"What I wish clinicians knew about reading research." Video + transcript Professor Donna Geddes, University of Western Australia

Transcript

Pam: It is a great honour, really, a privilege to have Professor Donna Geddes giving up this hour to be with us tonight. Donna, for those of you who don't know, is the Director of the School of Molecular Sciences at the Centre for Human Lactation Research and Translation and has other very significant roles as well. So we thought we'd take this topic of what clinicians need to know as we make sense of breastfeeding and lactation research in particular, and deal with it conversationally, and particularly through the lens of Donna's work and career, operating really as a world leader in research into human milk and human lactation. So I thought that I'd just start asking Donna some questions, and let's just jump into it. But I was wondering if Donna might start by giving us a picture actually, Donna, of what your unit does there at the University of Western Australia. So do you mind letting us know how many years you've been a researcher for, and what your background was prior?

Donna: So I had to count the years, Pam, but funnily enough, I was pregnant with my first baby, and she's 27, so I've been in the game 28 years. But when I started, I never ever thought I would be doing what I'm doing now, because I was a clinician, an auxiliary health worker, medical imaging technologist, so radiographer, but I specialised in ultrasound, and I loved ultrasound. In fact, I loved my job, but I didn't have a university degree, and I had a habit of still studying, so I had a postgraduate diploma in ultrasound. I didn't think it was a good idea to get another postgraduate diploma, so I went back to uni, and cut a long story short, I put a proposal in for a master's, and they said, you know, that's too big, perhaps you should go and talk to Jan Dickinson, who is an obstetrician at King Edward, who said, what do you do the most ultrasound in? I said, well, I do a lot of breast ultrasound, and then she said, I should go and talk to Peter Hartman, and I stopped him at a conference in Fremantle, and in the foyer, I said, oh, I'm a sonographer, I'm interested in doing some postgraduate work, and he said to me, I can scan the breast, yes, can you look at blood flow, yes, can you look at letdown? I'm like, what the heck is letdown? I hadn't had my baby by then, but I have friends that were doing that, so I kind of serendipitously did a postgraduate diploma, so that he could see if I was any good at research, he said, and I could see if I liked it, and then, of course, I fell in love with research, and the ability to make an impact on a global level, and do some really kind of groundbreaking work, integrating ultrasound into the lactation experience, I guess.

Key Research Contributions and What's on the Horizon [00:05:06.19]

Pam: Absolutely, and it's not possible, actually, to teach lactation medicine without drawing on your work. It's so profoundly shaped what we understand, not just anatomically, but in terms of function. So, very lucky, Donna, that you had those conversations with Peter Hartman, and went down that path. So, do you want to give us an overview of what the centre now that you head up at the University of Western Australia looks like, what's happening there?

Donna: Okay, so we are a big group on our own, looking at lactation. However, the opportunity arose at the University of Western Australia to create centres, and the whole idea was secretly I wanted to work with more and more people in a multidisciplinary manner, and we do do that, but under the banner of a centre, I have co-directors now. I have Dr Mary Sharp, who is director of the NICU and PCH NICU, so all of the neonatal work. We have an anthropologist who we've just sent a student to Uganda to look at breastfeeding experiences and culture over there, and the impact of social media, and we have a microbiologist who's well known at WHO for respiratory work, who's interested in early life, and of course, nutrition feeds into that, and then we have, for my missing, an allergist, so Dr Debbie Palmer, and our immunologists have been interested in breast milk from day dot, really, and she's really a trialist, devising nutritional interventions during pregnancy and lactation to try and reduce the amount of allergies that we're seeing in our babies. So with my group, under that, we engage with all of those groups and those areas more formally under the centre. As part of that, we've managed to get a grant from the Stan Peron Charitable Foundation to establish the first ever national biobank. It's the WA Human Milk Biobank, but it's the first one of its kind nationally, so that we can collect metadata on milk productions and milk samples from diverse areas. So it's quite different to your average biobank, where everybody's invited to donate samples, and typically you would get mainly Caucasian, highly educated women when you do that, no matter where you are. But we're target recruiting, so our stakeholders through the centre, so we have populations of Ugandian women, South Sudanese women, Asian women, and then we're using our stakeholders in the rural and the really hot areas of WA, so that we can collect a really diverse set of samples. Now the idea of that is that we can open up more research, so people can come to us, request samples with those metadata. We're only really needing to cost recover, which is an expense at the university, as opposed to many of the other institutes. So it took me about eight months just to get the freezers in, because we wait a while in WA, but we're building this program using the centre and that multidisciplinary way of, you know, tackling that. But the exciting thing is that I've just decided I'm going to do macronutrients on every sample that comes in, so people will be able to access compositional data without having to pay a lot of money for it, because they can, and then we'll have what we call the Southern Cross. So these are 500 samples that we know the composition of, that you can request from us to get started on research, so that you're already there. So it's quite an exciting endeavour to really engage many more scientists and clinicians, scientists, clinicians in this. So we build a community around that as well, so community engagement is part of that. So we have somebody leading that at the moment, the formation of that to inform research. And then the education's a little bit slow, but what we're doing is, as collaborators, we're increasing the amount of postgraduate education around breastfeeding and lactation.

Pam: It's very exciting stuff, Donna, that's happening there. Some quite extraordinary. So this is a bit weird to ask you, you know, as academics, it's a bit weird to be asked this, but I actually think it gives those of us who aren't sort of particularly engaged in academia, a kind of feel for reach and scale. Could you tell me roughly how many, I know that there's many more publications that are happening around you with these centres being built up, but in terms of your own contributions, research publications that have your name on it, can you just give us a feel for how many in your professional life?

Donna: So in the 28 years, I've published 266 publications. We have, I did write it down because I had to count it. We have two papers accepted, so in that process, they're accepted for publication and five under review. Sometimes I lose track of that, but we would be prolific publishers. And the reason for that is that I hold it, one of my highest values in this job is to get the information out there. And if we can publish it, it's there for good for people to, they can access it at whatever time or year they need to look at it. So that's what we need for the benefit of women and clinicians, but also for the benefit of research. So we're not investing money in repeating research that's already been done

Pam: Yeah, thanks. And just another couple of questions while I'm kind of setting the scene for the core of what we're wanting to talk about tonight, which is what we would like our clinicians who are working in the field of lactation to know about research. But I just wondered if, I guess, if you could just let us know what kinds of contributions, and I know there's groundbreaking research on multiple fronts, actually, that have come out of your center from before yourself, from Peter Hartman, as again, a pioneer internationally in lactation research. I wondered if you could give us the things that come to your mind as perhaps the most significant contributions from your perspective that you've been able to make through the research and a sense to just, you know, just briefly of who Peter Hartman was, because I think it's important, particularly here in Australia, for us to understand legacy in the field of lactation research.

Donna: Yeah, so we are, whether you know this or not, internationally renowned in Australia for our research with lactating women. Maybe as Australians, we're not scared of breastfeeding women, but in terms of the amount of research that we do here in Australia, it's really high. Now, Peter started this group, as you probably imagine, he took a risk on me. He was always someone that followed groundbreaking technology, had the first computer on the desk, and he, one of his biggest legacies was his computerized breast measurement system that he developed in collaboration with Dr. Robin Owens, Professor Robin Owens, with, you know, three video cameras and a rack that we put mothers in to measure breast volume. And what came of that was our milk production profiles that we do now, and our ability to estimate how much milk is in the breast before the baby or the pump removes it. So it's a much better estimate than volume, because it accounts for that variability at the beginning. And we often see that the breast is quite empty, even if it's at a low volume. So for example, if a mum has emptied the breast only an hour before she comes in to see it. Peter actually studied lactation his whole life. So he started with cows, he came to UWA, he moved on to pigs and quokkas, and then he finally turned to the bright side, which was lactating women. And he really didn't do much else with other animals once he realized the impact it would be, it would have with women. And then he was a great supporter of the Nursing Mothers Association, which is now the ABA. So he's very involved in the community and giving back. And really, we've probably got some of the most educated clinicians and counsellors in Australia sometimes, because we always send our students or anybody in the group, depending on what the ABA want to hear, so they get the research first. So he was a staunch researcher of human lactation. He was asked by the NIH and MRC when they used to interview for grants, why are you studying these unusual women? So he'd come right through that, virtually no breastfeeding to increasing breastfeeding and sometimes took a bit of credit for that as well. Great sense of humour. So, you know, he really built a lot of the research around the biochemistry. And he did something extremely unusual. Actually, he got an Order of Australia as well for his contributions to women and clinicians. But something really unusual is we still exist because he made sure we would. So unbeknownst to me, he called me into his office when he was going to retire and kind of told me what was going on and what he was thinking. And I walked out and I thought, he kind of said he'd like me to take over. I came out and I thought, did he ask me if I wanted the job? It was just a foregone conclusion for him. And it was very important to him that the research didn't disappear when he retired, which often happens with academics and perhaps 98% of the time that happens. So when it comes to mine, what have we discovered since then? I mean, I suppose the anatomy is always at back of mind, you know, scanning women, live women, looking at their breasts, not histology, not cadavers, but women that were actually lactating and still realising, as I reflect, that the anatomy of the breast is important for shield development, shield fitting, if we go down that controversial road. Sucking, you know, the sucking mechanism grew from that and then looking at sucking anomalies and things like downs and cleft and preterm vacuums, you know, things that you as clinicians can use to talk to your mothers and describe why things are happening.

So I think they were important. I'm quite proud of those, but I'm also quite proud of our pumping data that's coming out now, our milk removal data, and the fact that we're combining that with milk production to show you, for example, things like obesity and overweight and how these mothers are still emptying their breasts and it's not the fault of the pump or the baby or the mother, there's something intrinsically going on with these mothers. And I think that's exciting because that's now going to change clinical practice and the narrative around these mothers to help them extend their lactation, essentially, and their breastfeeding journey. I could keep going on. Another exciting thing is I'm part of an ARC centre where I co-lead a sensor group, so all these smart chemists and engineers that can make point-of-care sensors, and my PhD student and my team really in general have shown now that milk composition is a mirror of the function of the breast. So we can mine this for biomarkers to help clinicians determine, hopefully in the future, for example, that they can measure lactose and this can be translated into knowing right there and then that that mother has low milk production. We have a paper accepted for one of these sensors. So I think bringing these things into the clinician's hands to have another tool and piece of information to help both guide the mother and practice is going to be really exciting. Do you want me to keep going? I could keep going.

Pam: Well, maybe one more and then we'll move into the main part of our chat. It is really important for us, I think, to have a sense of what you're doing. So thank you.

Donna: Yeah. So we're working very closely with clinicians that are changing a model of care that's multidisciplinary. So Dr Stuart Prosser and you'll all know Dr Sharon Perella, really working in the clinic alongside the clinicians. And so we're doing things like screening for antenatal risk factors to flag women that might be at risk for low production. And the exciting thing about that is the conversations and the education is starting in pregnancy. And in fact, because we do the screening for every single woman, she gets to talk about breastfeeding, whether she's at high risk or not with someone at each time point. So bringing lactation back into the pregnancy journey and setting expectations for those. Oh, you know, your baby's going to feed every two to three hours. This is what looks like normal. Here are the red flags. Don't wait. Come and see us. This is what you can do in the meantime, but pull us back. And I think the feedback from the mothers that they feel supported, even if they don't get to full production, they breastfeed, you know, for six months, 12 months. And so changing that narrative slightly around that and you as clinicians hold a lot of knowledge about diagnosis and conditions.

So I think that's the exciting thing for me, you know, and I'm even doing ultrasound again, right? So when you ask me what my usual week looks like, it's like, I meant these mothers that have no answers often have underdeveloped breasts or differences in the distribution or the texture of their glandular tissue. And so we're collecting data on that. And just the sigh of relief when we can tell them this is not something you're doing wrong. There is definitely a lot of adipose tissue, for example, in your breasts and not as much glandular tissue, which may be limiting production. So those are exciting things on the horizon. I tend to be forward looking, maybe more so than backward looking.

Pam: Yes. Well, thank you very much for letting us know because there's lots to be excited about there. Alyse, I think we might bring that question at the end, because if you don't mind, I'd like to move now into asking Donna to let us know if you had a wish list around the things that you'd like clinicians to know about breastfeeding and lactation research, but about research in general, but as it obviously applies to our shared field.

What Clinicians Need to Know About Reading Research [00:23:30.17]

Donna: Yes. So I've been thinking hard about that. I think the difficulty for clinicians is time and experience and reading the scientific literature. It's not easy. But if you tend to look at the abstract before or not be able to read the whole paper in the abstract, there are some key things that I think are important. And I'd just like to highlight so that you can look at those. So if it's a secondary analysis of a study, and it should tell you in the abstract, then it's preliminary data. So it's not usually powered to look at the relationships that they look at. Can I jump in there and ask you to just unpack that a little bit, what you mean by secondary analysis? Yeah. So for example, if a randomised controlled trial has been conducted, it will be powered, a power calculation will be done to tell you how many women and babies you need in that trial to answer one question. And it's the primary question. So for example, let's take, I don't know, I haven't read the DANE trial again, but the DANE trial was all about safety, right? For antenatal expression of colostrum. So it's not powered for anything else. Or if there was an RCT looking at the moment, we're looking at feeding women cashews or peanuts in a time series. If that RCT is powered for an allergy outcome, it may not be powered for looking at that protein in the milk and relating it to an allergy, for example. So it's one thing to look at, right? I will say that in some of our studies, it's often thought that bigger numbers are better, but power calculations in our field usually sit at around 30 to 60. And that's because we're measuring a lot of things, right? So we have a lot of data on milk removal. So we can use that for the power calculation, which makes it easier to do and more accurate. So does that help answer your question? That's an important start.

Pam: Do you think that there's a lot of studies that are being used where people aren't understanding that the findings that the authors talking about is often secondary analysis and therefore not necessarily methodologically strong? Do you see that quite a lot?

Donna: I think if you see a secondary analysis, you should also see the words either preliminary or hypothesis building. Often we think associations are causation. And most of the time, unless you do an experiment and an intervention, you can never infer really safely causation. So for example, if there's a big cohort study and nipple shields are related to, nipple shield use is related to shorter breastfeeding duration, that doesn't mean nipple shields are causing breastfeeding, lower breastfeeding duration. It's likely the cause for using the nipple shield that is doing that. But sometimes people, this is where the translation comes in, in terms of the result.

Other things. So if you're going to read the results, they're usually quite heavy. So it must have a significant p-value. And if there's been lots of tests done, it should be corrected for multiple testing. So you should be able to see things like adjusted p-values. And that's quite important because some aspects disappear, some significance disappears. It usually stays if it's strong. And then it's the effect size that matters, right? So it might be expressed as a mean difference. And so you can have quite a small mean difference that is roughly 10% increase, say, which is significant. But is that clinically relevant to you? So as clinicians, the effect size is incredibly important before you jump in and every woman should have this particular intervention. So effect size is great. And if you go to the, so one rule I use when I look at papers is if the graphs don't look significantly different, then I really look at the effect size and the p-value. So if it's not obvious to you, but the author is saying it's significant, it probably is statistically. But is it at the level that you would change something or you would expect a big change in practice? And then there are sometimes conclusions that somewhat soften. So if the results and the conclusion don't match, then you should look a little bit harder. So I read a tongue-tie phrenotomy study and it was in older children. It was a reasonably big study. It was done looking at the primary outcome of speech, for example, and all of the groups had the same amount of speech therapy, which took about somewhere between nine months and 12 months before there was changes in the speech. And the conclusion was oddly that you should cut the frenulum earlier. But that's not what the study was designed, the question the study was designed to answer. So you will stumble upon these where the conclusions have kind of deviated from that primary aim. It's good to be careful. So as a scientist, I usually read the methods first, then the results, and then the rest, because that gives you a guide to how strong the study is.

Pam: Thanks, Donna. Is that your whole wish list?

Donna: Oh, whole wish list for clinicians? Look, I do appreciate it's hard to read the literature. What I'm concerned about is some of the translational stuff that's on LinkedIn or the social media that I see that is sometimes wrong and maybe AI generated. AI definitely gets things wrong a lot of the time. So if you feel like that is, it's looking or sounding like that, then be careful. I think too, though, on the flip side is to keep an open mind about the things that, I think the things that are most interesting are the things that disagree with long-held beliefs or what you might or think is the right thing. And think about that. The biggest value we have as scientists working with clinicians is research often stems from clinicians seeing things, not being able to describe them quite so well, but seeing differences or changes when they do something. So I think the reverse is also worth keeping in mind that if there's some good scientists that's saying something that disagrees with you, then that's a nice challenge to kind of rethink practices.

Questions [00:32:52.07]

Pam: Shall we go to questions and then maybe even go back to reviewing articles, but shall we open up for questions now? Elyse actually did have a specific question. Elyse is an IBCLC in France, very active in the field there in France. So her question there, I'll just say it myself, Elyse, if you like, is that there's a trend where she is to measure nipples at the base and the tip in clinical practice and coming along with the belief that this will actually help LCs be more effective. Elyse was wondering if you had a comment on that, which is a specific kind of intersection of research and clinical practice.

Donna: Always start with the controversial first. So I've given a talk which should be available online through Medela. We are doing an RCT right now on shield fitting. So the one thing I will say is that a long time ago we looked at this and we didn't publish, we didn't have a lot of numbers, but I can stop milk flow by doing two things. Making the shield really tight, which doesn't allow expansion of the ducts within the nipple or compresses that transition area from the base to the nipple, which is the ducts are very superficial under that. They're very compressible. So we restricted flow and we also restricted elongation. So if elongation doesn't happen, then the concertina ducts do not stretch out. They provide a lot of resistance to flow and then it diminishes flow. It might not stop it, but it'll diminish. Well, actually we stopped it completely, but in the case of what's going on now with contemporary shield fitting. The reason we're doing the RCT is we have our mantras room to move. So we had a case study and you'll see with those shield fitting papers, there's only one which we won't criticise right now, but the dimensions that were in that suggested that most were, a good proportion, well at least half, were fitted higher, wider than the base of the nipple. And some of them were smaller. And of course there's all individual stretching nipples and other things like that. And they only measured volume. So this is not a hard, fast rule. The actual criteria, it is you watch and work out with the mum. And I'll tell you why we're doing the RCT. We had a mum come in for an ultrasound. She was a NICU nurse. That's always the worst if you're in the field, you always have problems. She was obese. She had PCOS, she had GDM, she had twins, twin to twin transfusion syndrome. Couldn't get any worse, but she was remarkable. She was pumping around the clock, but she was only making somewhere between 60 and a hundred mil. ? So we call this mum a high risk mum. And these are the reason they end up seeing us. So she said to me things like, I could feel some ducts under here, which is unusual for people to just say ducts. And then she told me where she felt the glandular tissue. And it was in the most unusual position. So internal, like a medial in the breast, not so much at the bottom around there. And then when I looked at where the ducts were, they were ducts with very little glandular tissue. Anyway, we're sitting there and I'm looking at her nipples, as you do when you're a scientist, and I'm thinking, do you want to pump? And she said, yeah, I'll pump while I'm here. And I said, what shield size are you using? She said, well, I was using a 17, but it was pinchy and it hurt. So I was using that for a while. And then the LC on the floor said, oh, you know what? I think you're a 19.

Pam: Can I just jump in? We're talking, I was thinking we were talking nipple shields, but we're actually talking the phalanges for pumps. Okay. Just to clarify, because I got that wrong, even though the principles, we've got a little chat happening on the side, but the principles are the same, that we need to be able to have the nipple elongated. There needs to be room to move, as you say.

Donna: Yeah, the principles are the same. Reduce removal with nipple shields as well. Yeah. Sorry. Anyway, so this lovely lady, I reach over and get the electronic calipers and I don't even remember if I asked, but I measured her and she was 20 millimetres, flat nipples. Have you used a 24 before? And she's like, oh, no. Anyway, we put it on her. We start the pump and she goes, gee, that's comfortable. And milk starts to flow like quickly. And then she's like, oh, I'm like, it's flowing. We've got to switch it over. And she's like, what? And she got more than she thought she would get after not pumping for an hour and a half. But I think this individual, oh, the other thing is her milk starts in the um circumferential, like in the, they weren't central in the nipple. They were the ones that are often rudimentary on the edges of the nipple. So potentially it's difficult to see through those inserts. So potentially she was having her flow restricted. So it's a really tricky thing to study, but it's clear that you have to not just go with your first measurement because the nipple is not circular and it depends where you measure it. And I don't even know where the tip of the nipple is to measure because people keep asking me to do it. It's like, well, we're about from the tip. But also we will have differences week to week, even though we've got the same people measuring due to fullness of the breast or humidity or whatever the mum's been doing. So I think it's a little bit of a moving target, which is why we're in favour of being able to move and doing that with a clinician to look at flow, you know, and see, you know, it's a, it's a, it's a red flag for me. If you have to turn the vacuum down to make it comfortable, you know, you have to use lubricant because you can't get the nipple in the shield. So, so I guess if we were to hypothesise why it would do better, I'm struggling to come up with a hypothesis using the anatomy to support that. So I think we just have to be a lot, a lot more nuanced. And it may be that going a little bigger is better than going more, heading down that track versus the other. I'm glad there's people nodding because I think experienced clinicians are probably onto this anyway.

Pam: Yes, I think that that's really useful for us to hear. I think Julie has a question and then Anika.

Julie: Hello, Donna. It's lovely to meet you. I've been looking forward to tonight for a while. I'm a nurse and a lactation consultant and I work in a NICU in Sydney, and I am an LC, but I don't practise as an LC in my workplace. I practise as a possums practitioner in the community as an LC. And I'm a little bit constrained in my workplace because the gestalt method of breastfeeding isn't written into New South Wales health policy. And so therefore, I'm not really free to practise it as much as I would like to in the workplace. So I've started writing a paper to just look at this sort of dilemma, this sort of moral dilemma that clinicians can be in when new evidence comes through. And I'd like to talk to you about what I'm finding in the literature about this peristaltic tongue movement and you not agreeing and that you say it's more vacuum centric. But I've been also looking at Michael Woolridge's work and how adamant he is that it is peristaltic. And I'm just wondering how I talk about that in a published article, because I could adopt the view that what you have found and others have found is the way it is, but is it considered across the world the way it is? Or is the old peristaltic theory still pretty entrenched? And what do you think will help to change that?

Donna: Yeah, so Julie, it's quite a good question because what's changed since the 80s is... Which is when Mike's work started to come out, just to clarify. Yeah, it came out. I mean, technology, ultrasounds, so much better. Didn't have transvaginal probes, which is the probe that I put under the chin. So there were a lot of limitations back then. That was the first kind of ultrasound that was done and not done by a sonographer. So it's very easy to get an oblique view and distort images. So ultrasound is very operator dependent and technology dependent. We can see now milk flow and milk ducts opening up. We can see a lot more. You have to be very sagittal. Now when we talk about peristaltic, what we don't know and what Mike didn't have was the ability to see the milk being removed. So it was nonnutritive sucking is quite different to nutritive sucking. So when the baby is nutritive sucking, it is pulling down at the tip of the tongue and expanding the nipple, opening out the ducts and the milk is flowing, right? We see peristaltic actions in babies that either have issues or there's no milk. And the back of the tongue, so I'm talking about getting the milk out, the back of the tongue does this little, maybe you could call it a wave, for the swallow. So I don't know, because we didn't have access back to ultrasounds back then, whether that any of those things fed into what they were looking at and looking for. So I think you can, the other thing is we've seen the same action with preterm babies and described the same action. The work we did with Pam, seen the same action but different locations. When we see nipple pain, we get that rocking movement. So I would argue that the times we see peristaltic, like a real wave, you know, like a cow's tongue going, is when we see issues with the babies. So we don't know, again, if those babies were transferring milk back then or doing that. So it might have just been the design and the nature of the babies that we're looking at earlier. And we've also got quite a bit of work with Finesse Stachyledes' work as well, that day three looks just like day 21, it's just that there's more movement for the milk to come in. So, you know, I would like to say there's a lot more evidence in our corner of the court. And if we're moving forward, trying to say, look, the biomechanics are different, we understand them differently now, the anatomy is different, but then there's a whole other camp saying, no, it's not.

So there's some old data that shows that if you make babies, like in the 60s, the psychologist's own feeding, if you made the baby suck the milk out, they would use vacuum. If you didn't make the vacuum essential to sucking, they'd use a peristaltic movement. So they will adapt. They're incredibly smart. They'll adapt to however their milk is being fed. So I think it's discoloured a little bit by some of the bottle studies rather than breastfeeding. But we are writing a chapter for a book at the moment. So I will definitely take some of that in there. Yeah, yeah. I think I'll make sure it's covered because it's really needed. Thank you. Remind me, Pam, I can send a review that we've written as well for you. That'd be great. Thanks, Donna. I'm always saying that the biomechanics of sucking is contextual, you know, and of course, that's where fit and hold becomes relevant to I would propose. But I know that we have a tour happening, a couple of tours from a particular speaker in Australia coming in from overseas who talks about not the NDC Institute, but it's happening in Australia, talks about peristalsis. And I think that this speaker is drawing on one study that used a computerised analysis of ultrasound. There was just one publication.

But I do believe that there's confusion around the posterior tongue, the mid-tongue, the anterior tongue. And there was probably extension, which is how I critique that study and that it really didn't add anything beyond what your work has been saying. But it's being interpreted in a way that's very unhelpful. Right. And so is it being interpreted by someone else other than the researcher? This one particular study. So I think it's the latter. Ellen has correctly identified it as a study by Elad's team. So there's one particular researcher who is involved in this latter series of case studies. So you're right. You have to distinguish between the swallow and the milk removal portion. Yeah, that's it. And it's a lot harder to hand express than it is if you try and do that action manually. It would be very hard to get milk out of the breast because you're compressing the ducts. And only, we did a calculation, only pressing a tiny bit of milk out at a time. So that's another kind of expression, confirmation of the mechanism.

Pam: And Annika

Annika: Hi. Thank you for all of this wonderful information. It's been so informative. I'm Anika. I'm a RBCLC lactation consultant. I work in a private hospital and I also have my own business and NDC accredited. My background is in neonatal intensive care nursing before I was an LC. And I would love to circle back please to the discussion we were having about the flange sizes for pumping mums. Because I've had some interesting experience in my current role where I've been trialing smaller flanges to really just see if it allows women to feel more comfortable and get more milk yield based on that one study that was from 2025. And I'm also learning how to read papers. And I really appreciate your tips on how to interpret literature because it's something, sorry. It is a very difficult one to read that one. Yeah. So what I did, I'm just like really interested to know what I can understand in terms of the anatomy and the discomfort that I've had many patients experience when the flange is too big. They feel this pinching sensation at the base of the areola essentially, like the base of the nipple, just in that a small region of the areola is being sucked in usually at too high of a vacuum with the hospital grade pump. And this discomfort that they feel from the feedback I've collected has, I suppose you could say, possibly reduced the volume of milk they've been able to pump compared to when I've given them a smaller size purely because of that pain potentially reducing oxytocin and that milk removal. But I had one mum that had preterm babies that was pumping and she was having a really difficult time with pain and the flange that she'd been given was the largest size. She had really generous breast tissue and she'd been very, very committed to her pumping journey every three hours from birth. And she was about nine days in and she really did not produce any more than 50 to 70 mils maximum. And she was really at that point where she was about to stop and very emotional about it. And when I reviewed her, I actually had some inserts for a pump and so I measured her accurately. She hadn't seen an LC prior and she had a 17 millimetre nipple and a 19 millimetre nipple and she'd been using a 27 millimetre pump flange that was given to her because she had really generous breast tissue, I assume. But in fact, her nipple diameter was very small. And when I gave her the inserts and fitted her and sat with her, she produced a hundred mils and within only a couple of days, she was making more than double. And it was comfortable. Her anxiety was reduced. And this is what really got me interested in this because that was a really profound outcome and it wasn't the first. And so I have done my own trial of it.

Donna: So, you know, historically we did all of our pumping and because we can look at a milk removal as an estimate of percentage available milk, we used to do everything with a 24. And then there was a call for big shields. This whole field went, I don't know if you've been around long enough to bigger is better. And so we did another trial with 27s and 30s. And I picked it out. It might be in a thesis, but I circled all the mothers that did better with which whatever. And it was pretty much an even split. Right. So it is highly individualized. What we found in a big cross sectional study is that bigger might be worse. Right. So that is definitely a thing. And more recently, we've had the same thing. We've had a few moms with big shields because their areola is big. And we're like, where did that come from? The comfort is always the winner. Right. And comfort in the long term. So that's probably the key. And when I talk about the room to move, you know, so if you think about it, if the nipple is 17 one way and 19 the other, if you fit at 19, you're giving room to move. But if you're fitting at 20s, you are too. What we don't know, we do know that soft shields don't do well, like a whole shield being soft. That's why we don't see them on the market. Or you might have had experiences in the wild.

Um, they seem to not be conducive to good milk removal. So in the certs, we don't know how they're impacting versus a hard shield. Our study is using the hard shields at the moment. But I agree that too big is sometimes wrong as well. So it's this point, you're doing individualizing care and making it sure that the issue we had one mom call it an Olympic sport, trying to get a nipple into a shield that was too tightly fit in the middle of the night. And our NICU nurse on my way out said, Oh, should I still be using coconut oil? What? Um, you know, like, I think not only it just, it just doesn't make sense. It could be too tight if you need oil in there. So, and it will depend on anatomy and, and saying that, you know, your expert has been curious for every single month because there's no rule. It's, it's um, a guide, right. And like you say, you've got to look at, can they turn the pump up to get the milk out more efficiency, or do you have to keep turning it down, which will reduce the time and effectiveness of the pump. So I think those things are nuanced and perhaps I'm talking to.

The Challenge of Translating Research into Clinical Practice [00:57:16.22]

Pam: And there was one other question I did want to put to Donna. I just wanted to know, perhaps what the most difficult thing about being a professor heading up a centre is for you. I wondered if you'd be willing to speak to that for a moment. And so I think we're talking about scrutiny is the maybe the question.

Donna: Look, I sleep at night. Well, because I know that our science is thoroughly reviewed, goes through ethics, goes through multiple reviews. There's statisticians that kill us, like, you know, can't just slice and dice data to fit your narrative. And so the difficulty is this distrust of anything that is industry, you know, wherever our, our funding comes from, whether it's industry, federal funding, whatever that is. However, you know, we have to declare conflicts of interest. Every time we review, we have to declare who's been involved in the paper, whether there's been any, um, influence of funding bodies or whatever that is. So the difficulty is not so much that I can't do good science, it's my ability to translate it to you guys. Like, so I do believe that researchers understand what they've done the best. So to get that information out, we need to be talking to each other freely like we do now. Um, so, so I think I wrote that down at night. I think we are extremely transparent, um, and any kind of diminishing of that is really diminishing any science at all. In terms of translation, we rely on clinicians to translate, um, to our mums and babies, but we also rely on industry. So the ARC Centre I'm a part of, you know, there will be efforts to go to industry to bring a point of care sensor potentially in the future that has already gone through translation, clinical use, you know, through all of that to get that out to people and to make it affordable and equitable. So, um, yeah, I, yeah, I guess, I guess my more frustration is if I can't translate it and I see it incorrectly translated, that's difficult. You can always come to me to do that. Uh, and I think it's just so important that, um, there isn't this blanket rule applied to everybody that every, you know, it's like saying breastfeeding is natural. It should work for everybody. We know that doesn't happen. Otherwise we wouldn't be here.

So, um, yeah, I suppose I'm a little frustrated with this idea that it needs to be. And I think, you know, the way we can make a bigger impact is opening up this field to many more people and to get the importance and, um, attention it deserves, whether it's in pregnancy, post-birth, science, like science has to step up now. Our mothers are struggling. We need funding to step up, to answer those questions that you're asking me, just so that we can keep our mothers breastfeeding and lactating for as long as possible, despite some of their health conditions impacting production. So that's a little frustrating. I think that sometimes certain things get in the way of that, that are idealistic and not really focused on the work we do because we're all in it for the same reasons.

Pam: Absolutely. And so essentially at the moment we have researchers unable to present their own work in educational contexts, which, which actually I would propose is holding back the advance of our, um, science-based care for mothers and babies globally at the moment, I would propose it's a significant obstacle.

Donna: I would agree. I think I wrote that down that it is holding back the translation of the science. We will be forced to use other mechanisms like social media. I mean, we all combat social media now but that's not within our remit as for time and resources as well. So, you know, one of my comments was, do I have to get on TikTok and tell people that this isn't, it isn't hard or whatever is going on out there. But yeah, holding back, uh, science in this field. Well, I mean, we, we all need, we need the scientists to step back and say, what are the causes of low production without the science? We can't address them the way we need to. And right now the risk factor is great because it's extending, it's increasing wellbeing for mums. It's extending their lactation because they understand what's going on and they can map their journey to keep them, um, going to make it sustainable. But ideally we want to be developing things. For example, we're looking at the, what's called the editorial pathway that we already know that certain amino acids are deficient and supplementation could be a thing that could improve functional capacity. So we need to get that information out there when we discover it and yeah, work, work at making things better globally.

Pam: So exclusion, I would propose is holding back, advancing the wellbeing of breastfeeding women and their bubs and exclusion goes hand in hand with a certain kind of extraction that's, that's, um, also disrespectful I think to those who are being excluded. So it's, it's a significant problem I would consider in the field of lactation medicine at this time, but we're really grateful to you Donna for being so generous in coming again tonight to talk more broadly on this issue of research. Also touching there on some sort of deeper dive stuff to yeah. We could talk all night, so I'll stop there too. And I apologize for those whose questions we haven't been able to get to, but we do need to let Donna go.