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!