Database offers LactMed to professionals as well as the general public, and is another invaluable resource on drugs in human milk.  Most medications are compatible with breastfeeding, and in instances of a medication that is not compatible, an alternative medication is often safely prescribed.    

The website for the online version of Hale's Medications and Mothers' Milk by Dr. Thomas W. Hale RPh, PhD: https://www.medsmilk.com/

Kelly Bonyata's interview with Dr. Hale on her well-known website, KellyMom.com:   https://kellymom.com/bf/can-i-breastfeed/meds/interview-dr-hale/

Dr. Hale's website, the InfantRisk Center at Texas Tech University Health Sciences Center:   https://www.infantrisk.com/

Dr. Frank Nice's website:  https://nicebreastfeeding.com/

LactMed's website, part of the U.S. National Institutes of Health Toxicology Data Network:  https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm