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.

Eliminating Disparities in Breastfeeding and Infant Mortality: Conference 2018

Although breastfeeding rates are increasing in the US, significant disparities in breastfeeding and infant mortality persist.  Cincinnati Children’s Hospital Medical Center and partners were delighted to host the “Third Annual Conference to Eliminate Disparities in Breastfeeding and Infant Mortality:  Taking Action for Equity” as a pre-Conference to the Ohio Infant Mortality Summit at the Duke Energy Convention Center in Cincinnati, Ohio.  Our Keynote speaker was the inspiring Dr. Camara Jones from Morehouse School of Medicine, who helped us critically examine how racism must be acknowledged and addressed to make inroads toward health equity.

Our First Annual Conference with Keynote speaker, Dr. Michal Young, helped us to define the problem of breastfeeding disparities and infant mortality.  The Second Annual Conference featured Keynote speaker, Dr. Kimarie Bugg, who took us deeper by addressing the role of Implicit Bias.  Our participants provided feedback, requesting to leave the next conference with Action Tools to make changes in their own communities to eliminate disparities so this year we are “Taking Action for Equity”.

To that end, our Conference this year began with an inspiring opening from City of Cincinnati Health Commissioner, Melba Moore, who challenged everyone to develop novel ways to improve community health.  From there, the conference highlighted the successful efforts of 42 speakers from around the State of Ohio and beyond, representing these programs:  CenteringPregnancy, the State of Ohio efforts to improve breastfeeding (Ohio First Steps, WIC, Ohio Department of Health), Hospital Quality Improvement, the importance of Fathers, and the amazing work of Doulas.  These programs provided the first set of Key Highlights to nearly 400 health care providers, community members, and parents, who then were able to “go deeper” in workshop formats, along with an option to learn the basics of “Breastfeeding 101.”  After lunch, attendees rejoined for a second set of Key Highlights, with representatives from Home Visitation programs, Mom-to-Mom Support groups (https://www.facebook.com/Avondale-Moms-Empowered-to-Nurse-1257926900973280/), Rural and Appalachian breastfeeding groups and Breastfeeding while Going back to Work.  These presenters also provided a deeper dive with workshop sessions, and the option for a “Breastfeeding 911” course to help front-line providers and support people troubleshoot common problems.  Each workshop provided a take home “toolkit” for attendees.

In addition to many local Cincinnati area efforts to eliminate disparities in breastfeeding, we were delighted to have experts from Cleveland, Columbus and beyond share their expertise with us.  The Doula segment was especially exciting  as co-presenter, Jessica Roach from ROOTT (Restoring Our Own Through Transformation) arrived to the conference JUST as her bio was being read, (coming, of course, from a delivery, directly to the stage!), as well as Christin Farmer, at Birthing Beautiful Communities in Cleveland who brought her “Dude-la”, Neal Hodges!  We learned about ROBE (Reaching Our Brothers Everywhere) from our local Wisdom Council Member, Calvin Williams, and Founder, Wesley Bugg, Esq., the CenteringPregnancy program in Cleveland , and so many more Ohio highlights!

Dr. Lori Winter and Dr. Julia Ware

Commissioner, Melba Moore, Dr. Camille Graham, Dr. Corinn Taylor, Dr. Karen Bankston

Dr. Camara Jones and Jamaica Gilliam

Dr. Camara Jones took us through an intensive discussion of the multiple dimensions through which racism drives health disparities using her powerful 3-dimensional cliff analogy highlighting differences in: the quality of care received within the healthcare system, access to healthcare and preventive services, and life opportunities, exposures, and stresses that result in differences in underlying health conditions.

She defines racism as “a system of structuring opportunity and assigning value based upon the social interpretation of how one looks. Racism is a system that:

1. Unfairly disadvantages some individuals and communities
2. Unfairly advantages other individuals and communities
3. Saps the strength of the whole society through the waste of human resources.

Racism has created inequities in our country. Dr. Jones helped us to see that the barriers to health equity include the narrow focus on the individual (“I am not racist, so these facts don’t apply to me or how I treat my patients!”); the fact that we are an “A-historical” culture that is disconnected from and fails to acknowledge our recent past (“Slavery ended more than a hundred and fifty years ago – why can’t you get over it?”; we don’t recognize the underlying structural system of inequity and privilege that is at the foundation of health disparities (“Why is it that a mom’s zip code is more likely to predict birth outcomes, infant survival, and breastfeeding success than her access to health care?”); and that we are instead overly focused on the myth of meritocracy – an example – two babies – equal opportunity or equal potential? (“They just aren’t trying hard enough – they could breast feed if they really wanted to!”)

Some key takeaways from Dr. Jones:

1. When you feel uncomfortable, “LEAN IN”
2. To achieve health equity we need to:
   1. Value all individuals and population equally
   2. Recognize and rectify historical injustices
   3. Provide resources according to need
3. You can learn more about Dr. Jones’ Cliff Analogy in this 5 minute video by the Urban Institute.

An added treat to the Conference was an optional learning lunch with new AAP Section on Breastfeeding Chair, Dr. Lori Feldman-Winter, who was giving a talk on Safe Sleep and Breastfeeding at a Safe Sleep Summit occurring simultaneously to our Conference!  Over 130 of our participants were able to join this event, and enjoyed the review of the evidence and guidelines for safe sleep and breastfeeding from the AAP lens.

One of the most exciting aspects of the Conference is still to come.  We will harness the energy generated from the diverse Conference presenters and attendees to continue improving breastfeeding rates in marginalized populations. It is clear that we have a wealth of talent and will need to use many different strategies to achieve this goal. Our participants are filling out a “Call to Action” survey as part of their Conference evaluation, so that we can continue to connect and collaborate in areas of interest to eliminate disparities through learning communities across the state. Stay tuned for More to Come!

Pre- and post-conference video clips:

http://www.fox19.com/video/2018/12/14/breastfeeding-disparities-challenges/

http://www.fox19.com/video/2018/12/14/breaking-down-barriers-breastfeeding/

Shared Safe Sleep and Breastfeeding Posters (unbranded) from Ohio First Steps:

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Feeding-Safe-Sleep-flierUNBR.pdf

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Spanish-Feeding-Safe-Sleep-flier.pdf

Cincinnati Children’s Conference Co-Chairs:

Julie Ware, MD, MPH, FABM and ABM Board Member

Laura Ward, MD, ABM Member

Camille Graham, MD, Executive Community Leader

 

For more information, please contact Dr. Julie Ware, julie.ware@cchmc.org

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

Where will you be when (not if) you fall asleep while feeding your baby?

Healthy newborns wake easily and often to feed, and a “good sleeper” in this age group is one that lets you know when he or she is hungry, is an efficient and effective feeder, and settles after the feeding and falls back asleep.  Modern societal expectations often do not allow for or encourage new mothers to sleep during the 16-20 hours/day that a newborn sleeps.  There is often housework, family and visitors, thank you notes, older siblings, and far too often at least in the U.S., an earlier-than-it-should-be return to work.  The “village” that traditionally swooped in and surrounded the dyad with care and support is often spread across miles, even oceans, and these mothers, while still recovering from birth, are left alone as their partner returns to work.  It is not surprising that new mothers find themselves exhausted and in “survival mode” during which time the recommendations that they have heard to feed a certain way or have the baby sleep a certain way may fly out the window as they desperately try to achieve a little more sleep.  And even though they may or may not be planning to, mothers of newborns are falling asleep while feeding their babies.

In addition, depending on where they turn for information, the recommendations for infant feeding and safe sleep can be confusing and may appear to be at odds with one another.  We know that mothers who bedshare with their infant breastfeed for longer.  We also know that where babies start off the night is not always where they end up in the morning.  We know that breastfeeding is protective against Sudden Infant Death Syndrome (SIDS), but also that bedsharing may pose a risk for a sleep-related infant death, particularly in the setting of other risk factors such as prenatal smoking, formula feeding, maternal substance use, sedating medications, maternal obesity, prematurity, and the presence of soft bedding in the sleep environment.  Some organizations recommend bedsharing as a means of supporting breastfeeding and cite data about the physiologic patterns and postures of mothers and babies when they bedshare.  Other recommendations focus on safe sleep and recommend breastfeeding as a strategy to reduce the risk of SIDS but recommend against bedsharing to avoid an unintended sleep-related death.

ABM’s Model Maternity Policy Supportive of Breastfeeding: More than just a protocol revision

The new ABM Clinical Protocol #7 could have just been the revision of an outdated protocol. That was my idea when I received Wendy Brodribb’s invitation to help update the 2011 Breastfeeding Hospital Policy protocol. Being the national coordinator of the Baby-Friendly Initiative in Spain, a member of the BFHI coordinator’s network, and a practicing pediatrician, I am fully aware of the importance of a breastfeeding supportive policy in hospitals, so I was passionate about being part of the update of this specific protocol. I knew the subject, it was just an update and it was also about teamwork with great colleagues: Melissa Bartick, Paula Schreck and Cadey Harrell and the supervision of the ABM protocol committee. Before me I saw an idyllic task that seemed simple and rewarding even for a non-native English speaker. Thus I gladly accepted the challenge and was grateful to be able to contribute to ABM’s mission.

However, I had not envisioned the ambitious team we had formed! Soon it was clear that my “simply reviewing and updating” plan was to become an absorbing, demanding, and exciting piece of work to produce a completely new and comprehensive protocol. The last two months trying to meet the deadline were exhausting but really exciting with transoceanic telephone conversations and chats, and continuous emails. Working on the same document while adjusting our different timelines in mid-August (we took turns to write fervently while the others were sleeping) was really fun!

The social inequalities and structural determinants that result in health injustice are the same that interfere with a happy breastfeeding experience. These interferences and the lack of adequate protection and support for breastfeeding unjustly burdens the health of women and infants (the most vulnerable part of society) at risk, especially if they belong to disadvantaged classes or countries with the least resources. Health professionals and health care facilities can be part of the problem, or they may become part of the solution.

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.

Reclaiming “Breastfeeding” from “Human Milk:” Politics, Public Health, and the Power of Money

If there is one thing that formula makers and breastfeeding advocates agree on, it’s that mother’s milk is amazing stuff. Researchers have identified countless compounds in human milk such as lactoferrin, erythropoietin, docosahexaenoic acid (DHA), immunoglobulins, and human milk oligosaccharides, or HMOs. There are at least one hundred different HMOs in human milk and the infant doesn’t digest any of them—rather they seem to exist to feed the bacteria in the infant’s gut, its “microbiome,” and have some other properties, too.  Each mother secretes unique sets of HMOs for her infant. Often researchers discuss adding HMOs to formula in hopes of transforming the microbiome of a formula fed infant into one that more resembles that of a breastfed infant, as the microbiome of a breastfed infant is thought to better protect against disease.

Research into human milk composition has been exploding, funded by the federal government, private foundations, but especially by the $70 billion infant formula industry and other industries looking for commercial applications for the components of human milk. The motives for research might vary: to help understand why breastfeeding is truly superior; to help use components of human milk to fight diseases in infants, children and adults; or to synthesize components of human milk in order to add them to infant formula. The US government’s interest in human milk composition revolves around ensuring that infant formulas meet minimal nutritional requirements.

At the heart of the study of milk composition is the distinction between “human milk” and “breastfeeding.” The term “human milk” disembodies the substance from the precious act of nurturing, bonding, and intimacy between a mother and child. Language around “human milk,” as opposed to “breastfeeding,” is often used by entities concerned with breast pumps and infant formula, as well as for the necessary provision of milk for infants too tiny to suckle at the breast.

For breastfeeding advocates, the dark side of research on human milk composition is its application to the formula industry. The biggest recent application has been the synthesis of HMOs, which have been patented and added to formula, now for sale on supermarket shelves where they cost at least 30% morethan formulas without HMOs. It is unclear if these products are actually better for babies, even though they might technically resemble human milk slightly more than formula without HMOs. But given that genuine mother’s milk has unique HMOs for a unique infant, it’s unclear which HMOs a manufacturer should even be adding to a formula. So, is this product actually better, or is this just a marketing ploy and an excuse to mark up the price?

Marijuana and Breastfeeding

Ryan, Ammerman, and O’Connor’s Clinical Report on “Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes” was published recently in Pediatrics.  The report, co-authored by the American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention and the AAP Section on Breastfeeding, summarizes data on the prevalence of marijuana use in women of childbearing age.  Overall, rates of marijuana use have increased in recent years, according to the National Survey on Drug Use and Health.  Pregnant women use marijuana less frequently than do nonpregnant women in the same age range.

Legalization of marijuana has made both inhaled and edible forms of marijuana more widely available and have decriminalized its use in certain US states.  Medical marijuana is available in an even larger number of states. Some women report using marijuana during pregnancy to combat nausea and vomiting, and this has been advocated in certain social media postings. Federal laws in the US still prohibit the use of marijuana. 

Worldwide study on sudden infant death finds factors associated with poverty and racism are more important than bedsharing

Last week, we published our novel study, “Sudden Infant Death and Social Justice: A Syndemics Approach,” showing that bedsharing – which has been the main focus of many interventions – is not the primary risk behind sudden infant death.

Instead, factors associated with poverty and racism have much more to do with Sudden Unexplained Infant Death (SUID), which includes suffocation, and its subset, SIDS (Sudden Infant Death Syndrome). Looking at populations around the world and the known risk factors for sudden infant death, we found that the vast majority of infants dying are from poor or marginalized populations, especially people who have experienced historical trauma. On the other hand, many wealthy and privileged populations have high rates to moderate rates of bedsharing,like Asian Americans and Swedes, yet have some of the lowest rates of SUID/SIDS in the world.

We used the medical anthropological theory of syndemics to help explain how social inequities that may be driven by historical forces and their legacies lead to the clustering of these risk factors, which ultimately results in higher death rates in poor and marginalized populations. It is important to view SUID/SIDS in the greater context of the growing field of social determinants of health.

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.

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.