What Do I Say after I Say, "Hello"?
Big Flats, New York, USA
Do you remember completing the Preview when you were a Leader Applicant? I do! Although I had been assured that this was not a test, that it was simply a practice session, I was extremely nervous. What if I couldn't remember the correct answers? What if I said something totally inappropriate? And, supposing I actually was accredited, would I forget everything I'd learned when I received my first real La Leche League call? Talk about stage fright!
Somehow, I survived that practice session and went on to become a Leader, going on to help other young mothers through that same process. Almost all of them expressed the same concern: "What do you say after you say 'Hello'?"
One of the reasons I love being a Leader is because I am fascinated by mysteries. From the time I first discovered Sherlock Holmes and Agatha Christie, my goal was to solve the puzzle before the end of the book. I learned how to recognize and sift through the clues, discarding the red herrings until the truth emerged.
Exactly the same skills are needed when Leaders help mothers by telephone. We collect information, identify the pertinent parts, and attempt to solve the mystery. However, helping mothers to overcome breastfeeding obstacles is more serious than reading a book. Here are some suggestions for solving breastfeeding puzzles over the phone.
When a mother calls La Leche League, she is very often in distress. She may be hesitant to talk to a total stranger about what is, after all, a very intimate situation. She may be feeling overwhelmed or she may be anxious. Matter-of-factly asking for some basic information - her name, address, etc. - gives her a chance to calm herself. Saying something like, "Let me get my notebook and a pen so I can write this all down, and then we can see if a pattern emerges." gives the mother confidence that her concern is valid, and it helps the Leader feel organized too!
Occasionally, a mother will be hesitant to reveal her identity, despite being assured that our records are confidential. This most often happens when the caller needs information about how long it takes an illegal drug to go through her system so that it is again safe to nurse. We can reassure the mother that we will provide the information, even if she wishes to remain anonymous.
Keeping records of calls enables us to follow the mother's progress, to send written information when appropriate, to collect data about the area we are serving, and to know who is referring the mothers to LLL. It may also help us to identify the problem. Basic information can include the mother's name, address, and phone number; who referred her; other children and whether they were breastfed; and this baby's name, age, birth weight, and present weight.
Why is this mother calling? It is not at all unusual for a mother to start by talking about one concern, when it is an entirely different one that is bothering her. Sometimes a mother prefers to "test the waters" before plunging in headlong. In reply to gentle prompting she will slowly furnish information about her concerns. Using Human Relations Enrichment (HRE) communication skills can help a Leader gather both concrete information and inklings about the mother's feelings.
When? What? How?
We need to know when the problem started, what caused it, and how it manifests itself. Asking gentle, open-ended questions is the most effective way to discover these facts. It is important to be very specific. If we ask, "Does your baby nurse often?" the mother may give a yes or no response. "Often" can mean different things to different people. Consider asking instead, "Think back over the past twenty four hours. At what times did your baby nurse? Did you or your baby signal the end of the nursing? Did he seem satisfied? If not, what did you do? How many wet and dirty diapers did he have during this period?"
Suppose that a new mother asks, "What kind of pacifier do you recommend? I can't nurse the baby all day - there is the house to take care of, too!" By empathizing with the mother's feelings of frustration, we may encourage her to open up to us, and this will indicate the next direction to take. Perhaps she is asking about pacifiers because:
- She is nursing infrequently, resulting in a hungry baby.
- She believes that her baby must be stalled to meet a certain schedule.
- Her mother-in- law is coming to visit and she thinks that she needs to have a perfectly clean and tidy house.
- She thinks that babies need to have pacifiers because "everybody" uses them.
- Her doctor told her not to let her baby use her breasts as pacifiers or she will get sore.
- She was given a pacifier by the hospital but the baby doesn't like it.
- She has sore nipples and breastfeeding is painful.
Here is another example of an initial question where there may be a hidden agenda: "When we went to the doctor for the two week checkup, Annie had not yet regained her birth weight. I was told to give her a bottle after every feeding. How long do you think I will have to do this?" One appropriate response would be to ask, "What did your doctor actually say? Did he have a specific weight gain or time frame in mind? How much has your baby actually gained since birth? How many wet and dirty diapers has your baby had in the past 24 hours?"
When we have those facts, we can then look at some of the possibilities:
- Mother may not have been nursing often enough because of pacifier use, because she didn't recognize the baby's cues, or because the baby is still sleepy from the drugs that the mother received in labor.
- Mother may have been restricting each feeding to a set number of minutes at each breast.
- Her baby may be poorly attached. Mother may be sore but not complaining, or she might think it is normal for breastfeeding to hurt.
- Her baby may be ill, perhaps with severe jaundice or an undetected heart problem, rendering him too tired or weak to nurse well.
In each of these cases, we can explain normal newborn weight gain patterns and talk about how to establish a milk supply. If appropriate, we can suggest alternate feeding methods (cup feeding, for example) and ways of increasing the mother's supply (nursing more frequently, using a nursing supplementer, and/or pumping).
Another possibility is that the mother may not actually want to nurse, but feels obliged to do so. As La Leche League Leaders, it can be difficult for us to even imagine a mother not wanting to nurse her baby because we know about the innumerable benefits of breastfeeding, both for our babies and ourselves. We wonder how someone can know the facts and still refuse to nurse. Nevertheless, it is each mother's right to decide what is best for her and her family. We do not know her background; we have not walked in her shoes. Validating a mother's wish to wean her baby may be the most important - and the hardest - thing we do that day.
Answer the question!
Suppose that a mother says that she will be going back to work when her baby is six weeks old. She wants to know what kind of pump La Leche League recommends, how often she will need to pump, and how much milk to collect each day.
Just as it may be hard to imagine a mother choosing not to breastfeed, it may also be a challenge to answer a mother who will be separated from her baby by work. La Leche Leaders help all mothers who choose to breastfeed. Babies who are away from their mothers have an increased need for their mother's milk, and providing that milk helps their mothers to feel more connected to them.
The mother needs to know that there are different kinds of pumps for different situations. How much time will she spend away from home? How close is the sitter to the work site? Does she have a private office or is there is another sanitary, private place where she can pump?
Giving mothers information about how much milk a baby needs is just as important as helping her to decide the kind of pump that would work best for her situation and how the pumped milk will be given to her baby.
Information or advice?
The other day I was talking with a friend who had just had an argument with another mother. She was angry, indignant and disappointed. "All I did was tell her what to do!" she said.
Apparently, the other mother had asked a question about her baby's behavior. She didn't understand why, after falling off repeatedly, he continued to climb on the sofa. Why didn't he learn from past mistakes?
My friend had replied that you just had to watch babies of this age every second. The mother took this as a personal attack on her mothering and started yelling. You can imagine the scene! What went wrong? Who was to blame?
It is a fact of life that very few people like being told what to do. New mothers are especially vulnerable - just about everybody seems to know exactly what their babies need, and everyone gives different advice! In La Leche League, we pride ourselves on saying, "Mother knows best!"- and meaning it. We can share information, make suggestions and offer encouragement, but the mother knows her own baby better than anyone else, and she is the one to decide what will work in her unique situation. A Leader's job is to empower the mother.
When is telephone help not enough?
Although many common breastfeeding questions can be answered right away on the phone, some situations are more complex. When is it appropriate for a Leader to meet with a mother in person?
If it hurts to breastfeed, the most likely culprit is improper positioning. It may be possible to suggest certain adjustments on the phone, but the most effective way to determine the source of the pain may be to actually watch the mother and baby. Sore nipples may be due to a number of different causes that are difficult or impossible to pinpoint by phone.
If a mother is concerned about her baby's poor weight gain and the baby is sleepy or not producing the appropriate number of wet and dirty diapers, someone needs to see the baby. Encourage the mother to discuss her concerns with the baby's health care provider. If the mother or baby is experiencing any kind of problem that has not been resolved by information given by phone or email, he or she needs to be seen.
Leaders have varying degrees of experience and skills. A Leader can consult with her Professional Liaison (PL) Leader if she is concerned about the situation. If a home visit is indicated, a new or insecure Leader can ask a co-Leader to accompany her. Remember, however, that home visits are optional and are not considered one of a Leader's basic responsibilities.
When is it appropriate to refer a mother to a lactation consultant?
Over the past few years, lactation consultant services have become more widely available, both in hospital settings and in private practice. If a Leader feels uncertain, is not willing or able to make a home visit, and it is not possible to refer the mother to a more experienced Leader, then it is appropriate to suggest the mother contact a lactation consultant.* Lactation consultants usually help mothers deal with specific situations, rather than offering ongoing support. In fact, many of them refer mothers to La Leche League Groups to meet other nursing mothers and to observe normal baby behavior. Situations that warrant a referral include:
- The baby is not gaining weight.
- The baby is weak or listless.
- The baby is tense, hypertonic (points his toes, arches, and screams).
- The baby is unable to suckle.
- The baby is noticeably dehydrated (insufficient number of wet diapers, dry mouth, dry eyes, and poor skin tone).
- Anything out of the ordinary or whenever something just feels wrong.
Note that these are "red flag" situations. A Leader can consult with a PL Leader if she has concerns. Encourage the mother to discuss the situation with the baby's health care provider.
What if other help is needed?
As Leaders, our area of expertise is breastfeeding. It is important to recognize that some situations may go beyond our own level of knowledge and experience. Not every concern that a mother brings to our attention may be directly related to breastfeeding. We can help mothers find other sources of help when appropriate. A current list of local volunteer and professional organizations including contacts for doctors who have special skills; support groups for parents who have lost a child, had a miscarriage, or whose children have special health conditions; childbirth or prenatal classes; playgroups and mothers' groups; therapists who specialize in marriage counseling; and the local rape crisis center and safe house be useful.
Here are some typical situations where a referral to a doctor or other health care provider may be in order. Some are breastfeeding-related and some are not.
"My baby's bottom has a rash, and there are white spots in his mouth. The doctor prescribed a cream for his bottom and drops for his mouth. Could those drops be making my nipples itchy?"
Both mother and child will need to be treated simultaneously for thrush. Offer her written information to share with her own doctor.
"My baby's skin gets darker when he nurses. After a few minutes, he stops nursing and sort of pants. Then he starts nursing again. Is this normal?"
This baby needs to be seen immediately - at emergency room if it's after office hours. This is not normal newborn behavior.
"My doctor has told me I need to take Prozac and I need to wean. Is this true?"
The Professional Liaison Department has the latest information about this and other drugs as they relate to the nursing mother and her baby. The Leader can give the mother the information so that she can then share it with her doctor, and together they can make an informed decision.
"My baby is so sweet. When he tries to stick his tongue out, it has a cute little 'tuck' in the tip. But that's not why I'm calling. I'm calling because my nipples have been bleeding for two weeks."
This sounds like tongue-tie. THE BREASTFEEDING ANSWER BOOK contains information about this condition. Refer the mother to a breastfeeding-friendly oral surgeon, dentist, or pediatrician.
"How normal is it to feel nervous about having a new baby, especially when you've already had one child?"
Continuing this conversation reveals that the mother's ex-boyfriend stalks her when she takes an older child to nursery school or to the store. This mother needs a referral to the local safe house or women's shelter.
"Patsy was born with Down syndrome. I am trying to nurse her but she is so floppy that she has trouble latching on. What can I do to help her?"
First acknowledge mother's feelings, and then offer information about getting the baby to breast. Share information about support services available in the area.