What doctors wish patients knew about breastfeeding

Breastfeeding can be part of the many joyous moments a mother shares with her new baby. It allows mother to form deeper connections with the child while also providing the infant with vital nutrients needed to survive, grow and stay healthy. But breastfeeding can also be a challenge. Finding support and knowing what to expect is key.

More than 80% of families initiate breastfeeding, but only 26% exclusively breastfeed by six months, according to the Centers for Disease Control and Prevention (CDC). Breastfeeding inequities also exist, with 76% of Black infants ever breastfed, compared with 92% of Asian infants, and 85% of white infants and Hispanic infants, according to the CDC.

AMA policy supports breastfeeding and providing appropriate lactation services for mothers. Meanwhile, the American Academy of Pediatrics (AAP) has updated its breastfeeding guidance to encourage breastfeeding for two years or more, which is up from the previous recommendation of one year or more. The guidance also acknowledges that significant societal changes are needed to help parents meet these goals, and it calls on pediatricians to support families who want to keep nursing.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two pediatricians took time to discuss what doctors wish patients knew about breastfeeding. These AMA members are:

• Nusheen Ameenuddin, MD, MPH, MPA, a pediatrician at the Mayo Clinic in Rochester, Minnesota, and chair of the American Academy of Pediatrics Council on Communications and Media.
• Sarah Marsicek, MD, a pediatrician in Gainesville, Florida, and an alternate delegate in the AMA House of Delegates for the American Academy of Pediatrics.

“Breastfeeding decreases the risk of ear infections, diarrhea, respiratory illnesses and it also can decrease rates of sudden unexplained infant death syndrome,” said Dr. Marsicek. “Then it even goes on to work in long term with diabetes, obesity, asthma, eczema, inflammatory bowel disease and they even said leukemia in this most recent update from the AAP.”

“As far as moms go, there’s a huge part of this maternal bonding. A big thing is having that very intimate way to bond with your baby right away,” she said, noting that “as soon as the baby is born, we try to initiate breastfeeding as soon as possible to help not only stimulate the mom’s body, but also to start building that bond.”

“The AAP talks about benefits of breastfeeding past that one-year mark and into the second year of life,” said Dr. Marsicek. “They have seen that, as far as moms go, breastfeeding into that second year of life has a positive impact on mental health, decreases maternal type 2 diabetes, hypertension, breast cancer and ovarian cancer rates as well.”

“The AAP’s formal policy is that you exclusively breastfeed for up to six months. And then at six months is when we recommend starting to introduce foods,” said Dr. Marsicek. “Having that first golden six months of exclusive breast milk is very important, if possible, and then as babies increase their intake from other things, it's OK to start weaning them.”

“Up to 12 months is when those babies really rely on those macronutrients from the breast milk,” she said. “And then at 12 months is when we start seeing the shift from ‘I need all of my nutrients from breast milk’ to ‘now I’m taking enough solid foods and enough of a variety of foods to compensate.’”

“But if parents are still breastfeeding, they’re still getting those macronutrients and that decision of when to stop breastfeeding is a very personal decision,” said Dr. Marsicek.

“Even though, technically, we tell people breastfeeding is free—you don’t have to buy formula, you don’t have to mix it, you don’t have to clean bottles and all of the other accessories to go along with it—breastfeeding does take a fair bit of effort,” said Dr. Ameenuddin. “And, oftentimes, that can fall solely on the mother and without good support from the home and the workplace that can be extraordinarily difficult to sustain.”

Dr. Marsicek tries to tell new moms ahead of time about “how incredibly difficult breastfeeding is going to be.” She struggled with breastfeeding her first child due to complications developed after she underwent radiation treatment for Hodgkin’s lymphoma. “For some people, it becomes this very natural thing, and they pick up right away—it’s no challenge whatsoever.

“But what I have noticed more often than not in my practice is that it is a huge struggle for moms. And no one really talks about just how big of a time commitment and how difficult it has the potential to be, especially during those first couple of days when we’re waiting for the milk to come in,” she added.

“If it is painful, it's probably a good idea to inspect the breast to make sure that it isn't sore, that there isn't raw skin,” said Dr. Ameenuddin. “Is the baby getting a proper latch? Because if you're not getting a proper latch, that can cause soreness.”

Additionally, “is the baby sucking more for comfort than for nutrition, and if the baby's sucking more just for comfort and isn't doing full swallow, it's really best to take the baby off because otherwise you're just going to have really sore nipples,” she explained. “Another thing we watch for is it could be a yeast infection. And for babies that can manifest as thrush, which in general is a self-limited condition and can resolve on its own.

“But if it gets to the point where it’s painful, then it needs to be treated. Mom and baby can pass that yeast infection back and forth to each other,” Dr. Ameenuddin added. “There can also be really painful conditions, like mastitis, which require antibiotic treatment.”

“We know that there are tremendous benefits to breastfeeding, but we've gotten to a point in society where moms feel shame—and no one should ever feel shame if they're not able to breastfeed for whatever reason,” said Dr. Ameenuddin. “As pediatricians, more than anything we try to stress that a fed baby is a happy baby.

“And if the baby is fed with breast milk or formula that's OK,” she added. “You need to do what’s best for you and your baby.”

“My relationship with breastfeeding is: Absolutely if it works for mothers and it works for the family, then we should definitely support them 100%,” said Dr. Marsicek. “But there are going to be scenarios and situations where breastfeeding is not going to be what’s in the best interest of the child or the mother.”

“Ultimately, it's a very personal decision and one that people should not be made to feel guilty about,” she said.

“There are probably only two absolute contraindications to breastfeeding and one is a mother who is HIV-positive,” said Dr. Ameenuddin. “And the second one is a baby who's been diagnosed with galactosemia, which is a metabolic disorder where they need a special kind of formula. They cannot have breast milk or regular formula because their body doesn't break down the elements of the lactose in the right way.

“It's a fairly rare condition, but it's something that we screen for on the newborn screen,” she added, noting that while “those are really the only two absolute contraindications to breastfeeding, there are a number of things where it can just make it hard to breastfeed and some of it has to do with anatomy.”

“I've watched educational videos that have shown that some babies find the nipple and they latch on moments after delivery,” said Dr. Ameenuddin. “But it's not always that easy and it's not always as intuitive.”

“Moms are thinking this is the most natural thing in the world, women have been doing this for centuries upon centuries, so why is it so hard?” she said. “Sometimes there can be anatomical issues or there can be anatomical issues with the baby like with cleft lip or cleft palate or sometimes the baby just hasn't gotten the coordination right yet.”

“It's very common to have some challenges and that's why I've been very lucky and grateful for our lactation consultants and counselors,” Dr. Ameenuddin said.

“A newborn is going to need to feed every two to four hours. We really don't want them to go more than four hours without a feed, and most will probably feed about every two to three hours,” said Dr. Ameenuddin. “There might also be cluster feeding during certain times of the day or more often at night where the baby's feeding several times over a short period of time.”

“If you have a mom who is breastfeeding every two hours and the total feeding time takes about 30 minutes, that leaves you a very small amount of time to be able to rest in between,” she said. “If you're doing it much more frequently than every two hours, then someone's not getting rest and that's not going to be good for that mother baby dyad.”

“The more you take the baby to the breast, the quicker that supply is going to come and build up,” said Dr. Marsicek, noting “there are other things that you can do to help build up that supply.”

Try “eating a really good diet, taking your prenatal vitamins, drinking lots of water and keeping well hydrated. All of that goes towards building up that supply,” she said. “But, especially in those first couple days, taking that baby to the breast every two to three hours is paramount.”

“Even the moms that choose to supplement, we tell them before you give the baby the bottle, please ensure that you're taking the baby to the breast because your body needs to recognize that that baby's here,” Dr. Marsicek said. “And the only way that it’s going to do that is by that nipple stimulation.”

“A bigger thing that I notice in my clinic is that mothers who are really stressed, who are not getting enough sleep, who aren't getting adequate nutrition or hydration, or who aren't able to have enough time between feeds to really recover and replenish their supply,” said Dr. Ameenuddin, noting that is “a bigger difficulty to overcome.”

“I tell them that whether you choose to breastfeed or formula feed, whatever you want is going to be best, because a stressed mom is never going to produce as much as they should anyways,” said Dr. Marsicek.

“Always ask the doctor questions—that's their job,” said Dr. Marsicek. “Breastfeeding is a very important part of infant growth and development, so they'll know how to support you.”

“I want patients to know that we will support them in whatever feeding decision they make for themselves and their babies,” said Dr. Ameenuddin. “I do recommend breastfeeding and I will do everything that I can to support my families in breastfeeding, but I also want to make sure that they're not carrying guilt with it.”

“From a physician’s perspective, the mother’s health—mental health and physical health—is as important as the baby’s,” she said. “Anything you can do in the short term to facilitate longer-term breastfeeding, that’s the goal we’re looking for.”