Message:

Dear Barbara and Kay,

I have a client who has returned to work. Her baby was born 5/6/11. She is a PhD at a university. She asked about pumping frequency at work and the effects on supply if she skips a pumping. We discussed the implications of  regular milk removal. Breastfeeding is very important to her.

Her workday consists of many meetings with colleagues (all men). Her real question was how to tell her colleagues that she would need to step out periodically to go pump. She does not want to be perceived as not doing her job and would rather not tell them anything. I suggested that she pump before meetings and at breaks. She still feels as if she may be late returning to meetings after breaks and does not want to explain this to them.

Do you have any suggestions for this woman? She really feels as though she has no support at work.

Thank you!

Heather Henry
BS, RN, IBCLC

Barbara & Kay Respond:

This is a challenging counseling situation, because it involves presenting this (obviously very bright) woman with enough information to make an informed decision with regard to maintaining her milk supply.  We can confidently present evidence-based information on milk supply protection.  Information on strategies to manage her lack of support for workplace accommodations requires that we explore perspectives and strategies, which may not have occurred to her.

Let’s talk first about the research on localized feedback control for lactation. Particularly in the early phase of lactation (the first 3-4 months) the milk supply is sensitive to down-regulation if milk is not regularly removed. This information can be presented in a non-judgmental fashion, and you can cite references. (See below.) Pumping sessions with an effective double pump can be short; even 10-12 minutes will protect most women’s supply. Buying extra flanges eliminates the need to wash up until she goes home.  A discrete cooler with blue ice will keep her milk safe for about 15 hours and helps her avoid storing milk in a commonly shared refrigerator.

You can also talk to her about reverse cycle feeding, in which any missed expressions are made up by adding a pumping session or being willing to nurse the baby more during the night. Emptying the breasts 8 times per 24 hours will generally maintain full production. Many women do not feel that extra night time pumping or feedings permit them to get enough rest, so this issue should be gently explored and presented as merely another option.

We must also provide the information that if her milk supply does wane, she can begin to introduce formula, or (if the baby is over 4 months) start solids a bit early to protect the baby’s growth needs.

As Kay and I discussed our own experiences counseling working moms, our impression is that colleagues typically don’t want a lot of specific information about on-the-job pumping.  However, it will not have escaped them that she has just had a baby. Many of them will have had partners/wives/friends who have dealt with this issue.

She may be concerned that it is “asking for too much” if she arrives a few minutes late for a meeting.  It may help to point out that if a colleague (male or female) undergoes surgery, is recovering from serious illness, or has a sick child, people tend to be really kind, often sharing paid leave or temporarily shouldering more of the work load.  Most people understand that a woman just back from maternity leave is in a similar recovery mode.

While we have heard of truly toxic workplaces where women have been shamed and ridiculed for taking pumping breaks, your client may be surprised how sympathetically many of her colleagues will view her situation. An absence of 15 minutes every 3-4 hours would probably go un-remarked. I doubt she really needs to offer an explanation. If there are complaints, we recommend discussing her situation with her supervisor and letting that person manage the other employees. Slipping into meetings a few minutes late will probably not cause people to view her as a slacker if she continues to pull her weight in other aspects of her job, and occasionally brings donuts in the morning!

The new health care law does protect the rights of many working women to pumping breaks.  She should ask whether this affects her situation.  Law and public policy cannot, of course, manage the embarrassment factor, but I often ask well-educated or powerful women the following questions:

What is the point of having worked to accumulate some personal power through education if you do not intend it to benefit your own child? What possible hope is there for less powerful women to receive those accommodations if powerful women are too timid to step up forthrightly to claim this right?

The baby’s needs rightly trump the sensibilities of our colleagues as well as our own discomfort at appearing to require temporary special accommodation.  Integrating the maternal role involves being an advocate for our children, and claiming the right to pump milk for our baby is the first of many opportunities to learn how to be an effective parent.

The conversation we have with women on the more “political” aspects workplace pumping must clearly identified as an opportunity for sharing opinions.  We think it is a permissible discussion. The ILCA Scope of Practice describes LCs as change agents in our communities. It is wise to conclude such conversations by acknowledging that only the individual woman fully understands what risks she faces in her workplace as the result of claiming pumping accommodation rights.  Ultimately, the decision is hers to make.  We always reassure women we will respect and support her decisions.

Hope these suggestions are useful to you in helping your client.

Barbara & Kay

References:

Cox DB, Owens RA, Hartmann PE.  Blood and milk prolactin and the rate of milk synthesis in women, Experimental Physiol 1996; 81:1007-1020.

Prentice A, Addey C, Wilde C.  Evidence for local feedback control of human milk secretion.  Biochem Society Transactions 17 1989; 17:122.

Interesting updates on our recent Ask B & K case regarding the toddler who refused solids.  Ameera, the Egyptian IBCLC who wrote us about this case communicated the surprising news that the mother weaned the baby and the baby immediately began accepting solids.  This is a very counter-intuitive result, but in the interest of intellectual honesty, we feel obligated to report the outcome.

We also received a very interesting response from a mother with a similar problem whose baby was eventually diagnosed with swallowing dysphagia.  Read her story by scrolling down to the bottom of our response to Ameera.  Please send us your thoughts on these cases.

Swallowing dysphagia as a cause of rejection of solid foods

A mother wrote us in response to Meera’s question.  Her comments are quite interesting, and Kay and I thought we would share them because they represent another organic reason why a child might reject solids.  Shannon’s persistence in seeking a reason for her child’s delayed reaction to a normal developmental milestone shows how difficult it can be to find answers and how often it is necessary to seek second and even third opinions from care providers.

Shannon writes:

I want to share another possible reason why the baby in Egypt will not accept solids.  When my son, Finn, was 6 months old, I was concerned that he refused to take any solids.  He accepted food, but as soon as it touched the back of his mouth he gagged.  Pureed food could be thick or thin, but it always elicited a gag response.  We tried several varieties of fruits, vegetables, and cereals with no success.  Even juice, water or expressed breast milk fed from a spoon made Finn gag.

Some of my LLL friends told me not to worry, sharing that their babies refused solids until 10 months or 12 months. But what was so overwhelming and concerning to me was that Finn was  also unable to take a bottle or cup.   He had the same gag reaction to anything in his mouth, so eventually he began refusing the bottle or cup.  I recall he was able to take the bottle a few times in his first month, but from 2 to 6 months was unable to. This did not seem normal to me.

His breastfeeding behavior also concerned me.  Finn often broke suction once my milk let down.  I could hear him breaking suction as well as feel it. Even at 8 months old he would often come off the breast gagging, unable to handle a fast milk flow rate.  Finn began sleeping 4-5 hours at a stretch at night around 3 months old, giving me some rest, but when he was 7 months old he went back to nursing every 2-3 hours at night. The pediatrician and I thought this was because he was hungry.  We began doing weekly weight checks and he was staying in his curve, I think due to the frequency of his night feeds.

I teach classes in the evening once a week and am away from him for 4 1/2 hours.  My husband had to bring the baby to me before class, at the class break, and at the end of class to nurse because his feeding difficulty made it impossible for others to care for Finn.

The pediatrician looked in his mouth and noticed a bifid uvula and suggested we schedule an appointment with a pediatric ENT to rule out a submucous cleft of the palate.   It took a month to get the appointment.  In the mean time I contacted Early Intervention to see if Finn would qualify for services.

A Speech Therapist came out to perform an evaluation. After screening Finn for delays in all the developmental areas she did not observe enough delays for him to qualify for therapy, even though at 9 months, he could not take a cup or bottle, eat any solid foods, or sleep for more than 3 hours at a time.

The speech therapist told me to just let him “cry it out” at night.  She advised also my husband to let Finn cry because at 9 months he should be able to go 4 1/2 hours without eating and that the crying was a behavior issue not a hunger issue.  This advice disturbed me because although I know my husband is not at risk for shaking a baby, the statistics show that men who are left with crying babies are the most likely to shake them.  Her advice did not seem sound or humane to us.

We finally saw the ENT and he made a diagnosis of dysphasia and he ordered a barium swallow study.  Once we got the diagnosis, we became eligible for  Early Intervention services in our home. The Occupational Therapist (OT) helped us schedule the swallow study and was there to help us understand the results.  We learned that at 10 months old, Finn had the swallowing capability of a 3-month-old.  Along with the slight structural abnormality, his main problem was low tone.  The OT specialized in a technique called Vital Stimulation Therapy that uses externally applied low-current electric stimulation to the neck and face.  She told us that she had seen this help many infants improve their breastfeeding and solid feeding abilities so I was eager to try it.  (Their website http://www.vitalstim.com/ describes it as an “FDA approved therapy for dysphagia.”)

The OT attached electrodes to Finn’s neck and put ace bandage around to hold it on.  She started out at a low frequency and then after 10 minutes increased.  He tried to pull the wires off a few times, but got used to it quickly.  He nursed for the first 5 minutes, then the rest of the 30 minutes he sat on my lap and played as she increased the intensity.  A few days later, he was able to take a few tiny sips of juice from a small cup for the first time without gagging.  A week later he was able to take a few tiny tastes of yogurt off a baby spoon!  This was a milestone for Finn, but to me it meant freedom!

Finn only needed 3 more sessions of vital stimulation to achieve swallows from the sippy cup and move onto other foods like french fries. When Finn was 12 months old,  the OT decreased the therapy from weekly to twice a month.  At 16 months, Finn saw the OT only once a month.  At 21 months, we had our final OT session.  Finn is now 28 months old and still mostly nurses, only eats a few bites of food when he is around me, but when I am working and away he eats more.  At his last appointment he was up to the 47 percentile from 30th just three months before.

I hope sharing my story will help others consider swallowing dysphagia as a possible reason for solid food refusal.

Shannon.

Message: I have a client who has a baby boy who is 14 months old.  He is exclusively breastfed, but he refuses all kind of solid food.  The mother has tried almost everything.  He appears a little overweight. She asks if she has to wean him?

Ameera Hassan, IBCLC
Cairo, Egypt

Barbara & Kay Respond:

Dear Ameera,

Normally, between 4 to 6 months, babies become curious about foods and begin to reach for food from their mother’s plate. Eating with the family becomes an enjoyable social experience. When a child refuses all attempts to get them to eat solids, we would not describe this a breastfeeding problem.  Millions of babies enthusiastically consume solids while continuing to breastfeed.

Sometimes mothers misunderstand how much food the toddler should eat.  They may describe a child who eats only small portions or merely tastes things as “not eating”.  However, small portions are normal for toddlers.  In addition, some toddlers are very resistant to certain foods or even to being fed. Many families tell funny stories about toddlers who would eat only one food for weeks, or who would only eat if allowed to feed themselves.

Once babies are 6 months old, parents should try putting small amounts of mashed food from the table in front of babies and allowing the baby to taste things without any pressure to consume more than they want. Flexibility and a relaxed attitude are necessary when feeding toddlers.

There are some reasons for outright refusal of solid foods:

1. Vitamin and mineral deficiencies can result in  food refusal.  Sometimes the child has a medical problem that results in inability to metabolize micronutrients; sometimes the mother has a deficiency and the breastfed infant becomes deficient because the mother’s milk is lacking in a specific vitamin or mineral. There are case reports (see references below) of Vitamin B(12) deficiency resulting in solid food refusal.

2. There could be a mechanical problem in the child’s throat or intestinal track (a blockage or stricture) that may affect his willingness to swallow solids or ability to digest anything but a liquid diet.

3. Sometimes feeding aversions develop as the result of early unpleasant oral experiences (such as long periods of intubabtion.)  Feeding aversion can also result if something about the solid food feeding experience feels unpleasant to the child.

You mention that the boy appears slightly overweight.  Could an undiagnosed illness of some sort be causing him to retain fluids and appear swollen when perhaps he is actually malnourished?

Once again, we think this should not be labeled a “breastfeeding problem” but as a feeding problem.

The baby should have a medical evaluation, and the mother tested for Vitamin B(12) deficiency. Perhaps the mother could receive counseling to insure that she has realistic expectations of toddler feeding behavior.  Breastfeeding should continue while they figure out why the baby refuses solids.

Please let us know what the result of your investigation finds.  We are curious about this case.

Update

Ameera contacted us with the following additional information:

They did the blood work on the baby and everything looks fine.  The pediatrician is not convinced that it is necessary to do invasive investigations like endoscopy.  His diagnosis is that the  baby is taking too much milk through breast feeding so he is too full to try any new food.  He advised the mother to let the baby get hungry as much as possible.  According to the mother this did not work, so she decided to  wean him completely and abruptly despite anything I said to her.  Today will be the third day without any breastfeeding.  I am waiting to hear from her about the outcome of her decision.

Barbara & Kay respond:

It is good news that the baby’s blood work showed no problems, but how frustrating to still not have an answer.  Perhaps more will become clear over time.  Just to be re-emphasize one point, the Vitamin B(12) deficiency that is referred to in the reference below was a maternal vitamin deficiency that affects the baby, so the mother’s Vitamin B(12) levels should be checked.

References:

Eur J Pediatr. 2011 Jul 7. [Epub ahead of print]

Solid food refusal as the presenting sign of vitamin B(12) deficiency in a breastfed infant.

Ide E, Van Biervliet S, Thijs J, Vande Velde S, De Bruyne R, Van Winckel M.

Source

Paediatric Gastroenterology and Nutrition, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.

Abstract

Dietary vitamin B(12) (vitB(12)) deficiency, although common in the elderly, is rare in childhood. We report on an exclusively breastfed 8-month-old infant, presenting with persistent refusal of solid foods. Three months later, developmental regression and failure to thrive led to the diagnosis of vitB(12) deficiency, as a consequence of a subclinical pernicious anaemia with vit B(12) deficiency in the mother. Treating the infant with parenteral vit B(12) induced prompt recovery including acceptance of weaning food. Conclusion: This case illustrates refusal of complementary foods as a presenting symptom of vitB(12) deficiency in a breastfed infant. Symptoms, diagnostic tests and treatment of vitamin B(12) deficiency are reviewed. Early diagnosis and treatment are important to prevent irreversible neurological damage.

Eur J Pediatr. 2010 Mar;169(3):373-4. Epub 2009 Oct 28.

Food refusal in 1-year-old child.

Ravikumara M.

Source

Paediatric Gastroenterologist, Princess Margaret Hospital for Children, Roberts Road, Subiaco 6008, Australia. Madhur.Ravikumara@health.wa.gov.au

Abstract

This is a case report of a 1-year-old, otherwise healthy, girl who presented with the history of refusal of solid foods and vomiting of 1-month duration. She underwent upper gastrointestinal endoscopy, which revealed an eye-catching endoscopic finding and the cause of her symptoms.

Congratulations to this year’s winners of the Wilson-Clay/Hoover Poster Prize.  The poster that won the award this year was submitted by Pamela Hendrix, Susan Welke, Kerry Foligno, Angelina Rodriguez, “The Lived Experience of Lactation Following Bariatric Surgery.”

Shown (from left to right), are Syreeta, a WIC Peer Counselor from Virginia, Kay Hoover, and Victoria, an IBCLC from Ukraine, winners of the Wilson-Clay/Hoover ILCA Conference Scholarship.  Also shown (far right) is Joy Heads, a proud new ILCA Board member. The Wilson-Clay/Hoover Conference Scholarship was developed as a mentoring opportunity to assist new and aspiring LCs to attend the ILCA conference for the first time.  Barbara and Kay hope that the exceptional international environment and the educational stimulation of the conference will inspire these new members of our profession to take some of that excitement back to their own practices.

In just under a month, over 200 students preparing for the LC certification quiz have signed onto our website to take one of our new multiple choice clinical photo identification quizzes.  Students from all over the world, including Singapore, Greece, Poland, Canada, Australia, have emailed to say thanks for the opportunity to practice for this challenging portion of the IBLCE exam.  Kay and Barbara want to wish all the exam candidates good luck, and to thank everyone on the positive feedback.  There are great reviews of our quizzes from USLCA and The Journal of Clinical Lactation.

Question:
What are the issues involved in donating used breast pumps?

I work with a mother support group.  We have a policy against accepting used pump donations. Since we can’t take used pumps, what do you usually suggest that she do with the pump she is finished using?
Thanks!
Faye

Answer:
Barbara and Kay’s response

Unless the pump is a manual pump that can be completely disassembled and sterilized, or is a pump designed for multiple users, pump sharing is not advised. While this sounds wasteful to some, the issue is not about the parts that you can access for cleaning, like flanges, bottles, valves, etc. but the internal parts of electric motors which cannot be sterilized.  Pumps designed for multiple users have hepa-filters or are designed to create suction externally so that motor contamination is not an issue. Pumps with these infection control features are called “hospital grade” pumps and not generally priced for purchase by individuals.

Most of the electric pumps priced for individual users are labeled by their manufacturers as being for single users only.  Consequently, there is a legal liability issue along with an infection control issue.  Warranties become invalidated when instructions for use are ignored, and potential legal exposure exists in the event of any bad outcome.  The pump company is protected in such cases because they have labeled the equipment as single-user; for anyone else to advise a mother to ignore that labeling creates potential legal risk. This is why mother support groups establish policies to warn against pump sharing.

Experiments have demonstrated that when drops of milk splash on the bottom of a bottle, small particles (bacteria and viruses) can be sucked up in an aerosol form into the motor. (Blenkhorn 1989) Tiny amounts of particulate material can accumulate. The next time the pump is turned on, it can blow down small amounts of this material and “re-seed” fresh milk in a sterile bottle. This would not be much of an issue for a woman’s own baby (unless that baby were ill or very premature.) Healthy babies are already exposed to their own mother’s “germs”, and receive specific antibodies in the milk to protect them.  However, if the next person to turn on the pump is a different mom, perhaps with a compromised baby, then there is a risk associated with exposing that baby to new pathogens.  While there is no research to guide us, Kay has wondered whether there is any risk if the mother stores her pump between babies?  Would re-seeding be an issue for the next newborn?

In an effort to explore the phenomenon of aspirated milk potentially contaminating pump motors, Barbara Wilson-Clay purchased several small electric breast pumps at garage sales in the late 1990s.  Upon opening the motor casings with a screwdriver , the insides of these motors were found to contain white flakes and sticky gunk. Kay Hoover has had the same experience removing the white membrane on a well-know “back to work pump.”  When she opened the motor casing, she observed similar material that appeared to be old milk.

Just as casual milk sharing has associated risks that have been poorly documented and appear to be poorly understood, so too with pump sharing. Bad outcomes are under-reported. Most people would not perhaps recognize a bad outcome (a baby becoming ill), or think to associate the illness with pump sharing.  Most people do no know where to report bad outcomes, although the US FDA provides a website to report pump problems.

Finally, legal responsibility aside, there is an ethical component to this discussion.  Does anyone really want to take responsibility for exposing someone else’s newborn to a staph infection or any of the  various forms of hepatitis, all of which live a really long time on hard surfaces? When a mother asks about pump sharing or pump donation, it is always best to be very clear about what kind of pump is involved and whether it is safe to share.

References:

J Hosp Infect. <http://www.ncbi.nlm.nih.gov/pubmed/2564015> 1989
Jan;13(1):27-31.

Infection risks from electrically operated breast pumps.

Blenkharn JI
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Blenkharn%20JI%22%5BAuthor%5D> .

Source

Department of Bacteriology, Royal Postgraduate Medical School, Hammersmith Hospital, London.

Abstract

Using formula milk seeded with Staphylococcus epidermidis as indicator, bacteria were observed to pass beyond the collecting bottles of three electrically operated breast pumps. Bacteria were recovered from sites distal to the level of visible contamination, the incidence increasing with repeated use of the apparatus. Despite use of a sterile collecting bottle, retrograde contamination of freshly collected milk may occur from previously contaminated components of the pumps. The results suggest that a terminal in-line air filter is essential to ensure aerosols containing potentially pathogenic bacteria do not contaminate the suction source or be emitted to the environment with the exhaust air. Where a single pump is used by more than one person adequate sterilization of all removable components is essential.

J Hosp Infect. <http://www.ncbi.nlm.nih.gov/pubmed/11740876> 2001
Dec;49(4):274-81.

Contamination of breast milk obtained by manual expression and breast pumps in mothers of very low birthweight infants.

Source

Department of Paediatric, Hospital Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, 56000, Malaysia.
nyboo@mail.hukm.ukm.my

Abstract

The objective of this study was to compare the rates of bacterial contamination of expressed breast milk (EBM) obtained by manual expression and breast pumps in mothers of very low birthweight (VLBW) infants (<1501 g). This was a randomized, controlled study carried out on 28 mothers of such babies and 92 specimens of EBM were collected: 41 specimens from 13 mothers assigned to the manual group and 51 specimens from 15 mothers in the breast-pump group. EBM was cultured quantitatively by the Miles and Misra method. Breast milk expressed by breast pumps (86.3% or 44/51 specimens) had a significantly higher rate of bacterial contamination than milk expressed by the manual method (61.0% or 25/41 specimens) (P= 0.005). When breast milk was expressed in the hospital, there was no significant difference in contamination rates between the two methods. When breast milk was expressed at home, the rates of bacterial contamination by staphylococci (P= 0.003) and Gram-negative bacilli (P= 0.002) were significantly higher in the breast-pump group than the manual group. In conclusion, the rate of bacterial contamination of EBM of mothers of VLBW infants was high, especially when EBM was obtained by the breast pump or when expression was carried out at home.

J Hum Lact. <http://www.ncbi.nlm.nih.gov/pubmed/15886342> 2005
May;21(2):169-74.

Breast pump adverse events: reports to the food and drug administration.

Brown SL
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Brown%20SL%22%5BAuthor%5D> ,
Bright RA
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bright%20RA%22%5BAuthor%5D> ,
Dwyer DE
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Dwyer%20DE%22%5BAuthor%5D> ,
Foxman B
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Foxman%20B%22%5BAuthor%5D> .

Source

Division of Postmarket Surveillance, Epidemiology Branch, Center for Devices and Radiological Health, Food and Drug Administration, Rockville, Maryland 20850, USA.

Abstract

Breast pumps are medical devices used to express milk and maintain the milk supply. The purpose of this study was to characterize adverse events reported to the United States Food and Drug Administration (FDA) on breast pumps. Thirty-seven adverse event reports on breast pumps were identified from the Manufacturer and User Facility Device Experience database between 1992 and 2003. Four additional reports were found in the Device Experience Network database from 1992 to 1996. The most commonly reported adverse events for electric breast pumps were pain, soreness, or discomfort; the need for medical intervention; and breast tissue damage. Most frequently reported problems for manual breast pumps were breast tissue damage and infection. Contamination of breast milk during pumping was also reported. Breast pump adverse events are likely underreported to the FDA. Reporting adverse events is important for improving the design and manufacture of breast pumps and subsequently decreasing adverse events.

Barbara Wilson-Clay, BS, IBCLC, FILCA

Candice, one of the  great WIC peer counselors from the Atlanta area, presented the luncheon entertainment for the conference at which Barbara presented a day-long clinical training workshop.  What a fun group!

Anne Charest, IBCLC, and Ghislaine Reid, IBCLC, two lactation consultants from Quebec, Canada, generously translated the poster into French.  Anne and Ghislaine have agreed to let us share their translation with other French speaking lactation consultants around the world.  Both the English and French versions of Kay’s poster may be freely reproduced and shared.  Thanks, Anne and Ghislaine for expanding the usefulness of this important tool.

Radio-Contrast Materials and Breastfeeding Poster

BreastfeedingMaterials.com Training
Lactation Photo Identification Quiz Series; Quizzes 1 and 2
Barbara Wilson-Clay and Kay Hoover, © 2010 BreastfeedingMaterials.com
The Lactation Photo Identification Quiz Series is a new addition to Barbara Wilson-Clay and Kay Hoover’s collection of visual teaching and learning aids. It can be used by would-be lactation consultants or healthcare professionals who desire to improve clinical lactation assessment skills in a more interactive way than by reading words in a textbook, and by lactation consultants preparing to take or re-take the credentialing exam. The series consists of two separate quizzes, each with 50 lactation-related photographs and an accompanying multiple-choice question.

To truly evaluate this series, I took both exams myself. First, of utmost importance, the photographs are clear, and unambiguous. You see what you are supposed to see. I have taken the actual International Board of Lactation Consultant Examiners exam in the past, and I have used other methods to study for the photograph identification portion of the exam (http://www.iblce. org/). I have found myself unconsciously and somewhat laughably holding the practice tests and the test booklet up in the air, as if turning it this way and that would help me see what in the fuzzy, ill-lit, poorly colored picture they expect me to see! That was definitely not the case with these photographs. They are very well done, and are things that we see commonly. That is important to learners and those reviewing for the exam alike. These quizzes test knowledge of lactation issues that are common, or at least may be reasonably expected to be seen in a practice, not of esoteric conditions one will never see.

The next most important issue in such a learning guide is: Are the questions clear? The response—a most definitive yes! I did not find myself trying to secondguess the examiners. Were the questions easy? No—one needs to know one’s stuff. There were times I was stuck between two possible answers, just as often happens on the exam. But only one answer was correct, and that is what counts. The questions were well-written, and you learn if you don’t know the answer–or even if you do. There is immediate feedback on whether your choice is correct or not. Either way, once you enter your response, the correct response, an explanation of why it is correct pops up. Every response has at least one current reference if you require further reading on the topic. This is well done. A test and a learning exercise. It doesn’t get much better than that. With many examinees worried the most about the picture portion of the credentialing exam, this quiz series is a great way to beef up on that part of your test taking and lay some of those fears to rest.

Another clever feature—once you purchase the Lactation Photo Identification Quiz Series, you have unlimited access to the quizzes. The directions state that if you take the quizzes more than once, the questions will appear in random order, so you really will test your knowledge and not your ability to recall responses in order. I highly recommend this study guide whether you are just starting out in clinical lactation, you are reviewing for your certifying exams or you just want to challenge yourself and add to your knowledge in a fun and interesting way.

You can find the quizzes at:
https://training.breastfeedingmaterials.com/