Margaret Salty

The U.S. breastfeeding equity gap isn't a story about preference. It's a story about systems.

Initiation rates are relatively close across racial groups. Continuation rates aren't. The gap widens steadily over the first 6 months — and the biggest single driver is structural.

What this means for us in the room: name the system. Don't moralize about feeding decisions made inside constraints we wouldn't accept for ourselves.

Equity-centered practice is working on the system AND in the room — both, not one instead of the other.

Longer read on the blog: Telelactation: Expanding Access, Advancing Equity.

Confidence intervals are the most useful number in a research paper. Most of us learned to skim past them.

A 95% CI tells you the range of plausible values for the true effect — given the data. It doesn't promise where the truth IS; it brackets where it plausibly could be.

The two things to look at:
· Does the CI cross zero (for differences) or one (for ratios)?
· Is the WHOLE CI in a range that matters clinically?

Save this. Look at the next paper's CI before its p-value.

Most IBCLC candidates over-study the dramatic topics — tongue-tie, low supply, NICU. And under-study the topics that quietly show up in 1 out of every 6 questions.

Where I'd spend more time than feels comfortable:

1. Infant growth patterns — across feeding methods, week by week, month by month. Plateau vs faltering trajectory.

2. Medications and lactation — not every drug, the categories. What changes compatibility. How to read LactMed. Reasoning, not memorization.

3. Professional ethics and scope — Code of Professional Conduct, scope of practice, WHO Code. The right exam answer is the one that respects scope, not the one that solves the problem.

4. Anatomy and physiology of lactation — prolactin pathway, frequent removal, endocrine vs autocrine shift. When you understand the physiology, half the clinical questions become reasoning questions.

5. Normal feeding behavior across ages — the exam tests whether you know what's normal before it tests whether you know what's wrong.

6. Counseling and communication — motivational interviewing principles, family-centered language, delivering a hard finding. This is a clinical skill the exam asks about directly.

What these topics have in common: they can't be memorized with a flashcard. They require reasoning. Which is exactly what the exam scores.

Comment PASS and I'll DM you my free question-breakdown guide — it walks through how to study these topics for reasoning, not recognition.

Most new IBCLCs in private practice start with a website, a logo, and an Instagram account. And then wait. For months. The phone doesn't ring — because that's not where your first clients actually come from.

Your first 10 clients come from four places:

1. People who already know you exist. Tell every adult in your life what you're doing. Specifically. Your first clients are usually one degree away from you, not strangers from the internet.

2. The local providers your families talk to. Pediatricians, midwives, OBs, doulas, pelvic floor PTs. If one of them refers you twice a month, that's a quarter of your caseload. This is the work most new IBCLCs skip because it's slow and unsexy.

3. Your first two visits. They matter more than your next twenty — because of what they tell five other people.

4. Word of mouth from those visits. Postpartum families talk to each other constantly. One good visit gets referred to three more.

In your first six months, don't waste energy on logo redesigns, funnel automation, paid ads, or optimizing your fifth lead magnet. They matter later. They don't fill your first 10 visits.

A new practice isn't a marketing problem. It's a relationship problem.

Save this for the practice you're building — or thinking about starting. DM me PRACTICE if you want to know what I'd do in your first 30 days.

Your first 10 private-practice clients won't come from Instagram.

They'll come from referrals — and you'll get referrals when you make it easy for other providers to send them.

The unsexy 5-step process I'd run:
1. One-page referral document (who you serve + how to send)
2. Hand-deliver to 10 local providers (lobby visits beat cold emails)
3. Quarterly check-ins (short, specific, not needy)
4. Thank-you within 24 hours of every referral
5. Ask each client: "who else do you know who needs this?"

The Free Private Practice Mini Course walks through it step-by-step — link in bio.

Reimbursement for lactation care isn't a back-office detail. It's the policy lever that decides who gets lactation support in this country — and who doesn't.

When IBCLCs can't bill insurance directly, families pay out of pocket. That concentrates lactation care in zip codes that can afford $200+ for an initial visit. When CPT codes don't fit, when TLN takes a cut, when state licensure doesn't exist, the most experienced IBCLCs cut hours or leave private practice. We lose the workforce we need most.

More than a dozen states are testing pieces of the fix right now — Oregon, Texas, South Carolina, Louisiana, New York, Connecticut, Colorado, Washington. Each is solving a different part of the same problem. The federal pieces — dedicated CPT codes, reliable Medicaid coverage, a clearer licensure picture — are still mostly missing.

Fair reimbursement would mean more families seeing an IBCLC without choosing between a visit and groceries. More IBCLCs staying in the work long enough to become senior clinicians. More public health dollars actually reaching the families they were meant for.

This isn't abstract policy work. It's whether the family in your community gets help on day 4 — or doesn't.

Share this if more people in our profession should be thinking about this. Where does your state stand? Tell me below.

Sources: ALPP legislative tracker; state legislature records 2025–2026.

One of the highest-leverage things an IBCLC can do — and one of the least talked about.

Breastfeeding task forces and coalitions work at the systems level: hospital policy, community programs, legislation, insurance coverage, training standards. The families you see one at a time are shaped by those systems. If IBCLCs aren’t at that table, someone else is setting the policy.

7 reasons to get involved — and how to find your state coalition.

Most of us read research the way we read news headlines. We see the conclusion, we scan the abstract, we move on. But the headline is almost always the most oversold sentence in the paper.

Five things I check before I let a study change anything about my practice:

The word 'significant' without context. Statistical significance doesn't tell you the effect is meaningful — only that it's unlikely to be chance.

A small sample dressed up as a breakthrough. 'Promising new finding' from 18 dyads is a signal for more research, not a recommendation.

Correlation reported as causation. Babies who are breastfed are also more likely to live in households with other protective factors. The headline often forgets that.

A population mismatch between the study and the headline. A NICU preterm study is not a term-healthy-newborn study.

A limitations section that's missing or vague. Good researchers tell you where their study is weak. If they don't, read the paper twice.

One study rarely changes a clinical recommendation. It opens a question. Practice shifts when a body of evidence shifts — not when a single headline does.

Save this for the next study that lands in your feed. And if you want me to break down a specific paper, drop it in the comments.

The stat that changes how you read every breastfeeding headline.

"Breastfeeding reduces SIDS risk by 50%." Sounds huge.

But 50% of what? That's the question.

Relative risk reduction tells you the proportion change. Absolute risk reduction tells you the actual number. They can describe the same study — and feel completely different.

7 slides on the number most research headlines hide from you.