Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM Clinical Assistant Professor Community and Family Medicine and Pediatrics Medical College of Wisconsin
www.drjen4kids.com
Breastfeeding Strategies for a Successful Practice Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM
Every one of us has a role in that journey
What color hat? Nearly all births in the United States occur in hospital settings, but hospital practices and policies in maternity settings can create barriers to supporting a mother’s decision to breastfeed.
What Women Want • Information about breastfeeding and what to expect • Practical help with positioning the baby to breastfeed • Effective advice and suggestions • Acknowledgement of their experiences and feelings • Reassurance and encouragement
Most Helpful • • • • • • •
Effective advice for specific concerns Encouragement to keep going Reassurance that what they are going through was normal Knowing the benefits of breastfeeding Encouragement to look after themselves, rest, eat and drink well “Permission” to give bottle-feeds if they wished Being able to ask questions about breastfeeding
Not So Helpful • Advice that did not fit with their preferences or experiences (timing and duration of feeds, positioning, etc) • Not enough time or help with feeding • Not feeling listened to • Pressure to breastfeed • Being made to feel guilty about bottle-feeding • Negative attitudes towards breastfeeding • Conflicting advice
Insights • Little information given in the antenatal period • Collective loss of knowledge and experience of breastfeeding exists • Need for community or network of support • Give it to them straight • Your experiences may interfere with your professional advice
Step 3.
Inform all pregnant women about the benefits of breastfeeding.
Practitioner encouragement significantly increases breastfeeding initiation among women of all social and ethnic backgrounds.
Percentage
Breastfeeding initiation rates p<0.001 80% 70% 60% 50% 40% 30% 20% 10% 0%
74.6%
43.2%
Encouraged to breastfeed
Not encouraged to breastfeed
Adapted from: Lu M, Lange L, Slusser W et al. Provider encouragement of breast-feeding: Evidence from a national survey. Obstetrics and Gynecology, 2001, 97:290-295.
What we can do • Delaying procedures such as weighing, measuring, and administering vitamin K and eye prophylaxis (up to an hour) helps early interaction • Infants are to be put to the breast as soon after birth as feasible for both mother and infant (within an hour of birth) • This is to be initiated in either the delivery room or recovery room, and every mother is to be instructed in proper breastfeeding technique.
Rooming in as Standard Mother-baby rooming-in on a 24-hour basis enhances opportunities for bonding, for optimal breastfeeding initiation, and for protection from infection. To avoid unnecessary separation, infant assessments in the immediate postpartum time period and thereafter are ideally performed in the mother’s room. Evidence suggests that mothers get the same amount and quality of sleep whether infants room-in or are sent back to the nursery at night.
The rider and the elephant metaphor for changing behavior. From â&#x20AC;&#x153;Switchâ&#x20AC;? by Dan and Chip Heath.
Physician knowledge and attitudes about breastfeeding
I'm trying to think of a positive experience regarding breastfeeding with my twins' pediatrician, but all I'm coming up with is neutral ones. She never discouraged breastfeeding (even when they were older nurslings!) or raised an eyebrow, but she also wasn't really a cheerleader. And based on that I recommended her to other nursing moms... because finding a doc who didn't tell you stupid, untrue things about human lactation is a good find!
MD Breastfeeding Education â&#x20AC;˘ 25% of 1147 pediatricians in 1 national survey did not consider exclusive breastfeeding the best form of infant nutrition (1995)
The Pediatric Resident Hours of Breastfeeding Training
0
Number of Lactating Breasts seen
0
Number of pumps operated
0
Personal Physician Experiences • May not feel comfortable asking for help • Do not attend pre-natal breastfeeding classes • Reluctance to admit they what they do not know
Physician Personal Experiences "Even mothers who are medical professionals experience, and often cannot overcome, difficulties with breastfeeding. Women in medicine need enhanced breastfeeding support and services/resources. Advocacy is needed, in our work environments, for better breastfeeding support not only for our physician colleagues, but also for all lactating employees within our institutions."
Candy Riggins, Marc B. Rosenman, and Kinga A. Szucs. Breastfeeding Medicine. June 2012, 7(3): 151-154
Physician Personal Experiences • Dr. MILK • Mothers Interested in Lactation Knowledge • Monthly meetings • Web presence • Facebook page
Laurie B. Jones and Emily A. Mallin. Breastfeeding Medicine. June 2013, 8(3): 330-332.
Do you need to be an expert? When my first was born he wasn't transferring milk well. It was terrifying and I had no idea what I was doing. Our pediatrician gave him formula right there in the office, which made me feel like a colossal failure. But then she said, "Lots of moms get off to a rough start. You can still breastfeed!" and she gave me the number of an IBCLC who gave us great advice and had us off any supplementation within a week. I went on to breastfeed that baby until he was 3.5 years old. Just hearing the pediatrician tell me I could do it was a HUGE encouragement to me and made all the difference. I didn't realize at the time that so many pediatricians don't ever bother to address breastfeeding issues; they just tell moms to supplement and don't bother with rest. I'm so grateful mine told me where to get help and encouraged me that I could do it.
And potential roadblocks
How physicians learn
Strategies for Learning • Doctors learn by immersion in practice (so called situated learning) • Reading • Talking to colleagues and discussions in multidisciplinary teams (zero credits) • Educational events (not very important) • Guidelines, protocols
Hawkes, BMJ
Simulation • Improvements in medical knowledge • Comfort in procedures • Improvements in performance • Only a few studies have shown direct improvements in clinical outcomes from the use of simulation for training.
Typically, • Prototype in mind of physician based on experience and familiarity • Familiarity breeds conclusions • Sometimes it breeds a contempt for alternatives • Physicians, unfamiliar with something, may lack the courage of convictions, unsure of how hard to push
“How Doctors Think” Jerome E. Groopman 2008
Solution-Focused • Miracle Question Suppose you go to bed tonight and sleep well. Sometime, in the middle of the night, a miracle happens and all the troubles that brought you here are resolved. When you wake up in the morning, what’s the first small sign you’d see that would make you think, “Well, something must have happened- the problem is gone!”
Breastfeeding Friendly Office Practice 0 Bfmed.org, protocol #14 0 AAP policy
0 Pediatricians also should serve as breastfeeding advocates and educators and not solely delegate this role to staff or nonmedical/lay volunteers. 0 Communicating with families that breastfeeding is a medical priority that is enthusiastically recommended by their personal pediatrician will build support for mothers in the early weeks postpartum.
Elements of a Breastfeeding-Friendly Environment 0 0 0 0 0 0
Motherâ&#x20AC;&#x2122;s Room and Waiting Room Discourage formula marketing Track breastfeeding rates in the practice Use the right growth curves Get educated and know where to refer Give encouragement and assume that all women are still breastfeeding at each visit.
Corriveau, S. K., Drake, E. E., Kellams, A. L., & Rovnyak, V. G. (2013). Evaluation of an Office Protocol to Increase Exclusivity of Breastfeeding. Pediatrics. 2012-1310
Resources for education
Physician Education
Completion of the Wellstart Modules can be used to satisfy the requirement of 3 or more hours of training for their physicians by hospitals preparing for a Baby-Friendly assessment. Plus, theyâ&#x20AC;&#x2122;re free.
www.wellstart.org
www.bfconsortium.org
AAP Resources, Available at AAP.org
New Edition!
www.aap.org/breastfeeding/curriculum/
The curriculum was supported by a grant from the Health Resources and Services Administrationâ&#x20AC;&#x2122;s Maternal and Child Health Bureau.