Team-based primary care breastfeeding support

(left to right) Samantha Walters IBCLC , Ann Witt, MD, IBCLC, Lauren Lasko APRN, IBCLC, Kristen Auletta, RN, IBCLC, and Maya Bolman, RN, IBCLC team-up and provide breastfeeding support.

Imagine seeing a breastfeeding family two days after hospital discharge and having the time needed to correct latch, help manage engorgement, or review hand expression and supplementation for the baby with poor weight gain.  Health care provider support improves breastfeeding initiation and duration.  Yet, too often primary care providers (PCP) do not have the time or knowledge to provide breastfeeding support after hospital discharge.  These challenges can be solved with team-based lactation consultant and primary care (LC/PCP) providing breastfeeding support in the primary care office.

Per American Academy of Pediatrics and Family Physicians, a breastfeeding infant should be seen by their primary care provider (PCP) within two to three days of discharge (https://pediatrics.aappublications.org/content/125/2/405).  This visit includes evaluation of weight and jaundice.  In a breastfeeding infant, significant weight loss or jaundice is often triggered by breastfeeding difficulties including latch, pain, or delayed onset of milk production. Team-based primary care breastfeeding support combines the PCP’s initial post-discharge visit with lactation consultant support.  The team approach facilitates physician evaluation of the infant along with immediate lactation support on needed topics such as feeding patterns, output, latch, engorgement, and appropriate supplementation.

Team-based LC/PCP care acknowledges:

1. Families want to breastfeed.
2. Families experience breastfeeding challenges.
3. Feeding challenges require a plan that supports the breastfeeding dyad.
4. Education on that plan takes time and breastfeeding knowledge.

Over 80% of mothers initiate breastfeeding in the United States, yet many women do not meet their goal of continued breastfeeding beyond a year.  Given pain and low milk supply are common causes for weaning, breastfeeding support after hospital discharge is critical.

Ann Witt, MD, IBCLC, and Maya Bolman, RN, IBCLC with breastfeeding family during a clinic visit.

Having successfully provided team-based lactation care for over a decade within a suburban pediatric (https://www.ncbi.nlm.nih.gov/pubmed/21657890) practice, we look toward sharing this movement in other communities. Recently we partnered with a Federally Qualified Health Care system in Cleveland, Ohio to implement team-based lactation care.( https://www.jabfm.org/content/32/6/818)  Prior to implementation  a survey of providers at the FQHC found that 80% noted there was “not enough time” to provide lactation support during the visit  and 58% thought there was “inadequate lactation consultant staffing at the practice” with 80% of PCP’s commenting that patients were “not receiving adequate help.”  One year later, following implementation of team-based breastfeeding support, a repeat survey of PCP’s, found 100% reporting they were “providing better breastfeeding support” to their patients and liked having “breastfeeding support available for patient that NP/MD previously did not have time to provide.”  A majority of the PCP’s also liked having “a lactation consultant join an already scheduled visit so the patient does not need an extra visit,” as well as “on-site immediate lactation support.” The program has been so successful that the FQHC is expanding this service beyond their main clinic to satellite sites.

To implement team-based care, practices need to personalize it to fit their own practice needs. We determined feasibility of the team-based practice model at the FQHC by assessing breastfeeding intent and rates, health care provider knowledge, billing reimbursement, and currently available breastfeeding supports.  We used the information gathered to formulate a business plan, identify additional training needs, and facilitate communication with administration.  Other practices can build on this structure to implement team-based LC/PCP care in their own communities.

Now is the time for our health care system to help families get timely breastfeeding support after hospital discharge.  If your practice has already implemented a team-based primary and lactation care approach share your story so others know it is possible. If you are interested and trying to figure out how, gather the basic information, begin the dialogue and draw on other practice’s experience.

Together we can improve the care of our families after delivery, and better support breastfeeding duration!

References:

1. Stark et al. Committee on Fetus and Newborns 2008-09. Hospital Stay for Healthy Newborns. Pediatrics February 2010, 125 (2) 405-409;
2. Witt AM¹, Smith S, Mason MJ, Flocke SA. Integrating routine lactationconsultant support into a pediatric practice. Breastfeed Med. 2012 Feb;7(1):38-42.
3. Witt AM, Witt R, Lasko L, Flocke SA Translating Team-Based Breastfeeding Support into Primary Care Practice. JABFM Nov/Dec 2019

Blog posts reflect the opinions of individual authors, not ABM as a whole.

Towards Improved Support for Medical Trainees Who Are Breastfeeding

Dr. Helen Johnson

Ironically, physicians have some of the lowest rates of breastfeeding in the United States. Despite acute awareness of the medical risks of not breastfeeding and deep commitment to educating their patients about the importance of breastfeeding, many physician mothers face significant challenges in their own breastfeeding efforts. Medical trainees – including medical students, resident physicians, and fellows – are among the most vulnerable. This month’s IABLE podcast focuses on how to improve support of medical trainees who are breastfeeding.

Dr. Anne Eglash recording the IABLE podcast.

Medical trainees have jam-packed schedules with little to no control over their time. It can be a small feat to find time to scarf down a snack between surgeries or surreptitiously slip away from hospital rounds to run to the bathroom. In a culture in which self-sacrifice for the greater good of one’s patients is the norm, devoting 20-30 minutes every few hours to express breastmilk can feel like an indulgence. In addition, trainees may fear being perceived as less dedicated than their peers to their education or to patient care should they attend to personal needs at work. Even in a workplace environment that strongly supports breastfeeding – such as the obstetrics/gynecology department – lack of accessible, sanitary, and private spaces can limit a trainee’s ability to breastfeed at work.

In the past several months, several steps have been taken to improve support for medical trainees who are breastfeeding. In June, the American Academy of Family Physicians (AAFP) published a statement (https://www.aafp.org/about/policies/all/breastfeeding-accommodations-trainees.html) stressing the need to better support these women through policies that address protected time, adequate facilities, and a supportive workplace environment. On July 1, new Accreditation Council for Graduate Medical Education (ACGME) regulations went into effect: residency and fellowship programs are now required to provide clean, private lactation facilities for trainees that are in close proximity to patient care and include refrigeration capabilities.

Dr. Rebecca Snyder cartoon from her days as a surgical resident.

The ACGME notes: “While space is important, the time required for lactation is also critical for the wellbeing of the resident and the resident’s family.” Last month, a departmental lactation policy implemented by the surgery departments at the University of Michigan and the University of Wisconsin was published. This policy has been circulated on social media and adapted by dozens of other departments across the nation.

Most recently, my colleagues and I issued a “call to action”, urging the creation of a universal policy to better support resident physicians and fellows who are breastfeeding. We admire the grassroots efforts to create departmental policies and respect the significance of the new ACGME regulations. However, we feel that there is an urgent need to do more to ensure that all medical trainees have the support they need to breastfeed their children. In our publication, we underscore the importance of cultivating a supportive workplace culture, promoting access to appropriate lactation spaces, and ensuring adequate time for breastfeeding, and suggest specific action steps that program directors and institutional leadership can take to achieve these goals. Our piece was highlighted by Duke Forge and is discussed in detail in this month’s IABLE podcast.

Dr. Helen Johnson and her child visiting her at work as a surgical resident.

The podcast features not only the three authors of the “call to action” but also Laurie B. Jones, the founder of Doctor Mothers Interested in Lactation Knowledge. This online peer-to-peer breastfeeding support group for physician mothers has been instrumental in helping thousands of women – including trainees – meet their breastfeeding goals. Dr. MILK members encourage each other and share their wisdom for balancing breastfeeding and a medical career. Let’s take this to the next level by joining forces with breastfeeding medicine physicians and national organizations – together, let’s advocate for a universal lactation policy for medical trainees. ABM has already confirmed their support of the AAFP’s statement. Now it is time to amplify each other’s voices and effect meaningful change.

Dr. Katrina Mitchell and Dr. Laurie Jones in Sedona, AZ where they recorded the podcast for IABLE. The doctors’ three children have been breastfed for cumulative length of 14 years!

– Helen M. Johnson, MD is a general surgery resident at East Carolina University / Vidant Medical Center in Greenville, North Carolina. She is originally from Tampa, Florida and obtained her medical degree from the Warren Alpert Medical School of Brown University. Dr. Johnson plans to pursue fellowship training in breast surgical oncology after graduation from residency. She has a special interest in the intersection of breast cancer and breastfeeding, and is working towards IBCLC certification. Dr. Johnson enjoys gardening, playing the cello, and spending time with her husband, two children, and beloved cat. Connect with Dr. Johnson on Twitter: @HelenMJohnsonMD

Blog posts reflect the opinions of individual authors, not ABM as a whole.

I’m grateful for a community of physicians who care deeply about breastfeeding

Last week, more than 400 health professionals gathered in San Francisco for the Academy of Breastfeeding Medicine’s 23^rdInternational Conference. The conference drew participants from 25 counties and 41 US states, including 259 physicians from medical specialties ranging from neonatology to breast surgery.

Members of Dr. Milk at ABM 2018

We kicked off with two pre-conference courses, “What every physician needs to know about breastfeeding (WEPNTK)” and “What every physician needs to know about breastfeeding II.” WEPNTK covers the anatomy and physiology of breastfeeding that many of us missed in medical school. WEPNTK II covered more advanced clinical issues, like maternal risk factors for low milk supply, management of tongue tie, therapeutic ultrasound for mastitis, and postpartum depression.

ABM is unlike any other medical conference that I attend because the audience spans multiple medical specialties and brings together clinicians from around the world. The conference committee faces the daunting task of selecting speakers that address the interests of both subspecialists and general practitioners across the translational continuum from basic science to public policy. And as an international conference, our speakers are selected to include perspectives on breastfeeding policy and public health from around the globe.

ABM’s First Australia/ New Zealand Regional Conference

The inaugural ABM Australia/New Zealand Regional Conference was held  at the Gold Coast, Queensland, Australia on July 20-21 2018 with over 85 registrants from Australia, New Zealand, Malaysia, Indonesia and Taiwan.

 

The conference was preceded by a one day workshop “Breastfeeding Essentials for Medical Practitioners” which is a Australian/NZ version of the ABM ‘What every physician need to know about breastfeeding’ course, modified to meet the needs of Australian and New Zealand doctors.  In Australia and New Zealand, most breastfeeding medicine is provided by general practitioners (family physicians) who care for the mother-baby dyad routinely in the postpartum period.  Australian research in 2009, indicated only 23% of general practice registrars felt confident that their breastfeeding knowledge was adequate, with common sources of information being undergraduate teaching, post graduate teaching, general practice and personal experience. (1)  Our aim was to present a breastfeeding conference organised by doctors, for doctors, with clinically relevant and evidence based presentations.

There is a disappointing lack of routine data collection around breastfeeding in Australia; however in 2010 (2) around 96% of women initiated breastfeeding, with a rapid drop in the early months with 39% of women exclusively breastfeeding at 4 months (2). Data from 2007 (3) indicated only 28% of babies continued to be breastfed at 12 months of age. The Australian government has a paid parental scheme where mothers who earn less than AU$150,000 per annum are entitled to 18 weeks paid leave at the national minimum wage. Some employers also provide additional paid parental leave. All mothers are entitled to take up to 12 months maternity leave in total (paid and unpaid) and have their jobs protected under legislation. A similar scheme operates in New Zealand, with 18 weeks government paid parental leave,  increasing to 26 weeks in 2020.

On finding #MyPeopleABM: Physicians share what ABM means to them

Jennifer Caplan, MD, FAAP, IBCLC
North Scottsdale Pediatric Associates, AZ USA
I joined ABM after going to an AAP conference in 2008 with my nursing baby. At the conference, I ended up spending almost the entire time with the Section on Breastfeeding because my baby was not interested in staying with my husband—so I brought her with me. And I felt more comfortable hanging out with the breastfeeding crowd. I ended up riding in an elevator with some of the organizers and one of the women told me I should join ABM.

I had been so energized by the discussions at that conference—learning how to do frenotomies, hearing about the “Ban the Bag” efforts in Massachusetts, finding out about Baby Friendly Hospitals for the first time. So, I joined ABM and attended my first conference in 2009.

Being at an ABM conference is amazing. I’m really not a conference person—networking does not come easily to me, I don’t really like the marketing/advertising hall, but I do love learning about new things. ABM is the only conference I really enjoy going to. I always come away from the conference with at least a dozen new ways to practice and a new energy to spread my knowledge to others. And I love the people I meet at ABM conferences—so many perspectives, so many different ways they express their passion for supporting the mother-baby dyad. After another couple conferences, I had been convinced to become a lactation consultant.

I usually make it to the ABM conference, but even in years where I don’t go, I still get a lot out of my membership. I probably use the protocols more than anything else—always the most up to date, comprehensive source on breastfeeding topics. I enjoy seeing the new research coming out in the journals. And just knowing I’m a part of an amazing group that is a political force for advancing breastfeeding and advocating for women is important to me.

Surgeons who pump: #ILookLikeASurgeon

If you follow trends on social media, you have seen the viral tweets and pics from women surgeons who have copied the New Yorker magazine cover showing three women leaning over an operating table.   These posts share two common hashtags:  #ILookLikeASurgeon and #NYerORCoverChallenge.  As an admin for the 7,000+ member Dr. MILK online physician mother breastfeeding support group, I wanted to see this picture taken from the perspective of a multi-tasking surgeon mother who fits in pumping her milk between cases and a very hectic schedule.  I asked our members to try and coordinate OR schedules and pumping schedules to make this happen.  Three superstar OB GYNs from Baylor College of Medicine created this pic while at Texas Children’s Pavilion for Women in Houston, TX.  They don’t literally pump their milk while leaning over an operating table, but this picture represents the duality of surgeon moms who balance patient care needs with meeting the nutritional needs of their infants.  Their stories of breastfeeding/pumping challenges and successes will hopefully encourage mothers of all walks of life to confront and remove barriers to maintaining a milk supply while at work and #normalizePumping.

Here’s what their workday looked like when they managed to take this picture:  One doctor had a delivery and then a c-section while the second had a fetal surgery.  The third surgeon was performing a robotic hysterectomy.  They tried to coordinate the photo between the delivery and c-section but timing wasn’t right, and then just before the fetal surgery the three women rushed into an empty OR to make it happen. 

ABM Releases Revised Supplementation Protocol

During a time of abundant research surrounding the long term implications of feeding practices in the neonatal period on maternal and child health, it is of utmost importance that healthcare professionals are guided by the best available evidence regarding infant feeding while caring for breastfeeding dyads. We know that despite the recommendations against routine formula supplementation, this practice is commonplace in hospitals worldwide for a myriad of reasons. In developing ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate (Read the protocol here) newborn physiology and management of breastfeeding mothers were highlighted to impress upon healthcare professionals the delicate balance involved in helping mothers establish exclusive breastfeeding in the early postpartum days. Many mothers set out with the goal of exclusive breastfeeding, but still in many countries, few reach their feeding goals. Studies clearly demonstrate that when healthcare teams have a clear understanding of these topics, provide antenatal education, and implement supportive hospital practices, the need for supplementary feedings in term neonates is rare.

Preventing the need for supplementation altogether should be a common goal for all members of the healthcare team. It has been well established in the literature that exclusive breastfeeding protects mothers and infants from various poor health outcomes, is cost effective, and is the physiologic norm. Thus, the authors of this protocol dedicated substantial time and focus on practices that have been shown to reduce this need, which include many of the ten steps required by the Baby Friendly Hospital Initiative. The revised protocol contains an algorithm for caring for the breastfeeding dyad before and during the birth hospital stay and responding to common concerns.

It is important to recognize true medical indications of supplementary feedings as well as the preferred choice and volumes of supplement, which are appropriately outlined in this protocol, re-emphasizing that, while there is a time and place for formula use, a mother’s own expressed milk or donated human milk in volumes that mimic normal breastfeeding physiology are preferable to breast milk substitutes. The preference for donor human milk over formula use has been suggested by the Academy of Breastfeeding Medicine for years, and is further supported by emerging research on the long term health consequences of the infant microbiome and the role that breast milk substitutes may have on individual health outcomes years down the road.

Educating ourselves as healthcare providers about how best to support mothers in their breastfeeding journey is crucial to their success in meeting their personal feeding goals. This revised clinical protocol highlights supporting evidence and contains information and strategies needed to provide state-of-the-art care and support.

The Sixth European ABM Conference in Lisbon Portugal—A Win for Organizers and Attendees Alike!

I returned from a trip to Europe over a week ago tonight, my first stop Lisbon Portugal. I celebrated one of those “big” birthdays in Lisbon, you know, the ones that end in a “0” or a “5” with 230 of my closest friends and colleagues in Breastfeeding Medicine from 23 nations around the globe.  Honestly!!  Well, they were not all there just to celebrate my birthday, although some did stay an extra day just to celebrate the day with us!!

What began this marvelous journey was an invitation from conference organizers Elien Rouw, MD, FABM (Germany), Monica Pina MD, ABM (Portugal), and Reet Raukas MD, ABM (Estonia) to speak at the 6^th European Academy of Breastfeeding Medicine Conference, held on June 17-18, 2016 in Lisbon, Portugal.  Dr. Rouw has been behind these regional international conferences from the start, and is the mastermind in organizing them, along with local physicians and other like-minded organizations at various times in the countries in which they have been held.  The success she and her co-coordinators have had is a tribute to their hard work, their desire to bring quality physician education in breastfeeding medicine and related subjects to Academy of Breastfeeding Medicine (ABM) members and other physicians and health care members outside the United States, and their tireless efforts to make these conferences affordable, with little support outside their own “blood, sweat and tears”.  This is in actuality a matter of equity and disparities in our field.  Many US physicians cannot afford to travel to Europe or Asia or Australia yet we expect our non-US colleagues to travel to the US yearly to the Annual conference, which is expensive for many of us even if we live in the US.  So do Dr. Rouw and her European colleagues accomplish their goals?  They most certainly do!!!  If one watches and grabs an airfare when they are at their lowest, even from the US this conference is very affordable, and the bonus is, no matter where you come from, you are treated to a beautiful European city, its gracious hospitality and phenomenal cuisine!

This success has built over the past 10 years. Former conferences have been organized in Germany (2007), Austria (2008), Poland (2010), Italy (2012) and Romania (2013).  The 6^th Conference in Lisbon was organized in collaboration with SOS Amamentação Portugal and with support of the city council of Lisbon —the largest thus far, and buzzing with activity!!

The speakers and some attendees from outside Portugal stayed in a wonderful hotel that was noted as not far from the site of the conference. The morning of the 17^th a bus was arranged to pick all of us up who were staying at the hotel an hour before the conference started to transport us the short distance to the conference venue, Auditório Polo ArturRavara ESEL, a relatively new site of the nursing school in Lisbon.  After a late arrival, we drove around for quite a while.  Turns out our (native Portuguese) bus driver was lost, because he got the wrong address!  So, we started the first day a bit late. Was this a problem?  Not at all!  Everyone rose to the occasion and soon the conference had begun in a beautiful and comfortable venue and we were all immersed in breastfeeding medicine!

Watch your baby, not the clock

Dr. Jon Matthew Farber published the final installment of pearls reflecting on his practice in the January 1, 2016 edition of Contemporary Pediatrics. (Farber, Pearls from the trenches: Part 4, Contemporary Pediatrics. ) As Dr. Farber noted in the introduction, “I have heard it said that half of what we practice now will be out-of-date in 10 years, but the trick is to know which half.” Many of his clinical observations are quite valid and helpful for the practitioner. Unfortunately, one of the tips in that edition is out-of-date and could be counterproductive.

Under “Words to Live By,” item #10 addresses breastfeeding routines and states that “After 10 minutes, if not sooner, a breast is mostly empty. Having a child feed for 20 to 30 minutes at the first breast will exhaust both the mother and the child (and can lead to very sore nipples). Particularly for newborns, I recommend 10 minutes at the first breast, switching breasts for another 10, and then “topping off” for another 5 to 10 minutes at each breast if the baby is still hungry.” This statement includes the Lancet reference. ( Lancet. 1979 Jul 14;2(8133):57-8. )

Indeed, as Dr. Farber has noted, in the more than 35 years since that publication, our understanding of breast milk production and transfer, as well as the composition of milk, has improved significantly. We also know that each baby is different, as he or she masters the skills of feeding from the breast with continued practice. While some babies may indeed consume a substantial volume of milk in 10 minutes, others, and especially newborns, may take significantly longer. (Breastfeed Med. 2013 Dec;8(6):469-73. )In addition, the greatest proportion of fat is consumed towards the end of a feeding. Frequent “switching” from side to side may result in relatively higher water and sugar intake, with proportionately less fat intake, tending to make babies more fussy and gassy, with frequent frothy, green stools. In some circumstances, these babies may suffer from growth faltering. (J Am Board Fam Med. 2016 Jan-Feb;29(1):139-42. ) Therefore, it is no longer recommended that parents follow the clock when feeding, but instead observe the baby for signs of satiety, such as, relaxing of the posture or falling asleep. A full feeding (no specific time, but noted by less frequent swallowing or the baby drifting off to sleep) on the first breast offered, followed by as much feeding as desired on the second breast, if requested by a baby, works well for most babies, especially during the newborn period. (Breastfeed Med. 2010 Aug;5(4):173-7.) The breast never completely empties, because production continues throughout the feeding. Soreness of nipples does not correlate with the time spent nursing, but with the adequacy of latch.

If the mother is experiencing sore nipples (J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37), the latch should be carefully evaluated by someone skilled in breastfeeding assessment, whether that be a doctor, nurse, lactation consultant, or other helping professional. Fellows, or members, of the Academy of Breastfeeding Medicine, an organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation, are excellent resources. ( Academy of Breastfeeding Medicine) Good breastfeeding routines are especially important in the early days and weeks in order to establish and maintain a good milk supply. Timed feedings may actually increase the risk of insufficient milk supply, which can be challenging to resolve.

While the pearls gleaned from practical experience can be very useful in our clinical decision making tool kit, they must be combined with current knowledge of clinical practice. The majority of mothers initiate breastfeeding, however, 60% do not meet their own breastfeeding goals. (Pediatrics. 2012 Jul; 130(1): 54–60. )
. Evidence-based medicine combines careful review of the medical literature with clinical experience and judgment. In order to support breastfeeding families optimally and achieve the improved health outcomes for both mothers and children, it is critical that physicians and other health care providers communicate current information and recommendations to colleagues, instead of relying only on our own observations and dated references.

Joan Meek is a Associate Dean for Graduate Medical Education and Professor of Clinical Sciences
Florida State University College of Medicine. She has served as president of the Academy of Breastfeeding Medicine, Chair of the American Academy of Pediatrics Section on Breastfeeding, and Chair of the United States Breastfeeding Commitee. 

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Of goldilocks and neonatal hypernatremia

A heart-wrenching story has been circulating on social media about an exclusively breastfed baby who suffered brain damage after 4 days of ineffective feeding. The mother,  Dr. Christie del Castillo-Heygi, is a physician, and she shares how she was reassured that all mothers can make milk, and did not realize until she engaged a lactation consultant at 96 hours postpartum that her child was profoundly dehydrated.

It’s a tragic story. Dr. del Castillo-Heygi is petitioning public health leaders to warn all parents about the risk of irreversible brain damage with exclusive breastfeeding. That warning would directly challenge efforts across the US, and around the world, to emphasize the value of exclusive breastfeeding and the risks of unnecessary supplemental feeding. This push for exclusive breastfeeding is part of efforts to implement the Baby Friendly Hospital Initiative, a set of quality improvement efforts that increase the likelihood that women achieve their personal breastfeeding goals. For healthy infants, supplementation can interrupt the demand-drives-supply physiology of breastfeeding, reduce a mother’s milk supply, confuse baby’s latch, and expose the infant’s gut to allergens that may impact lifelong health.

So who’s right? Well, it’s complicated – and my sense is that this debate reflects the challenges of ensuring that families have the knowledge and support they need to initiate and sustain breastfeeding in the early weeks after birth.

We might start by acknowledging, once and for all, that not all mother-baby dyads are able to breastfeed exclusively. Reproductive physiology is not infallible. 10.9% of women have difficulty getting pregnant or carrying a baby to term. 15 to 20% of pregnancies end in miscarriage, 10% of infants are born preterm, and 1 in 100 infants are stillborn. Similarly, less than 100% of women can exclusively breastfeed.