Paced Bottle Feeding- What is it?

Liliana Cruz, MS4, Drexel University College of Medicine

Many new moms are hesitant to see lactation consultants if they are not choosing to breastfeed their newborn, thinking that they will be shamed for formula feeding or that we only want to help breastfeeding moms. However, paced bottle feeding is a useful technique that breastfeeding and formula feeding moms alike can use to help prevent overfeeding and improve digestion for their baby.

 When using the paced bottle feeding technique, babies are positioned in an upright sitting position, and the bottle is held horizontally to their mouth. Instead of just accepting the flow from a bottle with minimal effort from the baby, which is what often happens when babies are fed laying down, baby needs to use their suckling strength to draw milk from the bottle, similar to what happens when a baby is breastfeeding. Moms are also encouraged to pause and burp their baby periodically throughout the feed to ensure that baby is only taking in as much as they need in that moment and to help smooth digestion.

We often advise breastfeeding moms to feed “on demand” or whenever their baby is exhibiting hunger cues like suckling on their hands or rooting. Babies who are fed at the breast will only take in as much milk as they can handle at that moment, often returning for a short “snack” or “dessert” after their main feed if they feel hungry again. With paced bottle feeding, formula fed babies are also only taking in as much as they need in the moment, and thus will also need to be fed in a similar on demand fashion. Feeding then becomes less about how many ounces have been consumed and more about the signals your baby is showing you.

Paced Bottle Feeding can also be useful for breastfeeding moms if they have to be away from their baby and another caregiver needs to feed the baby. Because paced bottle feeding mimics breastfeeding, babies are less prone to develop nipple confusion, an occurrence where babies start to prefer bottles to the breast due to their “easy access” flow of milk.

Thus, Paced Bottle Feeding is a technique that all moms can benefit from. We hope to encourage more moms to meet with us, even if they are not exclusively breastfeeding. Most lactation specialists will always encourage moms to breastfeed when they can, they serve as a support to all moms in feeding their baby!

Trauma-Informed Care – The Pelvic Exam

 Leila Hilal, MS4, Drexel University College of Medicine

As healthcare workers, we have a unique privilege in society; patients trust us at their most vulnerable moments and rely on us to help them reach their greatest potential in terms of their health.  Patients who have experienced sexual assault are at an even more vulnerable position when it comes to routine gynecologic exams to for cervical cancer prevention.  Trauma acts as a barrier to accessing healthcare. However, by providing patient-centered care with a trauma-informed approach, we can support our patients while providing the healthcare they need.

Within the past decade, there has been a large societal shift in the discussions around sexual assault and autonomy, best shown by the #MeToo movement.  It is a clinician’s daily choice, and a necessary one at that, to be mindful of traumas that our patients carry, whether they choose to share them or not.  In this blog, I’d like to review some of the ways to care for patients during a pelvic exam which can be a very stressful and triggering experience for survivors of sexual assault.  

The basic framework of any clinical institution should recognize the 4 “R”s established by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the foundation for trauma-informed care: Realize the impact of trauma and the potential for recovery, Recognize signs and symptoms of trauma, Respond by integrating knowledge about trauma into policies, and actively Resist Re-traumatization⁴. 

 So how do we follow these 4 Rs?

 SAMHSA suggests 6 key principles to follow: Safety, Trustworthiness and Transparency, Peer Support, Collaboration and Mutuality, Empowerment Voice & Choice, and Cultural Historical and Gender Issues⁴. 

Safety:

Ensuring that the patient and staff feel safe creates a calmer trusting environment.

1)      Have a chaperone in the room 

2)      Offer a safety person to accompany patient into the room

3)       Listen carefully to concerns or questions

4)      Allow for extra time – this prevents an exam from being rushed       

5)      Use the smallest speculum possible while still optimizing viewing

6)      Use lubricant       

7)      Offer shifting of clothing rather than clothing removal

8)      Avoid potentially triggering phrases such as “spread your legs” or “stirrups”, and instead choose phrases such as “allow your legs to fall open to the side” or “footholds”.

Trustworthiness and Transparency:

By being open and honest with your patient, a rapport of trust can be established.

1)      Explain everything you will be doing in advance, and while you are doing it¹ – (but ask the patient if they would like the explanation prior to giving it).

2)      Show the tools you will be using prior to starting an exam – but ask first! This may or may not help the patient.

3)      Keep the patient covered, exposing only areas necessary for examination.

 Peer Support:

Having resources to other trauma survivors can promote healing, but this does not play a large part during a pelvic exam.

1)      Offer up trauma peer support materials at the end of an exam

 Collaboration and Mutuality:

The aim of this principle is to establish a partnership and lessen the power dynamic between the physician and patient to decrease discomfort during the exam.

1)      Establish rapport before the exam

2)      Greet the patient while they are still fully dressed and sitting upright

3)      Normalize any feelings of anxiety they may have about pelvic exams

4)      Explain the importance of the exam and its utility

5)      Check in regularly during the exam to monitor the patient’s stress levels

6)      Offer up distractions during the exam (e.g., talking or music)

7)      Offer self-insertion of speculum⁵

 Empowerment, Voice & Choice:

By supporting a patient to have space to become a stronger self-advocate, the power dynamic lessens between physician and patient thereby creating a calmer and safer environment.

1)      Give the patient as must control and choice as possible

2)      Allow a female provider to perform the exam if requested

3)      Ask the patient if they have suggestions on how they would be more comfortable

4)      Before starting the exam, tell the patient that the exam will stop if they feel uncomfortable - reinforce that they are in control

5)      Ask permission before beginning the exam

6)      Be willing and ready to reschedule the exam for a later time

Cultural, Historical and Gender Issues:

Recognize any move past any stereotypes, biases or cultural barriers that may impede on a connection based on trust

 As a patient, how can you advocate for your needs?

·         If you have experienced trauma, or find pelvic exams nerve-wracking, consider letting your physician know when they schedule your pap if you are comfortable.  This allows them to be aware in advance of how you are feeling and can be more sensitive to your needs during the exam. 

·         Know that it is a common experience for women to feel nervous for their pelvic exams & pap smears – talk to friends or family who have gotten it done, and how they reduce their anxiety.

·         If you have coping methods or grounding methods that you use during anxiety-producing situations, ask your physician how you may be able to incorporate these methods into the pelvic exam if you need them. 

·         If you would rather insert the speculum yourself, ask your physician to do so and ask for proper technique.

·         If you are more comfortable with a certain gender of provider, ask for this when scheduling your appointment.

·         If you would rather not get undressed for the procedure, talk with your provider on how the exam may be performed while staying dressed.

·         If talking/having a family member or friend there/listening to music/watching a video makes you more comfortable during an exam, ask the provider at the beginning of the office visit – they will be willing to accommodate you.

·         If you do not want to be told what is happening during a pelvic exam as it is going on, let your provider know so they don’t introduce more anxiety for you.

·         Know that you can always say no to an exam or stop an exam before or during the office visit.

·         Establish a word or signal that if said or done will make your provider stop the exam until you are ready for them to continue.

·         If you have considerable anxiety during such experiences, talk to your provider about any anxiolytic medications that may be used to help you complete your screening with less discomfort.

·         Check out this post by Dr. Glomski on other tips to help prepare for a pelvic exam: Mayo Clinic Health System - Preparing for your first pelvic exam².      

By recognizing trauma and approaching patients with care and compassion, clinicians can support resilience and empower them to overcome obstacles to their healthcare.  By normalizing trauma-informed care, sensitive clinical exams can become a less anxiety-producing experience for patients knowing that they can trust their provider and feel safe to obtain the care they need.

References

 1.      Bates C, Carroll N, Potter J. The Challenging Pelvic Examination. Journal of General Internal Medicine.2011; 26(6): 651-657.

2.      Glomski, Bridget, and Hannah Miller. “Preparing for Your First Pelvic Exam.” Mayo Clinic Health System, 22 June 2021, www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/preparing-for-your-first-pelvic-exam.

3.      Sharkansky E. Sexual Trauma: Information for Women’s Medical Providers. National Center for PTSD. 2014.

4.      Substance Abuse and Mental Health Services Administration . SAMHSA™s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884 . Rockville : SAMHSA ; 2014 .

5.      Wright D, Fenwick J, Stephenson P, Monterosso L. Speculum ‘self-insertion’: a pilot study. Journal of Clinical Nursing. 2005; 14(9): 1098-2111.