Breastfeeding...for Doctors

Breastfeeding Medicine Breastfeed Med. 2011 October; 6(5): 345–347. doi: 10.1089/bfm.2011.0087 PMCID: PMC3192361 Breastfeeding—So Easy Even a Doctor Can Support It Todd Wolynn Author information ► Copyright and License information ► Imagine, if you will, a Super Medicine. It's stable and palatable. It reduces and prevents multiple diseases. It reduces and prevents deaths. One dose treats two patients simultaneously. It can even be manufactured safely and legally at home. It requires no insurance coverage. It's free to anyone who needs it. You don't have to imagine that Super Medicine, because it already exists. Breastmilk is all that, and a whole lot more. Which begs the question: Why are so few people using it? The answer is as simple as it is disheartening: Because not enough doctors, nurses, and healthcare workers are supporting it. It's difficult to imagine those same people not supporting penicillin. Vitamin K. Or the Haemophilus influenzae type b vaccine. Breastfeeding can save tens of billions of dollars, reduce infections, reduce cancers, prevent deaths, and bring a whole host of other health benefits to both child and mother, yet doctors aren't supporting it.1 Many of them aren't even recommending it. For more than 250,000 years, humans flourished by doing what mammals do: Giving birth to live young and feeding them mother's milk. In the past century, however, we've seen the decimation, the almost wholesale elimination, of three generations of breastfeeders and breastfeeding supporters. In less than 100 years, thanks to the advent of mass-produced infant formula, a quarter million years of 100% breastfeeding rates were reduced to 21%.2 It used to take a village to raise a child. Now it takes a factory. It's true that breastfeeding rates have improved significantly in the past 20 years and that, in some areas of the country, they're even exceeding Healthy People 2010 goals for breastfeeding initiation rates of 75%.3 But, duration rates are still pathetically low almost everywhere in the United States. The American Academy of Pediatrics recommends exclusive breastfeeding through the first 6 months of a child's life, yet by 6 months after delivery, breastfeeding rates drop to about 13%.4 How did things get so backward? And how do we get them moving forward again? Go to: Being the Mad Men. Business is business, and health care is now the single largest sector of the U.S. economy. What started with some cans, jars, and bottles of treated cow's milk has grown into a $4 billion dollar annual infant formula market in the United States.5 As a physician with a Master of Medical Management degree, as an entrepreneur, and as the president of my own pediatric practice, I'm all about business. I get it. But I draw the line where good business gets in the way of good health. I'm not anti-formula. For some families, formula is a necessity—even a lifesaver. Still, the babies and families who have no choice but to use formula are a small percentage of the total number of infants who could be, but are not, breastfeeding. Formula companies view every baby as a potential customer, and they aren't afraid to go after their customers. But we are. The dirty little secret of this irony is that we helped make it happen. Doctors and nurses, in lockstep with the formula industry, helped dismantle breastfeeding as the norm in our culture. As healthcare providers, we're supposed to do no harm. But we're all accomplices. The even dirtier secret is that the bulk of our healthcare workers—doctors, nurses, medical assistants, even receptionists—don't have a clue that they're still doing it. They don't realize that they're actively working along with the formula companies to promote their products. Formula reps, with their “free” samples and “free” discharge bags, are given almost complete access to our hospitals, neonatal intensive care units, and nurseries. Oddly, this comes even as leading medical centers have restricted all access to their institutions from the “other” pharmaceutical ”drug” reps and their free samples. Study after study has shown that these reps inappropriately influence prescribing patterns and negatively impact medical practices to favor their product.6 We don't let them get away with it for any other product they're peddling. Why do we let them get away with it for formula? The problem, however, runs even deeper than that. We're giving formula reps access to our hospitals, yes, but they don't have direct access to babies or new parents. Only we have that access. And what do we do with it? We're walking into hospital rooms, sitting at the bedsides of moms who've just given birth, and advising new and frazzled parents on how to feed their newborns with formula. We're even giving them free samples. The reps give the formula to us, and we give it to the parents. We're doing their jobs for them. In fact, we're doing it better than they ever could. Who are those frazzled parents going to believe? Some modern-day Don Draper and his slick-talking, infant-formula Mad Men? Or the good doctors and nurses they look up to and listen to and trust to tell them what's best for their baby? If a formula rep put formula in their hands, most parents would at least be skeptical. When healthcare providers put it in their hands, most parents are sold. We're immersed in, and indeed have helped to create, an infant formula culture that has about 4 billion reasons—one for each dollar the market is worth every year5—to make sure we stay there. Go to: Where the Change Begins. In 2011, we have some good news: Breastfeeding advocacy momentum is building and reaching new heights, riding a wave from the grassroots support of the 1960s and 1970s, to the bench research of the 1980s and 1990s, to the epidemiological, statistical and economic population-based studies of the 2000s. That's a potent legacy, and thus a powerful means of support. But one key ingredient is still missing: The front-line healthcare providers. To help get a baby breastfeeding, you don't need a researcher, an epidemiologist, or even an economist. What you need is a mom, a baby, and the right person, in the right place at the right time, with the right knowledge and right mindset to help them. You just need a doctor, a nurse, or some other member of a healthcare team to provide the support it takes to start. We need more of those people. But to get them, and to get them actively supporting breastfeeding, we must first remove some obstacles. Go to: Enough with the Guilt. We've heard it before: That many healthcare providers won't actively promote breastfeeding for fear of making a new mom or pregnant woman feel guilty. Even when pressed by parents, some providers will offer no preference or, worse still, tell parents that breastmilk and formula are basically equivalent, so they should choose whichever one they want. It's safe to say those same providers aren't worried about inducing parental guilt when they recommend that parents use car seats, immunize their infants, and refrain from smoking around their children. The guilt these providers should be worrying about causing is the guilt felt by moms who tried and failed to breastfeed, or by those who never tried at all, because no one even spoke to them about the benefits of breastfeeding or supported them at all. Go to: It's Not All or Nothing. This is the mantra at my practice. We'll support a family's infant feeding choices, whether they're 100% breast, 100% formula, or somewhere in between. The “in-between” often surprises people. It shouldn't. For families who choose to formula feed, I tell them that they don't have to exclude breastfeeding. I explain that they can partially breastfeed and supplement with formula, even using formula for a majority of the feeds if necessary. I'm clear with them that to have this option, they must really work to establish exclusive breastfeeding for the first few weeks. Even with this recommendation, offering a long-term middle ground often takes significant pressure off of new moms. Knowing that they have options and that their breastfeeding choice doesn't have to be all or nothing creates in them a willingness to try to breastfeed. To many new moms, the concept of “Not All or Nothing” is refreshing, even liberating. It provides a valuable opportunity to connect to women who might have otherwise opted to formula feed exclusively. This same mantra applies to healthcare professionals; it doesn't have to be all or nothing for them either. You don't have to be a lactation consultant or breastfeeding medicine specialist to support breastfeeding. As healthcare professionals, we're always the right people in the right place at the right time. All we need is the right knowledge and the right mindset. Go to: It's Easy. Really.. Sometimes it's easy for a new mother to breastfeed. Sometime it isn't. Rarely is it impossible. If we set aside the complicated cases that require a lactation consultant, a pump, medicines, or maybe even all three, we're still left with a huge number of moms who would find breastfeeding easy, or reasonably easy, if they would just try and receive a little bit of help in the trying. Many women don't try because they think it's hard. They think it's hard because they don't know any better. They don't know any better because no one ever tried to talk to them, teach them, or support them. To get them to try, all we need are the right people with the right mindset at the right time, armed with the right advice and support for parents. Contrary to popular belief, that advice and support are also easy. Go to: Baby to Breast. Would you consider trying to teach a child to tie a shoelace without the shoe or the lace? Imagine: “Well, Johnny, pretend you have a shoe, and you take this string-like thing and make some bunny ears, and then make the one loop crawl through the hole, and….” It seems a bit ridiculous, doesn't it? That's what it's like when a woman who's never used her breasts to feed a baby is told, “Just latch the baby to your breast, and get the baby to feed,” without anyone helping her, or showing her how, or supporting her when she tries it. This sounds ridiculous too, and yet it happens all the time. With the loss of those three generations—with the loss of a tradition that brought support from breastfeeding mothers, grandmothers, aunts, and sisters—a new mom may never get the help she needs. She may never be shown, or taught, or guided. She most likely has no one there with her, helping her put her baby to breast. That's where we come in. Obstetricians/gynecologists, labor and delivery room and postpartum nurses, pediatricians, family medicine docs—tell Mom to put the baby to the breast. If you learn just a few simple points of support and use those to help the mom in the hospital room or the exam room—if not you, who? if not then, when?—you can make a tremendous difference. If not, there's precious little time from the baby's birth until a new mom becomes unsure, scared, even physically traumatized to the point where giving up on the idea of breastfeeding seems reasonable, even desirable. That's an easy next step, even against all good science and medicine, when giving up on breastfeeding is the national norm. Go to: As Easy as 1-2-3. The following describes the approach of one pediatrician: Keep it easy, make it simple, and just do it. Here's how. With nothing more than 5 or 10 minutes, I have a quick, informative pitch I give to tired, stressed-out parents with newborns at their bedside. It's all I need to get them started, and it's all they need to feel empowered. I focus on three holds and three tips. It's not an exhaustive review or an in-depth demonstration; it's designed to be the exact opposite of that: Something short, sweet, memorable, and useful. I present some clear, simple concepts that they can remember (even in their frazzled state) and that provide them with all the tools they need to get started, and feel supported, in their breastfeeding. Three holds Two—the Cross-Cradle and the Football—are easy. One—the Cradle—is not. I demonstrate all three, with a focus on control of the baby's head in one hand, position of the baby's body, and use of the free hand to support the breast. The revelation here, for most parents, is that the iconic cradle hold—straight off the front of a Hallmark card, and the most natural hold for cuddling a baby—is in fact not a good position for breastfeeding. The Cross-Cradle and Football holds, ones most parents have neither seen nor tried, are excellent positions for breastfeeding. This knowledge, imparted in about 2 minutes, has a tremendous impact. Three tips 1. Mouth: Deep and Wide Latch 2. Lips: Rolled Out Like a Fish 3. Baby Awake—Milk Flowing In a nutshell, I explain (with humor and analogies), illustrate, and demonstrate that a proper latch shouldn't hurt or traumatize mom. The two most important ways to do this are to make sure that the baby's mouth goes deep and wide over the nipple and that the baby's lips are rolled out (like a fish) during the latch. Remembering and practicing these two principles are another revelation for most moms; correctly applied, they remove the pain from the process. I complete the pitch by helping parents learn how to keep the baby awake and help keep the colostrum/milk flowing to make the feeding a success. Poor feedings are often interpreted as the baby being “not hungry” or sleepy. This misinterpretation frequently leads to trouble and often to premature weaning. The truth is that babies can be kept awake while feeding, and that the free hand—thanks to one of the two good holds—can help keep the milk flowing. At the end of just those 10 minutes, with information that is neither difficult to learn nor to remember, new parents are empowered to know when things are going well and when they aren't. A follow-up appointment within 24–48 hours provides reinforcement, an added safety net of support, and the sense that they have already begun to pave a road to prolonged and successful breastfeeding. Go to: Back to the Future. Every year, more than 10 million people in the United States spend time, energy, and money to get trained and certified in cardiopulmonary resuscitation. It's a valuable skill set, of course. But as an intervention, applied alone, it's ineffective about two-thirds of the time.7 Most people, including most healthcare professionals, never use the training. Imagine if just a tiny fraction of those 10 million people took less than an hour of their time to learn the breastfeeding basics I teach to new parents. Imagine if, in that same time, they also learned how to teach those simple, empowering, life-changing basics to others. They would learn an intervention that, applied alone, is likely to be highly effective. It's an intervention they'll have the chance to practice time and time again—how many pregnant women or new mothers do you think they'll see?—throughout their personal and professional lives. It's an intervention, a tremendous skill set, that could improve the life and health of every family, mother, and baby they touch. Right now, women in villages with no electricity, no running water, and no schools are helping their friends, daughters, sisters, nieces, and granddaughters to breastfeed. They're doing it with no hospitals, no electronic medical records, no lactation consultants. They're doing it with no smart phone apps, no video, no internet. They're just the right people at the right time, with the right knowledge and the right mindset to make a difference. It's about time we go back, move forward, and join them.