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Tuesday, 30 November 2010

How much does your doctor REALLY know about breastfeeding?

When M was very little we were frequent visitors to our local GP’s surgery due to her (as yet undiagnosed) silent reflux.  She was in a lot of pain and every day it was a struggle to get her to feed at all.

Usually one of the first questions the doctor (and it was never the same one twice!) would ask us was ‘what milk have you got her on?’.  The first time I was asked this question M was just 8 weeks old.  I was a bit confused (and for some reason, embarrassed), but I answered ‘mine’.

‘Oh’ came the reply – she seemed surprised.

And so began a very upsetting and frustrating journey into trying to find someone who could help us to soothe our breastfed baby.

That day our GP didn’t suggest we call a breastfeeding advisor, nor did she suggest contacting a lactation consultant.  To be fair to her, she didn’t suggest I gave M formula (no, it was a consultant who did that), but I can honestly say she wasn't able to offer me any more meaningful help than to suggest that we give her infacol and calpol.

Over the next few months we went on to see numerous GP’s (both at our own surgery and at various out-of-hours clinics), several paediatricians and two consultants from the children's hospital. Not one of them suggested we see a lactation consultant, even though they were obviously aware that I was doing all I could to maintain breastfeeding at that time.

I had always assumed that medical professionals knew about breastfeeding. I assumed that if, (like with any other problem) they didn’t know enough about it, they would refer me on to someone more specialised.  Turns out, I was wrong!

Now I'm sure there are exceptions to this. I know there are GP’s who are brilliant at handling breastfeeding problems. There are paediatricians who are incredibly supportive of breastfeeding mums. Some have even gone out of their way to do additional training in breastfeeding support and many will have breastfed themselves.

However, whilst I was doing a bit of digging online (into the challenges women face in overcoming breastfeeding difficulties), I came across a study published in 2006 entitled ‘A training needs survey of doctors’ breastfeeding support skills in England’, and it shocked me.

This survey was the first in the UK to assess and compare the training needs of UK GPs and paediatricians.  In total just 57 GP’s returned the survey along with 120 paediatricians. 
The first paragraph on page 2 reads:
‘In England, there is no central responsibility for coordinating breastfeeding education and assigning standards for practice, and post-registration education for breastfeeding is not mandatory for any health practitioner group. None of the UK professions require core content on breastfeeding in pre-registration training, even midwives[…]' The training needs questionnaire was circulated to NHS ‘primary care and maternity services, in London, the West Midlands and Leeds, across both rural and urban areas…. The response rate overall was not possible to determine, but was in the region of 7% for the paper version, and 29% for the electronic version.’
Here are just a few of the findings (you can read the rest of the report here) 
  • only 1/3rd of GP's and just over half of the Paediatricians felt they were competent* to prescribe medication to a nursing mother,
  • 3 out of 4 GP's and half of Paediatricians did not consider themselves able to give good breastfeeding advice to mothers after a c-section,
  • more than 1/3rd of GP's and 2/3rds of Paediatricians admitted they were not confident in their ability to advise about thrush,
  • 4 out of 5 GP's (80%) and 70% of Paediatricians felt unable to competently advise a mother who’s child was refusing the breast.
  • Less than third of GP’s and less than half of the Paediatricians knew the correct government guidance about the youngest age solid foods should be introduced.
  • More than half of the Paediatricians and more than a fifth of the GP's surveyed, thought that the World Health Organisation only advise exclusive breastfeeding for 4 months (or less). As you probably know - the actual WHO reccommendation is to exclusively breastfeed for six months before beginning to introduce solids.  It's worth remembering that introducing anything other than breastmilk into a baby's system early can be damaging to their health.  You can read more about this here
Perhaps most worrying of all, only 8.8% of the GP’s and only one Paediatrician admitted that they did not know the current government advice about when to begin complementary food. 
‘Worse still’, the researchers say, ‘the rates on ‘do not know’ are very small, suggesting factually incorrect beliefs.’.

And these were the ones who bothered to complete and return the questionnaire!

* The competence scale used in the research had four response options. These were: expert, competent, adequate and not competent. The first two were combined in the research to give a 'threshold level of competence'.

So what does all this mean in real terms?

It’s hard to say. You might be lucky and have a GP who is really clued up on breastfeeding. You may encounter a hugely supportive paediatrician in hospital who is willing to go the extra mile to help you breastfeed.  If so – hurrah!

However, you won’t have to look far within your group of friends (or online) to come across stories of doctors getting it wrong.  It’s not hard to discover a hospital paediatrician who prefers to give the ‘known quantity’ of formula instead of the ‘unknown quantity’ of human breastmilk, even to the very sickest babies.

I had a few such encounters with consultants along the way, and were it not for the fact that I was born with a healthy disdain for ‘authority figures’ I might well have given up breastfeeding after just a few months – believing it was better for my daughter.
I estimate that we were probably seen by 8 GP’s and at least 3 paediatricians over roughly a 3 month period.  It is hardly surpising (given the figures shown above) that I found it hard to find anyone who could help with my daughter’s breast refusal.  One of the consultants suggested we wean her at 12 weeks old - I didn’t do it. 

It's hardly surprising to find that most doctors cannot advise when it comes to breastfeeding problems - as well as having no training in breastfeeding support they are also constantly bombarded by advertising from formula companies.  Some rules on formula advertisements do not apply to medical journals, so specialist formulas and 'first milks' can also be marketed directly to doctors.  Formula companies have specialist websites through which they can target their marketing directly at Health Care Professionals - and whereas an ad on television which breaks the WHO code can be reported to the advertising standards agency by the public, code breakages in these specialist websites are much harder to police.  If you've got five minutes, take a look around some of these websites - they're certainly eye-opening!  Formula companies also pay 'celebrity doctors' to help promote their products - for example Dr Hilary Jones. They are also frequent sponsors of medical conferences.


formula ad from the British Medical Journal (rear cover)  2010

A 2006 report published in the 'Archives of Disease in Childhood' focused on the influence the formula industry has on doctors and pediatricians, and concluded: 
'If breast feeding, with all its benefits, is to be established as a majority activity, we paediatricians must learn to recognise the elaborate web woven around us by formula manufacturers, which currently ensures our goodwill and support for a product that we may acknowledge, but would mostly not wish to actively promote. Fifty years ago nearly everyone, including doctors, smoked and it was perceived to be a necessary and inescapable part of our culture. Now it is unimaginable that we would smoke in front of our patients or accept gifts from cigarette manufacturers. It is time for a similar shift to take place with respect to formula milk. Just because many mothers currently choose to bottle feed their infants and a tiny number of infants cannot be breast fed, it does not mean we should be seen to be endorsing a product that causes net damage to the health of children. The time has come for paediatricians to recognise the influence of IFMCs, shake off their silken chains, and become truly uncompromised advocates for breast feeding and against the hazards of formula milk. '
In the end it was a GP (not my own) who had previously specialised in paediatrics who knew enough about our problem to help us, and who was able to reassure me that breastfeeding really was the best option. I suspect he was also someone with a personal interest in breastfeeding issues.

Worryingly the report identified that:

'if the GP or paediatrician you encounter has a genuine interest in breastfeeding support, they are more likely to have educated themselves. If they do not have this interest it seems unlikely that they will have sought out training.'
How can we know that the advice we’re getting is good advice?
Vincent Iannelli MD has this to say on the subject:

‘A good way to tell is if at the first sign that you are having problems breastfeeding, your doctor recommends supplementing with a bottle, changing to formula or 'just keep trying….  Another way to tell if your doctor supports breastfeeding is by the type of anticipatory guidance that is offered at your doctor visits. Is breastfeeding even mentioned?  How is it discussed?’
The UNICEF 'Baby Friendly' Initiative has certainly improved the levels of breastfeeding support available in the hospital maternity units which have been awarded an accreditation.  To locate your closest Baby Friendly hospital, click hereHowever, a huge number of breastfeeding issues are not dealt with in this setting, so how can you locate good support if you’re in difficulty?

The numbers listed at the side of this blog are a good place to start. These helplines are staffed by breastfeeding counsellors from well-known organisations with a wealth of experience in dealing with common breastfeeding concerns.

Organisations such as the La Leche League, the Association of Breastfeeding Mothers and the National Childbirth Trust can offer support through groups and provide access to trained breastfeeding counsellors.  Some areas now offer peer-to-peer support schemes which can help a great deal if your problem is a straightforward one, and many women find this is enough to resolve their difficulty.  Click here for more information.

If your situation requires more in-depth assistance, you may be able to access an appointment with a lactation consultant (IBCLC) through your local hospital.  Sadly many hospitals do not currently have this resource.  To the best of my knowledge it is not common practice for a GP to suggest such a referral, and you may also find it is not something you can access through the NHS.  You can find a list of IBCLC’s here.

As things currently stand, a large number of women are being failed by their medical professionals - and they don't even know it.  Like me, they don’t realise that not all GP’s and paediatricians have a good understanding of breastfeeding.  They put their faith in the hospitals, midwives and doctors to give them the best advice and support.  After all, breastfeeding is ‘pushed’ quite hard antenatally – so we just assume that the follow-up care will be there for us once we have our babies in our arms.  Sadly this is often not the case.

We often hear women saying 'I couldn't breastfeed' or 'I didn't make enough milk' - but can we really be sure that they weren't booby-trapped by poor advice?  Often a mother will approach her Health Visitor with a problem in the weeks following birth.  They might have concerns following one if the frequent 'weigh ins' and will be advised to see their GP.  What is the GP going to do?  Without an understanding of breastfeeding management many GP's will simply advise the mum to 'top-up' with formula - and that very often spells the end of breastfeeding.  If the study I've quoted is in any way representative, it would seem that very few of them are comfortable admitting a lack of knowledge.

With hindsight I realise that a solution for the problems I encountered whilst trying to feed M would most likely have been pinpointed much more quickly had I simply asked about them at a La Leche League meeting.  If only there were more of them in my part of the world!

I’m not sure how much has changed in the five years since this report into 'training needs' was compiled.  UNICEF offers on-line breastfeeding training for GPs (find out about it here), but it is fairly brief, and by no means compulsory - and that's a real problem.  Perhaps if more of us asked our Practice Managers to promote this training in their practice then things might improve slightly, but in my opinion until adequate breastfeeding training is a compulsory part of medical training then we're still fighting a losing battle.

The research concludes:
‘the survey has shown that there are many areas of breastfeeding care and support where doctors are not fully skilled even by their own admission, and knowledge of public health policy and guidance on breastfeeding is markedly poor.'
It seems to me that the only way to be sure that the advice you’re getting is ‘good advice’ is to ask someone who specialises in breastfeeding problems.

General practitioners are just that – general.  Paediatricians are specialists in the medical care of infants, children, and adolescents.  Both may have good advice to give you on breastfeeding issues, but there are no guarantees.

Breastfeeding problems are a specialist area – if you’re struggling, talk to a breastfeeding specialist.

7 comments:

  1. Am sadly unsurprised, and that survey probably misses the high % of health professionsals who will give 'advice' which is actually just opinion, uninformed and just plain wrong, and if the parents don't know enough to find out the better information then that BF relationship is probably doomed.
    I was advised to stop feeding my 8 month old as he would become 'too dependant; by my Hv and GP ;(

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  2. when my daughter was 9 weeks old she was admitted into hospital with RSV, when she eventually recovered and we were due to be discharged the paediatrician stood there and gave me advice on how to give her her medication in her bottles even though I was sat right in front of him breast feeding her at the time. All the literature available in the hospital on feeding after care was all about bottle feeding. I had a horrible fight with all the staff to be allowed to continue to put my baby to my breast, they wanted to tube feed her as they said breast feeding would be too hard work for her, even though at the time it was my only way to comfort and soothe her and get her to sleep. It was extraordinarily distressing to us both, but I continued to feed her myself and she recovered. Thankfully she was my second child, the first was 5 when he self weaned and my daughter will be given the same opportunity. I had to really fight for my rights and was horribly pressured. I requested several times to speak to a lactation consultant but none was provided. I so hope that no new mother would be put in that situation, but I bet they are.

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  3. We were readmitted to hospital after a 10% weighgloss with dd1 and I was advised to top up with no help about bf except being told I'd stay longer with Mw team. I really thought that the hospital would have a LC and that paediatricians would know about bf. It was the end of our bf relationship and whyi expressed instead. I think things are improving a little but more and more mums seem to end up expressing. I wouldn't bother discussing bf issues with GP and go straight to hcp in bf groups with any questions.

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  4. Oh what a great post to share. Thank you for taking the time to write this. This is the bottom line. This is where it comes back too. The things coming from medical professionals are ridiculous. Through my own daughter's GERD I have been told some pretty crazy stuff. Thankfully, I am scientific and analytical, and when doctors did not make sense I looked for something else. But as a Breastfeeding Mom-to-Mom Support Volunteer, Oh this drives me crazy!

    The human in the white coats are not 'god' and does not know everything. They are just human in the white coat. Not perfect, just human, that's all.

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  5. Amazing blog!! Wish you could get the word out more!

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  6. In my experience, a Baby Friendly hospital only seems to refer to the maternity department. At 3 days old my daughter was diagnosed with posterior tongue tie, and the next day was admitted to the paediatric ward with 12% weight loss (later discovered she was weighed incorrectly at birth - another story!) and slightly raised sodium levels. There was no space on the postnatal ward, which is why we were sent to paediatrics. At this "Baby Friendly" hospital we were told we had to give her formula - 80mls every 3 hours!! - and her tongue tie was ignored. After a day and a half there we were able to get midwives and the infant feeding coordinator to come down and help, but not until my milk supply was very negatively affected.
    Not good enough!

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    Replies
    1. Yes, you're right Laura, it is to do with maternity services, but doesn't apply to paeds, a just issue I agree. I had the same issues when my first daughter was taken to scbu and given formula without our knowledge. :(

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