The American Academy of Family Physicians (AAFP) has long supported breastfeeding. All family physicians, whether or not they provide maternity care, have a unique role in the promotion of breastfeeding. Family physicians understand the advantages of family-centered care and are well positioned to provide breastfeeding support in that context. Because they provide comprehensive care to the whole family, family physicians have an opportunity to provide breastfeeding education and support throughout the life cycle to all members of the family.
Family physicians may provide prenatal care and labor support, deliver the infant, help in the prompt initiation and continuation of breastfeeding, and continue caring for the baby and family. Breastfeeding education and support can be woven throughout these visits. Family physicians have the unique opportunity to emphasize breastfeeding education beginning with preconception visits and continuing throughout prenatal care, delivery, postpartum care, and during ongoing care of the family. Encouragement from a physician and other family members, especially the baby’s father and maternal grandmother, are important factors in the initiation of breastfeeding.65,70,77,83 In caring for a mother’s immediate and extended family, a family physician should encourage her social support system to support breastfeeding.58
Throughout most of history, breastfeeding was the norm, with only a small number of infants not breastfed for a variety of reasons. In the distant past, wealthy women had access to wet nurses, but with the industrial revolution this practice declined as wet nurses found higher-paying jobs. By the late 19th century, infant mortality from unsafe artificial feeding became an acknowledged public health problem. Public health nurses addressed this by promoting breastfeeding and home pasteurization of cows’ milk. After the turn of the century, commercial formula companies found a market for artificial baby milks as safer alternatives to cows’ milk. During this same period, infant feeding recommendations became the purview of the newly organized medical profession. Partially due to the support of physicians and a vision of “scientific” infant care, the widespread use of formula as a breastmilk substitute for healthy mothers and babies emerged in the first half of the 20th century.2,37
Throughout the middle part of the 20th century, most physicians did not advocate breastfeeding, and most women did not choose to breastfeed. Therefore, an entire generation of women-and physicians-grew up not viewing breastfeeding as the normal way to feed babies. Despite the resurgence of breastfeeding in the late 20th century in the United States, breastfeeding and formula feeding continued to be seen as virtually equivalent, representing merely a lifestyle choice parents may make without significant health sequelae.
Current attitudes concerning infant nutrition have been molded by the manufacturers of human milk substitutes who have aggressively created markets for their products. They have advertised to physicians and directly to the public in ways that are inconsistent with the International Code of Marketing for Human Milk Substitutes (see Appendix 3).115 While much of the literature about breastfeeding distributed by formula companies is factual, omissions and images can mislead mothers, reinforce misconceptions about breastfeeding, and suggest that breastfeeding mothers also need to use formula. Physicians have been used to convey this advertising and encourage brand loyalty through “free” literature and formula samples.48 Use of commercial literature and samples has been demonstrated to decrease breastfeeding rates and increase premature weaning.112
Currently, the World Health Organization (WHO) recommends that a child breastfeed for at least two years.116 The American Academy of Pediatrics, like the AAFP, recommends that all babies, with rare exceptions, be exclusively breastfed for about six months.5 The United States Public Health Service’s “Healthy People 2010” set national goals of 75% of babies breastfeeding at birth, 50% at six months, and 25% at one year.104
The United States has not yet met its breastfeeding goals. Data from1995, the most current year for which published data is available, showed that 60% of U.S. mothers initiate breastfeeding, and 22% are still doing some breastfeeding at six months. While some subpopulations come close to Healthy People 2010 initiation goals, many do not, and few mothers breastfeed exclusively.94 Unfortunately, breastfeeding rates quoted for the United States reflect data that does not distinguish between exclusive breastfeeding, breastfeeding with supplementation, and minimal breastfeeding. We have little national data on exclusive breastfeeding or breastfeeding beyond six months of age.38
Despite growing evidence of the health risks of not breastfeeding, physicians, including family physicians, do not receive adequate training about supporting breastfeeding.31,32 Although physicians make health recommendations about many aspects of infant care, many physicians still worry that advocating breastfeeding will cause parental guilt. In fact, parents may feel less guilt if they have had an opportunity to learn all the pertinent information and make a fully informed decision.61
Family physicians can make a difference in increasing breastfeeding initiation rates, and especially breastfeeding continuation rates, by advocating breastfeeding, supporting breastfeeding patients and providing appropriate, evidence-based care for breastfeeding couplets.
Family physicians also need to be familiar with the evidence supporting the recommendation to breastfeed. Evidence about breastfeeding’s health effects is growing exponentially, and it is beyond the scope of this paper to specifically review all of the literature. Several excellent review articles outline the evidence supporting the role of breastfeeding in optimal health outcomes for mothers and children.5,62,72 Because breastfeeding is the physiologic norm, we will refer to the risks of not breastfeeding for infants, children, and mothers.
Evidence shows that breastfeeding has profound effects on the developing immune system. Babies not fed human milk have higher rates of otitis media, allergies, respiratory tract infection, necrotizing enterocolitis, urinary tract infection, and gastroenteritis in infancy. Babies who are not breastfed have a higher risk of hospitalization in the first year of life due to serious bacterial illness. They have higher rates of type 1 and type 2 diabetes, allergic disease and asthma, lymphomas, and inflammatory bowel disease later in life. They develop lower antibody titers in response to immunization.61,97,100 Studies of intelligence and development have also shown lower IQ and lower developmental scores among children who were not breastfed. 46,68
The strongest evidence indicates that these positive effects of breastfeeding are most significant with six months of exclusive breastfeeding. Most of the studies, however, show that the effects are dose-related, with improved outcomes being associated with more longer breastfeeding . Similarly, the risks increase as the period of exclusive breastfeeding decreases, with the highest risk in babies who received fed no human milk.5,97
Maternal health outcomes are also affected by breastfeeding. Mothers who do not breastfeed risk higher rates of anemia and closer child spacing. Women who have a significant lifetime history of breastfeeding have lower rates of ovarian, endometrial, and breast cancer compared with the general population. Lactation affects calcium metabolism, with increased bone density after weaning, and may decrease a woman’s risk of postmenopausal osteoporosis.59
The evidence overwhelmingly supports the recommendation for breastfeeding for almost all mothers and babies. Increasingly, evidence-based practices that enhance the likelihood of successful breastfeeding have been described. Appendix 1 summarizes some of the appropriate practices. Appendix 2 lists references that may be helpful for family physicians as they support breastfeeding. The remaining portions of this paper discuss special breastfeeding issues and unique concerns of certain populations.
Special Breastfeeding Issues
Medication and Substances
Almost all prescription and over-the-counter medications taken by the mother are safe during breastfeeding. Several resources are available to help estimate the degree of drug exposure an infant will receive through breastmilk.7,47,52 Physicians must weigh the risks of replacing breastfeeding with artificial feeding against the risk of medication exposure through breastmilk. Even a temporary interruption in breastfeeding carries the risk of premature weaning, with the subsequent risks of long-term artificial feeding. Generally it is recommended that breastfeeding should be interrupted if the mother ingests drugs of abuse, anticancer drugs, and radioactive compounds.52,101 Among antidepressants, cardiovascular medications, immunosuppressants, and many other classes of medications, certain medications are preferred over others for lactating women. In a particular class of medications it is best to choose a medicine that has the least passage into breastmilk, has fewer active metabolites, and/or is used locally rather than systemically.4,47,52
Some medications and substances, such as bromocriptine, nicotine,108 moderate or large amounts of alcohol,22 and estrogen-containing oral contraceptives, are known to decrease milk supply. Infants should not be exposed to cigarette smoke. Children of mothers who smoke cigarettes have elevated cotinine levels in their urine compared with children of nonsmoking women. Nursing women who smoke pass a significant amount of cotinine through the breastmilk to the baby, such that the baby’s cotinine levels are higher than those of babies exposed to passive cigarette smoke only.11,71 Women who breastfeed are advised not to smoke, but if they cannot quit, it is probably still more valuable to breastfeed, although they should be advised to not smoke in the infant’s environment, to smoke as little as possible, and to smoke immediately after nursing (rather than before) in order to minimize the nicotine levels in their milk. Alcohol passes easily into breastmilk. While it is safest for nursing mothers to consume no alcohol, there is no documented risk from small amounts of alcohol. Mothers may be assured that having an occasional alcoholic drink need not preclude breastfeeding.7
Occupational Exposure and Pollutants
Women without specific occupational or other known poisonous exposures to pollutants may nevertheless be found to have a variety of polluting chemicals in their bodies.92 Some of these chemicals may be transferred to fetuses in utero, and possibly to infants postnatally through breastmilk. However, the risk of cancers and less-than-optimal neurologic development remains higher in formula-fed babies compared with breastfed babies in similar environments.30 Women with average environmental exposure do not need to worry about having their breastmilk screened for pollutants. For women with known poisonous exposures, testing of breastmilk may be necessary. Because noncommercial fish and wildlife ingestion can be a very significant environmental source of pollutants, health professionals should remind pregnant and nursing women to follow the fish and wildlife consumption guidelines provided by their state, U.S. territory, or Native American tribe (www.epa.gov/ost/fish).27
For most maternal infections breastfeeding helps to protect the infant against the disease or decreases the severity of the illness, because of anti-infective components of breastmilk. Only a few maternal infections preclude breastfeeding:
Women with chronic noninfectious illnesses may be empowered by their ability to breastfeed. For most illnesses, medication issues need not prevent breastfeeding, as reasonable medication choices can almost always be made. Exceptions include treatment of breast or other cancers, which necessitates use of antimetabolites.62 Women with severe trauma or acute life-threatening illness may be too ill to nurse or express milk. Should maternal illness require separation, women should be assisted to maintain lactation.
Some women who have had breast augmentation may not be able to produce sufficient amounts of breastmilk. Some of these women may have had insufficient breast tissue before surgery.79,80 Breast reduction surgery also increases the risk that a woman will not be able to produce sufficient breastmilk.19,40 Breast biopsy with circumareolar incision can interfere with milk supply and transfer in that breast.19 These women should be encouraged to breastfeed, but mother and baby need to be followed closely to ensure that the infant has an adequate milk intake. Women who develop a suspicious breast mass during lactation should not wean for the purpose of mass evaluation. Mammograms and breast mass biopsy can be done without interfering with lactation.13 Family physicians should assist their patients with decisions about breast surgery. They should communicate with the surgeon to advocate for their patient’s future breastfeeding needs and breastfeeding conservation surgeries whenever medically feasible.
Infants with chronic diseases benefit from breastfeeding and/or breastmilk. However, infants with galactosemia are unable to breastfeed and must be on a lactose-free diet. Infants with phenylketonuria should breastfeed, but they must receive supplementation with a low-phenylalanine formula.62 Breastfed infants with phenylketonuria have better developmental outcomes compared with those exclusively fed low-phenylalanine formulas.91
Nursing Beyond Infancy
Breastfeeding should ideally continue beyond infancy, but this is currently not the cultural norm and requires ongoing support and encouragement.85 Breastfeeding during a subsequent pregnancy is not unusual. If the pregnancy is normal and the mother is healthy, breastfeeding during pregnancy is the woman’s personal decision. If the child is younger than two years of age, the child is at increased risk of illness if weaned. Breastfeeding the nursing child after delivery of the next child (tandem nursing) may help to provide a smooth transition psychologically for the older child.61
Employment and Breastfeeding
In the past 30 years, significant demographic shifts have affected child care and, more specifically, lactation. Coincident with a reduction in family size has been a progressively earlier return of mothers to the workforce, as well as an increased percentage of families headed by women and families in which both parents are employed. These demographic changes have made breastfeeding more difficult to implement. In fact, the most significant obstacle to breastfeeding duration is the mother’s need to return to work.28,63 The day-care industry has concurrently grown, fueled by the early return of new parents to the workplace. Regardless of the quality of the day-care facility, studies have documented an increased rate of transmission of infectious diseases in these settings.54
Employers can benefit when they promote a positive attitude towards lactation.18 Many new mothers bring skills and experience to the workplace, and an encouraging atmosphere will promote retention of these valued employees. Women who feel their employers are positive towards their desire to continue breastfeeding are often less torn between their child and loyalty to an employer; such positive attitudes generally result in greater employee productivity. Additionally, breastfeeding mothers lose less time from the workplace because breastfed babies tend to stay healthier than their formula-fed counterparts.23 Employers may choose to capitalize on their pro-lactation policies. Such policies may generate customer approval and favorable publicity in the community.
The logistics involved in promoting ongoing lactation vary from employer to employer. Large employers with on-site day-care may simply choose to allow breaks to be taken in the day-care center where the mother may breastfeed. All employers should be encouraged to have a written policy about the promotion and protection of breastfeeding in the workplace. Ideally, employers should provide a dedicated space for women to nurse or express breastmilk (see Table 1). Some employers may choose to offer their employees the option of working part-time or telecommuting the first four to six months when lactation is most time-intensive. A positive approach by employers goes a long way towards assuaging concerns on the part of other employees. In time, federal and state tax benefits could be offered to companies that implement affirmative lactation policies for their employees.
Family physicians may encourage employers to provide the option of either a postpartum leave of at least four months’ duration; or part-time employment, telecommuting, or any other available option that could permit the breastfeeding mother to spend more time with her baby. Medical students, family practice residents, and practicing family physicians should be afforded the opportunity to establish and maintain lactation.
A Breastfeeding-Friendly WorkplaceWorkplaces should provide the following:1. A private room, or section thereof, for either expressing milk or nursing a baby2. A comfortable chair 3. Electrical outlet and small table for breast pump4. Access to a sink to wash hands and equipment5. Small, secure refrigerator for milk storage6. Protected breaks every 3 hours for pumping (may be in place of other breaks) 7. Nonharassment policy for breastfeeding mothers
Military mothers share many issues in common with other employed mothers, but they also face some unique challenges. Although the Pentagon has established lactation rooms and other support, there are no consistent Department of Defense Policies about breastfeeding, which can vary significantly among individual commands.
All three services provide 6 weeks of maternity convalescent leave; the active-duty service member can request additional leave, which is granted at the discretion of the supervisor. However, active-duty members also face prolonged assignments and deployments. For some Navy mothers, in particular, deployment can mean 6 months away from home on a ship beginning as early as 6 weeks’ postpartum. Some field-duty sites have limited potable water supplies, electricity, and/or restroom facilities. Military mothers also face conflicting and negative attitudes about being a warrior and a mother from supervisors, co-workers, and families. The Department of Defense and the individual services are assessing current policies and considering necessary modifications to help support the active-duty breastfeeding mother.
Family physicians working with military populations should be especially aware of the unique challenges these families face. Family physicians should work to develop appropriate policies supporting breastfeeding by active duty service members and by mothers who are military dependents.
Breastfeeding the Preterm Infant
The period following the birth of a premature infant can be overwhelming for families. The advice and support of a trusted family physician can be invaluable to parents confronted with unforeseen decisions and numerous uncertainties. Some relatively mature preterm infants may be able to breastfeed right away. Family physicians can provide immediate guidance on maintaining lactation when mother-infant separation is required.
Mothers of preterm infants should be presented with information about the effects of breastmilk and breastfeeding on the premature infant. Women who are hesitant to make a long-term commitment to breastfeeding can be encouraged to nurse or express colostrum for the first week or to nurse or express breastmilk for her infant until it can be discharged from the hospital. The mother of a preterm infant faces almost all of the barriers encountered by other mothers plus those of potentially prolonged breast-pumping, limited infant contact, medical equipment and monitoring devices attached to her infant, and emotional stress. When family physicians work as part of a team of neonatologists, nurses, social workers, dietitians, and lactation consultants, they can be effective in supporting the successful initiation and continuation of breastfeeding after the birth of the preterm infant.
Preterm breastmilk differs from term breastmilk and provides both short- and long-term health advantages for preterm infants. Preterm infants who receive breastmilk have greatly reduced rates of sepsis and necrotizing enterocolitis compared with infants who receive milk substitutes.26,67 Studies of preterm infants have also demonstrated reduced rates of atopic disease in infants with a family history of atopy.66 A recent meta-analysis concluded that breastfeeding is associated with long-term cognitive advantages and that preterm infants derive more benefit than full-term infants.6 Breastmilk has also been associated with enhanced retinal development and visual acuity in preterm infants.15 However, breastmilk may need to be supplemented with a fortifier for smaller or more fragile preterm infants.98,99
Studies have shown that preterm infants show greater cardiac and respiratory stability when breastfeeding rather than bottle-feeding.16,98 Therefore, initiating breastfeeding in preterm infants does not require demonstrated ability to bottle-feed. In addition to promoting physiologic stability in premature infants, skin-to-skin contact or “kangaroo care”36,113 increases maternal milk supply and may trigger the enteromammary immune system by which a mother produces antibodies in response to antigens in the infant’s environment.
There are several excellent resources on breastfeeding management for physicians caring for breastfeeding preterm infants and their families, including chapters in texts by Lawrence & Lawrence , and Riordan & Auerbach.61,90
Teens and Breastfeeding
While teenage mothers share issues with their adult peers, they also face many unique pressures. The family physician is well positioned to assist the pregnant and breastfeeding teen and her family. All adolescent mothers should be encouraged to breastfeed.3
Many adults in our society may have a negative attitude toward the pregnant teen. It is essential for her family physician to be aware of these negative attitudes, including his or her own feelings about pregnant teens. The family physician can help the pregnant teen deal with these issues and empower her to breastfeed.8 Enlisting the teen’s support system is important; including the baby’s father, peers, and friends may make the difference. Peer counseling by other breastfeeding teens can be very powerful. Teens are usually interested in learning about the practical issues of breastfeeding and learn quickly. However, they may often have an incorrect understanding, and dispelling myths is key.
Pregnant and breastfeeding teens often have significant concerns regarding body image. These concerns can be addressed by providing positive images of discreet breastfeeding and educating them about changes that will occur during pregnancy and breastfeeding. Often teens are disinclined to bring up such concerns, but if asked they are willing to discuss body image concerns, as well as issues such as sexuality and contraception. Because teens worry about their changing bodies, it is important to proactively share information about proper nutrition, diet, exercise, and weight loss with the teenage mother and those in her support system.41
Milk production in teens has been evaluated because of concerns about a possible decreased milk supply in adolescent mothers.64 Teens may make less milk as a result of having less breast tissue.76 Teenage mothers often feed their infants less frequently and supplement with solids earlier.50 However, most teenage mothers with proper support have ample milk supplies.
Continued support of the adolescent mother will help her maintain breastfeeding. Anticipatory guidance about her baby’s growth and development, as well as ongoing parenting education, will help the teen mother and her family maintain breastfeeding as part of her lifestyle.
Family physicians often care for adoptive parents. The physician should offer the adoptive mother the opportunity to breastfeed her child. A knowledgeable physician or lactation consultant may help the mother to develop a milk supply either before or after an adoption.20
While the adoptive mother often does not develop a full breastmilk supply, with induced lactation techniques it is often possible to provide a significant amount of breastmilk. Suckling at the breast has developmental advantages for babies. In many cases, the opportunity to emotionally bond during nursing is the primary benefit of breastfeeding for adoptive mothers and babies.107
Mothers of twins and higher order multiples should be encouraged to breastfeed. These mothers will need additional support for breastfeeding. Most mothers can fully breastfeed twins,42 however mothers of higher order multiples are more likely to need to supplement their breastmilk. Support groups can be especially helpful for mothers of multiples.61,90
Breastfeeding in Diverse Populations
Breastfeeding is important for all infants, but children exposed to overcrowding or to poverty are especially vulnerable to the risks of not being optimally breastfed. Yet racial, ethnic, and socioeconomic disparities in breastfeeding rates persist despite overall increases.44,110 Incidence and duration data, however, do not truly measure breastfeeding rates among various ethnic and cultural groups. Statistics gathered under the simplistic groupings of “African-American,” “Hispanic,” etc., inadequately represent the many cultures and ethnicities included in each category.
Reasons for the relatively low rates in several ethnic and socioeconomic subgroups are both cultural and economic.118 Women of lower socioeconomic status may have less education and are often employed in positions where work hours, transportation, and other constraints interfere with the maintenance of a regular schedule of breastfeeding and/or pumping. Provision of formula through WIC may make bottle-feeding an attractive alternative, despite concordant attempts to encourage breastfeeding. Family responsibilities, the cost of nursing paraphernalia, lack of a private space to nurse, and issues of partner acceptance pose additional obstacles to lactation.10,33,75 In addition, these mothers often lack personal role models as well as access to breastfeeding information and to lactation specialists. Certain populations are potentially more vulnerable to the effects of aggressive infant formula marketing practices.25
Ethnic subgroups within our society also face significant obstacles to lactation even when economics is not a factor. First-generation immigrants from countries where breastfeeding is the norm are more likely to breastfeed than are second- and later-generation women. This may be due to convenience, belief in modern food technology, and attempts to acculturate into a society where bottle-feeding is perceived to be the norm.90 Thus, breastfeeding role models are lost with successive generations. Additionally, accurate breastfeeding information is less available in languages of smaller ethnic minorities. Few lactation consultants or other health care personnel are equipped to help women who speak languages other than English or Spanish. Some ethnic and cultural groups are under-represented in the lactation consultant field. Many cultures also have unique beliefs about lactation, including rituals regarding milk production, concerns about colostrum, sexual taboos, and beliefs about wet-nursing.90 These beliefs need to be taken into account when counseling about the lactation process.
Family physicians can promote lactation among their patients of various ethnicities and socioeconomic levels in a number of ways. These include the following:
Education of Medical Students, Residents, and Family Physicians
In the preclinical years, courses in anatomy, physiology, and biochemistry, among others, should include aspects pertinent to lactation. These include anatomy of a lactating breast and how this relates to baby’s latch-on, physiology of milk production and the milk ejection reflex, biochemistry of human milk and the vast differences in artificial substitutes. Some topics could be covered as “clinical correlation” lectures. Aspects of lactation relevant to particular disciplines could be integrated into the existing curriculum. For example, the basics of the passage of medications into human milk could be incorporated into the pharmacology course. In the introductory clinical course, students should be taught the importance of a patient’s own infant feeding history as a possible risk factor for disease, how to take a breastfeeding history when appropriate, and how to examine lactating breasts (Table 2).
In the clinical years, patient care experience in family medicine, obstetrics, and pediatrics should include instruction in normal breastfeeding, including risks to mother and baby if alternate choices are made (“informed consent” for formula use).74 Topics to be included are preparation to breastfeed during pregnancy, anticipatory guidance for the mother during the first week of lactation, normal growth of breastfed infants, and anticipatory guidance for other issues that arise regarding breastfeeding of older infants and toddlers. Management of other special considerations in breastfeeding couplets, such as breastmilk and breastfeeding jaundice, infectious disease and lactation, contraindications to breastfeeding, medications in the breastfeeding mother, nutritional support, lactation and fertility, and the allergic family should be addressed. Other issues that should be incorporated in the curriculum include assisting mothers with breastfeeding an ill or special-needs infant, reestablishing lactation, inducing lactation for an adoptive family, advocacy for employed mothers, and psychosocial support for the breastfeeding family (Table 3).
Venues for instruction include lectures, clinics, wards, special lactation clinics, and mentoring by instructors with expertise in breastfeeding medicine. Modes of instruction should include case presentations, problem-based learning modules, direct patient care, patient education opportunities, didactics, and computerized learning modules. Family medicine interest groups could present workshops about breastfeeding to complement the medical school curriculum.
In view of the lack of adequate medical education regarding breastfeeding and human lactation31 until recently, it is crucial to provide appropriate faculty development opportunities in order to provide medical students with faculty knowledgeable in evidenced-based breastfeeding management.
Family Medicine Residency
Family medicine residency curriculum should reinforce the concept that breastfeeding is the physiologic norm for mothers and children. Risks to the child of not being breastfed should be addressed, including nutritional differences between human milk and substitutes,61 and short-term and life-long health,74 developmental,15,46,60,68,111 and social risks.1 Risks to mother of not breastfeeding, including health,14,21,24,39,57,81,93 financial, and social ones,1,54,105 should be covered. Risks to the family of not breastfeeding should also be addressed, such as financial aspects, stress of having an ill child, and long-term loss from a child with suboptimal development. The special role of the father and/or the mother’s partner, relatives, and friends in supporting breastfeeding should be addressed. Additionally, risks to society as a whole should be taught, including increasing health care costs9,73,103 and ecological considerations.30,87
All aspects of normal breastfeeding (Table 3) and management of common problems (Table 4) should be covered and integrated longitudinally in the three-year residency curriculum. Individual topics may be addressed as appropriate in the following areas:
Specific elective experiences in breastfeeding medicine should be made available for residents who want more intensive education. Residency practices should model support of their breastfeeding patients. Specific support should also be provided for medical students and residents (and other staff members) who are themselves breastfeeding.
Continuing Medical Education for Practicing Family Physicians
With breastfeeding rates rising steadily, it is incumbent upon practicing family physicians to seek continuing medical education (CME) opportunities regarding evidence-based practice for breastfeeding support and management of problems that may occur. Many conferences and seminars on breastfeeding for health professionals offer CME hours for physicians as well. The AAFP is a cooperating organization for the La Leche League International Annual Seminar for Physicians on Breastfeeding, and includes workshops on breastfeeding at many of its national conferences (Appendix 2).
Suggested Topics for Preclinical Years
Physiology of the breast during lactation
Composition of breastmilk
Latch and suckling dynamics
Teaching the mother-infant couple to breastfeed
Mechanisms of jaundice in the breastfeeding baby
Psychosocial aspects of breastfeeding
Suggested Topics for Clinical Years: Normal BreastfeedingEffects of labor and delivery interventions on initiation of breastfeedingFacilitating and assisting mother with the first feeding in the delivery roomNeonatal breastfeeding assessmentSupporting mothers returning to school/employmento Pumps and pumpingo Advocacy
Suggested Topics for Residency CurriculumNormal Breastfeeding topics (as in Table 2) plus the following:Management of common lactation problems Maternal Inadequate weight gain Sore nipples Tongue-tie Plugged ducts Frenotomy Mastitis Special situations Candidal infections of breast Prematurity Inadequate milk supply Congenital anomalies that may affect breastfeeding Infant Down syndrome Latch and suck problems Congenital heart defects Supplementary feeds Cleft lip/palate Jaundice
Family Physicians and Breastfeeding Advocacy
Family physicians have had a long history of advocating for patients in various aspects of their health care. To reach the AAFP’s breastfeeding goals, we will need to be advocates with and for our breastfeeding patients. Until breastfeeding is seen as the norm, family physicians will need to be involved in shaping policies that affect breastfeeding. Family physicians can become advocates for breastfeeding in several areas, including in physician offices, hospitals, birthing centers, and workplaces, and with insurance companies. Family physicians can help shape public health policies and encourage research. While an individual family physician is not likely to be involved in all areas of advocacy for breastfeeding, family physicians working together as a group can become effective advocates with our breastfeeding patients.
Studies have shown that the physician’s recommendation to breastfeed increases breastfeeding initiation and duration rates.12,35,65 Eliminating formula company literature, advertising, and distribution of samples encourages breastfeeding as normal infant feeding.112 We need to be sure that our office policies support our breastfeeding patients and employees. There are some simple steps that all physicians can take in order to advocate breastfeeding in our offices (see Appendix 1).17,56,69,74,77
When advocating for breastfeeding issues related to insurance coverage and workplace changes, the economic benefits of breastfeeding are essential issues. Several studies have shown substantial increase in cost to families, communities, health care systems, and employers when babies are not breastfed.9,73,89,103 Physicians must be aware of this data in order to be effective advocates in promoting change in policies regarding breastfeeding.
Family physicians have assumed many administrative roles in hospitals, managed care plans, insurance companies, and large physician organizations. In these roles, family physicians are in a position to promote breastfeeding and ensure appropriate reimbursement for lactation services provided by physicians or lactation consultants. Family physicians should advocate for improved access to lactation services by encouraging increased availability of lactation consultants.
Family physicians should support and advocate for public health policies that would increase breastfeeding rates. They should actively promote legislation that would encourage the ease, safety, and security of breastfeeding. Family physicians should advocate for and become involved with breastfeeding-related research aimed at increasing the evidence base and increasing breastfeeding rates.
Family physicians are active and influential in their communities. By projecting a positive attitude toward breastfeeding in the office and the community, they can strongly affect patients’ decision to breastfeed. Family physicians provide a wealth of patient education in their offices. As a part of their health education and promotion activities in schools, family physicians should incorporate breastfeeding into their education for both boys and girls. Making breastfeeding education available to all family and community members will make breastfeeding the community norm.
Appendix 1: Recommendations for Breastfeeding Promotion and Management
AAFP Policy Statement on Breastfeeding
Breastfeeding is the physiological norm for both mothers and their children. The AAFP recommends that all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for about the first six months of life. Breastfeeding should continue with the addition of complementary foods throughout the second half of the first year. Breastfeeding beyond the first year offers considerable benefits to both mother and child, and should continue as long as mutually desired. Family physicians should have the knowledge to promote, protect, and support breastfeeding.
General Recommendations For All Family Physicians
1. Breastfeeding promotion and education need to occur throughout the life cycle.
a. Provide accurate and appropriate breastfeeding information at all preventive health visits throughout the lifespan.
b. Provide accurate information about infant feeding during preconception and all prenatal visits.
2. Family physicians, whether or not they provide maternity care, should establish a breastfeeding-friendly office.17,20
a. Avoid the direct or implied endorsement of artificial baby milks (formula) by eliminating the distribution of samples and formula-company sponsored materials.11,12
b. Display culturally appropriate breastfeeding pictures and posters.
c. Ensure that all office staff are knowledgeable about and supportive of breastfeeding.
d. Have current breastfeeding resources available in the office.
3. Family physicians should actively promote breastfeeding in the community.
a. Promote practices consistent with the “Ten Steps to a Baby-Friendly Hospital” (see Appendix 3).23
b. Provide educational programs in the community about the importance and practical aspects of breastfeeding.
c. Advocate for mother-friendly policies in the workplace.
d. Support legislation and public policy that protects breastfeeding.
Specific Clinical Recommendations24
1. Preconceptual and Prenatal Education
a. Address the infant feeding decision before conception or as early in pregnancy as possible; women make their decision about breastfeeding very early. Continue to bring up the issue of infant feeding throughout the prenatal period.17,20
b. Determine the mother’s intent and any concerns or misconceptions she may have. Provide appropriate education and anticipatory guidance to encourage her to consider breastfeeding and determine what support she will need to make and carry out this decision.15
c. Elicit any factors in the family medical history that may make breastfeeding especially important (e.g., atopic diseases, diabetes, obesity, cancers), and advise the woman of these factors.3,6,7,19,24,26
d. Elicit any risk factors for potential breastfeeding problems and any potential medical contraindications to lactation. Provide appropriate support and eduation.14,17
e. Encourage the participation of the mother’s support persons and educate them as appropriate.2,8
f. Recognize the feelings of relatives who did not breastfeed, or weaned prematurely. Encourage them to learn what is currently known about breastfeeding for the optimal health of the mother and baby.
g. Encourage the woman and her support persons, in a culturally sensitive manner, to attend breastfeeding classes and/or support group meetings prenatally.13
h. Provide the woman with accurate, noncommercial breastfeeding literature and recommendations for accurate lay breastfeeding resources (e.g., books, Web sites, etc.).
i. Educate women about the potential breastfeeding problems associated with the use of intrapartum analgesia and anesthesia. Encourage the use of a labor support person (doula).9,29
2. Intrapartum support
a. Provide appropriate labor support intended to minimize unnecessary analgesics or anesthesia.9,29
b. If mother and baby are stable, facilitate immediate postpartum breastfeeding. Minimize separation of mother and infant and wait until after the first breastfeeding to perform routine newborn procedures such as weighing, ophthalmic prophylaxis, vitamin K injection, etc.21
c. Provide warming for the stable newborn via skin-to-skin contact with the mother, covering both mother and baby if necessary.
3. Early postpartum education and support24
a. Advocate for 24-hour rooming in for mother and baby.
b. Encourage the mother’s support people to provide optimal opportunities for breastfeeding.
c. Ensure that breastfeeding is being adequately assessed on a regular basis by qualified professionals.22
d. Educate mothers about the importance of frequent, unrestricted breastfeeding with proper positioning and latch.
e. Help mothers recognize the baby’s early feeding cues (e.g., rooting, lip smacking, sucking on fingers or hands, rapid eye movements) and explain that crying is a late sign of hunger. Help mothers also recognize signs that the baby is satisfied at the end of a feeding (e.g., relaxed body posture, unclenching of fists).
f. If mother and baby need to be separated, assist them to maintain breastfeeding and/or ensure that mother receives assistance with expressing milk.
g. Provide mothers with clear verbal and written discharge breastfeeding instructions that include information on hunger and feeding indicators, stool and urine patterns, jaundice, proper latch and positioning, and techniques for expressing breastmilk.
h. Educate mothers about the risks of unnecessary supplementation and pacifier use.5,10,16,18,22
i. Avoid the use of discharge packs containing formula samples and formula company advertising or literature.4
j. Ensure that the mother and baby have appropriate follow-up within 48 hours of discharge and provide mother with phone numbers for lactation support.1
k. Identify breastfeeding problems in the hospital and assist the mother with these before discharge. Develop an appropriate follow-up plan for any identified problems or concerns.
l. Provide the family with information about breastfeeding support groups in the community.
4. Ongoing support and management17,20
a. Evaluate the mother and baby soon after hospital discharge to assess adequacy of milk intake and address any problems that have developed.
b. Use breastfeeding-friendly approaches to treatments for problems.
c. Continue to encourage breastfeeding throughout the first year of life and beyond, both at well-child visits and at other visits.
d. Be knowledgeable about prevention and management of common breastfeeding challenges.
e. Develop a working relationship with professionals with expertise in lactation issues, such as International Board Certified Lactation Consultants. Consult when breastfeeding concerns exceed your level of expertise.
f. Encourage mothers who are returning to work to continue to breastfeed.
g. Encourage mothers who do not feel they can continue to exclusively breastfeed to continue partial breastfeeding as long as possible.
h. Support mothers who choose not to breastfeed or who wean prematurely.
General Reference Material
Lawrence RA, Lawrence RM. Breastfeeding: A guide for the medical profession 5th ed. St. Louis: Mosby, 1999.
Riordan J, Auerbach KG. Breastfeeding and human lactation. 2nd ed. Sudbury, MA: Jones and Bartlett, 1999.
Management Appendix References
Appendix 2: Resources For Family Physicians and Other Health Professionals
The following is a limited list of references and resources to assist family physicians in their efforts to support recommendations of the AAFP Position Paper on Breastfeeding.
General Directories of Support Services
The Breastfeeding Resource Guide
A comprehensive list of organizations, groups, distributors, and other companies that provide breastfeeding services, support, products, and resources.
Best Start Social Marketing
Provided in the AAFP’s Physician’s Breastfeeding Support Kit
American Academy of Family Physicians
The National Women’s Health Information Center
Provides a list of breastfeeding publications and organizations.
A Project of The HHS Office on Women’s Health
U.S. Department of Health and Human Services
Departments of Public Health
Many states have excellent comprehensive programs that support breastfeeding and breastfeeding education.
Many state universities or extension services offer information, training materials and educational opportunities for physicians and other health professionals..
Breastfeeding : A Guide for the Medical Profession
Ruth A. Lawrence, Robert M. Lawrence
5th edition (December 1998)
Breastfeeding and Human Lactation
Jan Riordan, Kathleen Auerbach
2nd Edition (1999)
Jones and Bartlett Publishers
Medications and Mothers’ Milk
Thomas W. Hale, Ph.D.
9th edition (2000)
Pharmasoft Medical Publishing
Breastfeeding the Newborn: Clinical Strategies for Nurses
1st edition (January 15, 1999)
Drugs in Pregnancy & Lactation: A Reference Guide to Fetal & Neonatal Risk
Roger K. Freeman, Sumner J. Yaffe, Gerald G. Briggs
5th edition (May 15, 1998)
Lippincott, Williams & Wilkins
The Breastfeeding Answer Book
Nancy Mohrbacher, IBCLC, Julie Stock, IBCLC
Revised edition (1997)
La Leche League International
Resources for Lactation Education and Training for Physicians
Annual Seminar for Physicians on Breastfeeding
Presented by La Leche League International
Cosponsored by AAP and ACOG, in cooperation with AAFP
La Leche League International
1400 N. Meacham Road
Schaumburg, IL 60173-4840
Annual International Meeting
Physician’s Basic Course “What Every Physician Needs to Know About Breastfeeding”
Academy of Breastfeeding Medicine
P. O. Box 81323
San Diego, CA 92138
Lactation Management Curriculum – A Faculty Guide for Schools of Medicine, Nursing, and Nutrition
Attn: Educational Materials Coordinator
4062 First Avenue
San Diego, CA 92103-2045
A free online basic breastfeeding course; may be used as curriculum for a student or resident rotation.
Additional courses with AAFP Prescribed credit may be found through the Academy’s CME database (www.aafp.org).
Physician’s Breastfeeding Resource Kit
American Academy of Family Physicians
11400 Tomahawk Creek Parkway
Leawood, KS 66211-2672
The Womanly Art of Breastfeeding
Gwen Gotsch and Judy Torgus
6th revised edition (September 1997)
La Leche League International
1400 N. Meacham Road
P.O. Box 4079
Schaumburg, IL 60168-4079
A Woman’s Guide to Breastfeeding
American Academy of Pediatrics (1998)
Division of Publications
P.O. Box 747
Elk Grove Village, IL 60009-0747
Breastfeeding Support Organizations
American Academy of Family Physicians
A national organization representing over 93,100 members who provide comprehensive, coordinated, and continuing care to all members of the family and serve as the patient’s advocate in the changing health care system. Breastfeeding support materials and CME training are available through AAFP.
11400 Tomahawk Creek Parkway
Leawood, KS 66211-2672
The Academy of Breastfeeding Medicine
A worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation.
ABM Executive Office
P.O. Box 81323 San Diego, CA 92138
Toll free: 1 877-836-9947
Implements the U.S. UNICEF Baby-Friendly Hospital Initiative, including the award process.
8 Jan Sebastian Way #13
Sandwich, MA 02563
Best Start Social Marketing
Provides information and products to support the promotion of breastfeeding.
3500 E. Fletcher Avenue, Suite 519
Tampa, FL 33613
International Board of Lactation Consultant Examiners
Offers voluntary certification examination for specialists in lactation management. Publishes the Code of Ethics for lactation consultants.
PO Box 2348
Falls Church, VA 22042-0348
International Lactation Consultants Association
The professional organization for lactation consultants. The International Lactation Consultant Association (ILCA) promotes the professional development, advancement, and recognition of lactation consultants worldwide for the benefit of breastfeeding women, infants, and children.
Publishes the Journal of Human Lactation.
4101 Lake Boone Trail
Raleigh, NC 27607
La Leche League International
Their mission is to help mothers worldwide to breastfeed through mother-to-mother support, encouragement, information, and education, and to promote a better understanding of breastfeeding as an important element in the healthy development of the baby and the mother.
1400 N. Meacham Rd.
Schaumburg, IL 60173-4048
A private, non-profit organization that promotes maternal and child health, specializing in the area of breastfeeding. Through programs and publications, Wellstart provides educational opportunities for perinatal health care professionals, focusing on the scientific basis and management of human lactation. Wellstart staff serve as consultants on local, national, and international levels and provide training for a variety of health organizations.
4062 First Ave
San Diego, CA 92103
Appendix 3: National and International Breastfeeding Initiatives
The Baby Friendly Hospital Initiative
The Baby-Friendly Hospital Initiative is a worldwide project of UNICEF and the World Health Organization (WHO). The goal of the initiative is to recognize hospitals and birth centers that take special steps to provide an optimal environment for breastfeeding. Approximately 14,000 hospitals worldwide have received this prestigious award. In the United States, hospitals and birth centers may take a first step toward receiving Baby-Friendly designation through the Certificate of Intent program. For an application packet, call 508-888-8044.
There are 10 steps to successful breastfeeding underlying the Baby-Friendly Hospital Initiative:
The WHO/UNICEF Code of Marketing of Breastmilk Substitutes
In 1981, the World Health Assembly adopted The International Code of Marketing of Breastmilk Substitutes, as a tool to protect breastfeeding. Formula marketing targets women. New mothers are given free samples of formula, babies are given bottles in hospitals, coupons or food samples arrive in the mail, or booklets and videotapes are distributed on breastfeeding and weaning. The Code prohibits marketing of these products in these ways. It covers formula, other milk products, cereals, teas and juices, as well as bottles and teats.
The Code has 10 important provisions:
The Innocenti Declaration was produced and adopted by participants at the WHO/UNICEF policymakers’ meeting on “Breastfeeding in the 1990s: A Global Initiative,” co-sponsored by the United States Agency for International Development (AID) and the Swedish International Development Authority (SIDA).
We therefore declare that:
§ As a global goal for optimal maternal and child health and nutrition, all women should be enabled to practice exclusive breastfeeding and all infants should be fed exclusively on breastmilk from birth to four to six months of age. Thereafter, children should continue to be breastfed, while receiving appropriate and adequate complementary foods, for up to two years of age or beyond. This child-feeding ideal is to be achieved by creating an appropriate environment of awareness and support so that women can breastfeed in this manner.
§ Attainment of this goal requires, in many countries, the reinforcement of a “breastfeeding culture” and its vigorous defense against incursions of a “bottle-feeding culture.” This requires commitment and advocacy for social mobilization, utilizing to the full the prestige and authority of acknowledged leaders of society in all walks of life.
§ Efforts should be made to increase women’s confidence in their ability to breastfeed. Such empowerment involves the removal of constraints and influences that manipulate perceptions and behavior towards breastfeeding, often by subtle and indirect means. This requires sensitivity, continued vigilance, and a responsive and comprehensive communications strategy involving all media and addressed to all levels of society. Furthermore, obstacles to breastfeeding within the health system, the workplace, and the community must be eliminated.
§ Measures should be taken to ensure that women are adequately nourished for their optimal health and that of their families. Furthermore, ensuring that all women also have access to family planning information and services allows them to sustain breastfeeding and avoid shortened birth intervals that may compromise their health and nutritional status, and that of their children.
§ All governments should develop national breastfeeding policies and set appropriate national targets for the 1990s. They should establish a national system for monitoring the attainment of their targets, and they should develop indicators such as the prevalence of exclusively breastfed infants at discharge from maternity services, and the prevalence of exclusively breastfed infants at four months of age.
§ National authorities are further urged to integrate their breastfeeding policies into their overall health and development policies. In so doing they should reinforce all actions that protect, promote, and support breastfeeding within complementary programs such as prenatal and perinatal care, nutrition, family planning services, and prevention and treatment of common maternal and childhood diseases. All health care staff should be trained in the skills necessary to implement these breastfeeding policies.
All governments by the year 1995 should have:
Appointed a national breastfeeding coordinator of appropriate authority, and established a multisectoral national breastfeeding committee composed of representatives from relevant government departments, nongovernmental organizations, and health professional associations.
Ensured that every facility providing maternity services fully practices all ten of the Ten Steps to Successful Breastfeeding set out in the joint WHO/UNICEF statement “Protecting, promoting and supporting breastfeeding: the special role of maternity services.”
Taken action to give effect to the principles and aim of all Articles of the International Code of Marketing of Breast-Milk Substitutes and subsequent relevant World Health Assembly resolutions in their entirety.
Enacted imaginative legislation protecting the breastfeeding rights of working women and established means for its enforcement.
We also call upon international organizations to:
Draw up action strategies for protecting, promoting, and supporting breastfeeding, including global monitoring and evaluation of their strategies.
Support national situation analyses and surveys and the development of national goals and targets for action.
Encourage and support national authorities in planning, implementing, monitoring, and evaluating their breastfeeding policies.
HHS Blueprint for Action on Breastfeeding
The Blueprint for Action introduces an action plan for breastfeeding based on education, training, awareness, support, and research. The plan includes key recommendations that were refined by the members and reviewers of the Subcommittee on Breastfeeding during their deliberations of science-based findings. Recognizing that breastfeeding rates are influenced by various factors, these recommendations suggest an approach in which all interested stakeholders come together to forge partnerships to promote breastfeeding.
David Satcher, M.D., Ph.D.
Assistant Secretary for Health
U.S. Department of Health and Human Services
Healthy People 2010, Breastfeeding Goals, U.S. Department of Health and Human Services:
To increase to 75% the proportion of mothers who breastfeed their babies in the early postpartum period.
To increase to 50% the proportion of mothers who breastfeed their babies through five to six months of age.
To increase to 25% the proportion of mothers who breastfeed their babies through the end of the first year.