Breastfeeding Medicine

Physicians blogging about breastfeeding

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Establishing the Fourth Trimester

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Lisa Selvin’s provocative article, “Is the Medical Community Failing Breastfeeding Moms?” has elicited a wide range of reactions from the breastfeeding community. Some have argued that the piece, which focuses on unmet needs of mothers who encounter physiologic problems with breastfeeding, “sensationalizes” breastfeeding, making it sound so treacherous and difficult that mothers should avoid it altogether.

I would argue that there’s a very fine line between “sensationalizing” and “truth in advertising.” Reproductive biology is imperfect — some couples can’t conceive, and some pregnancies end in miscarriage or stillbirth. The silence around these losses and the isolation that women have historically experienced has probably worsened the suffering for many women. On the other hand, emphasizing these risks and creating a culture of fear harms the majority of mothers who will have successful pregnancies and births. Read the rest of this entry »

Written by astuebe

January 4, 2013 at 12:45 pm

Announcing our Newest Protocol: ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant (34 0/7 to 36 6/7 Weeks Gestation) (First Revision June 2011)

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I am pleased to announce our newest protocol has been published in Breastfeeding Medicine: ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant (34 0/7 to 36 6/7 Weeks Gestation) (First Revision June 2011).  This is a revision of the previously entitled ABM Clinical Protocol #10: ‘‘Breastfeeding the Near-Term Infant (35 to 37 Weeks Gestation)”.  As this protocol starts out explaining:

“At the time this protocol was first written ‘‘near-term’’ infant was commonly used to describe infants born in the few weeks before the 37th week of gestation. In July 2005 a panel of experts assembled by National Institute of Child Health and Human Development designated infants born between 34 0/7 to 36 6/7 weeks of gestation as late preterm to emphasize the fact they are really ‘‘preterm’’ and not ‘‘almost term’’ and establish a uniform designation for this group of infants.  This definition, however, includes infants born 1 week more premature (34 0/7–34 6/7 weeks) than the previous Academy of Breastfeeding Medicine protocol for the ‘‘near term infant’’ that encompassed infants born at 35 0/7 weeks to 36 6/7 weeks. In addition, infants born at 37 0/7–37 6/7 weeks may be at risk for breastfeeding problems and associated risks, and, therefore, the following guidelines may be applicable to these infants as well”.   Breastfeeding Medicine 2001; 6(3):151-156.

This protocol is the perfect example of what we as the Protocol Committee hope can happen as we update and revise our Clinical Protocols on a 5 year basis.  Unless the evidence has changed dramatically, the plan is to attempt to update the references and the data in such a way as to follow the general outline of the original protocol.  The reasoning is that those of you who are used to using a particular protocol will think everything is changed if you see a completely differenct document, when maybe only one or two things have actually been changed.  If the format remains generally the same, you will be able to easily see what has been updated and what has changed since the last version, and easily be able to update your own practice.  Sometimes this is not possible if either practice really has changed extensively, or author styles and interpretation of the data are so different that there is just no way around it.  But this protocol is an excellent example of how some of the evidence has changed, starting with the basic definition of the population, and there are many more references available ( 13 cited in 2004 versus 52 in 2011) but the basic outline has been followed, enhanced, and expanded to make an even better protocol than the original was.

As the ABM Protocol Chair, I speak for my Committee and for the ABM Board of Directors when I say we are very proud of these Clinical Protocols and our Statements, all of which can be found on our website.  The Clinical Protocols are also accepted and published by the National Guidelines Clearinghouse, sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health & Human Services, which has very stringent requirements for acceptance to their website.

So please check out this newest protocol, and keep your eye open for our next one, the brand new Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant!

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

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

Written by kmarinellimd

June 6, 2011 at 7:45 am

ABM Protocol and Statement Updates!

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Today I wear my dual hats as ABM Protocol Chair and ABM Blogger.  It came to the attention of the Protocol Committee that there were typos/errors in a couple of our ABM protocols after publication.  Two protocols have been corrected in the on-line copies for Breastfeeding Medicine previously, and have now been updated on the ABM website as of today. 

Here are the corrections that have been made:

1.  Protocol #3—Supplementation—Volume 4, Number 3:

  Table 3, page 178  under “Time” the second line was originally printed 24-28 hours; correction is 24-48 hours.

2.  Protocol #7—Model Hospital Policy—Volume 5, Number 4:

  Page 176 and in the listing of the Ten Steps.  Step #6: only the US version require that hospitals purchase their formula.  The original published text stated: 

   6.  Give newborn infants no food or drink other than breast milk, unless medically indicated. (A hospital must pay fair market price for all formula and infant feeding supplies that it uses and cannot accept free or heavily discounted formula and supplies.)

Now it correctly and in keeping with the original, international Ten Steps says:

  6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

I will let you know if any future changes occur in published protocols or statements. 

And by the way, the just published issue of Breastfeeding Medicine contains ABM’s second Statement, Educational Objectives and Skills for the Physician with Respect to Breastfeeding.  Check it out in the latest Journal (Breastfeeding Medicine. April 2011, 6(2): 99-105).  Our first ABM Statement, Position on Breastfeeding (Breastfeeding Medicine 2008;3(4):267-270), can be found under the “About Us” tab on our web page right now.  As we now have two statements, and several more on the way, we are setting up a “Statements” section on our Protocol page to make them easy to find all in one place.  Please be a little patient with us!  Our newest statement will be on our website soon!

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

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

Written by kmarinellimd

April 11, 2011 at 5:04 pm

Physician Mothers: How do we fare with breastfeeding?

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A recent study published in the Breastfeeding Medicine by Sattari et al looked at breastfeeding intentions of female physicians.  They looked at breastfeeding behavior of these women at 3, 6, and 12 months.  Not surprisingly, of the 50 women surveyed, 100% of these physicians had intentions of long-term breastfeeding.  However, as the results showed, the rates of exclusivity/any breastfeeding declined as the women were followed. Although the sample size was small, it brings to light many of the issues women physicians face when going back to work.

Physicians know the benefits of breastfeeding, and it’s interesting to see that most plan on breastfeeding.  The authors point out that not only does breastfeeding benefit the mother and her baby, but our personal stories can usually help a patient.  In my case, breastfeeding didn’t come easy.  My personal struggles to provide breastmilk for my 3 children have helped me counsel mothers in my pediatric practice.  But ironically, even though I work in a field that should obviously support breastfeeding, this wasn’t my experience.  I struggled with finding the time and space to express milk—and yes, I did pump in a bathroom stall!! Ironically, it was after my 3rd child, when I was working in a Pediatric emergency room, that I was given the most support: nurses told me in the middle of my shift to go pump, with my director even offered me a hospital-grade pump!!

This study highlights that specialty and stage of career can and do affect breastfeeding longevity.  Attendings are generally in the best position to alter their schedule to accommodate pumping breaks, as opposed to residents.  During residency and fellowship, I had many friends who chose to breastfeed only for the 6 weeks of their maternity leave, or found, after returning to work, that the long hours and stress of call nights severely diminished their supply.  A primary care specialty is more likely to be favourable, compared with a surgical specialty where women struggle to find time to pump during the day.  The authors point out that the logistics of timing of surgeries and proximity of lactation rooms make it difficult for women in surgical subspecialties to express milk.  I’ve seen this among my friends as well—regardless of stage of career.  One friend mentioned that due to the timing of the cases and fear of missing an interesting case, she would have to choose between eating or pumping since there wasn’t enough time to do both.

Although the study didn’t address this, I suspect that many women in surgical specialties still have to deal with the fact that they may still be in a male-dominated specialty, and bringing up the topic of time and space for expressing breastmilk would not be well-received.

As the RRC has instituted a decline in resident work hours, this may work favorably for women doctors who choose to continue to breastfeed.  However, every woman, every specialty, and every institution is different.  What works for one may not work for another.  But I have to ask: with the passage of the new health reform bill and the increasing popularity of the Business Case for Breastfeeding, can these programs catalyze change within our medical specialties?

There is a light on the horizon. As a breastfeeding community, our efforts to educate and advocate have put the terms breastfeeding, expressing breastmilk, and workplace in the forefront.  10, 5, or even 3 years ago, we wouldn’t even be having this discussion.  My hope is that with this increasing attention, women in the medical field will feel that they have more options to continue nursing after returning to work—regardless of specialty, work hours, or stage of career.

I ask my medical colleagues: what were your experiences, and what changes can make to support our own?

Natasha K. Sriraman is a general pediatrician and a professor of Pediatrics at Children’s Hospital of The King’s Daughters/Eastern Virginia Medical School in Norfolk, VA.

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

Written by NKSriraman

January 4, 2011 at 11:29 am

Highlights from day one of ABM 2010

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We’re in San Francisco for ABM 2010, and the energy is extraordinary. This is the biggest conference in the organization’s 15-year history, with more than 400 physicians and health team members gathering to further the Academy of Breastfeeding Medicine’s mission of promotion, protection and support of breastfeeding and human lactation,

We kicked off the day with a presentation from Suzanne Haynes, senior science advisor for the Office on Women’s Health. Dr. Haynes shared public comments for the forthcoming Surgeon General’s Call to Action of Breastfeeding, expected out next month. Key themes from pubic comments included support for workplace breastfeeding, paid maternity leave, and improved maternity care through the Baby Friendly Hospital Initiative. She emphasized Dr. Regina Benjamin’s commitment to breastfeeding, particularly to addressing disparities in breastfeeding rates.

The scientific sessions began with Peter Hartmann, a breastfeeding researcher from Australia who leads the Human Lactation Research Group. Hartmann took issue with the recent New York Times story on breastpump coverage, stating, for the record, “Breastmilk is not orange juice,” to widespread applause. He reviewed state-of-the-art research on how milk is made — and how much we still need to learn. He noted that the lactating breast uses more energy than the brain — but only 200 researches study the breast, compared with 38,000 neuroscientists.

After Hartmann’s talk, gastroenterologist Michael Haight explored the biology of cow’s milk allergy and intolerance in breastfed infants. He does not recommend mothers pump and dump on an elimination diet for days or weeks for an infant with bloody stools — in his experience, eliminating allergens and continuing to breastfeed is sufficient.

The morning concluded with abstract presentations that will be published in the next edition of ABM’s peer-reviewed journal, Breastfeeding Medicine. Marnie Rowan reported on an Australian study of women with painful nipples, and reported that 1/3 of mothers with minimal visible trauma had positve cultures for Staph Aureus. A. Ali Basma of Minia University in Egypt reported that both mature human milk and colostrum killed the parasites E. histolytica and Giardia lamblia in vitro, but artificial milk substitutes had no effect. Ann Kellams of the University of Virginia reported on breastfeeding and cognition. In a study of 1050 infants, she found that breastfeeding was linked with higher IQ, but not after adjusting for quality of the home environment, maternal parenting attitudes and IQ, breastfeeding was no longer an important predictor. Finally, Leslie Parker presented work from a pilot study of mothers of very low birthweight infants, where she found that starting pumping within the first hour after birth, rather than at 1-6 hours, greatly increased milk supply at 3 and 6 weeks.

The afternoon included talks by Robert Lawrence on breastfeeding and viral illness, Roberto Gugig on early exclusive breastfeeding among WIC moms in San Francisco, and Vanessa Sakalidis on ultrasound studies of infant sucking in early lactation.

The day wound up with Larry Grummer-Strawn’s overview of major US policy changes for breastfeeding in 2010. He discussed health care reform’s mandated pump breaks for hourly workers, which is modeled on Oregon’s workplace breastfeeding law. Notably, in Oregon, no businesses have been granted a hardship exemption for accomodating pumping, and both Grummer-Strawn and Haynes stated that the expectation was that all businesses would find solutions to accomodate nursing mothers.

Grummer-Strawn emphasized that US breastfeeding policy will focus on removing barriers to breastfeeding, not simply exhorting mothers to do it more and longer. The forthcoming surgeon general’s report will target issues such as access to lactation care, maternity practices and maternity leave to ensure that mothers can achieve their feeding goals. Similarly, the proposed Healthy People 2020 goals are not simply about rates, but will track workplace lactation support, unnecessary hospital supplementation of breastfed infants and the number of births at Baby Friendly Hospitals. Grummer-Stawn also alluded to a recent expert panel on improving maternity care and consideration of state programs to link Medicaid reimbursement to Baby Friendly Hospital Certification.

The energy here is palpable — and the best part, as always, is the chance to interact with colleagues who share an unflagging commitment to providing evidence-based care so that every mother can achieve her breastfeeding goals. This is my fifth ABM annual meeting, and it’s a highlight of my year. I’ve already put ABM 2011 on my calendar. Save the data — we’ll be in Miami November 3-6, 2011.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the Academy of Breastfeeding Medicine.

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

Written by astuebe

October 28, 2010 at 8:22 pm

How babies grow

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The United States Centers for Disease Control (CDC) recently recommended a long-awaited change in the way we track babies’ growth.

For years, US pediatricians and family docs have used growth charts from the CDC for monitoring infants and children. These charts were based on cross-sections of small segments of the (largely formula-fed) US population. They are considered “references” rather than “standards”, even though it is easy for doctors and parents to assume there is something wrong if a baby’s growth doesn’t follow the expected curve. And because breastfeeding babies’ growth patterns differ from formula-fed babies, this situation made it possible for some babies to be given formula unnecessarily for “poor growth”.

Now an expert panel convened by the CDC, National Institutes of Health (NIH) and American Academy of Pediatrics (AAP) recommends that clinicians use World Health Organization (WHO) growth charts for infants up to two years of age. The WHO growth charts are based on consecutive measurements over time of healthy breastfeeding babies around the world (almost 19,000 measurements in more than 800 babies). These charts serve as a standard rather than a reference for growth, since these were carefully selected healthy infants and, as the CDC’s statement points out, breastfeeding is the optimal form of infant feeding. Because of the variation in babies’ growth and the lack of correlation with poor outcomes, care providers are advised to “accept” growth within 2 standard deviations from the norm, i.e., between approximately the 3rd and 97th percentiles rather than 5th and 10th.

The CDC statement takes care to point out that for babies whose growth deviates from the standard, “clinicians need to carefully assess general health issues and ensure appropriate management of lactation. Only if there is evidence of lactation inadequacy should they consider supplementation with formula.” It also reminds us, as always, to be mindful of environmental and social factors contributing to challenges in growth.

The bottom line: this is a welcome — some might say overdue — affirmation of breastfeeding as the standard for infant nutrition.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

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

Written by neobfmd

October 6, 2010 at 4:57 pm

Discussions with Doctors

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I went to San Francisco, because I never been there, in 1999 to attend an AAP meeting so that I could get some needed continuing medical education credits. One of the speakers, ABM member Dr. Nancy Wight, spoke on breastfeeding. Almost every word was news to me. Medical school, residency, chief residency and part of a neonatology fellowship and I did not know about any of the content she was presenting. One of the other speakers lectured on lice- that I knew something about. But breastfeeding? Nope. How did Dr. Wight know this stuff when I didn’t? Who taught her yet set me loose on an unsuspecting patient population armed only with my personal 7-week breastfeeding experience?

I went back home after that conference and talked my hospital’s IBCLC and asked her why she had let me get away with being so, so…wrong. I’ve learned so much since then, thanks to my colleagues at the ABM, AAP and that very patient lactation consultant.

The point is most physicians don’t ruin breastfeeding intentionally. Read the rest of this entry »

Written by drjen4kids

May 1, 2010 at 11:26 am