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Decoding Photos on the IBLCE Exam: Frequently Asked Questions

Magnifying glass to decode photos

Of course IBCLC candiates fret about the decoding photos part of the exam. Those who have “been there, done that” know how daunting it can be. If you’re taking the exam for the first time, you’ve probably heard re-certifiers describe — in vivid detail, despite the passage of 10 years since their last exam — how anxious and bewildered they felt about it.

One thing is clear: Whether you’re a first-timer or a re-certifier, if you’re taking the IBLCE™ Exam, you’ll need some strategy to wrestle with the pictures.

I offer my Guide to Decoding Lactation Photos Course. The goal of the course is to be able to decode the photos.

Read on for the most frequently-asked questions I’ve heard about the exam’s pictures.

Is the IBLCE exam pictures-only?

No. But let me give you a little context with a few quick facts:

  • The entire exam consists of 175 questions.
  • The first part of the IBLCE exam is text-only.
  • The second part has about 75-100 or more images. A few years ago, I faced 102 images on the exam. More recently, I’d say it was more like 80 or so.
  • The vast majority of the images are clinical photos, or — as many exam-takers say — “skin.”
  • Sometimes, the “images” are not clinical photos. By that I mean that diagrams, charts, or drawings are also fair game for the exam.
  • What does all of that mean for you? It means that your ability to correctly answer 50 percent or more of the exam will rely on your ability to decode photos.

What will you see?

When you’re taking Part 2 of the IBLCE exam, you’ll be looking at mothers and babies, healthy and ill, from a few minutes after birth until about 2 years old. This includes plenty of variations of normal.

You could also be looking at equipment (e.g., tube-feeding devices), gizmos (e.g., pacifiers) lesions (“sores”), behaviors (e.g., an older infant feeding himself), processes (e.g., hand expression), and more.

How do you decipher “sore” nipples or “sore” breasts?

Unfortunately, I can’t cover this broad topic in one blog post. (I do provide a lot of information in the workbook, though!) But here are the “big four” clues that I used while writing the workbook: size, shape, color, location. Of these, I would say location is often the most important.

Here’s an example: A yeast infection can be anywhere. But unless the “thing” is present on the nipple, it’s highly unlikely to be yeast if the characteristic color, shininess, and texture isn’t present on the nipple as well as the areola. An exception would be if you see cracking and characteristic yeast signs at the nipple/areolar junction.

Here’s another one: Mastitis will cause redness — which can be anywhere on the breast — but it is frequently located in the upper, outer quadrant of the breast. And, mastitis is rarely bilateral, so if you see redness on both breasts, strongly consider another explanation.

Here are several others: A cleft of the lip is always on the upper lip. A natal tooth is always in the lower alveolar ridge. A torticollis is on the right side in 75 percent of the cases. True, you’ll need to know more than this to pick the right answer, but often, knowing location might help you to at least eliminate some of the options.

How do you distinguish between normal, variations of normal, and abnormal?

Again, this is a huge topic! But let’s say the photo shows small breasts and the question asks what impact it will have on the baby or on milk production. Pause before you say “no problem.”

Is this micromastia, or hypoplasia? The former has little or no clinical impact; the latter may have a huge impact. Are the breasts symmetrical? Do the nipples and areolae look “proportionate” to them? What is the shape of the breasts? You’ll want to go a little further than the obvious in decoding photos like these!

How do you tell if it’s a scar — or something else?

Maybe you see a “scar” around the areola. Is this line a scar, or just an indentation? If the line has “railroad tracks,” you can bet that’s evidence of sutures that held the incision together. But if it’s smooth, it’s probably an indentation from a breast shell, clothing, or something else.

How do you tell if it’s a birth mark — or child abuse?

Yeah, this is a hairy one, isn’t it? Anyone credentialed in healthcare is obligated to report signs of child abuse, so this is fair game for the IBLCE exam.

Here, location is of little importance; both abusive marks and birth marks can be anywhere. But a slate blue mark is flat, and it does not change colors within a few days. A bruise IS likely to be swollen above the skin’s surface, changes color as it heals, and often has the distinctive shape of the item that caused it.

What I’ve given you here is only the tip of the iceberg regarding decoding photos on the exam. But I hope it will help you to start looking critically at the clues that are in the photo.

You still have time to get my workbook, (or packaged with the Breastfeeding Atlas, 7th edition) and there, you can use the narrative, paper-and pencil match-up and many other written exercises to cement your knowledge, and even blast through the quiz at the end of every chapter!

How prepared do you feel for decoding photos on the IBLCE exam? Tell us in the comments below!

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  1. Kim cook

    I’m on my second time through the Breastfeeding Atlas and your work book! I did it earlier for scheduled April test and am doing it again for Sept. test. It has made me feel very confident in looking at pictures. I hope it transfers over to the test! Thanks for putting it together. I highly recommend it!

    • Marie Biancuzzo

      Kim, I am *so* glad you found it helpful! Creating that workbook was one of the most difficult tasks I’ve ever taken on. But I’d also say it’s one of the best resources I’ve ever created. There’s so much variety and the person gets so much feedback. Glad to know it worked for you, Kim! Thank you!

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