How to be a Breastfeeding Supporting Health Care Professional
Which health care professionals should be expected to be knowledgeable and well-informed about breastfeeding? Is breastfeeding management relevant to the practice of most doctors? What is the level of knowledge that should be expected of health care professionals?
All health care professionals should have a basic knowledge of breastfeeding as the norm in infant nutrition. Those who do not work directly with mothers and babies should know that breastfeeding is the gold standard of nutrition for infants, and should know the accepted guidelines concerning breastfeeding, such as the guidelines of the American Academy of Pediatrics. (See box.) All practitioners with the exception perhaps of geriatricians may find themselves treating and prescribing for breastfeeding mothers. Thus, even the podiatrist may find himself doing so, and should know that most drugs are not contraindicated during breastfeeding, because the risks associated with not breastfeeding are almost always greater than the risk of a small amount of the drug in the milk.
Radiologists should know that MRI scans are not contraindicated during breastfeeding. Cardiologists should know that most antihypertensive medications are not contraindicated, and they should know the pharmacology and comparative safety of drugs in lactating women.
What a health care provider can do to be breastfeeding-friendly:
Everyone who works with mothers and babies should work to optimize the birth experience. A birth with as few medications and interventions as possible is important in allowing breastfeeding to get off to a good start. Women who trust their bodies and birth successfully are more able to breastfeed successfully. Mothers and babies should not be separated after birth; procedures such as bathing, medical tests and treatments (eye drops, vitamin K, heel sticks) should be delayed until breastfeeding has been initiated. There should be no normal newborn nursery in hospitals, and babies should room-in with mothers. Couplet care at the bedside should be routine, even if brighter lights and portable equipment are needed.
- The primary care provider for the baby should know how to help with breastfeeding, what normal breastfeeding looks like, and how and where to get help if something is not working. Anyone that works with newborns should have a clear understanding of how to determine if supplementation is needed (see breastfeeding decision-making tree). This policy should be flexible, and those who determine a need for supplementation should be very knowledgeable about normal breastfeeding behavior. A lactation consultant should be available on all shifts during which babies may be born or mothers may need help; this means 24 hours a day. Care providers should refer to lactation consultants when specialized care is needed.
Anyone who is in a position to discuss infant nutrition with a mother needs to advocate the use of donor human milk when supplementation is needed. They need to know how to prescribe donor milk, how to obtain and use it, and should support its use rather than ABM. Midwives and doctors need to know that ABM is not equivalent to human milk, and be willing to prescribe donor milk. They need to understand the dangers of using ABM in place of human milk, and be able to educate mothers about any decisions they make about their choice in feeding.
Care providers should know that breastfeeding is not the same as bottle feeding. They should understand the fundamental physiologic differences, and know that artificial feeding methods are unproven and not at all similar to breastfeeding. For example, it should be understood that what is commonly called “non-nutritive sucking” is an important part of milk production and the breastfeeding relationship. No one should be telling a mother that any method of delivering milk to a baby’s mouth is even remotely similar to the human breast. This includes understanding that any artificial nipples can undermine breastfeeding, including pacifiers. Anyone that suggests or provides ABM or pacifiers to a mother and baby should have written consent from the parent before they are used.
HCPs should encourage parenting styles that support breastfeeding, and discourage mother-baby separation. Any questions about parenting practices should be answered in light of normal breastfed baby behavior. Your personal experience with breastfeeding and child rearing may not be typical. All babies are different. Use your own experience only to underscore suggestions based on normal infant behavior, not to promote artificial ideas about babies’ need or capabilities.
Everyone who works with mothers and children should support and expect breastfeeding to continue throughout the first year, with no outside limits beyond that time. They should know the recommendations about breastfeeding, such as the AAP statement and the WHO code. Parents should not be encouraged to start solids until the middle of the first year, based on signs of readiness from the baby. Early weaning of the baby should be avoided, and can usually be prevented with adequate support of breastfeeding and skillful resolution of breastfeeding problems.
HCPs should understand the continuing role of human milk in the child’s diet beyond infancy, and understand the role of breastfeeding in the child’s psychosocial development past infancy. Medical practitioners should know that human milk contributes to a child’s immune system competency for as long as breastfeeding continues, and that the nutritive value of human milk changes to suit the age of the child, but never becomes valueless. HCPs should support child-led weaning, and understand that breastfeeding beyond the first year strengthens a child’s emotional well-being, and does not lead to future psychological difficulties, or indicate an inappropriate relationship between mother and child.
HCPs and institutions should not undermine breastfeeding by using or distributing advertising materials for ABM companies. This includes using common tools or printed materials with the name of ABM companies on it, even if they purport to be “educational.” Giving out any material with a company name on it implies to parents that the HCP endorses that company’s products. No one who fully supports breastfeeding wants to be seen as doing advertising work for companies that produce ABM. If you, as the medical advisor to a mother and baby, would not recommend that the mother or baby smoke cigarettes, you would probably not give the mother free gifts or advertising materials provided by a tobacco company. It is clear that the distribution of materials for ABM companies is profitable to them, or why else would they be so eager to have it done?
Interrupting breastfeeding may have serious, long-term side effects for mother and baby. Breastfeeding should not be interrupted except for the most critical, emergent, medically valid reasons. Contrary to general opinion, very few medications, medical tests, or infant or maternal illnesses require interruption of breastfeeding. Any medications or treatments recommended to the mother or baby should allow for continued breastfeeding. Any time a treatment is necessary that requires an interruption of the breastfeeding relationship, all measures should be employed to ensure that the disruption is handled as smoothly as possible. Mothers should be helped to express and store milk in advance of such an event, and time should be allowed to help the baby get used to an alternative method of feeding. Whenever possible, alternative drugs, tests, or treatments should be chosen with the goal of continuing uninterrupted breastfeeding. Use of tetracycline, for example, while contraindicated for use in children and during pregnancy, is quite safe for the mother to use during breastfeeding. Hospitals should be able to care for a breastfeeding mother and baby together to minimize the impact that hospitalization will have on both of them.
Jaundice appears quite commonly in breastfed as well as bottlefed babies. This fact alone should imply that there is an as yet unknown physiologic reason for jaundice. Physicians must know the difference between breastmilk jaundice and “lack of breastmilk” jaundice, and how to manage both situations. Higher than average bilirubin levels in the first few days, if not caused by hemolysis or other pathology, is usually due to inadequate intake of breastmilk. Stopping breastfeeding is not only unnecessary (because the baby is already not breast “feeding” sufficiently), but positively harmful because the mother gets the message that her breastmilk is dangerous, and the interruption makes breastfeeding more difficult to establish. It is true that giving formula will result in a drop in bilirubin, but so will giving adequate amounts of breastmilk. When the problem is inadequate intake, the solution is to fix the breastfeeding so that the baby gets breastmilk.
HCPs should operate an evidence-based practice. They should not extrapolate from personal experience, especially when it is negative, and should not operate on the basis of unsubstantiated beliefs. They should use current information about breastfeeding that is accepted by practitioners in the field, and not use information provided by those with a vested interest in undermining breastfeeding. Critical analytical skills should be used in evaluating research or literature about infant nutrition.
HCPs and institutions that work with mothers and babies need to move ahead to a new era of support for breastfeeding. They need to support the Baby Friendly Hospital Initiative and encourage their institutions to adopt these practices; they need to know how to use local resources, such as breastfeeding support groups and milk banks; and they need to continue to educate themselves about lactation. They should be able to provide parents with the information needed to make informed decisions about feeding. A mother should not be told she must discontinue breastfeeding; it is the mother’s choice to wean or breastfeed, and medical advice offered to parents should support this choice.
Written by Jack Newman, MD, FRCPC
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