ABM Candid Conversations: A Virtual Interview with Protocol Authors Helen Johnson, MD and Katrina Mitchell, MD IBCLC

ABM is excited to launch the beginning of our Candid Conversations series, featuring ABM members and their various initiatives within the Academy as well as their professional lives. This week, ABM sat down virtually with Helen Johnson, MD and Katrina Mitchell, MD IBCLC, two authors of our most recent protocol Breast Cancer and Breastfeeding, to discuss how they became interested in breastfeeding medicine, what lead them to creating their protocol, and what shifts they’ve seen in practice over the last year with the current health crisis.

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  Katrina Mitchell, MD IBCLC

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  Helen Johnson, MD

Q: Please introduce yourself and provide any background or work information you’d like shared.

HJ: I am a native of Tampa, Florida and a graduate of Brown University’s Program in Liberal Medical Education.  I am currently in my fourth year of general surgery residency at East Carolina University/Vidant Medical Center in Greenville, North Carolina.  After residency I plan to pursue fellowship training in breast surgical oncology, and am currently working towards IBCLC certification.  My goal is to be able to provide high-quality care for patients with any breast condition, whether benign or malignant, and/or occurring during unique periods such as pregnancy or lactation.  I am passionate about research and evidence-based medicine, and hope to contribute to the advancement of scientific and medical knowledge related to breast disease. 

KM: I’m a breast surgeon and lactation consultant in Santa Barbara, California.  My practice focuses on the operative management of breast cancer, but I also care for breastfeeding dyads with a variety of lactation-related questions and concerns.

Q: How did you discover/enter the world of breastfeeding medicine? 

HJ: I experienced challenges breastfeeding my children.  When I sought medical evaluation for a breast condition, I was shocked by the fragmentation of care.  I was able to receive timely, helpful support from a lactation consultant, but it was much more difficult to find a clinician with prescribing privileges who was knowledgeable about lactation.  A colleague encouraged me to join the Facebook group Doctor Mothers Interested in Lactation Knowledge (“Dr MILK”), where I learned a great deal about breastfeeding from other physicians.  It was through Dr MILK that I first learned about ABM and the field of breastfeeding medicine.  I was so pleased to learn that there is a field devoted to breastfeeding medicine including care of the lactating breast, as I want to be able to help any patient with any breast concern. 

KM: During my breast surgical oncology fellowship in Houston, Pamela Berens was my breastfeeding medicine physician after the birth of my son.  She introduced me to the ABM, and my son and I attended our first conference in Portugal when he was 7 months old.

Q: How has being a member of ABM contributed towards your profession/life? 

HJ: Contributing to ABM protocols has been such a rewarding experience.  I have gained a deeper appreciation for the strength of the evidence for specific recommendations, and the process of developing societal guidelines.  I have especially enjoyed collaborating with other physicians who are passionate about breastfeeding medicine.  Through these collaborations, I have cultivated both professional connections and meaningful friendships.  

KM: The collaborative multidisciplinary aspect of ABM has opened an entirely new dimension in my professional and personal life.  I have developed a much more complex understanding of breast biology and pathophysiology than I ever knew as a breast surgeon alone.  I also have learned a great deal about pediatrics and the peripartum care of women, including the mental health challenges many patients experience. I have been so fortunate to have multiple mentors in breastfeeding medicine from different specialties, and I continue to learn something new each day.  I feel like I have completed a second residency in breastfeeding medicine!

Q: What lead you to identifying the topic you chose for the Protocol?

HJ: As a surgical resident who plans to practice breast surgery, I have a strong professional interest in the intersection between breast cancer and breastfeeding.  Little is taught about lactation in medical school or surgical training, yet breast surgeons and other physicians are entrusted with caring for breastfeeding patients with a current or past history of breast cancer.  As a moderator for Dr MILK, I read countless questions from other physicians about breast cancer screening, breast cancer treatment during breastfeeding, and breastfeeding among breast cancer survivors.  My impression was that physicians across multiple specialties would benefit from a practical, evidence-based resource to utilize when caring for this unique patient population.  

KM: Hyperlactation often results in complications that are surgical in nature – such as plugging, galactoceles, abscesses, and nipple conditions.  We thought it would be helpful to outline a standard approach to decreasing milk production in these patients to reduce maternal and infant complications of hyperlactation.  At the IABLE Ranch conference in 2019, we drafted this protocol and had great input from colleagues in different specialties who have practiced breastfeeding medicine in a variety of contexts.

The intersection of breastfeeding and breast cancer is a very challenging clinical scenario, and can be difficult for patients psychosocially as well.  Because we receive so many questions regarding this topic, we wanted to outline standard, evidence-based guidelines for the care of these patients.

Q: What difficulties has COVID-19 and its side effects (both in medicine and practice) presented to the implementation of your protocol? Or conversely, are there aspects of the current pandemic that have assisted it in any ways? 

HJ: In general, there have been many delays in routine cancer screening as a result of COVID-19, and sadly there has been an increase in the proportion of cancers which are advanced at presentation.  Many institutions had to halt non-emergent surgeries in order to divert resources towards care for COVID-19 patients, creating the need to utilize neoadjuvant treatment for breast cancers that were otherwise appropriate for up-front surgical therapy.

KM: Both cancer surgery and the care of breastfeeding dyads is not elective, so I have continued to see a large majority of patients in person, using standard precautions.  Telemedicine has allowed me to care for patients in other parts of our state, but there are significant limitations to evaluation via telemedicine.  The protocols have been very useful to share with colleagues during this time. 

Q: In your own life, what ways have you seen the pandemic change your daily working and life routines? 

KM: Remote learning is a real challenge for children and families.  We are very fortunate that my son meets state of California childcare guidelines for attending transitional kindergarten in person.  I am incredibly thankful to his school and teachers for what they do.  I’m concerned about the multitude of psychosocial and economic impacts of the shutdown, as well as patients avoiding care for other medical problems not related to Covid. 

Q: What are suggestions or tips you may have for physicians trying to implement your protocol, or more generally, support a breastfeeding parent at this time? 

HJ: I would remind readers that these protocols are living documents which are updated regularly, and that there remain many areas in breastfeeding medicine with limited evidence.  As such, I would encourage cross-disciplinary collaboration with other ABM members when seeking assistance for a challenging case as there may be more recent evidence to consider, and tips to be learned from the experiences of other breastfeeding medicine physicians.  

KM: Using standard precautions, I think it’s essential to evaluate patients in person whenever safely possible.

Q: Any additional thoughts? 

HJ: I would encourage surgeons who perform breast surgery to utilize ABM protocols and seriously consider joining ABM and learning more about breastfeeding medicine.

KM: Thank you to my ABM colleagues for their mentorship, friendship, and support.  Thank you to Helen Johnson for her friendship and incredible work ethic as a researcher and publisher.

New Protocol on Breast Cancer and Breastfeeding

New Rochelle, NY, June 10, 2020 — Managing women with breast cancer who are breastfeeding is a complex issue. The Academy of Breastfeeding Medicine presents new recommendations in the peer-reviewed journal Breastfeeding Medicine. Click here to read the article now.

“The aim of this new protocol is to guide clinicians in the delivery of optimal care of breastfeeding women as it relates to breast cancer, from screening to diagnosis, treatment, and survivorship,” state coauthors Helen Johnson, MD and Katrina Mitchell, MD.

It addresses the spectrum of care, including oncologic breast surgery, chemotherapy, and adjuvant and endocrine therapy. A section on breastfeeding women who have a previous history of breast cancer is included.

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, states: “This protocol is a guide for mothers who are undergoing diagnosis and treatment for breast cancer. It emphasizes that they do not have to categorically give up on their nurturing role as breastfeeding moms.”

Breast cancer is the most common malignancy in women worldwide. One in 20 women will develop breast cancer in their lifetime.

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About the Journal
Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 12 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine
The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher
Mary Ann Liebert, Inc., publishers is known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

Pregnant and Lactating Women with COVID-19: Scant Clinical Research

New Rochelle, NY, May 18, 2020 — Pregnant and breastfeeding women have been excluded from clinical trials of drugs to treat COVID-19, and as result, there is no safety data to inform clinical decisions. Such drugs include remdesivir according to a new article in the peer-reviewed journal Breastfeeding Medicine. Click here to read the article.

Since pregnant and lactating women are not included in clinical trials, little is known about whether the drug transfers into breast milk and reaches the infant’s circulation.

The lack of such data complicates a decision between giving lactating women a potentially life-saving drug and having them stop breastfeeding or risking any potential adverse effects of the drug on the infant, writes Alison Stuebe, MD, University of North Carolina School of Medicine and President of the Academy of Breastfeeding Medicine.

Suspending breastfeeding in mothers infected with COVID-19 could be detrimental because the infant is missing out on critical nutrients in human milk. Additionally, antibodies acquired from the mother may protect the infant against acquiring COVID-19.

“This quandary illustrates the consequences of longstanding policies to exclude pregnant and lactating women from clinical trials,” Stuebe says. “Rather than excluding pregnant and lactating women from research, we must protect them through research.”

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, states: “Pregnant and breastfeeding women and their fetuses and infants cannot continue to be administrative orphans regarding new drug trials, and this situation warrants immediate correction.”

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About the Journal
Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 12 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine
The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher
Mary Ann Liebert, Inc., publishers is known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

Should infants be separated from COVID-19-positive mothers?

MARY ANN LIEBERT, INC./GENETIC ENGINEERING NEWS

New Rochelle, NY, April 9, 2020–In a new commentary, Alison Stuebe, MD, President of the Academy of Breastfeeding Medicine, addresses the risks and benefits of separating infants from COVID-19-positive mothers following birth. Although multiple public health organizations recommended keeping mothers and infants together, the United States’ Centers for Disease Control and Prevention advises facilities to consider separating mothers and babies temporarily until the mother is no longer contagious, and recommends that the risks and benefits of temporary separation should be discussed with the mother by the healthcare team.

In her commentary, Dr. Stuebe, Professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and distinguished professor in infant and young child feeding at the Carolina Global Breastfeeding Institute at the UNC Gillings School of Global Public Health, notes that there is no evidence to show that early separation of infants and mothers with suspected or confirmed COVID-19 improves outcomes. While separation may minimize the risk of transmission of the virus from mother to infant during the hospital stay, it has potential negative consequences for both mother and infant, according to the commentary published in Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine published by Mary Ann Liebert, Inc., publishers. Click here to read the protocol free on the Breastfeeding Medicine website.

Dr. Stuebe outlines several risks of separating mothers and infants in the hospital, which disrupts breastfeeding and skin-to-skin contact during the critical hours and days following birth. For example, infants who lack skin-to-skin contact with their mothers tend to have higher heart rates and respiratory rates and lower glucose levels. The separation also stresses the mother, which could make it more difficult for her to fight off the viral infection. In addition, separation interferes with the provision of maternal milk to the infant, which is important for the development of the infant’s immune system. Separation also disrupts breastfeeding, which puts the infant at increased risk of severe respiratory infections, including pneumonia and COVID-19.

“As we navigate the COVID-19 pandemic,” Stuebe writes, “I am hopeful that we can center mothers and babies and remember to first do no harm.”

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, concurs that “there is no need or indication to categorically separate infants from COVID-19 suspect or positive mothers other than in circumstances wherein the mother’s medical condition precludes her caring for the infant. Feeding mothers’ own breast milk, either by nursing or by feeding of expressed milk, is OK and desired!”

About the Journal

Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 10 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine

The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher

Mary Ann Liebert, Inc., publishers is a privately held, fully integrated media company known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research, including Journal of Women’s Health, Childhood Obesity, and Pediatric Allergy, Immunology, and Pulmonology. Its biotechnology trade magazine, GEN (Genetic Engineering & Biotechnology News) was the first in its field and is today the industry’s most widely read publication worldwide. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

Support for Lactating Medical Trainees

Authored by: Sarah Shubeck, MD and Megan Pesch, MD, MS

The culture of medical training and demands of residency work is often regarded as not conducive to the needs of lactating physicians. The need for “breaks” or perceived lack of dedication to workplace can lead to misperception of lactating trainees and pressures to stop milk expression before reaching an individual’s goal. Additionally, recent work has demonstrated that physician mothers struggle to meet their personal breastfeeding goals at rates higher than their peers, most often attributed to the demands of their work and lack of workplace support and infrastructure.

Those successful lactating medical trainees have squeezed in quick “pump breaks” in between patients or cases, struggled with mastitis or discomfort from extending duration between milk expression, or have experienced being reprimanded for taking time to express milk. Additionally, the lack of clean and available lactation spaces result in women turning to bathroom stalls or skipping times for expression. Despite these discouraging and humiliating encounters, many lactating medical trainees have found success through pressing on individually, but often with having to sacrifice their supply and morale and compromise their personal breastfeeding goals.

The plight of the breastfeeding medical trainee has received recent well deserved attention. Several publications, including those by Livingston-Rosanoff et al., and Pesch et al, have highlighted these difficulties and proposed protections and education around the needs of lactating physicians. This recent work highlights three key components:

• First, there is a critical need for supporting trainees to be allowed time for milk expression as determined by the trainee and her healthcare providers. For example, residents are often hesitant to ask for a “pump break,” but departmental support for milk expression times allows women residents to meet their health needs without sacrificing learning opportunities.
• Second, as required by federal mandate, medical resident employees must be provided lactation spaces that are clean, private, and close to patient care settings to minimize time away from clinical and educational opportunities. Program directors and departments can work to provide convenient and private spaces through creative use of call rooms and empty patient care settings to meet the needs of their lactating trainees.
• Finally, creating an open and supportive culture around lactation within a department and institution is essential. Workplace education of faculty, staff, and trainees and the adoption of policies and guidelines can protect and support lactating trainees can function to normalize lactation in medical training. (See Livingston-Rosanoff et al., and Pesch et al, for examples of policies and guidelines).

Supporting lactation for medical trainees is not only the right thing to do for their health and wellness, but it will almost surely have a trickle-down effect to the care they provide their breastfeeding patients.

The well-being of mothers and children is not a tradeable commodity

Breastfeeding is the foundation of public health and economic development. All major medical organizations recommend 6 months of exclusive breastfeeding, followed by continued breastfeeding through the first one to two years of life and beyond.

Evidence continues to mount that disrupting optimal breastfeeding contributes to disease burden and premature death for women and children. Globally, optimal breastfeeding would prevent 823,000 child deaths each year. In the US, enabling optimal breastfeeding would prevent 721 child deaths and 2619 maternal deaths each year, as well as 600,000 ear infections, 2.6 million gastrointestinal illnesses, 5,000 cases of maternal breast cancer and more than 8,000 heart attacks.

Optimal infant feeding is also essential for economic development. Being breastfed is associated with a 3 to 4 point increase in IQ, leading to better school performance and workplace productivity. As stated by the World Bank’s Keith Hansen, “If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics.”

Breastfeeding is vital and essential to protect the world’s children, the most vulnerable who cannot speak for themselves.  Given the essential role of breastfeeding in global health and wellbeing, it is imperative that every nation supports policies and programs that enable women and children to breastfeed. It is therefore deeply troubling that the United States delegation to the World Health Assembly actively undermined efforts to enable optimal breastfeeding, as reported by the New York Times.

Separation of children and infants from parents – breastfeeding implications

June 21, 2018 – The Academy of Breastfeeding Medicine, an international physician’s organization, condemns policies that result in the separation of parents from their children.

As the UN High Commissioner of Human Rights has established, “Children have the right to life, survival and development and to the highest attainable standard of health, of which breastfeeding must be considered an integral component.” Mothers similarly have the right to nurture their children: “Restriction of women’s autonomy in making decisions about their own lives leads to violation of women’s rights to health and, infringes women’s dignity and bodily integrity.”

“Separating children from their parents results in toxic stress that impacts breastfeeding and health for a lifetime,” said Timothy Tobolic MD, President of the Academy of Breastfeeding Medicine. “Furthermore, separating a mother from her breastfeeding child violates the human rights of both mother and child.”

Separation of the breastfeeding mother-baby pair further confers risk of acute illness for mother and child. Breastfeeding women who are separated from their infants and unable to drain their breasts will become engorged and are at risk for mastitis and breast abscesses. Unrelieved engorgement will precipitate involution and loss of milk supply.

Infants who are not breastfed face increased risks of ear infections, gastroenteritis and pneumonia. Separation of any infant from their mother also has untold emotional harms on those children. These risks are magnified if they are housed in facilities where proper preparation of formula or washing bottles and teats is not available.

Indeed, in emergency settings, such as refugee camps for migrant populations fleeing oppression, the first principal of the 2017 Operational Guidance for Infant and Young Child Feeding in Emergencies is the protection, promotion and support of breastfeeding. Separating a mother from her breastfed child violates this first principal.

ABM recommends reuniting infants and children with there parents without delay. When mother and child are reunited, the Academy of Breastfeeding Medicine and IYCFE guidelines recommend individual-level assessment by a qualified health or nutrition professional trained in breastfeeding and infant feeding issues. The mother-child pair will need sustained support to reestablish lactation, with access to an appropriate breast milk substitute until the mother’s milk supply is reestablished or until at least six months of age and beyond.

“We agree with President Trump’s executive order to stop the separation of infants and children from their parents.” said Dr. Tobolic. “Families belong together and breastfeeding must be supported for the health of the children.”

The Academy of Breastfeeding Medicine Issues Guidance on Informal Milk Sharing for Healthy Term Infants

New Rochelle, NY, January 8, 2018—In response to the increasing informal sharing of human milk, the Academy of Breastfeeding Medicine (ABM) has published guidelines to minimize the risk of this practice while enhancing the health benefits. The position statement is published in Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine published by Mary Ann Liebert, Inc., publishers. The article is available free on the Breastfeeding Medicine website until February 8, 2018.

“Academy of Breastfeeding Medicine’s 2017 Position Statement on Informal Breast Milk Sharing for the Term Healthy Infant ” discusses strategies to maximize the safety of community-based breast milk sharing, including 1) medical screening of the donor and 2) safe milk handling practices. Donors should have no medical illness where breastfeeding is contraindicated nor on any medication that is incompatible with breastfeeding. Mothers can further reduce the risk of infections by performing home pasteurization of donated milk prior to giving it to her infant; however, pasteurization can decrease some of the beneficial components of human milk. ABM also emphasizes that while informal milk sharing has potential health benefit, “internet-based milk sharing is not recommended under any circumstances.”

“Informal breast milk sharing is becoming increasingly common for healthy term infants as 21^st century families desire to feed their infants human milk,” says Dr. Timothy Tobolic, president of ABM. “Physicians and other health care providers can help mothers and families evaluate the risks and benefits of informal milk sharing.”

ABM Ethics Committee Formal Grievance Review is Ongoing

November 9, 2017 – The Academy of Breastfeeding Medicine has a formal process in place to address any member grievances, including potential conflict of interests. These routine procedures are outlined in our bylaws and our Code of Ethics. Both documents are available to all with no restricted access at www.bfmed.org.

Last week, the grievance review process was activated. Today, the Board of Directors discussed this ongoing matter in person at the regularly scheduled board meeting.

The Ethics Committee is actively reviewing ABM’s Conflict of Interest policies. The results of this policy review and any recommendations will be shared with membership following the January meeting of Board.

 

 

CDC issues guidelines on breastfeeding and Ebola

Both families and physicians are anxious about the potential impact of the Ebola virus for mothers and infants.

The CDC has recently issued guidelines for field and partner organizations regarding how to advise breastfeeding women with probably or confirmed Ebola infection:

“When safe alternatives to breastfeeding and infant care exist, mothers with probable or confirmed Ebola virus disease should not have close contact with their infants (including breastfeeding).

In resource-limited settings, non-breastfed infants are at increased risk of death from starvation and other infectious diseases. These risks must be carefully weighed against the risk of Ebola virus disease.”

The Ebola virus has been detected in the milk of infected women. For mothers who recover from Ebola, it is not known when it is safe to resume breastfeeding. The CDC recommends waiting to resume breastfeeding until milk can be shown to be Ebola-free in laboratory testing.

As the Ebola outbreak continues to evolve, the Academy of Breastfeeding Medicine recommends consulting CDC guidance on how to minimize risk for infants of affected mothers.