Medscape One-on-One With Regina M. Benjamin, MD, MBA

Surgeon General: Address Breast-Feeding Challenges With Your Patients

Eli Y. Adashi, MD; Regina M. Benjamin, MD, MBA


March 10, 2011

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Eli Y. Adashi, MD: Hello. I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape One-on-One. Joining me today is Dr. Regina Benjamin, the 18th Surgeon General of the United States. Our topic: "Breast-Feeding -- Now More Important Than Ever." Welcome.

Regina M. Benjamin, MD, MBA: Thank you. Good to be here.

Dr. Adashi: What a pleasure it is to have you with us again.

Dr. Benjamin: Yes, I had a good time last time, so thanks for having me back.

Dr. Adashi: Our pleasure. You have recently issued a Call to Action in support of breast-feeding. Could you describe the essence of this initiative and the drivers behind it?

Dr. Benjamin: Basically, my whole platform is prevention. This is just another place in my prevention strategy to continue. Breast-feeding used to be more commonplace than it is now. We as clinicians, doctors, and nurses know the benefits of breast-feeding. We know that as the antibodies are transferred from the mother to the baby, fewer upper respiratory infections and ear infections occur. We also see [fewer diagnoses of] SIDS [sudden infant death syndrome] in babies. So, we know the benefits [of breast-feeding for the baby].

What we don't seem to talk about as often is the benefits of breast-feeding for the mother. Breast cancer and ovarian cancer are less likely to develop in mothers who breast-feed. We wonder why we aren't seeing more breast-feeding among mothers. We know that more than 75% of women initiate breast-feeding, but by the time they're 6 months [postpartum], they're not breast-feeding anymore. The rate has dropped down to less than 10%-12% [at this point]. Something happens [during those 6 months, and] we wonder why.

What we're finding is that our society is not as friendly to breast-feeding for moms who want to breast-feed. We know that many mothers cannot or choose not to breast-feed, but among those who want to breast-feed, we need to make it easier for them: to make the environment [more open to breast-feeding].

Everyone can help with breast-feeding. Grandmothers and mothers in earlier generations used to breast-feed, but this is not as common nowadays, so we need to help educate moms and grandmoms. We have a number of organizations available in communities that are willing to help moms, grandmoms, and fathers to support the mother who wants to breast-feed.

The same holds true for the workplace. More and more women work today. We want them to be able to breast-feed when they have to go back to work. So we are making the workplace more breast-feeding-friendly through the Affordable Care Act, by requiring a company simply to provide a clean and private room or place for a mom to breast-feed other than a bathroom. These are some of the main ways that we want to encourage people to help moms who want to breast-feed.

Dr. Adashi: So when we say that breast-feeding is more important now than ever, we mean, in part, that the emphasis on and perhaps the support of breast-feeding has not been perhaps all that it could be?

Dr. Benjamin: We're finding that we're not making it easy for women to breast-feed, so the most important thing now is that we -- the clinicians and the healthcare community -- can chip in and give that support. We know that our patients trust us and they trust what we say. We can start encouraging women who want to be moms in the future to start thinking about breast-feeding even before they become pregnant.

We can also encourage women by talking about the benefits of breast-feeding and the things that we might not think about. For example, a mom at our [January 20th] launch [for a "Call to Action to Support Breastfeeding"] had her baby with her. She said there's nothing like having your baby there looking and connecting with you eye to eye. It's a connection -- a bonding -- that you wouldn't get otherwise.

Dr. Adashi: In a way, if I were to put words in your mouth, you are asking our viewers who are providers, among other [healthcare professionals], to serve as advocates for breast-feeding and provide whatever support they can.

Dr. Benjamin: Support and leadership -- to make hospitals breast-feeding-friendly by having lactation centers. Doctors and nurses might or might not always know how to [advise new moms] themselves, and we can learn more. We can consult with those who are experts. Breast-feeding is personal. Again, everyone may not want to breast-feed, but we can offer support to those who want to breast-feed.

Dr. Adashi: In the Call to Action, you actually cite a number of specific steps that families, communities, employers, and healthcare professionals can take to improve breast-feeding rates and increase support for breast-feeding. Could you perhaps describe some of these strategies and what the evidence is that backs them up?

Dr. Benjamin: There are 18-20 specific strategies in the Call to Action. The first one involves the family to be a part of this [experience], because everything starts at home. The family, the community, lactation specialists, and organizations, such as La Leche [League], are very helpful in teaching [new mothers]. Moms, aunts, and grandmoms used to educate women about breast-feeding, but, nowadays, they themselves haven't necessarily breast-fed, so we have to bring in the whole community, organizations, and others to help teach them all [about breast-feeding. We have to] make sure that the fathers feel included because many feel left out. The mom is breast-feeding the baby, so what role do fathers have? Many fathers will now say that the moms will pump and at night they will feed the baby with the pumped milk while the women get a chance to sleep. This opportunity is helpful in having fathers feel engaged and be supported, and allows all of them to bond together.

When we talk about going outside the community, particularly in the workplace, it's important to make women feel that it's okay to ask for a break to be able to breast-feed or to pump and not to feel guilty. In particular, hourly-wage earners, such as cashiers, should feel that it's ok to take an extra break rather than feel guilty because they need to pump [breast milk]. We shouldn't make [working women] feel guilty. They should feel comfortable; [breast-feeding] is a part of life and it's natural. Their coworkers and their employers need to be supportive. [Nursing mothers] need to have a clean and private place, and that's a simple thing to do.

Doctors and nurses should be supportive of their patients and make referrals [to lactation specialists] when needed. They should ask the mom whether she is having problems with the baby latching on. It may be simple things like, "Do you feel like you're making enough milk?" It may be that she just needs some water to drink -- that she's not getting enough hydration. Simple little things.

Dr. Adashi: It seems as though this is really a good time to increase the awareness of both providers and communities to the import of breast-feeding and to reinforce some values that we may have perhaps neglected somewhat over the last several years.

Dr. Benjamin: We are going back to basics. Nature is a wonderful thing. She has provided for you to be able to give your baby all the things it needs [from breast milk] and to protect yourself at the same time, and we should take advantage of that. Nothing is wrong with formula, and some people need it, but it shouldn't be the first option. Give moms the natural option first and encourage them. If they need to supplement with formula, that's one thing, but at least give them that [support to breast-feed]. We've also been looking for some celebrities and young stars to make breast-feeding hip again, which is going to be important particularly with the younger generations.

When I launched this Call to Action paper, we had a couple of folks present who were fairly younger moms, and [Director] Spike Lee's wife, [Tonya Lewis Lee,] was one of the people there. She's a writer and a successful woman in her own right. The younger generation knows her and looks up to her. She talked about how her husband was very supportive [of breast-feeding].

Dr. Adashi: Despite progress, breast-feeding, in addition to the issues that we discussed, continues to be challenged by elements, such as the mandatory discharge from the hospital 24 hours [after childbirth], giving women relatively little time to learn to adjust and to practice in a sense. Then there is the absence of reimbursement for breast pumps and the limited, if spotty or if any, coverage for lactation consultants. Can you perhaps discuss the steps taken to address these barriers to the extent that is possible and any progress that is being made in those areas?

Dr. Benjamin: Yes, I was very active with the AMA [American Medical Association] in the '90s trying to fight against what we used to call the 24-hour drive-thru deliveries. I think we've gotten through to the insurance companies since then; many don't enforce that [policy] anymore. Doctors, particularly obstetrician-gynecologists and family physicians who deliver babies, really are looking after the mom and what's in her and the baby's best interests before they are discharged. Hopefully that is improving a little bit. However, with reimbursements [early discharge remains] an issue. We still want mothers and babies out of the hospital as soon as possible but without putting them at risk.

In regard to the lactation supplies, just this past week the IRS [Internal Revenue Service] has come out with a ruling that lactation supplies, such as breast pumps, are considered medical devices that can be covered and claimed as a taxable deduction. That was a big win for us because we've been trying to get that [ruling. Lactation supplies now qualify] as a taxable deduction and as part of your medical savings accounts, which is wonderful.

We're still trying to make sure that insurance companies will understand the importance of lactation consultants, because we have to learn that these are experts just like any other consultants we use. When we talk about obesity, for example, we know that a baby who is exclusively breast-fed for the first 6 months of life is less likely to be obese. Having a lactation consultant to be able to help you with [breast-feeding] is important.

Dr. Adashi: One other major barrier that women will encounter when breast-feeding is pain. What practical advice or insight can you share with our viewers who are providers as to how we can address this very real challenge?

Dr. Benjamin: It is a very real challenge. As a family doctor, the first thing that I do when a breast-feeding woman's pain gets to be serious, and there are no minor issues, is to refer her to a lactation consultant because they seem to know their area of expertise and specialty very well. That's the first thing I would say; know and have on hand as a backup a lactation consultant who you trust and to whom you can refer. There are other things that you can use, such as warm compresses and showing a mom how to help the baby latch. [The timing of breast-feeding sessions and the application of home remedies can also help] keep women from being sore. However, lactation consultants spend time with [nursing moms]. They'll be in their homes and check on them, call them, and show them these little tricks of the trade. Lactation consultants have a really important role, and I can't stress enough how important they are.

Dr. Adashi: What more could we potentially do on the educational front in terms of training for providers of any kind so that they are better prepared to advise their patients about breast-feeding?

Dr. Benjamin: We can do so much with continuing education. We can learn a lot more and be more comfortable with discussing [breast-feeding] with moms, or with making the referrals or knowing when we need to make the referrals [to lactation consultants]. We need to understand that sometimes a mom may not tell you the problem that she is having. She may just keep it to herself, [so clinicians should] know when to ask. We can educate ourselves a little bit better on those matters because we often took it for granted that [breast-feeding] was something that was natural. Oftentimes a mom may be having problems and staying up at night wondering whether the baby is not [breast-feeding enough]. We weigh the baby and say that the baby hasn't gained [enough weight]. Then the mom feels guilty because she's not making enough milk. We, as her doctors, nurses, and clinicians, can say that that is normal, and these are the things we can do to improve [the situation] and give her support.

Dr. Adashi: It would probably make sense, in addition to continuing medical education, to attempt to inject this issue into the medical school curriculum perhaps and in appropriate residency training programs into graduate medical education.

Dr. Benjamin: Yes, not just for obstetrician-gynecologists or for pediatricians, but also for family physicians, any primary care providers, and some of the specialists so that we're aware and have a basic understanding that [breast-feeding] is natural in any specialty.

Dr. Adashi: Thank you very much for revisiting an issue that almost certainly needed a little nudge, having been perhaps taken for granted, having perhaps been assumed to be a nonissue --

Dr. Benjamin: And also knowing that moms start out wanting to breast-feed, but they just can't continue and keep it going. We can help them.

Dr. Adashi: With women in the workplace, there's no question that the scene has changed dramatically. Breast-feeding at home before the mass movement of women into the workplace was a very different challenge than it is now, and so updating an issue that has obviously been with us forever is very useful. We thank you for taking on that responsibility and sharing it with us.

Dr. Benjamin: Many people didn't want to talk about [breast-feeding], so I hope that they'll continue to talk about it, raise awareness, and make women comfortable with breast-feeding.

Dr. Adashi: Thank you very much.

Dr. Benjamin: Thank you.

Dr. Adashi: On that note, sincere thanks to Dr. Benjamin and to you, our viewers, for joining Medscape One-on-One. Until next time, I am Eli Adashi.


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