Welcome to what will likely be the shortest section of my blog post series on low milk supply, about pediatricians and breastfeeding! If you’d like to follow along in order, please start at part 1: research and then continue to part 2: breastfeeding data before starting on this post.
Pediatricians and Breastfeeding: what do they know?
Pediatricians are amazing, because they have to know a lot of details about a LOT of topics.
In the United States, your pediatrician is your go-to for everything health related; you see the pediatrician an average of seven times in the baby’s first year of life, and that’s all just well-baby visits. If you’ve got a kid who as frequent skin issues, or ear infections, or is accident prone, you really get to know your pediatrician.
Our society expects pediatricians to be our go-to for everything related to babies’ health and well being, so most people go to their pediatrician first when they have a question about breastfeeding.
Unfortunately, pediatricians get very little breastfeeding education in medical school.
It’s hard to definitively find out how much breastfeeding education pediatricians get; I’ve heard of some doctors who say they only had a couple of hours of instruction on breastfeeding basics while in med school. Others have told me they had one class about how breast milk is produced and on the anatomy of the breast.
A 2004 survey of 875 United States pediatricians found that 33% of respondents had NO breastfeeding education during medical school or their residency. 12% of responding pediatricians had never read an article about breastfeeding management, and 21% of respondents had no interest in gaining any further knowledge about breastfeeding (Feldman-Winter LB, Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians and the Promotion and Support of Breastfeeding. Arch Pediatr Adolesc Med. 2008;162(12):1142-1149.).
We have four medical schools in Massachusetts (Boston University, Harvard, Tufts University, and UMASS Worcester). I searched the course catalogs for medical coursework degree requirements and found that only ONE school (Boston University) has courses that mention breastfeeding as part of the curriculum- in their Family Medicine and Pediatrics departments.
A Massachusetts study done in 2005-2006 showed that just ONE 12-hour intensive breastfeeding course for health care practitioners raised the breastfeeding initiation rates at four local hospitals with low breastfeeding rates (Hospital Education in Lactation Practices (Project HELP): Does Clinician Education Affect Breastfeeding Initiation and Exclusivity in the Hospital?. Birth, 36: 54–59.).
When a parent goes to the pediatrician with milk supply concerns, what happens?
Well, I can tell you what I wish WOULD happen:
- the pediatrician listens to the parents’ concerns and asks more questions to find out what’s making the parent feel like baby isn’t getting enough.
- the pediatrician weighs the baby, and schedules another weight check within 48 hours.
- the pediatrician either
- has sufficient knowledge of breastfeeding to troubleshoot, make a care plan, and help the family or
- has a trusted lactation professional in their office or close by that can help the family within 24 hours.
What does happen instead?
Here’s an example I heard from a mom this week, who brought her month old baby to his check-up. Baby’s weight gain was slow- he just got back up to birth weight (we’d like babies to be back to birth weight within 2 weeks of birth). Mom mentioned her concerns to the pediatrician.
Doctor: “Your baby’s weight gain isn’t ideal. Have you considered supplementing with formula?”
Mom: “I’m not opposed to formula, but when I started supplementing my first kid with formula it was the end of breastfeeding for me. I really want breastfeeding to work this time.”
Doctor: “OK, we’ll check his weight again in three weeks and see how it’s going. Maybe you’ll have to give him pumped milk. See you then.”
When the mom told me this story, my jaw dropped. Three weeks? So much can go so terribly wrong in three weeks.
Thankfully, I don’t have this happen often… but it’s not the first time that I’ve seen a baby who could have benefited from much earlier feeding interventions.
With so little required breastfeeding education, how do pediatricians support nursing families in their practices?
Well, 87% of the pediatricians in the 2004 survey I cited above were confident that they could answer parents’ breastfeeding questions… yet only 37% of respondents had taught breastfeeding techniques to at least 5 families in the previous year.
53% of the respondents had NO personal experience observing breastfeeding. Ever. Not even once.
24% of respondents felt a mother should stop breastfeeding- or never start breastfeeding to begin with- if she was “too young or immature”.
I’ll say it again. Pediatricians have to know A LOT OF STUFF about A LOT OF DIFFERENT THINGS. Breastfeeding? Maybe not as high on their priority list as we think it should be.
Imagine how different the breastfeeding landscape in the USA would look if all pediatricians had to meet a competency requirement in breastfeeding and also one in formula feeding.
The American Academy of Pediatrics has developed a breastfeeding residency curriculum; it includes giving a presentation on low milk supply and other common breastfeeding problems. Their curriculum is designed to be implemented over “one rotation, one year, or during the entire length of residency.”
I can’t help but wonder how many parents dealing with low milk supply (and so many other infant feeding problems) could be helped if their pediatricians had more training in breastfeeding.
upcoming posts in the low milk supply series
part 4 onward, we’ll delve into what parents know about milk production, what they hear about milk supply, and what symptoms make them suspect low milk supply.
Stick with me, folks. It’s gonna be a long, bumpy, milky ride. I think we’re past the half way point. I could be wrong.
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Thank you for this great article!
Your link for the residency curriculum is not working. I found an updated one that I think is correct. https://www.aap.org/en/learning/breastfeeding-curriculum/#:~:text=The%20American%20Academy%20of%20Pediatrics,breastfeeding%20education%20into%20existing%20curriculum.
I’m loving reading through this series, thanks for writing it. There is so much that I can personally relate to, and also now that I’m working with breastfeeding mums too. Your little scenario with what the paediatrician says? EVERY. TIME. Every friggin time.
Last week my little boy had his two-year check-up at the paediatrician. I went in thinking that he is a very happy, very clever, very healthy little boy (who happened to have a cold)… and then they weighed him. He dropped from around the 40th percentile to the 3rd. I was hit with the most extreme self-doubt — I suddenly thought about his continued night waking, that maybe I’d been a bit too stingy with other milks for too long when perhaps he really needed it, considering my history of such chronic low supply, and I was thinking of all the advice I am giving mums, and what a fraud I am, when I can’t even keep my own baby growing healthily… and what is wrong with me that I can’t even notice when my little bubba isn’t growing well?! I’m lucky that my paediatrician respects me enough to listen to my concerns and to weigh him again. He unplugged the scales, recalibrated, weighed him again. And he was 1.4kg heavier, bringing him up to his ‘following the curve’ 40%. So the doctor gave me a pat on the shoulder, told me I’m doing a great job, keep doing what I’m doing, and that I have good instincts there. So phew. But… what about the other mums that came in that day? How long has this been a problem? How often does this happen? How often are mums made to think that they have major problems when they don’t, and they don’t have the confidence to contradict the doctor and demand a second weigh-in? How often are mums told to supplement due to an electronic failure? What if the last baby weighed there was a three month old that was labeled as Failure to Thrive?
Sigh. Just another paediatrician thing I thought I’d share…
Wow… I have to wonder how many babies were incorrectly weighed on that scale before it was re-calibrated. If it’s scary for you (or me) as an “experienced” mother how would that 1.4 kg difference feel to a new parent?
I read this while I was pregnant: http://www.cnn.com/2013/01/03/health/medical-breastfeeding/
* That’s because lactation is probably the only bodily function for which modern medicine has almost no training, protocol or knowledge. When women have trouble breast-feeding, they’re either prodded to try harder by well-meaning lactation consultants or told to give up by doctors.
* Today there are 88 physicians in the entire world who are fellows of the Academy of Breastfeeding Medicine, and have “demonstrated evidence of advanced knowledge and skills in the fields of breast-feeding and human lactation.”
* Dr. Marianne Neifert writes in her article, Prevention of Breastfeeding Tragedies, “The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.'”
sorry for the typos! multitasking with the baby!
One of the mantras in the supprt groups I belong to is “your pediatrician is a childhood illness expert, not a breastfeeding/sleep/parenting/behavior expert.” Wash, rinse, repeat. I think medical school cirriculum is doing a diservice to our providers and I question whether that will change before there’s generational turnover in the faculty ranks. I have heard from BSN and MD friends that as little as 30 minutes was spent on breastfeeding. How alsp do you communicate to new parents that you may not be able to rely on your pediatrician for everything? Friends I know that wouldn’t hesitate to get a second opinion for themselves or drop a doc because they don’t mesh well personally are too afraid to question or change providers because “he/she knows more than I do?” I found myself in this very situation and when I did switch, I only wish I’d done so sooner. And as mych as I like our current ped, I still tend to expect little in this dept/if they don’t meet my expectations I now know I can seek concurrent breastfeeding support elsewhere. My guess is that part of it (which is outside the scope of your series, but nonetheless related) is the obstetrics system, which whispers in your ear throughout pregnancy: you are not enough, you are not to be trusted, your body is not to be trusted.
I posted this article on my own profile and (not surprisingly) got some backlash from the pediatricians I work with. Thing is, this isn’t really about pediatricians. It’s about the way the system fails everyone. It isn’t just pediatricians who don’t get enough lactation education, it’s MDs in all specialties, DOs, NPs, PAs, RNs… in all of these professions, there is very little breastfeeding education happening. I suspect that if I was a pediatrician (I am an NP), or if the article had been about healthcare providers in general, I wouldn’t have seen the backlash. It’s interesting to watch the defensive stance physicians tend to take when a non-physician comments on their knowledge base.
Interesting Laura, thanks. You’re right, it’s NOT just about pediatricians. I narrowed down my post scope to pedi’s because they are our society’s go-to for infant feeding, and have been so since the turn of the 20th century as infant formula had to be prescribed and “formulated” by doctors for each baby.
It’s absolutely a systemic problem. Hey, everyone has their area of interest… I really don’t expect everyone to be a lactation expert. But I do think that something so intrinsic to the care of infants and children should be better taught to those who are responsible for their medical care.
Yes!! A pediatrician is expected to be an expert in baby care and will see an otherwise healthy baby no fewer than seven times in the first year of their life. In that first year of life they are expected to be able to provide guidance on a major topic that they’ve not even been trained on. You are absolutely right! We can’t expect that breastfeeding will be everyone’s passion. Supporting breastfeeding doesn’t need to be what gets each pediatrician out of bed every morning. The problem isn’t even that they can’t provide adequate support. The problem is that they cannot identify normal versus abnormal and recognize when a referral to see an IBCLC. Furthermore many of them are not aware of their blind spots and can’t identify what they don’t know. For example, I was not trained on choosing ventilator settings for patients who are intubated. I realize that the only thing I know about using a ventilator is how to plug it into the wall. For this reason, I would never ever attempt to blindly manage the care of a child who is dependent on a ventilator. I would never represent myself as an expert on ventilatory support. If I did, someone might die. (Dramatic example I know but making a point). In contrast: Even though the pediatrician received little to no education on how to manage a breastfeeding relationship, many of them don’t realize how little they know (Breastfeeding? How hard could it be, right?) and attempt to manage these relationships on a daily basis from a barren knowledge base. One might go so far as to say that this is unethical.
Anyone you can read the information you presented here and take it as a personal insult has missed the point entirely. Thank you for putting this information out there. It is important not only for families to understand as they seek care, but also for care providers to step back and assess their ability to provide good support to these families.
Please keep up the awesome work! I love your blog.