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) 

Children’s book celebrates the joy of natural-term breastfeeding

Monica Haywood is a researcher by nature. When she became pregnant with her daughter, she read all of the baby books. 

She read about prenatal vitamins, proper nutrition, prenatal appointments, etc., etc., etc. 

“I wanted to do everything right,” Haywood says. 

Sometime during her second trimester, her focus narrowed in on breastfeeding. She was familiar with the stories her mother told about breastfeeding her, but she wanted to know more. Haywood attended La Leche League of Louisville meetings and scoured websites for infant feeding information. 

She felt prepared and laid out a plan to breastfeed her baby for three months. 

“Little did I know, the journey was slightly different,” she laughs. “You can read, read, read, but be prepared to pivot on things that you may have read about.”

Baby Noelle was born in 2017 and instead of breastfeeding for the planned three months, Noelle and Haywood nursed for 34 months. 

Haywood says that while exclusive, natural-term breastfeeding was sometimes challenging like balancing her baby’s needs and self-care and managing other people’s perceptions mostly, breastfeeding created a sense of empowerment and bonding. 

Haywood shared another connection with Noelle through her love of books early on. 

“She was only a couple months old and my husband and I were reading books to her,” she shares. 

“[Reading] helps with language development, and we also thought it was important to find books that she could relate to… characters that look like her and that can relate to her experience,” Haywood continues.  

She found that most children’s breastfeeding books were geared toward weaning, but she was looking for something that celebrates the breastfeeding journey, something that could capture what she and Noelle were doing. 

And when she couldn’t find it, she created it. Haywood wrote Noey Loves Nursing, a colorful book that commemorates her nursing journey, celebrates a diverse character,  and educates and brings awareness to extended breastfeeding. 

“I wish I could get it in the hands of every breastfeeding mother!” Haywood exclaims. 

The book is highly admired by younger readers including her daughter who Haywood says is really excited by the book. 

Another young reader, Blake, shares his reading of Noey Loves Nursing @readingwith_blake

“When I saw [the video],  it literally brought me to tears,” Haywood says. “It’s just awesome.” 

Before COVID-19, Haywood enjoyed sharing Noey Loves Nursing at in-person gatherings like LLL Louisville’s Live Love Latch during National Breastfeeding Month and Healthy Children Project’s International Breastfeeding Conference. She’s also shared her story with local WIC offices.

This summer, Haywood adapted to Zoom and Facebook Live events to celebrate Black Breastfeeding Week and National Breastfeeding Month with her book. 

Haywood looks forward to the United States Breastfeeding Committee’s (USBC) National Conference in 2021 where she hopes to bring her mother and Noelle– three generations sharing their breastfeeding journeys. 

The second edition of Noey Loves Nursing will be released later this year or in early 2021. Get connected with Haywood on social media @noeylovesnursing, @monicareneeinc and on Facebook.

Spotlight on Infant and Young Child Feeding in Emergencies during National Breastfeeding Month

It’s Week Three (August 16-24) of National Breastfeeding Month, recognized as Spotlight on Infant and Young Child Feeding in Emergencies by the United States Breastfeeding Committee (USBC). 

Among the many effects of the novel coronavirus, the pandemic has truly exposed our nation’s deficiencies; one of them being emergency unpreparedness. 

Years ago, Federal Emergency Management Agency (FEMA) called Hurricane Katrina “the single most catastrophic natural disaster in US history.”

In preparation for the storm, the government organized an alternate site for the Super Bowl but failed to employ an infant feeding in emergencies (IFE) plan, Healthy Children Project Executive Director Karin Cadwell reports. In the aftermath of the catastrophe, pets and exotic animals were accounted for, but mothers and infants were separated from one another as hospitals were evacuated.

In 2016, Healthy Children Project, Inc. (HCP)  convened an Expert Panel to complete the World Breastfeeding Trends Initiative (WBTi), an international tracking, assessment and monitoring system for national implementation of the Global Strategy on Infant and Young Child Feeding, as originally reported in Underdeveloped plans for infant and young child feeding during emergencies

WBTi Panel Members

The USA scored 0 out of 10 points on WBTi Indicator 9, which measures implementation of actions to protect infant and young child feeding (IYCF) during emergencies.

WBTi originator Dr. Arun Gupta challenged HCP to conduct a state-by-state review of WBTi indicators that can be measured on a state level. 

The US Expert Panel reconvened in 2017 to complete the United States of America and U.S. Territories 2017 Assessment Report. Results further show the absence of state policies ensuring babies and young children are safely fed during emergencies.

HCP’s Cindy Turner-Maffei says that the lack of well-developed plans for protecting IYCF during emergencies was one of the most worrisome findings of the U.S. WBTi Assessment.

She explains: “Scores above two points were rare, and most of the points scored regarded funding allocation for emergencies, not for specific inclusion of the needs of infants and young children in emergency plans.”

Puerto Rico and Texas scored 0 out of 10. New Jersey and Mississippi scored 2 out of 10. Oklahoma 3 out of 10. Connecticut took the lead at 6 out of 10.

“Panel members were struck by the fact that few of the states and territories that had recently experienced significant disasters were among those with significant scores for Indicator 9,” Turner-Maffei continues. “Ironically, some states and territories have well-elaborated plans for the care and feeding of household pets in shelters, but none for infants and young children.”

Photo by Luiza Braun on Unsplash

Although there are always crises occurring, since being thrust into a global pandemic, our nation has had to reevaluate how we care for families with babies and young children. Especially in marginalized populations, poverty, health inequities, and other burdens are amplified during an outbreak or other emergency. 

Carolina Global Breastfeeding Institute states,  “Any crisis presents an opportunity for positive, sustainable change and coordinated involvement of all. #COVID19 taught us that we are all affected and an immediate societal response is required.” 

In an effort to increase awareness and preparation, 1,000 Days— a non-profit working to improve nutrition and ensure women and children have the healthiest first 1,000 days–compiled a list of five things we need to know about breastfeeding in emergencies in a 2018 blog post:

1. Breastfeeding is the safest, most nutritious and reliable food source for infants under the age of six months.

2. Breastfeeding decreases the risk of infection and disease, which is vital to survival in emergency settings.

3. Breastfeeding mothers need (even more!) support during emergencies.

4. When breastfeeding is not possible, immediate support is necessary to explore feeding options and protect the health of vulnerable infants.

5. Preparedness is key to ensure babies everywhere have the best opportunity to survive and thrive. 

Parents and care providers can consult Global Health Media’s video How to Express Breastmilk in situations where hand expression is warranted. 

More recently, USBC has compiled a comprehensive resource page for Infant and Young Child Feeding in Emergencies, including COVID-19.

USBC calls on us to take action by urging policymakers to take three actions to integrate infant and young child feeding into emergency preparedness and response efforts:

  • Expand the Federal Interagency Breastfeeding Task Force to include emergency and infectious disease experts
  • Direct the Federal Emergency Management Agency to ensure breast/chestfeeding people have appropriate services and supplies during a disaster or pandemic
  • Enact World Health Assembly Resolution 12.6 related to infant and young child feeding in emergencies

The CDC offers their guide to disaster planning here

CGBI’s Dr. Aunchalee Palmquist leads Lactation and Infant Feeding in Emergencies (L.I.F.E.) Amid the Pandemic Initiative, an active hub of research, policy advocacy, and technical support with recommendations relating to current emergency situations.

The World Alliance for Breastfeeding Action (WABA) has made available an interview between Dr. Felicity Savage and Dr. Amal Omer Salim which touches on proper breastfeeding support during normal and crisis situations. 

Dr. Savage points out that one of the biggest concerns about breastfeeding counseling during emergent situations is actually getting the counseling to parents. Specifically during the Covid-19 pandemic, Drs. Savage and Salim emphasize that separating mother and baby is not necessary to prevent the spread of the infection from mother to child, and make clear that care providers should follow WHO and UNICEF guidelines

#NBM20 

#IYCFE 

#ManyVoicesUnited

Spotlight on Fédora Bernard, Program Officer at The Right Livelihood Foundation

Fédora Bernard is currently Program Officer at The Right Livelihood Foundation, an organization established to “‘honour and support courageous people solving global problems’… now widely known as the ‘Alternative Nobel Prize’”. 

Bernard presenting in Rio.

Before transitioning into her work at The Right Livelihood, Bernard served as Geneva Association for Baby Food and International Liaison Office of the IBFAN Network (GIFA) Program Officer beginning in April 2019, having just newly graduated from the Institut des Hautes Etudes Internationales et du Développement with a Masters in International Affairs. 

This week, Our Milky Way is pleased to share a Q&A session with Bernard. 

Q: Please share a few highlights during your time with IBFAN. 

A: I am deeply passionate about human rights and GIFA was specialized in exactly that. I think that throughout my time at IBFAN, some highlights would probably be the sessions of the Committee on the Rights of the Child that I attended and advocated at, the World Health Assembly, the fifth session of the Open-ended intergovernmental working group on transnational corporations and other business enterprises with respect to human rights and of course, the World Breastfeeding Conference in Rio. They were all avenues where we could raise awareness and advocate for better national policies.

Q:  What would you consider your greatest triumph with IBFAN?

A: I am not sure I could speak of triumph, at the end of the day my time with IBFAN was quite short and all I did was trying to keep up with the amazing work that has been done by the Geneva office for the past 40 years. Nevertheless, I am very proud of the achievements with the Committee on the Rights of the Child, as during my time with IBFAN, “breastfeeding” was mentioned in almost all concluding observations.

Q: In November 2019, you had the opportunity to present IBFAN’s Green Feeding documents. What was that like? How was it received by participants at the World Breastfeeding Conference? 

A: It was an incredible experience, it was an honor to prepare this with Alison Linnecar, who wrote the document and to present it along with experts in the field. I don’t think that I can define myself as an expert, let alone a breastfeeding expert, but I am starting a career in advocacy. I therefore decided that I wanted to emphasize how the Green Feeding Documents could be used as an advocacy tool from an environmental perspective. Therefore, while Alison explained the science behind all of it, I focused on the link between breastfeeding and human rights, more in particular how it can be used in relation to the right to a safe, healthy environment. At the end of the presentation, I was so happy to see that most people in the audience wanted a copy of the green feeding documents…I thought that 30 copies would be enough, but clearly, I was wrong! I wish I had brought more.

Jose Angel Rodriguez-Reyes, expert of the Committee on the Rights of the Child pictured alongside Bernard.

Q: In your piece BREASTFEEDING: BEYOND “WHAT IS BEST FOR YOUR CHILD”, you mention the WHO/UNICEF Global Strategy on Infant and Young Child Feeding to Protect, Promote and Support Breastfeeding. We have the framework for better global health outcomes; What is holding us back? Is there one significant barrier standing in the way of a better world? 

A: I believe that from a political perspective, two things are holding us back: The first being the patriarchy and political systems dominated by men. As long as women will not be allowed to play a greater role in global health governance and domestic politics, public health issues such as breastfeeding or issues surrounding menstrual health will not be given the right amount of attention. 

The second element is political will, which is deeply related to the first. Breastfeeding is only seen as a public health issue in developing countries, and aggressive marketing from the formula industry has managed to convince women themselves that they are actually more empowered if they don’t breastfeed. Breastfeeding is thus seen as a weight imposed on them rather than a right that should be protected, promoted and supported by governments. In some societies, it is indeed currently a real hurdle for women to achieve their breastfeeding goals but instead of women in their breastfeeding journeys benefiting from policies, they are given a bottle. I am of the idea that improved breastfeeding policies are not only a matter of public health but also of women’s rights. 

Q: Any advice on how to navigate a climate where people dispute basic facts?

A: That is a very difficult question…Especially because those disputing basic facts are often deeply attached to their position and will give you alternative “facts”…I believe very much in trusted sources, and would always advise these people to check their sources and question them. For instance, if someone shows me an article from the industry containing “facts on breastfeeding” I would draw their attention on why this article could be biased and not based on adequate scientific evidence.

Q: Breastfeeding is a topic that spans across all disciplines. Will you please give us a glimpse into the work you’re doing at The Right Livelihood? 

A: The Right Livelihood Foundation honors and supports courageous people solving global problems, in all disciplines. IBFAN is actually one of them. With civil society space shrinking all over the world, human rights defenders are facing increasing difficulties, which is very true also for breastfeeding advocates. My work at the foundation therefore consists in using the advocacy skills that I developed with IBFAN, to support laureates all over the world.