Tuesday, 28 January 2014

Doctors and breastfeeding - a follow-up post

Sometimes blogging completely takes me by surprise. Last week I posted about GPs and breastfeeding. Compared to some of my posts, hardly anyone read it - which is, of course, fine - but those who did then engaged in such fascinating and lengthy debate, on Twitter, on Facebook and by email, that a follow-up post is the result. I guess sometimes you just have to put things 'out there' to get to the heart of the matter.

(I should probably say that I was in two minds about even posting last week's piece. I have enormous respect for doctors, the standard of their training and the work they do in tough times for the NHS. On the other hand, I think that when we're considering an issue as thorny as how to raise breastfeeding rates in our society, we have to look critically at everything that might be having an impact and wonder about how changes can be made. Sometimes we'll be barking up the wrong tree. Sometimes new insights will come.)

One point that I don't think I made well enough last week was actually about breastfeeding supporters (I include myself) and how we respond to articles in the media or comments by individuals. While I think it's right that misinformation be challenged, I can't help feeling that there's an irony in the fact that we can Tweet and blog up a storm - in what is sometimes quite an aggressive way, if only due to the sheer volume of complaints - in response to a media doctor's quote in a magazine, but have no meaningful way of addressing the same misinformation when it's dished out to women one-to-one by a GP or other health professional.

Some of the comments by doctors in response to my post took me to task - rightly - for calling for more training for GPs when their time and budgets are so sorely stretched, and when every other 'single-issue' group thinks the same about their area of interest. It was pointed out to me that if a GP must do 50 hours of CPD each year, and the breastfeeding training takes half an hour, then that means that breastfeeding must be in the top 100 things the GP considers that year (and that's assuming they all take half an hour; some will obviously take longer. Some topics GPs are contractually obliged to cover). When you start to consider the list of things that GPs need to be abreast of (!) you can see why breastfeeding doesn't automatically push itself to the top of the list, particularly in areas with low breastfeeding rates where GPs see very few breastfeeding women, or in areas where there are reasonable breastfeeding support services away from the GP.

Something that came out of this discussion for me was the idea that there is work to be done in increasing awareness among GPs, possibly via representation to the Royal College of General Practitioners, of the public health aspect of increasing breastfeeding rates and the potential beneficial impact on GPs - the cost implications of fewer appointments for ear infection, gastroenteritis and lower respiratory tract infection are outlined in this UNICEF report. I would love to see a case study showing this in practice.

Another point that was raised, and which I found fascinating, was the degree to which GP services vary across the country. I mentioned some of our local frustration with tongue-tie referrals via GP - and discovered that in North London tongue-tie referrals can be made by a midwife or IBCLC at a drop-in group, rather than by the GP, and that in Bristol, although four people across the city can snip tongue-ties, one is off sick and thus waiting times are around four weeks (a long time in the context of a troubled breastfeeding relationship). In some GP practices in the south-east parents can self-refer to an in-house GP for tongue-tie cutting, although the long-term availability of that service can't be guaranteed. Is there anything that can be done about this variability? It was suggested to me that breastfeeding supporters engage with CCG pharmacists and educationalists to discuss issues of prescribing for lactating mothers and best practice in treating breastfeeding women and infants, and I wonder if there's an opportunity - somehow, for someone - to do that work.

Finally, some really interesting ideas surfaced from the discussion. These included finding ways to have more IBCLCs working in or alongside the NHS, perhaps in larger GP practices or rotating between several practices, and the idea of increasing the numbers of peer supporters by offering them a £200 voucher incentive (as opposed to the mothers themselves). I also loved this link about innovative ways in which breastfeeding training is being delivered to busy doctors and nurses in the US.

In the end, it's a problem with no easy solution. But another common theme of the discussion was frustration with the way things are - on both sides. Perhaps we (and by we I mean anyone with an interest in breastfeeding) can start by broaching the subject with our own GP practices - we might at least open a dialogue that could be beneficial. Some great resources for doctors are Wendy Jones's book Breastfeeding and Medication and Dr Thomas Hale's Medications and Mother's Milk. The Breastfeeding Network's factsheets are another excellent source of information for GPs.

Thanks to all those who contributed to the discussions of the original post.

Wednesday, 22 January 2014

Doctors and breastfeeding - room for improvement

Image from Fit to Bust by Alison Blenkinsop,
published by Lonely Scribe. It appears opposite
a page criticising Dr Jessen for overlooking the
importance of breastmilk for toddlers in 2010.
This post has been prompted, in part, by the Twitter-storm yesterday about Dr Christian Jessen's comments on breastfeeding, published in Closer magazine this week. He complained he'd been misquoted; Closer issued an online clarification - my feeling was that although he had been misquoted, there was still quite a lot wrong with what he'd actually said. Luckily I don't need to take his words to pieces - the fabulous Analytical Armadillo, IBCLC and Tracy at Evolutionary Parenting have already done a brilliant job, complete with plenty of references to actual research. Baby Milk Action have issued a comment, and Milli Hill has written a piece for Best about it.

Coincidentally, I was thinking about doctors and breastfeeding yesterday anyway. I came across this PDF about the management of thrush in breastfeeding women, written by an Infant Feeding Specialist in Derbyshire, which distils current thinking and best practice for doctors and prescribers, and circulated it to our group of peer supporters. We encounter a lot of mums who struggle to get the treatment they need from GPs and I thought it might be helpful if we could point them to this resource. We shouldn't really have to: I don't think it's unreasonable to expect GPs to have an up-to-date working knowledge of breastfeeding.

Dr Christian Jessen is a high-profile example (there are others: Dr Ranj Singh, Dr Carrie Ruxton, Dr Ellie Cannon) of a doctor who is regularly invited to comment on general health matters, including breastfeeding, despite having no specialist knowledge in the field. In this, he's not unlike GPs across the country who see breastfeeding mothers in their surgeries day in, day out. What comments like Dr Jessen's show, writ large across our national media, is how little our doctors often know about breastfeeding - not only in terms of actual lactation, but also in terms of how a breastfeeding relationship affects the lives of mothers and their babies. The implications of this are profound: the high-profile media doctors' inaccurate pronouncements undermine the efforts of those striving to improve breastfeeding rates, in pursuit of gains in public health and reduced cost to the NHS, and provoke online rows that often divide breast and bottle feeders and reinforce tired stereotypes. And
GPs in their surgeries nationwide, if they do not have training in breastfeeding or prescribing for breastfeeding mothers, are being equally unhelpful.

Every peer supporter I know has a story to tell about breastfeeding advice from GPs (sometimes unsolicited when attending for something unrelated!). Here are just a few examples we've come across recently in our own area:

- a mum told to stop breastfeeding for 48 hours while on high-dose antibiotics. It transpired she wasn't taking a high dose and that it was safe to continue breastfeeding.
- a mum told to stop breastfeeding for two weeks (!) in order to pump all feeds to 'see how much she was making'.
- a mum referred to GP to request a tongue-tie referral (HV sent mum to GP after peer supporter raised issue). In our area this simply requires GP to fax consultant. However, GP insisted that tongue-tie would split on its own, that it didn't affect feeding (it was) and that he would prescribe Gaviscon for the infant's reflux (which was probably due to the tongue-tie...)
- one mum mentioned the WHO guidelines to her GP, and was told they only applied in developing countries (they don't).
- a mum with persistent ductal thrush was told no further treatment was possible, despite having been told by another GP at the same practice to come back for stronger/longer meds if necessary. Dr eventually looked it up and realised this was true.
- a mum whose GP called her 'ridiculous' for still breastfeeding her 18-month-old.

Earlier this week I saw a status from Wendy Jones, on her Breastfeeding and Medication page, bemoaning the number of calls she's had recently from mothers of young babies, who've never experienced pain-free breastfeeding, who've been 'diagnosed' and treated for thrush which is not resolving. These women need help with position and attachment (and possibly tongue-tie!), not thrush treatment, and their GPs should realise this.

I;m not interested in bashing doctors here. We can't leave doctors out of breastfeeding. They have a crucial role to play, particularly where, as is the case in my area, there's no way of referring women on for BFC or IBCLC support for breastfeeding problems. If the peer supporters and health visitors can't help, mums must go via the GP for any onward referral. But our GPs need to be up to speed, and the examples above show that many are not.

I've done a bit (and only a bit) of digging into where the problems arise. GPs in practice now may have followed quite different training pathways from each other. It's entirely possible that a doctor qualified as a GP having never done an obstetrics/gynaecology/paediatrics rotation in training, which it seems is where exposure to breastfeeding problems would come in. However, even then trainee doctors may have been warned off by midwives from giving breastfeeding advice - disempowering them from the start and leaving them with the distinct impression that breastfeeding is something dealt with by 'others'. While this might be true in a teaching hospital situation with highly trained midwives and infant feeding specialists on staff, it doesn't help that doctor a few years later when faced with a waiting-room full of mothers and babies. Not all doctors find it easy to say to patients that they are unsure about something and need to look it up; not all doctors are aware of the importance of breastfeeding to the breastfeeding mothers themselves. Some doctors have personal experience of breastfeeding issues - and I don't discount the value of that - but in the absence of additional training, using one's own experience to advise patients can cause its own problems. Indeed, peer supporters, health visitors and midwives who are trained to support breastfeeding mothers are encouraged to debrief their own experiences and then leave them aside when dealing with other mothers, whose circumstances may be very different, to concentrate on giving good, evidence-based information.

There is some good news: doctors-in-training today should have at least a cursory knowledge of breastfeeding. At Keele University, for example: "...there is formal teaching about breastfeeding, to support problem-based learning in the context of a growing family, for students in their first year. Thereafter students will meet the issues [diagnosing and treating breastfeeding problems like thrush and mastitis, prescribing for lactating women] as part of their learning on placements – they have units on Child Health and Women’s Health in secondary care; and extensive patient contact in primary care placements (22 weeks across the curriculum, of which 15 are in final year). One difficulty is that much of the peri- and ante-natal care that GPs used to do is now done via midwives and students have much less contact with them for learning opportunities." (my italics)

What more can be done to improve GPs working knowledge of breastfeeding? In Derbyshire, where we're aiming for full Baby-Friendly Accreditation, we're encouraging local GPs to do the UNICEF Baby-Friendly GP E-learning module: it costs around £10, takes around 25 minutes to complete, and is endorsed by the Royal College of General Practitioners. The problem is that many doctors don't know that it even exists! Mothers everywhere: contact practice managers at your local surgeries and ask them if your GPs can do this training. It counts for their CPD (continuing professional development). If mothers are better informed, they can push for better service from their GPs. Ask your GP to check whether medication is suitable while breastfeeding, or ask them to look up the relevant Breastfeeding Network fact sheets on the condition they're treating. Ask them who else might be able to help with a breastfeeding problem. Ask your peer supporters which local GPs are most clued-up about breastfeeding.

I've focussed on GPs today but really, the same applies to any doctor who meets breastfeeding women and their infants regularly. I'm not suggesting all doctors should be breastfeeding specialists, and I understand the pressures that GPs and indeed all doctors operate under - but I would like to see fewer women on the receiving end of poor advice.

You can read my follow-up piece to this post here.

What do you think? Have you had poor breastfeeding advice from a GP? How do you think the situation can be improved? Leave your thoughts in the comments!