Colorado pediatric office becomes breastfeeding friendly employer

Castle Rock Pediatrics (CRP) made a splash this summer at the Douglas County Fair Parade where they displayed their incredible Under the Sea themed float. Patients and families created a colorful array of paper plate fish that “swam” through pool noodle crafted seaweed.

CRP also attended the  Renaissance Expeditionary Magnet School Back to School Carnival and the Downtown Castle Rock Concert Under the Lights where they set up a lactation station.

After breastfeeding her own young children and later completing the Lactation Counselor Training Course (LCTC), Laura Westover PA-C, CLC, one of the providers at CRP, dove into helping transform her office into a Breastfeeding-Friendly Employer and soon-to-be Breastfeeding- Friendly Medical Office.

Their work is supported by a grant through the Tri-County Health Department. Westover has been working alongside Susan Howk, a breastfeeding policy specialist, to create their policies and lactation spaces through a six-point plan which includes policy, staff and provider training, patient education, environment, evaluation and sustainability, and continuity of care.

The grant has funded things like a chair, end tables, a hospital-grade multi user breast pump and kits, a stuffed animal nursing dog with her puppies for siblings to play with, and a lactation scale for weighted feeds.

Westover displays the breastfeeding friendly employer certificate in March 2022 standing in their first lactation space.

Their lactation space started in one of their smallest exam rooms, but has recently graduated to one of their larger exam rooms, which is now near the end of its renovation. Westover notes that the space also functions for newborn and young baby visits.

Westover reports that CRP owners since November 2021 Drs. Anderson and Bouchillon have been highly supportive of the breastfeeding-friendly changes.

Prior to the implementation of their lactation policies, Westover says their office “was not lactation friendly at all.” She describes stacks of formula in plain view.

“It gave the impression that we were promoting formula,” she comments.

Gift bags for patients were also riddled with formula-promotions, so the team phased out the branded materials and replaced them for non-branded, breastfeeding-friendly items.

Now, Westover and her colleague Sydney Gruenhaupt RN-BSN, CLC  see breastfeeding dyads weekly for office visits; whereas they once had to refer out. Of mothers’ main concerns are poor weight gain and uncomfortable or painful latch.

Westover points out that Colorado has very high breastfeeding initiation rates, but like the national trend, tapers dramatically at 6 months and beyond. While Westover and her colleagues are not currently tracking their office’s breastfeeding rates, it’s part of the plan in hopes that their numbers will hold steady beyond initiation rates. Westover explains since they’ve switched over to a larger electronic medical records system, there should be potential for a simple, infant feeding tracking system. A 2016 project by the County of San Diego Healthy Works program, implemented by UC San Diego Center for Community Health with funding from First 5 San Diego extensively explores current practices and future possibilities of  breastfeeding measurement in the outpatient electronic health record.

Westover and her colleagues will be out and about again this fall where they’ll craft their  lactation tent at events like Oktoberfest and the town of Castle Rock Spooktacular Halloween celebration.

“[It’s] really wonderful because we are able to promote [to] the whole community,” Westover shares.

For more about CRP’s lactation services visit https://castlerockpediatrics.com/Services/Additional-Services .

Physicians as breastfeeding supporters

Photo retrieved from: https://tobacco.stanford.edu/cigarette/img0079/

“More doctors smoke camels than any other cigarette,” claims the ad from 1950. Today, it’s preposterous to imagine that any physician would align themselves with the tobacco industry. Starting  in the 1920s and continuing well into the 1950s though, tobacco companies used doctors to help them sell their products. Stanford’s Research into the Impact of Tobacco Advertising has a collection of over 1,000 advertisements that feature doctors endorsing tobacco products. 

In an eerie parallel, WHO’s February 2022 report, How the marketing of formula milk influences our decisions on infant feeding, states that “Recommendations from health professionals are a key channel of formula milk marketing. Health professionals spoke of receiving commissions from sales, funding for research, promotional gifts, samples of infant and specialized formula milk products, or invitations to seminars, conferences and events.” (p. 7) 

Last week, Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500 and I shared our reflection on the forces that shape physicians’ personal infant feeding experiences. In this second installment, we explore how physicians as professionals can support breastfeeding despite being targeted by the breastmilk substitute (BMS) industry and despite generally being woefully equipped with proper lactation education, training and counseling skills. These predicaments can lead physicians to “explicitly or inadvertently, introduce doubts around the ability of women to breastfeed and the value and quality of their breast milk.” (WHO, p. 12) 

 

Pervasive industry influence for generations

Because “health professionals are among the most respected and trusted members of society…[their] advice…is highly influential for pregnant women and parents of infants and young children, including around infant feeding decisions.”  Formula milk companies exploit this relationship of trust. (WHO, p. 12)

Source: United States Breastfeeding Committee

BMS representatives target physicians “with a range of incentives, including funding for research, commissions from sales, ambassadorial roles, merchandise, gifts and all expenses paid promotional trips.” (WHO, p.13) 

The psychology behind gift-giving, both big and small is that “ it imposes…a sense of indebtedness…. The…rule of reciprocity imposes…an obligation to repay for favors, gifts and invitations…” (Katz 2003) Instead of supporting infant feeding purely through a health and wellness lens, physicians feel obliged to a company muddying their relationships with their patients. 

Interestingly, most physicians feel immune to marketing’s influence, despite clear evidence to the contrary, Frederick S. Sierles, MD lays out in The Gift-Giving Influence

Curious consumers can search their doctors’ names through ProPublica’s Dollars for Docs project to learn about gifts they have accepted. 

 

Mechanical culture 

Our culture fails to acknowledge the mother baby unit as a dyad, and this influences the way physicians can support breastfeeding too.

Source: United States Breastfeeding Committee (USBC)

“We are never taught, in our fragmented system, that the mother and baby are a unit,” Lee reiterates. “OB/GYN/midwife sees mama; peds sees babies. There are even different places for them in the hospital: nursery, postpartum unit. What a struggle we had with the BFHI to keep mother and baby together.” 

[As a side, Attorney Leah Margulies recently shared in Protecting Breastfeeding in the United States: Time for Action on The Code that formula companies provide architectural designs to maternity care facilities in a deliberate attempt to separate dyads.] 

The Alliance for Innovation on Maternal Health’s (AIM) Patient Safety Bundles offer models for how health professionals can use task force approaches that break down silos of care and open channels of communication. The strategies used in these bundles aim to ultimately shift from fractured care to continuity of care where the dyad is protected.  

We must also consider how physicians are compensated for their work. In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans, as we mentioned in our first installment. In short, the more RVUs a physician racks up, the more they’re paid. Breastfeeding counseling takes time.

 

Inadequate education 

How are physicians to spend time with their patients, educating and supporting breastfeeding when they’ve had little to no breastfeeding education invested in them? Dr. Nigel Campbell Rollins pointed out in WHO’s How the marketing of formula milk influences our decisions on infant feeding webinar that faculty in medical schools themselves sometimes believe that formula products are inevitable or necessary. 

A cross-sectional study in the UK suggests that UK medical schools are not adequately preparing students to support breastfeeding patients.  

Source: United States Breastfeeding Committee

Samantha A Chuisano and  Olivia S Anderson’s findings in Assessing Application-Based Breastfeeding Education for Physicians and Nurses: A Scoping Review “… align with existing literature in finding a dearth of high-quality studies assessing breastfeeding education among physicians and nurses. The variability in teaching and evaluation methods indicates a lack of standardization in breastfeeding education between institutions.”

Elizabeth Esselmont and colleagues’ piece Residents’ breastfeeding knowledge, comfort, practices, and perceptions: results of the Breastfeeding Resident Education Study (BRESt) concludes: “Pediatric residents in Canada recognize that they play an important role in supporting breastfeeding. Most residents lack the knowledge and training to manage breastfeeding difficulties but are motivated to learn more about breastfeeding. Pediatric program directors recognize the lack of breastfeeding education.” 

 

A collection of physicians’ stories 

Often, it is a physician’s own struggle to breastfeed that seems to spur advocacy and change. Our Milky Way’s repository includes a breadth of physicians’ stories of personal struggles that have inspired them to become breastfeeding champions for their patients and communities. 

Source: United States Breastfeeding Committee (Photo by Sara D. Davis)

Some of those stories are linked below: 

Sarah Jacobitz-Kizzier, MD, MS, in Resident physician advances breastfeeding support,  shares that her lactation education in medical school included a one hour lecture about the anatomy of the breast and a brief discussion in physiology about lactogenesis.

“There was no training about [breastfeeding] technique, no discussion about common problems before discharge, no training about clinical problems as far as in the first few months postpartum…when to introduce complementary food,” she continues.

Physician calls for peer breastfeeding support features the work of Colette Wiseman, MD, CLC. 

In Breastfeeding in the healthiest county in Virginia, Janine A. Rethy, MD, MPH, FAAP, FABM, IBCLC, a general pediatrician in Loudoun County, Va. describes her dedication to improving breastfeeding outcomes. In it, she shares a resource she and her colleagues created –the Breastfeeding Support Implementation Guide for the Outpatient Setting which includes information on how to bill insurance for lactation services.

Skin to skin in the OR showcases Rebecca Rudesill’s, MD, CLC quest for more breastfeeding education. 

Kristina Lehman’s, MD, CLC work is featured in Internist looks to augment breastfeeding education

James Thomas Dean III, DO and Assistant Professor of Pediatrics at the University of Texas San Antonio Dr. Perla N. Soni, MD share their perspectives in Lack of breastfeeding education in med school harms families

Alison Stuebe, MD, MSc tackles big topics in OB/GYN sheds light on breastfeeding culture.

We are honored to have been able to feature the work of the late Audrey Naylor in Commendable contributions to the field of lactation. ​​With a lifetime interest in illness prevention, Naylor said she was quickly convinced of the power of breastfeeding after only attending a few hours of a breastfeeding seminar in 1976.

“Neither medical school nor pediatric residency taught me anything about breastfeeding,” Naylor said.  

Elizabeth Sahlie’s, MD, FAAP and Jesanna Cooper’s, MD work is featured in Birmingham Mother-to-mother support helps moms reach feeding goals. Cooper says that before she became a mother, she had no idea that her medical training and education had been so lacking.

“It is easy to become frustrated with nurses and physicians who – often inadvertently sabotage breastfeeding mothers and babies, but I also sympathize,” she explains. “We are in a position where we are supposed to have answers, but no one has taught us the skills necessary to provide those answers.”

Other stories and models for care 

Lori Feldman-Winter’s, et al  Residency curriculum improves breastfeeding care showed that “a targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.

 As part of their work to build a cohort of breastfeeding-friendly pediatricians, the Georgia Chapter of the American Academy of Pediatrics and the Georgia Breastfeeding Coalition launched a “Breastfeeding-Friendly Pediatrician Interest Form.” Georgia pediatricians who are interested in becoming certified as a “Breastfeeding-Friendly Pediatrician” are invited to fill out the form.

 

Further reading and resources

Physicians, Formula Companies, and Advertising: A Historical Perspective

Inspire Health, CHAMPS,  and the University of Mississippi Medical Center’s Breastfeeding, Human Medicine,  Interprofessional Education training   

CDC Physician Breastfeeding Education  

What Every Physician Needs to Know About Breastfeeding from the W.K. Kellogg Foundation

The Institute for the Advancement of Breastfeeding & Lactation Education (IABLE) is a nonprofit membership organization whose mission is to optimize the promotion and support of breastfeeding for families in the outpatient sector. IABLE is dedicated to building Breastfeeding Knowledgeable Medical Systems and Communities. 

Academy of Breastfeeding Medicine (ABM) Breastfeeding-friendly Physicians protocol 

 

Physician group position papers and recommendations on breastfeeding 

American Academy of Pediatrics (AAP)

American Academy of Family Physicians (AAFP)

The American College of Obstetrics and Gynecology (ACOG) 

Lactation counselor invents one-of-a-kind, hand expression education device

For as long as there have been humans, there has been human milk. As it happens, according to Greek mythology our entire galaxy originates from breastmilk. 

Although people have been breastfeeding for millennia, breastfeeding doesn’t necessarily come naturally, especially in our modern world where common birth practice, industry influence and cultural phenomena are at play. 

Adhering to a mentality where breastfeeding is viewed as completely natural, is one of the most “harmful and hurtful” beliefs because it assumes that lactating people don’t need support, Founder/CEO of Orolait Ana Rojas Bastidas, CLC explains. 

“The majority of women are not able to fulfill their [infant feeding] goals, and that’s unbelievably sad,” Rojas Bastidas says. 

“That’s where innovation comes in,” she continues. 

Rojas Bastidas’s company Orolait, is a breastfeeding apparel company at its core, but this summer she released a one-of-a-kind lactation education tool: the LactoPRO Trainer

The LactoPRO is an anatomically-correct, tissue-mimicking human breast used for demonstrating hand expression. The device features a realistically-sized areola, nipple, and six lactiferous ducts and effectively ejects a human milk-like or colostrum-like substance. The breast is available in various skin shades too. 

In April 2020, Rojas Bastidas shifted Orolait operations to help provide Personal Protective Equipment (PPEs) to a hospital in Haiti alongside a Houston-based company that creates surgical organs.  With Rojas Bastidas’s vision and entrepreneurship and the company’s patented technology, the LactoPRO Trainer came to fruition. 

Rojas Bastidas and the team are working to create a model with inverted nipples as well as fashioning a breast that can develop clogs and mastitis. 

Rojas Bastidas emphasizes that she is always working to make her contributions more affordable and accessible.

“Having great things that are not accessible to the community are not helpful to anyone,” she says. 

Through her movement PowerToPrevail and other projects,  Rojas Bastidas has been a force for body positivity, cultivating self worth and supporting modern motherhood. This work led her to complete the Lactation Counselor Training Course (LCTC) earlier this year. 

“As I was going through the course and tried to teach hand expression, I became frustrated by the lack of options to demonstrate it accurately and in a constructive way,” she reports. 

Evidence-based lactation care emphasizes a hands-off approach. Couple this with the idea that infant feeding is a learned behavior and in American culture we don’t grow up seeing lactating breasts and breastfeeding, hand expression is a terribly abstract practice to teach. 

The LactoPRO helps fill this void. 

“Innovation in the lactation space has been slow and overlooked, so this is really exciting for me,” Rojas Bastidas says. “I’ve created something for the private sector that’s going to push public perception.” 

She likens her invention to the evolution of professional lactation care services; maternal child health advocates took a stand and refused to let women suffer, she explains. Like lactation care, Rojas Bastidas has created something that validates people’s stories and experiences. 

Rojas Bastidas’s influence stems from her experience as a new mom and the way she viewed her evolving body. 

“I didn’t realize that the way I viewed my body was impacting so much of my life including my breastfeeding journey,” she says. 

So many parents sympathize with the conundrum of breastfeeding in public spaces for instance. To do so discreetly often means lifting your shirt and exposing the midsection.

It seems vain and trivial, Rojas Bastidas acknowledges but when you multiply it by the millions of moms who experience challenges like this, there’s got to be a solution.

“Don’t be afraid to tackle whatever problem you see,” Rojas Bastidas encourages. “Innovation is for anyone.” 

Rojas Bastidas’s apparel serves as functional fashion. Simultaneously, her pursuit celebrates the bodies that have been largely misrepresented and often altogether censored. 

“The absence of bodies sends a broader message that those bodies don’t exist,” she explains. 

“It makes every battle so much harder, but that’s what keeps driving me. I  should have just closed up shop because this is so hard, but  I’m going to make as many people as uncomfortable as humanly possible,” Rojas Bastidas says of being a female innovator in health and wellness advocacy. 

She adds that by showing the public what bodies actually look like, it frees us, elevates us and empowers us. 

“Lactating individuals deserve to be seen, heard and helped.”

Rojas Bastidas has a lot to offer on her website including her shop, lactation counseling services, a member forum and blog. Check it out here

Follow her on social media @orolaitofficial and @powertoprevail

Progress through podcast: Care provider supports families through relevant lactation education

When Tangela L. Boyd, MA, IBCLC, CLC, CLE, CCCE, CPD, a Union Institute & University affiliated faculty member and owner of Mommy Milk  & Me, Inc., had her twin boys 14 years ago becoming a mother of four, she simultaneously entered a space of advocacy.

“I had a very adventurous time with those guys in the NICU,” Boyd remembers. “It changed the way I thought about breastfeeding.” 

As a young Black mother, Boyd says she feels fortunate to have had support from hospital staff to feed her twins (which she went on to do for three years), acknowledging that this is not often the case for BIPOC families

“That support in turn gave me the desire to help other mommies,” she says.

Boyd’s passion lies in uplifting underserved communities, particularly families living in the rural regions of the Southeast U.S. where she lived for nearly 20 years. 

Now located in Florida, Boyd’s newly released podcast, The Early Postpartum Period, offers a way to stay connected and reach underserved mothers with basic, relevant breastfeeding information. 

Boyd admits that the technology was something new to her and it required much patience to bring the project to fruition. Still, she says, it’s something that she wants to commit to for a long time to come, connecting with families especially in the time after they’ve left the hospital. Boyd hopes to soon host focus groups to get a better understanding of what kind of information families would like her to cover in the episodes. 

In the meantime, she plans to release more episodes over the summer. Her practice emphasizes the importance of organization, so she’s planning a podcast featuring organizational skills and time management tips. 

“There is a lot of lactation education out there and I don’t want to be repetitive,” Boyd begins. “I want to hit areas that will really be relevant and give [parents] something they can use, not just something they can listen to.”  

Boyd explains that learning organizational skills can bring a sense of calmness which allows parents the energy to move forward with daily tasks, rather than getting engulfed by an often chaotic world. She suggests things like preparation, avoiding procrastination and working up endurance through taking a breath and stepping away when necessary. 

Especially as our country examines our foundations and current events have brought race to the forefront, Boyd emphasizes the urgency to address high Black maternal mortality rates.

The pandemic has illuminated ways in which to address these rates, Boyd explains, like out of hospital birth and doula support. 

“We have to move forward,” Boyd encourages. 

You can connect with Boyd on Twitter here and find her website here

Boyd has been featured on Ifeyinwa Asiodu’s PhD, RN, IBCLC Blacktation Diaires for her work on increasing breastfeeding and perinatal education rates among BIPOC. She has also written for Kimberly Seals Aller’s Mocha Manual.

Breastfeeding in shelters

Among the many effects of the novel coronavirus, the pandemic has exposed our nation’s deficiencies: emergency unpreparedness, racial health disparities, our “highly polarized, fragmented, and individualistic society…” (I would add arrogant), and the failure of capitalism.  In marginalized populations, poverty, health inequities, and other burdens are amplified during an outbreak or other emergency. 

Long before the pandemic hit, individuals and advocacy organizations have been ringing the alarm, calling for better access to education, better healthcare, and equity and justice for all.

Of these trailblazers is Powerhouse Nikki Lee RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, CKC, RYT whose recent endeavor includes creating and implementing the 10 Steps to a Breastfeeding Friendly Shelter

In her role at the City of Philadelphia Department of Public Health, Lee noticed the challenges breastfeeding people face in shelters. 

The barriers are a result of our cultural attitude toward lactating people and misunderstandings about their bodies and needs. 

Lee talks about issues of privacy and ‘fairness’ in a shelter. Organizational dress codes often require residents to dress modestly, so when a person exposes their breasts to feed a baby, other residents can wonder why they’re not allowed to wear short shorts. Parents can express concern about the teenage boys in their families seeing breasts while a baby is being fed.

There’s the concern over safe milk storage and the mythology around reimbursement through the Child and Adult Care Food Program. Shelter staff may believe that if a mother breastfeeds, the facility will lose money to buy food because the allotted amount for infant formula isn’t getting used. Lee clarifies that if a mother breastfeeds, the institution will have more money to spend on food.  

Just like in the rest of the US, there tends to be a push for formula feeding because the baby’s intake is easily measured, and staff are more comfortable with what is familiar, i.e. bottle-feeding

Lee continues, “There is a genuine honesty from people who don’t understand anything about breastfeeding, ‘Why are we breastfeeding?’ ‘Why are we bothering?’”  Staff in hospitals have been educated about breastfeeding over the past few decades; staff in shelters have not.

So when she conducts trainings, she starts at the rudimentary level of ‘what are mammals?’ 

“All the worst mythology that you can imagine is in the shelter,” Lee says. “All the worst in how society treats mothers and babies gets magnified in shelters.” 

With the problem identified, Lee says she started “from scratch in a way,” looking for a written policy to support breastfeeding people.  Early on in her search, she followed up on a news story featuring a homeless mother in Hawaii. She posted inquiries on Lactnet, CDC listserv, international online forums, Facebook groups, and reached out to shelters at random wondering if they had breastfeeding policies . 

“Nothing,” Lee reports. “There is probably a shelter somewhere that has a policy, but after two years of a global search, I wasn’t able to find it.” 

In all her search,  Lee found one published document— a Canadian study looking at the factors that influence breastfeeding practices of mothers living in a maternity shelter– that could be helpful. 

Lee wrote the first draft of the 10 Steps to a Breastfeeding Friendly Shelter with policies like the Ten Steps to Successful Breastfeeding and Ten Steps to Breastfeeding-Friendly Child Care in mind. 

She sent it out to colleagues at CHOP’s Homeless Health Initiative for feedback, and for quite a while, there was none. Lee’s colleague Melissa Berrios Johnson, MSW,  a social work trainer with HHI, and the convenor of its breastfeeding workgroup subcommittee, helped to make the policy reality. 

Partner agency Philadelphia Health Management Corporation (PHMC) received a grant that funded research which took the policy to four different shelters for staff and resident feedback. 

“Everyone, residents and staff alike, felt this policy was important and feasible,” Lee says. 

PHMC’s next step was to identify a shelter staff member to become a breastfeeding champion. This champion would be provided with free breastfeeding training, and receive an honorarium.

As program oversight changed though, “breastfeeding champion” became a job, with a list of responsibilities. So far, Lee says they’ve only found four people out of 10 shelters who are willing to take on the task.

“There are some folks in shelters working hard to make things better,” Lee says. “They are those champions, most of whom have breastfed themselves.”

Currently, Lee and colleagues are in the process of developing training for staff members and ironing out how to help staff implement the policy.  

Lee’s and co-authors Alexandra Ernst MPH, and Vanesa Karamanian MD, MPH landmark paper about the 10 Steps to a Breastfeeding Friendly Shelter has been submitted to the  Journal of Human Lactation (JHL)

At present, COVID has put all of this work on hold.