CLC - Certified Lactation Counselor Special Infant Considerations Questions and Answers — Questions and Answers
Question 1: A CLC is counseling the parents of a late preterm infant (35 weeks gestation). The mother reports the baby is very sleepy, often falls asleep after only a few minutes at the breast, and has had infrequent stools. Which of the following is the MOST important concept for the CLC to explain to the parents?
- The infant is likely getting all the needed nutrition in those few minutes.
- Late preterm infants often need formula to have enough energy to breastfeed.
- Sleepiness and a weak suck are common and can lead to inadequate milk transfer, requiring careful monitoring and management. (Correct answer)
- The mother's milk supply is likely low and is the primary cause of the infant's sleepiness.
Correct answer: Sleepiness and a weak suck are common and can lead to inadequate milk transfer, requiring careful monitoring and management.
Late preterm infants (34 0/7 to 36 6/7 weeks) often appear like term infants but are physiologically immature. They are characteristically sleepy, have low stamina, and may have an uncoordinated suck-swallow-breathe pattern. [3] This can lead to ineffective milk transfer, even with a seemingly good latch, resulting in poor weight gain, dehydration, jaundice, and hypoglycemia. [2] The CLC's primary role is to educate the parents about these risks and implement a feeding plan that involves waking the infant for frequent feedings, ensuring effective milk removal (possibly with pumping and supplementation of mother's own milk), and closely monitoring output and weight. [2]
Question 2: A mother is concerned because her 5-day-old breastfed infant's skin appears yellow. What is the CLC's best advice regarding the management of common, physiologic jaundice?
- Temporarily stop breastfeeding for 48 hours and give formula to see if the yellow color improves.
- Give the baby sips of sterile water between feedings to help flush out the bilirubin.
- Ensure the infant is feeding effectively and frequently, at least 8-12 times in 24 hours, to promote stooling. (Correct answer)
- Advise the mother to get as much rest as possible, as maternal fatigue is the main cause of infant jaundice.
Correct answer: Ensure the infant is feeding effectively and frequently, at least 8-12 times in 24 hours, to promote stooling.
For physiologic jaundice, the primary management strategy is to ensure the infant is receiving adequate milk. [27] Colostrum and breast milk act as a laxative, and frequent stooling is the main way the infant's body excretes bilirubin. [26] Increasing breastfeeding frequency to at least 8-12 times per day helps to establish the mother's milk supply, ensures the infant is well-hydrated and nourished, and facilitates the passage of meconium and subsequent stools, which helps resolve the jaundice. [26, 27] Giving water is contraindicated and can worsen the situation. Stopping breastfeeding is rarely necessary and should only be done under medical supervision for specific, severe cases. [25]
Question 3: An infant is born with a cleft palate but an intact lip. The mother is highly motivated to provide breast milk. Which of the following presents the MOST significant challenge for direct breastfeeding with this condition?
- The infant's inability to create adequate negative pressure for suction. (Correct answer)
- The mother's breast tissue being too large to fit in the infant's mouth.
- The infant's tendency to swallow excessive amounts of air.
- The risk of milk irritating the exposed nasal passages.
Correct answer: The infant's inability to create adequate negative pressure for suction.
The primary challenge for an infant with a cleft palate is the inability to create a vacuum or negative pressure inside the oral cavity. [19] The opening in the palate prevents the mouth from being sealed off from the nasal cavity, making it impossible to generate the suction needed to draw milk from the breast. [15] While milk can enter the nose and the infant might swallow air, the fundamental problem is the lack of suction for effective milk removal. [15, 22] Therefore, interventions often focus on alternative feeding methods (like specialized bottles) or at-breast supplementers, combined with positioning and breast compressions to assist milk flow. [14]
Question 4: A CLC is working with a mother and her newborn diagnosed with Down syndrome. The CLC observes that the infant has difficulty sustaining a latch and seems to tire quickly. This is most likely related to which common characteristic of infants with Down syndrome?
- An unusually strong suck reflex.
- Hypotonia, or low muscle tone. (Correct answer)
- Aversion to close physical contact.
- A smaller-than-average oral cavity.
Correct answer: Hypotonia, or low muscle tone.
Hypotonia, or low muscle tone, is a hallmark characteristic of infants with Down syndrome. [16, 17] This affects all muscles, including those of the mouth, tongue, and jaw, which are critical for breastfeeding. [24] Low tone can make it difficult for the infant to achieve a deep latch, maintain a seal, and coordinate the suck-swallow-breathe pattern effectively, leading to fatigue and inefficient milk transfer. [17, 30] The CLC can help by suggesting supportive positions (like the dancer hold) that provide extra stability for the infant's head and jaw. [30]
Question 5: A hospital-based CLC is reviewing a list of newborns on the postpartum unit. Which of the following infants should be most closely monitored for hypoglycemia and require a proactive feeding plan?
- A 39-week gestation infant who is average for gestational age (AGA) and whose mother had an uncomplicated pregnancy.
- A 40-week gestation infant who is large for gestational age (LGA) and whose mother has gestational diabetes. (Correct answer)
- A 41-week gestation infant whose mother plans to formula feed from birth.
- A 38-week gestation infant who had a brief period of tachypnea after a vaginal birth that has since resolved.
Correct answer: A 40-week gestation infant who is large for gestational age (LGA) and whose mother has gestational diabetes.
Infants at highest risk for neonatal hypoglycemia include those who are large for gestational age (LGA), small for gestational age (SGA), late preterm, or born to mothers with diabetes. [5, 6, 8] An infant of a diabetic mother (IDM) is exposed to higher levels of glucose in utero, leading to fetal hyperinsulinism. [5] After birth, the glucose supply from the placenta is cut off, but the infant's high insulin levels persist, causing a rapid drop in blood sugar. An LGA infant who is also an IDM has two significant risk factors. [6, 9]
Question 6: A mother of newborn twins is concerned about her ability to produce enough milk for two babies. Which of the following is the most important principle for the CLC to emphasize for establishing an ample milk supply?
- Limiting feeding duration to 15 minutes per baby to avoid exhaustion.
- Ensuring frequent and effective milk removal from both breasts, aiming for 8-12 sessions per 24 hours. (Correct answer)
- Assigning one baby permanently to each breast to create a specialized supply.
- Supplementing with formula after every feeding for the first two weeks.
Correct answer: Ensuring frequent and effective milk removal from both breasts, aiming for 8-12 sessions per 24 hours.
The principle of lactation is 'supply and demand.' Milk production is stimulated by the removal of milk from the breast. To establish a supply sufficient for twins, both breasts need frequent and effective stimulation. [21] The goal should be a combined total of at least 8-12 milk removal sessions (either by nursing or pumping) in a 24-hour period. [1, 7, 28] This high frequency in the early weeks signals the body to produce a robust milk supply capable of nourishing two infants. Limiting feeding time or routine supplementation would signal the body to make less milk.
CLC - Certified Lactation Counselor Special Infant Considerations Questions and Answers
A CLC is counseling the parents of a late preterm infant (35 weeks gestation).
The mother reports the baby is very sleepy, often falls asleep after only a few minutes at the breast, and has had infrequent stools.
Which of the following is the MOST important concept for the CLC to explain to the parents?