equity Archives - Our Milky Way

April 23, 2023April 18, 2023

Pregnant and breastfeeding individuals’ involvement in clinical trials

During her second pregnancy, a mother tested positive for cytomegalovirus (CMV). The CMV virus can cross through the placenta and infect a developing fetus, potentially causing birth defects or other long-term health problems. This mother was contacted and presented with the opportunity to participate in a clinical trial where she would be infused with a drug that would potentially mitigate the risks of her child developing congenital CMV.

The mother reports that because her child was already at risk, she saw participating in the trial as something she could do to avoid the risk of potential health problems.

The process of participating was relatively simple considering her work-from-home arrangement and having reliable child care for her older child.

At last, her daughter was born healthy and continues to thrive.

This mother reports that, until recently, she hadn’t considered what she would have done if something had gone wrong as a consequence of participating in the trial. She said that she’s unsure what kind of compensation might make up for a hypothetical injury to her child who was unable to consent to the trial. She emphasized that parents dedicate themselves to making the right decisions for their children, so the stress of raising a child with special needs coupled with the guilt of having made the “wrong” decision, could be shattering.

The inclusion of pregnant and lactating people in clinical trials is part of an evolving national and international conversation.

Earlier this spring, the Committee on Developing a Framework to Address Legal, Ethical, Regulatory, and Policy Issues for Research Specific to Pregnant and Lactating Persons held a workshop to discuss how institutions make risk-benefit decisions regarding the inclusion and exclusion of pregnant and lactating persons in clinical research, and the role of liability, risk management, and trial insurance in those decisions as well as reviewed existing compensation schemes for research-related injuries and potential to scale these models to serve the needs of research participants.

Historically, pregnant and breastfeeding women have been excluded from clinical trials, due to concerns about the real or perceived potential risks to the fetus or child. [FDA Voices, 2021] Namely, the thalidomide crisis in the 1950s largely shaped the culture around risk aversion and clinical testing on the pregnant population.

“A 2011 study on all medications approved by the FDA from 1980 to 2010 found that 91 percent of the medications approved for use by adults did not have sufficient data on safety, efficacy and fetal risk of medication taken during pregnancy,” the authors of Fair inclusion of pregnant women in clinical trials: an integrated scientific and ethical approach write. “At the same time, the number of pregnant women who take medications, as well as the number of medications that these pregnant women take, has increased.”

Today, health advocates are pushing for the inclusion of this population in clinical research on the basis that patients should have solid evidence in order to make informed decisions about their health.

“Not having this evidence can result in unfairness in the distribution of benefits and burdens (injustice) and can curtail the autonomy in making informed choice,” Catriona Waitt writes in Clinical trials and pregnancy. “This may make it impossible to provide the best treatment, undermining the principle of beneficence, and risking increasing harm.”

Speakers at the workshop cited several roadblocks to the inclusion of pregnant and lactating people in clinical research.

Institutional Review Boards (IRBs) are charged with keeping patients safe, so they often take a very conservative approach. [White, 2021] Elisa A. Hurley, PhD, executive director of Public Responsibility in Medicine and Research (PRIM&R) explained that the current framework does not encourage or assess the risk of not doing research on this population, and that the culture needs to shift from exclusion to inclusion as the default. Dr. Hurley cited the University of Washington where there’s been a shift to require justification to exclude pregnant and lactating populations.

Lorien Urban, Ph.D., Senior Medical Director Clinical Development at Ferring Pharmaceuticals pointed out that IRBs tend not to acknowledge a distinction between pregnancy and lactation when reviewing trials. In fact, while the placental barrier can be sensitive, there are very few drugs that pass through to mothers’ milk. [InfantRisk Center]

Photo credit: United States Breastfeeding Committee

Metin Gülmezoğlu, M.D., Executive Director at the Concept Foundation argued that pregnant and lactating women should demand to be included in research, and that governments should react accordingly, assuming responsibility and taking action.

Gülmezoğlu’s project AIM responds to the created culture of risk aversion in the field. Gülmezoğlu said that risk aversion doesn’t get rid of risk; instead it shifts risk to another person: either the care provider or the pregnant person themself.

Risk is of primary concern for companies and organizations conducting research in these populations.

Sara E. Dyson, M.P.H., C.P.C.U.,Vice President of Underwriting Operations & Risk Management at Medmarc laid out the ways in which institutions can make their trials less risky and more attractive to underwriters:

demonstrate for the potential risk,
conduct significant bench testing,
conduct informed consent on video,
ensure compensation is reasonable and cannot be construed as coercion
consult with reputable IRB (multiple IRBs in some cases),
select a trial site (for instance an institution with specialty in high risk pregnancy)

Niranjan Bhat, M.D., M.H.S., Senior Medical Officer at PATH, shared that PATH’s global umbrella policy which covers any adverse event during participation of the study is a key research enabler.

Michelle Mello, J.D., Ph.D., Professor of Law and Health Policy at Stanford University and Renée J. Gentry, Esq., one of the leading experts on vaccine injury litigation in the National Vaccine Injury Compensation Program (NVICP), laid out the ways in which tort versus private compensation programs can be successful or unsuccessful in compensating injured clinical trial participants. In either case, proving causation tends to be the primary difficulty on the battleground for product liability.

The tort system is capacious enough to handle injury claims, Dr. Bello began. However, using Winston Churchill’s metaphor for democracy– “Democracy is the worst form of government – except for all the others that have been tried.”– it tends to favor the wealthy, is laborious in terms of time, and presents high volatility in terms of settled amounts.

Perhaps not a solid alternative, a system like NVICP, is at a “breaking point”, according to Gentry. The program started with eight special masters when it began in the 1980s; today this number remains. Set up to cover six vaccines, the program now covers 16 vaccines; as such the number of complaints have quadrupled in the past decade. People are waiting two to three years to have their trials scheduled. In fact, some seniors have died waiting for their trials.

Gentry advises that when considering the creation of a compensation system, there should be flexibility built in to include the modification of staffing levels and scheme.

In a private system, like the UW-Washington Human Subjects Compensation Program, this flexibility is a positive attribute; however, speakers pointed out that private systems do not address two major points:

A private system does not get around addressing causation difficulties.
A private system does not necessarily address equity and has the potential to lead to a patchwork of compensation of different solutions at different levels of generosity.

As health professionals, consumers and other individuals and organizations work to shape the legal, ethical and policy frameworks that affect research on the pregnant and lactating population, you might consider consulting the following readings and resources.

Further reading

Clinical trials and pregnancy

A Comparison of FDA and EMA Pregnancy and Lactation Labeling

FDA’s Pregnancy and Lactation Labeling (Drugs) Final Rule (2014)

FDA Updates: Pregnant Women Subjects and Medical Device Investigations (2018)

Current resources for pregnant and lactating individuals and care providers

The Trash the Pump and Dump (TPD) app encompasses medical conditions, medications and substances of concern during lactation.

Drugs and Lactation Database (LactMed®)

FDA Pregnancy Categories

E-lactancia: comprehensive medication and herbal medicine database in Spain, available in English and Spanish

Organization of Teratology Information Specialists

Brigham and Women’s Hospital Drugs, Herbs, and Supplements during lactation

January 29, 2023

Breastfeeding is an opportunity to learn.

–This post is part of our 10-year anniversary series “Breastfeeding is…”—

Breastfeeding is an opportunity to learn. Although breastfeeding is an ancient practice, there is still so much to learn about the lactating breast, breast function and the process of breastfeeding, especially as our modern lives continue to change.

Many current textbook depictions of the anatomy of the lactating breast are largely based on research conducted over 150 years ago, Donna T. Geddess points out in The anatomy of the lactating breast: Latest research and clinical implications.

“…Few studies have actively investigated the anatomy of the lactating breast despite the obvious importance a clear understanding of the lactating mammary gland has to both mother and infant,” Geddess writes. “Perhaps this lack of information is a part of the greater reason why many women continue to experience breastfeeding problems.”

Katherine Lee writes in Katie Hinde Championing the Fun Side of Science Through Virtual Animal Games, Thunderdome Style about Hinde’s hope to change the perception about breastmilk and quotes her saying “‘Still to this day, there is no integration between breastfeeding and milk composition and volume,’ noted Hinde. ‘In Pubmed, there are more articles about tomatoes than human breast milk.’ When they listed the human microbiome project, they didn’t include breastmilk…”

This week we present several recent (in the last 5 years) publications that are helping to shape our understanding of infant feeding. We have also included studies that relate specifically to pregnancy as pregnancy, birth and breastfeeding are all part of a continuum.

It is important to note that research published in medical journals is not the only way to capture and develop an understanding of infant feeding experiences. For instance, Camie Jae Goldhammer, MSW, LICSW, IBCLC, (Sisseton-Wahpeton), founder of Hummingbird Indigenous Doula Services says that their program is proudly not rooted in “evidence”; instead, it’s a community designed program. Anecdotal evidence and indigenous knowledge and wisdom should be honored. Moreover, as with any research, we must always consider how the research is funded, who is or is not being represented, and how the research is presented. For more on equity in science, check out Increasing equity in data science and the work being done at the Urban Indian Health Institute.

Lactation duration and stroke risk

In February 2022, Ziyang Ren, MD, et al released Lactation Duration and the Risk of Subtypes of Stroke Among Parous Postmenopausal Women From the China Kadoorie Biobank.

Stroke is a growing global health problem. It is the third leading cause of disability adjusted–life years (DALYs) worldwide and the first leading cause of DALYs in China, Ren, et al point out. Stroke imposes a financial burden on patients, families, and society. The cohort study found that lactation duration significantly lowers the risk of stroke.

Up until now, most research has focused on the association between lactation and cardiovascular diseases (CVDs), but this piece lays out the association between lactation and stroke subtypes.

Specifically, the study found that parous postmenopausal women with lifetime lactation duration of at least 7 months had lower risks of ischemic stroke and intracerebral hemorrhage (ICH) compared with women who never lactated. For subarachnoid hemorrhage (SAH) though, such associations were found only in participants with lifetime lactation duration of longer than 24 months. In addition, the authors found that those with an average lactation duration per child or lactation duration for the first child of at least 7 months were less likely to develop stroke and its subtypes.

Marijuana exposure in utero

Birth Outcomes of Neonates Exposed to Marijuana in Utero: A Systematic Review and Meta-analysis by Greg Marchand, et al, the largest meta-analyses on prenatal cannabis use to date, the authors found significant increases in seven adverse neonatal outcomes among women who were exposed to marijuana during pregnancy versus those who were not exposed during pregnancy.

The systematic review and meta-analysis demonstrated higher rates of low birth weight (<2500 g) and small for gestational age (<fifth percentile), lower mean birth weight, preterm delivery (<37 weeks’ gestation), higher rate of admission to the neonatal intensive care unit, poorer Apgar scores at 1 minute, and smaller head circumference in those exposed to marijuana.

The prevalence of marijuana use during pregnancy is significant, and many people cite the belief that marijuana use is relatively safe during

pregnancy. This work may help to raise awareness and be used to educate patients about adverse outcomes with the hope of improving neonatal health.

With increased marijuana legalization in mind, Kara R. Skelton, PhD and Sara E. Benjamin-Neelon, PhD, JD, MPH in Reexamining Risks of Prenatal Cannabis Use—Mounting Evidence and a Call to Action urge states that have legalized and commercialized cannabis to retroactively prioritize protection of neonatal health.

More on cannabis during the perinatal period here.

Childhood obesity

The authors of Childhood Obesity and Breastfeeding Rates in Pennsylvania Counties-Spatial Analysis of the Lactation Support Landscape examined the relationship between childhood obesity and breastfeeding rates in Pennsylvania (PA) counties, the relationship between geographic access to professional lactation support providers (LSPs) in PA counties and breastfeeding rates, and the relationship between geographic access to professional LSPs and childhood obesity in PA counties. They found a significant, inverse relationship between breastfeeding rates and childhood obesity prevalence at the county level and a significant, inverse relationship between the number of CLCs and the number of all professional LSPs and childhood obesity rates at the county level. Thus, the authors conclude, the availability of breastfeeding support is significantly related to breastfeeding rates and inversely related to childhood obesity rates across Pennsylvania.

Measuring optimal skin-to-skin practice

The authors of Mapping, Measuring, and Analyzing the Process of Skin-to-Skin Contact and Early Breastfeeding in the First Hour After Birth show how process mapping of optimal skin-to-skin practice in the first hour after birth using the algorithm, HCP-S2S-IA, produced an accurate and useful measurement, illuminating how work is conducted and providing patterns for analysis and opportunities for improvement with targeted interventions.

More specifically, the algorithm provides a tool to help reduce delays or decrease interruptions during skin-to-skin contact (SSC). The authors note, “Not suckling in the first hour after birth places newborns at higher risk for neonatal morbidities and mortality. Examining patterns and developing strategies for change optimizes patient outcomes.”

Acknowledging the social determinants of health

Pregnancy and the origins of illness (2022) by Anne Drapkin Lyerly begins by acknowledging that the COVID-19 pandemic has induced a collective trauma that is expected to be felt for generations after the virus is contained. The study of epigenetics has shown that children gestated or born during times of great tragedy, carry a genetically coded and inherited imprint of their mother’s experience with lifelong consequences to their health.

Recognizing the “maternal-fetal interface” as the “nexus of inter-generational trauma” raises the question of how we should think about this implication of maternal bodies, especially in light of the current pandemic.

The author explores the growing field of developmental origins of health and disease (DOHaD) and its use of epigenetics. Thinking about the tools of history, philosophy, and gender studies of science, the author advises we proceed with caution as we consider maternal effect science which raises several concerns that can impact practice and the well-being of mothers and consequently their children.

Namely, there may be a tendency to ascribe blame on pregnant people for the health outcomes of their offspring that are well beyond their control. This approach doesn’t adequately weigh the effects of paternal, postanal, and other social and environmental factors that also influence the long-term health of children.

Analyzing epigenetics can eventually contribute to the erasure of the mother as a person, and further, characterizing the maternal body as an environment may excuse women from being appropriately considered in public health policies, clinical care and health research.

The author considers DOHaD research a corrective approach to near-sighted fetal origins science and urges that we expand our understanding of the gestational environment from not simply the womb, but to the broader environment in which a person gestates, marking the importance of acknowledging the social determinants of health. To best direct our efforts during the current pandemic, the author suggests shifting the focus off of maternal behavior and choices and instead focus on limiting the harm of climate change, racism, and other structural inequities.

Can’t get enough?

Check out the Breastfeeding Medicine Podcat’s episode Review of a Potpourri of Research Topics with co Hosts Anne Eglash MD, IBCLC and Karen Bodnar MD, IBCLC. You can find a full list of their podcast episodes here.

Subscribe to SPLASH! Milk Science Update

Check out The International Society for Research in Human Milk and Lactation

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As part of our celebration, we are giving away an online learning module with contact hours each week. Here’s how to enter into the drawings:

Email info@ourmilkyway.org with your name and “OMW is 10” in the subject line.

This week, in the body of the email, tell us: What fascinates you about breastfeeding and/or what do you wonder about breastfeeding?

Subsequent weeks will have a different prompt in the blog post.

We will conduct a new drawing each week over the 10-week period. Please email separately each week to be entered in the drawing. You may only win once. If your name is drawn, we will email a link with access to the learning module. The winner of the final week will score a grand finale swag bag.

January 15, 2023

Breastfeeding is food sovereignty. Breastfeeding is health equity. Breastfeeding is healing.

–This post is part of our 10-year anniversary series “Breastfeeding is…”—

Breastfeeding is food sovereignty. Breastfeeding is health equity. Breastfeeding is healing.

Breastfeeding is a “weapon of mass construction”, a phrase coined by Camie Jae Goldhammer, MSW, LICSW, IBCLC, (Sisseton-Wahpeton).

In her Reclaiming the Tradition of Breastfeeding: the Foundation of a Nation webinar, Goldhammer describes how breastfeeding has the power to heal those suffering the effects of generational trauma, specifically through the release of oxytocin, subsequently allowing mothers and their babies to feel empowered and independent.

Kathleen Kendall Tackett’s work also illuminates how breastfeeding can heal trauma. Her videos, How Birth Trauma Affects Breastfeeding and Breastfeeding Can Heal Birth Trauma and Breastfeeding’s Healing Impact on Sexual Assault Trauma discuss the mechanisms behind why and how breastfeeding can be helpful for trauma survivors. Essentially, breastfeeding allows for the down regulation of stress responses, specifically adrenocorticotropic hormone (ACTH) and cortisol, and similar to exercise, improves maternal mood, decreases the risk of depression, decreases hostility, and improves the mother infant bond.

Jennie Toland, BSN, RN, CLC offers commentary on the role lactation care providers play in offering trauma-informed care in this piece.

This Invisibila episode, Therapy Ghostbusters, shares the incredible story of how a Cambodian practitioner worked to help heal an entire community from generational trauma. It took him over a year to simply earn individuals’ trust.

“…That’s pretty unique,” the podcast hosts point out and offers insight into how our nation approaches care for individuals with specific mental health needs and cultural considerations.

Goldhammer quotes Round Rock elder Annie Kahn: “When a mother nurses her baby, she is giving that child her name, her story and her life’s song. A nursed baby will grow to be strong in body, mind and spirit.”

This connection to the past that Kahn refers to, also offers a form of healing. Breastfeeding is an example of Indigenous food sovereignty, “a part of living culture” and facilitates the revitalization of traditional knowledge. (Cidro, et al 2018)

The revitalization of breastfeeding spans the Black Indigenous People of Color (BIPOC) experience and is a channel to champion equity.

Ifeyinwa V. Asiodu, Kimarie Bugg, and Aunchalee E.L. Palmquist write in Achieving Breastfeeding Equity and Justice in Black Communities: Past, Present, and Future:

“Breastfeeding is an especially important public health issue in Black communities, particularly given that Black families and communities continue to experience the highest burden related to poor maternal and infant health outcomes, including higher incidence of preterm birth, low birth weight, maternal mortality and morbidity, infant mortality, and lower breastfeeding rates. Owing to lifetime exposure of racism, bias, and stress, Black women experience higher rates of cardiovascular disease, type 2 diabetes, and aggressive breast cancer. Given that cardiovascular disease and postpartum hemorrhage are leading causes of maternal mortality and morbidity, increasing breastfeeding rates among Black women can potentially save lives.”

More specifically, studies show that the experience of racial discrimination accelerates the shortening of telomeres (the repetitive sequences of DNA at the ends of chromosomes that protect the cell) and ultimately contributes to an increase in people’s risks of developing diseases.

It has been found that higher anxiety scores and inflammation are associated with shorter telomere length.

Because physical and psychological stressors trigger the inflammatory response system, one way to counter this reaction is by supporting ongoing breastfeeding relationships; when breastfeeding is going well, it protects mothers from stress. (Kendall-Tackett, 2007)

Another study found that early exclusive breastfeeding is associated with longer telomeres in children.

The authors of Achieving Breastfeeding Equity and Justice in Black Communities: Past, Present, and Future continue, “Yet breastfeeding is rarely seen as a women’s health, reproductive health, or a public health strategy to address or reduce maternal mortality and morbidity in the U.S. Inequities in lactation support and breastfeeding education exacerbate health inequities experienced by Black women, specifically maternal mortality and morbidity, and thus a greater investment in perinatal lactation and breastfeeding education and resources is warranted. Breastfeeding is an essential part of women’s reproductive health.”

Journalist and maternal child health advocate Kimberly Seals Allers’ approach is one “For Black people, from Black people.”

“…The call to revive, restore and reclaim Black breastfeeding is an internal call to action,” Kimberly Seals Allers begins in Black Breastfeeding Is a Racial Equity Issue. “… Breastfeeding is our social justice movement as we declare the health and vitality of our infants as critical to the health and vitality of our communities.”

Specifically through her work with Narrative Nation, Seals Allers and colleagues are promoting health equity “by democratizing how the story of health disparities is told,” centering BIPOC voices. Additionally, through her Birthright podcast, KSA uplifts stories of joy and healing in Black birth.

Especially after the deaths of George Floyd, Breonna Taylor and Ahmaud Arbery, organizations made statements about their commitments to dismantling structural racism and focusing efforts on equity.

Equity has become a buzzword; in fact, one author brands the sentiment “Fakequity”. This year, United States Breastfeeding Committee (USBC) National Conference and Convening presenters expressed their fatigue with the word.

“We want to see action,” they said.

Nikki & Nikki LIVE offer their Allies, Advocates and Activists Equity in Lactation webinar which covers the meaning of equitable in lactation care, how to show up for the marginalized and how to make a lasting impact.

In other efforts, the CDC has identified breastfeeding as a priority area to address health inequities.

NICHQ’s Achieving Breastfeeding Equity campaign also focuses on closing breastfeeding disparity gaps, viewing their efforts through an equity lens.

Director of policy and partnerships at the National Women’s Health Network Denys Symonette Mitchell offers commentary on a way forward with key policies that will ensure investment in breastfeeding to ultimately advance health equity.

Watch Racism and the Colonial Roots of Gendered Language in Public Health and Biomedicine with Dr. Aunchalee Palmquist, PhD, IBCLC for more on these issues.

——–

As part of our celebration, we are giving away an online learning module with contact hours each week. Here’s how to enter into the drawings:

Email info@ourmilkyway.org with your name and “OMW is 10” in the subject line.

This week, in the body of the email, tell us about how you are contributing to working toward healthy equity.

Subsequent weeks will have a different prompt in the blog post.

May 10, 2020May 11, 2020

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.

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