Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
My name is Emily Fronk and I am a 4th year medical student at the University of Virginia. This episode was developed along with Dr. Ann Kellams, Professor of Pediatrics and Director of Breastfeeding Medicine at the University of Virginia. This is the first of two episodes about breastfeeding counseling. If, after you listen to this episode, you’re interested in learning more, we recommend that you listen to the episode entitled, “Breastfeeding 102- Initiation and Management of Common Early Breastfeeding Concerns”.
Today, we will be reviewing what you need to know before your first time working with a breastfeeding parent. This will include topics such as how to ensure families feel comfortable, benefits of and contraindications to breastfeeding, how to approach conversations about breastfeeding, and the science behind lactation or milk production.
During your Pediatrics clerkship, as well as on your OB/GYN clerkship, you will generally get to spend time with newborns and post-partum families. Today’s podcast is focused on helping you feel prepared for how to talk with breastfeeding parents and families to help them successfully meet their feeding goals.
It’s important to remember that every family is different- you may encounter people who are excited about breastfeeding or those who are scared or have no desire to breastfeed. Some may have taken courses or read books on how to breastfeed or have breastfed previous children, whereas others may have no prior knowledge and this could be their first time. How we talk about breastfeeding and the support that we can offer to families is crucial for their success in meeting their feeding goals. Given this, it’s important to meet each family where they are at and have a non-judgmental, open discussion about breastfeeding.
Before we go into some of the details about breastfeeding, let’s set the stage on some key things to keep in mind while on the mother-baby unit. First, I’d always encourage you to knock when going into the room. Ask the parents if this is an ok time to talk; remember, they’re often overwhelmed and sleep-deprived. Give them the autonomy to choose for you to come back later, after they’ve had a chance to eat, rest, or do anything else that’s important to them. Be prepared that when you walk into the room and start talking about feeding, you can encounter a wide range of reactions, from excitement that it’s going well to tears, frustration, and worry. Make sure to read the room and ask them if it would be helpful to provide more information, rather than just doing so. Secondly, if you walk in on a mother who is breastfeeding, it’s essential that you don’t make them feel embarrassed. Act like it’s normal because it is! If we make them feel uncomfortable breastfeeding in the hospital, it’s going to be nearly impossible for them to feel comfortable when “out in the real world” where they may be faced with the stigma and embarrassment that is unfortunately part of our society. You can help combat this stigma by providing a welcoming and nonjudgmental environment. Lastly, I’d encourage you to get used to using appropriate medical terminology, such as breast, areola, and nipple. By practicing using these words, you’ll be more comfortable talking about these topics and, as a result, will make your patients feel more comfortable and confident.
Now let’s talk about one of the most important topics: why we recommend that babies breastfeed.
For the birth parent, the oxytocin release from breastfeeding increases uterine contractions, which helps to reduce blood loss and results in faster postpartum recovery. Additionally, breastfeeding results in a reduced risk of developing type 2 diabetes, breast cancer, ovarian cancer, hypertension, and postpartum depression. For the baby, breastfeeding reduces the risk of developing gastrointestinal illness and hospitalization, severe respiratory tract infections, Necrotizing Enterocolitis or NEC, childhood leukemia, diabetes, otitis media, late-onset sepsis in pre-term infants, urinary tract infections, and sudden infant death syndrome, aka SIDS.
Because of the benefits of breastfeeding, there are only a few situations in which breastfeeding is absolutely contraindicated. These include infants with classic galactosemia, mothers with active untreated tuberculosis or varicella, mothers with active herpes simplex virus lesions on the breast, and mothers who are currently using illicit drugs. Be sure to look into the new guidelines for HIV and breastfeeding as, in the proper setting, breastfeeding may be possible with continued HIV medication for mothers and infants of mothers with undetectable viral loads. I’ve included a link to these guidelines in the show notes.
Now that you know why it’s important, let’s discuss how to approach conversations about breastfeeding with families.
Most families have already decided on how they want to feed their baby prior to coming to the hospital for birth. Therefore, it can be ideal for patients to discuss some aspects of breastfeeding before baby arrives, often with their OB; however, this isn’t possible for every patient. As a result, your discussion with the family, even if after birth, might be the first they’ve had to learn about this information! It’s usually helpful to start the discussion by exploring their reasons for or against wanting to breastfeed. Even if parents state that their plan is to formula feed, it’s still important to ask what brought them to that decision. For example, some parents may state that they can’t breastfeed because they plan to go back to work at 6 weeks; in a situation like this, you can share with them the benefits of having baby breastfeed even for a short period of time or alternative options, such as pumping. It can be helpful to counsel parents on the benefits of breastfeeding, both for mom and baby, that we previously mentioned. However, remembering that this is an overwhelming time for the family, we’d recommend keeping the discussion short and trying to not use too much medical jargon. It’s important to help families understand their options, so that they can make an informed decision that is right for their family. Talking about previous breastfeeding experiences (if there are any) can be helpful to explore if these were successful, positive experiences, as this can both impact their desire to breastfeed their current baby and identify what help is needed for this baby to try to prevent problems. It’s important to know if they are planning to return to work and when that will happen, and to establish if they need a breast pump, as this is something that we can help with during the hospital stay.
Our goal is to make sure that parents have all the most up-to-date information when deciding how to feed their baby, not to make them feel guilty about their decision. Remember your motivational interviewing techniques that you’ve learned throughout medical school to understand where each family is and see if there’s a way that you can help them get to the healthiest choice that they are ready to make for themselves and their baby. If you sense that they’ve made a final decision, it’s important that you respect this. Finally, we feel it’s important to mention that studies have shown that minority patients typically receive less education and support in their breastfeeding efforts from healthcare providers and breastfeeding rates for non-Hispanic Black, American Indian, and Alaskan Native mothers are much lower compared to non-Hispanic White and Asian mothers. Therefore, we encourage you to consider the effect of bias and discrimination when talking to patients about breastfeeding, just as you would when discussing any other sensitive topics, and to treat each family in an individualized, yet equitable, manner.
While you might not be the one having this discussion with families, it's also important to consider risk factors for low milk supply. These risk factors include polycystic ovary syndrome, diabetes, hypothyroidism, obesity, previous breast surgery, infertility, low milk production for previous baby, and excessive postpartum blood loss, among others. It’s also important to know what the consensus recommendations for breastfeeding are. The American Academy of Pediatrics, the World Health Organization, and the Institute of Medicine are among many organizations that recommend exclusive breastfeeding for the first 6 months, with continuation of breastfeeding for 2 years or longer, as mutually desired by parent and baby. However, remember that these recommendations can feel intimidating, particularly to sleep-deprived, overwhelmed parents. Sometimes it can be helpful to simply tell parents that the various organizations mentioned above recommend that parents breastfeed as much and as long as they can, as any breastfeeding is better than none.
Let’s now talk a bit about the process of lactogenesis, which is how breast milk production starts and continues. This is important to understand when you counsel patients on breastfeeding. There are 3 stages to lactogenesis. Stage 1 of lactogenesis, also called secretory initiation, begins during the second half of pregnancy. The placenta supplies high levels of progesterone. This prepares the breast for milk production. Differentiation of the breast’s alveolar cells stops, resulting in increased potential of the breasts to produce milk and proliferation of secretory cells. In this stage, women produce drops of early breastmilk or colostrum, which is nutrient dense and high in antibodies. In stage 2 of lactogenesis, also called secretory activation, there is increased milk production. This phase happens after birth and is stimulated by the removal of the placenta which causes a rapid drop in progesterone. Additionally in stage 2, having the baby suck on the breast results in a rise in prolactin, cortisol, and insulin. Usually, by 3-5 days postpartum (longer for women who underwent a cesarean delivery), women experience swelling of their breasts, along with increased milk production. Finally, stage 3 of lactogenesis, also called galactopoiesis, refers to the maintenance of milk production through frequent emptying of the breasts. In general, the more milk that is emptied from the breast, the more milk is produced. By understanding this process, you can help to make the family aware of how important it is for the mother’s breasts to be frequently emptied, either by the baby suckling or by pumping to maximize milk-making capacity. Each breastfeeding or milk expression session is a signal to the mother’s body to make more milk.
Although breastfeeding is ultimately exciting and rewarding, it can sometimes initially be a painful and frustrating experience for new families. This is often a surprise to parents, as they assume that something so natural will be easy. However, it can take 2-3 weeks for both the baby and the parent to get the hang of it. By helping parents understand what to expect and how to manage common concerns, you can help to positively influence a special part of their and their baby’s journey.
OUTRO:
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