Breastfeeding Medicine

By Melissa Bartick, MD, MS, FABM

This week, the results of the COVID Mothers Study were published in Breastfeeding Medicine, providing more evidence that it may be safe to keep mothers and newborns together and, importantly, that separating them causes significant harm.  Indeed, as the authors point out, the “significantly low rate of [neonatal] hospitalization in the literature indicates it may be nearly impossible to demonstrate a clinical benefit from disrupting Baby-Friendly practices.”

Like other studies involving COVID-19, coordinating and launching this study had to be done quickly, for answers were urgently needed.  As the World Health Organization declared a pandemic on March 11, news stories appeared about infected mothers being forcibly separated from their infants with the rationale of protecting infants from infection, without evidence to support this practice, which violated existing quality standards of maternity care from the World Health Organization.  By the end of March, I, together with Dr. Lori Feldman-Winter, and Dr. Verónica Valdés had planned to gather such evidence. Lori and I had known one another for many years and had collaborated before, and we both met Verónica when she volunteered to help us after I sent out an email to the ABM membership.  Lori and I are Americans; Verónica is Chilean. We met and planned out a study using a survey, initially thinking we would quickly and easily get a large number of respondents by recruiting from social media platforms. Lori was also able to recruit statistical support (Dr. John Gaughan, PhD) and medical student manpower with social media expertise (Nikhil Bhana, B.S.) from her university.

We took full advantage of ABM’s internal communications networks to help us line up people who could translate and distribute the survey. Word of the study spread around the world. Having heard of the study through an Italian ABM member, we were thrilled to be approached by Angela Giusti, PhD of the Italian National Institute of Health (ISS) and Elise Chapin, MEd of the Italian National Committee for UNICEF, and they joined our team. Not long afterward, Dr. Maite Hernández-Aguilar, an ABM member, joined us and became instrumental in getting the survey around Spain, where cases numbers were very high.  Other ABM members in Germany (Dr. Elien Rouw) and Saudi Arabia (Dr. Fouzia AlHreashy) came forward, and still other members led us to contacts that helped with translation and recruitment in Brazil and other parts of Latin America, as well as Asia. This is how we came to meet nursing professor Elysângela Dittz Duarte, RN, PhD of Brazil, an important member of the research team. 

When it became clear that there were not nearly as many birthing women with histories of active COVID as the news led us to believe, we relied on our networks of doctors and their colleagues, including midwives and other health professionals, to get the survey to patients they knew.  We engaged Lucia Jenkins, RN, IBCLC of Baby Café USA to send the survey out immediately via social media to her network of 158 breastfeeding support sites in 28 U.S. States, expanding geographical reach. We are able to engage many American ABM members, including those who worked in COVID “hot spots,” to directly reach their patients. Together, our total sample size of 357 infants is one of the largest to date for a single study, and the neonatal subset of 129 infants, with 84 SARS-CoV-2+ mothers, is among one of the larger sizes for a COVID study.

We could not have done this study without the amazing network that ABM provided, as well as many other people we knew or got to know around the world.  We are grateful to all of them, and to the mothers who took the time to answer our survey.

ABM is excited to launch the beginning of our Candid Conversations series, featuring ABM members and their various initiatives within the Academy as well as their professional lives. This week, ABM sat down virtually with Helen Johnson, MD and Katrina Mitchell, MD IBCLC, two authors of our most recent protocol Breast Cancer and Breastfeeding, to discuss how they became interested in breastfeeding medicine, what lead them to creating their protocol, and what shifts they’ve seen in practice over the last year with the current health crisis.

Q: Please introduce yourself and provide any background or work information you’d like shared.

HJ: I am a native of Tampa, Florida and a graduate of Brown University’s Program in Liberal Medical Education.  I am currently in my fourth year of general surgery residency at East Carolina University/Vidant Medical Center in Greenville, North Carolina.  After residency I plan to pursue fellowship training in breast surgical oncology, and am currently working towards IBCLC certification.  My goal is to be able to provide high-quality care for patients with any breast condition, whether benign or malignant, and/or occurring during unique periods such as pregnancy or lactation.  I am passionate about research and evidence-based medicine, and hope to contribute to the advancement of scientific and medical knowledge related to breast disease. 

KM: I’m a breast surgeon and lactation consultant in Santa Barbara, California.  My practice focuses on the operative management of breast cancer, but I also care for breastfeeding dyads with a variety of lactation-related questions and concerns.

Q: How did you discover/enter the world of breastfeeding medicine? 

HJ: I experienced challenges breastfeeding my children.  When I sought medical evaluation for a breast condition, I was shocked by the fragmentation of care.  I was able to receive timely, helpful support from a lactation consultant, but it was much more difficult to find a clinician with prescribing privileges who was knowledgeable about lactation.  A colleague encouraged me to join the Facebook group Doctor Mothers Interested in Lactation Knowledge (“Dr MILK”), where I learned a great deal about breastfeeding from other physicians.  It was through Dr MILK that I first learned about ABM and the field of breastfeeding medicine.  I was so pleased to learn that there is a field devoted to breastfeeding medicine including care of the lactating breast, as I want to be able to help any patient with any breast concern. 

KM: During my breast surgical oncology fellowship in Houston, Pamela Berens was my breastfeeding medicine physician after the birth of my son.  She introduced me to the ABM, and my son and I attended our first conference in Portugal when he was 7 months old.

Q: How has being a member of ABM contributed towards your profession/life? 

HJ: Contributing to ABM protocols has been such a rewarding experience.  I have gained a deeper appreciation for the strength of the evidence for specific recommendations, and the process of developing societal guidelines.  I have especially enjoyed collaborating with other physicians who are passionate about breastfeeding medicine.  Through these collaborations, I have cultivated both professional connections and meaningful friendships.  

KM: The collaborative multidisciplinary aspect of ABM has opened an entirely new dimension in my professional and personal life.  I have developed a much more complex understanding of breast biology and pathophysiology than I ever knew as a breast surgeon alone.  I also have learned a great deal about pediatrics and the peripartum care of women, including the mental health challenges many patients experience. I have been so fortunate to have multiple mentors in breastfeeding medicine from different specialties, and I continue to learn something new each day.  I feel like I have completed a second residency in breastfeeding medicine!

Q: What lead you to identifying the topic you chose for the Protocol?

HJ: As a surgical resident who plans to practice breast surgery, I have a strong professional interest in the intersection between breast cancer and breastfeeding.  Little is taught about lactation in medical school or surgical training, yet breast surgeons and other physicians are entrusted with caring for breastfeeding patients with a current or past history of breast cancer.  As a moderator for Dr MILK, I read countless questions from other physicians about breast cancer screening, breast cancer treatment during breastfeeding, and breastfeeding among breast cancer survivors.  My impression was that physicians across multiple specialties would benefit from a practical, evidence-based resource to utilize when caring for this unique patient population.  

KM: Hyperlactation often results in complications that are surgical in nature – such as plugging, galactoceles, abscesses, and nipple conditions.  We thought it would be helpful to outline a standard approach to decreasing milk production in these patients to reduce maternal and infant complications of hyperlactation.  At the IABLE Ranch conference in 2019, we drafted this protocol and had great input from colleagues in different specialties who have practiced breastfeeding medicine in a variety of contexts.

The intersection of breastfeeding and breast cancer is a very challenging clinical scenario, and can be difficult for patients psychosocially as well.  Because we receive so many questions regarding this topic, we wanted to outline standard, evidence-based guidelines for the care of these patients.

Q: What difficulties has COVID-19 and its side effects (both in medicine and practice) presented to the implementation of your protocol? Or conversely, are there aspects of the current pandemic that have assisted it in any ways? 

HJ: In general, there have been many delays in routine cancer screening as a result of COVID-19, and sadly there has been an increase in the proportion of cancers which are advanced at presentation.  Many institutions had to halt non-emergent surgeries in order to divert resources towards care for COVID-19 patients, creating the need to utilize neoadjuvant treatment for breast cancers that were otherwise appropriate for up-front surgical therapy.

KM: Both cancer surgery and the care of breastfeeding dyads is not elective, so I have continued to see a large majority of patients in person, using standard precautions.  Telemedicine has allowed me to care for patients in other parts of our state, but there are significant limitations to evaluation via telemedicine.  The protocols have been very useful to share with colleagues during this time. 

Q: In your own life, what ways have you seen the pandemic change your daily working and life routines? 

KM: Remote learning is a real challenge for children and families.  We are very fortunate that my son meets state of California childcare guidelines for attending transitional kindergarten in person.  I am incredibly thankful to his school and teachers for what they do.  I’m concerned about the multitude of psychosocial and economic impacts of the shutdown, as well as patients avoiding care for other medical problems not related to Covid. 

Q: What are suggestions or tips you may have for physicians trying to implement your protocol, or more generally, support a breastfeeding parent at this time? 

HJ: I would remind readers that these protocols are living documents which are updated regularly, and that there remain many areas in breastfeeding medicine with limited evidence.  As such, I would encourage cross-disciplinary collaboration with other ABM members when seeking assistance for a challenging case as there may be more recent evidence to consider, and tips to be learned from the experiences of other breastfeeding medicine physicians.  

KM: Using standard precautions, I think it’s essential to evaluate patients in person whenever safely possible.

Q: Any additional thoughts? 

HJ: I would encourage surgeons who perform breast surgery to utilize ABM protocols and seriously consider joining ABM and learning more about breastfeeding medicine.

KM: Thank you to my ABM colleagues for their mentorship, friendship, and support.  Thank you to Helen Johnson for her friendship and incredible work ethic as a researcher and publisher.

New Rochelle, NY, June 10, 2020 — Managing women with breast cancer who are breastfeeding is a complex issue. The Academy of Breastfeeding Medicine presents new recommendations in the peer-reviewed journal Breastfeeding Medicine. Click here to read the article now.

“The aim of this new protocol is to guide clinicians in the delivery of optimal care of breastfeeding women as it relates to breast cancer, from screening to diagnosis, treatment, and survivorship,” state coauthors Helen Johnson, MD and Katrina Mitchell, MD.

It addresses the spectrum of care, including oncologic breast surgery, chemotherapy, and adjuvant and endocrine therapy. A section on breastfeeding women who have a previous history of breast cancer is included.

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, states: “This protocol is a guide for mothers who are undergoing diagnosis and treatment for breast cancer. It emphasizes that they do not have to categorically give up on their nurturing role as breastfeeding moms.”

Breast cancer is the most common malignancy in women worldwide. One in 20 women will develop breast cancer in their lifetime.

About the Journal
Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 12 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine
The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher
Mary Ann Liebert, Inc., publishers is known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

New Rochelle, NY, May 18, 2020 — Pregnant and breastfeeding women have been excluded from clinical trials of drugs to treat COVID-19, and as result, there is no safety data to inform clinical decisions. Such drugs include remdesivir according to a new article in the peer-reviewed journal Breastfeeding Medicine. Click here to read the article.

Since pregnant and lactating women are not included in clinical trials, little is known about whether the drug transfers into breast milk and reaches the infant’s circulation.

The lack of such data complicates a decision between giving lactating women a potentially life-saving drug and having them stop breastfeeding or risking any potential adverse effects of the drug on the infant, writes Alison Stuebe, MD, University of North Carolina School of Medicine and President of the Academy of Breastfeeding Medicine.

Suspending breastfeeding in mothers infected with COVID-19 could be detrimental because the infant is missing out on critical nutrients in human milk. Additionally, antibodies acquired from the mother may protect the infant against acquiring COVID-19.

“This quandary illustrates the consequences of longstanding policies to exclude pregnant and lactating women from clinical trials,” Stuebe says. “Rather than excluding pregnant and lactating women from research, we must protect them through research.”

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, states: “Pregnant and breastfeeding women and their fetuses and infants cannot continue to be administrative orphans regarding new drug trials, and this situation warrants immediate correction.”

About the Journal
Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 12 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine
The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher
Mary Ann Liebert, Inc., publishers is known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

MARY ANN LIEBERT, INC./GENETIC ENGINEERING NEWS

New Rochelle, NY, April 9, 2020–In a new commentary, Alison Stuebe, MD, President of the Academy of Breastfeeding Medicine, addresses the risks and benefits of separating infants from COVID-19-positive mothers following birth. Although multiple public health organizations recommended keeping mothers and infants together, the United States’ Centers for Disease Control and Prevention advises facilities to consider separating mothers and babies temporarily until the mother is no longer contagious, and recommends that the risks and benefits of temporary separation should be discussed with the mother by the healthcare team.

In her commentary, Dr. Stuebe, Professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and distinguished professor in infant and young child feeding at the Carolina Global Breastfeeding Institute at the UNC Gillings School of Global Public Health, notes that there is no evidence to show that early separation of infants and mothers with suspected or confirmed COVID-19 improves outcomes. While separation may minimize the risk of transmission of the virus from mother to infant during the hospital stay, it has potential negative consequences for both mother and infant, according to the commentary published in Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine published by Mary Ann Liebert, Inc., publishers. Click here to read the protocol free on the Breastfeeding Medicine website.

Dr. Stuebe outlines several risks of separating mothers and infants in the hospital, which disrupts breastfeeding and skin-to-skin contact during the critical hours and days following birth. For example, infants who lack skin-to-skin contact with their mothers tend to have higher heart rates and respiratory rates and lower glucose levels. The separation also stresses the mother, which could make it more difficult for her to fight off the viral infection. In addition, separation interferes with the provision of maternal milk to the infant, which is important for the development of the infant’s immune system. Separation also disrupts breastfeeding, which puts the infant at increased risk of severe respiratory infections, including pneumonia and COVID-19.

“As we navigate the COVID-19 pandemic,” Stuebe writes, “I am hopeful that we can center mothers and babies and remember to first do no harm.”

Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine, concurs that “there is no need or indication to categorically separate infants from COVID-19 suspect or positive mothers other than in circumstances wherein the mother’s medical condition precludes her caring for the infant. Feeding mothers’ own breast milk, either by nursing or by feeding of expressed milk, is OK and desired!”

About the Journal

Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine, is an authoritative, peer-reviewed, multidisciplinary journal published 10 times per year in print and online. The Journal publishes original scientific papers, reviews, and case studies on a broad spectrum of topics in lactation medicine. It presents evidence-based research advances and explores the immediate and long-term outcomes of breastfeeding, including the epidemiologic, physiologic, and psychological benefits of breastfeeding. Tables of content and a sample issue may be viewed on the Breastfeeding Medicine website.

About the Academy of Breastfeeding Medicine

The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding. Our mission is to unite members of the various medical specialties with this common purpose. For more than 20 years, ABM has been bringing doctors together to provide evidence-based solutions to the challenges facing breastfeeding across the globe. A vast body of research has demonstrated significant nutritional, physiological, and psychological benefits for both mothers and children that last well beyond infancy. But while breastfeeding is the foundation of a lifetime of health and well-being, clinical practice lags behind scientific evidence. By building on our legacy of research into this field and sharing it with the broader medical community, we can overcome barriers, influence health policies, and change behaviors.

About the Publisher

Mary Ann Liebert, Inc., publishers is a privately held, fully integrated media company known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research, including Journal of Women’s Health, Childhood Obesity, and Pediatric Allergy, Immunology, and Pulmonology. Its biotechnology trade magazine, GEN (Genetic Engineering & Biotechnology News) was the first in its field and is today the industry’s most widely read publication worldwide. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publisher’s website.

By Melissa Bartick, MD, MSc, FABM

The Academy of Breastfeeding Medicine has released its updated Bedsharing and Breastfeeding Protocol. The protocol presents evidence-based recommendations synthesized by an international collaboration of authorities on the topic who conducted a rigorous review of the literature.

Aimed at physicians and other health care professionals caring for families who have initiated breastfeeding, the protocol recognizes that bedsharing promotes breastfeeding.  In contrast to recommendations by some organizations, breastfeeding mothers and infants are not advised against bedsharing, as long as no hazardous circumstances exist. The protocol emphasizes that all parents should be educated on safe bedsharing, recognizing that bedsharing is very common, and when bedsharing is unplanned, it carries a higher risk of infant death than planned bedsharing.

Hazardous circumstances include sleeping with an adult on a sofa or armchair; sleeping next to an adult impaired by alcohol, medications, or illicit drugs; tobacco exposure; preterm birth; and never having initiated breastfeeding.

The ABM protocol takes a “risk minimization” approach, emphasizing a discussion of risks and benefits of bedsharing with parents. This type of approach is being increasingly adopted in countries such as the UK and Australia. “Having conversations about safe bedsharing is important for removing stigma around the topic and facilitating open and honest dialogue between parents and providers,” says Dr. Lori Feldman-Winter, Professor of Pediatrics at Cooper Medical School in Camden, New Jersey and one of protocol’s authors. Dr. Feldman-Winter serves as co-faculty chair on the National Action Partnership to Promote Safe Sleep (US), and she was also an author of the American Academy of Pediatrics’ 2016 protocol on safe sleep.

ABM was pleased and honored to collaborate with three of the world’s leading experts on this topic: anthropologists Helen Ball and James McKenna, and epidemiologist Peter Blair. Dr. Blair, Professor of Epidemiology and Biostatistics at the University of Bristol (UK) is chair of the International Society for the Study and Prevention of Perinatal and Infant Death (ISPID), and Dr. Ball, Professor of Anthropology at the University of Durham (UK), directs the Durham Infancy & Sleep Centre, as well as serving on ISPID Board. Dr. McKenna is known for his ground-breaking work from his Mother-Infant Sleep Lab at the University of Notre Dame (Indiana, USA). Dr. Kathleen Marinelli, Clinical Professor of Pediatrics at University of Connecticut Medical Center and co-author, was instrumental in arranging the participation of Drs. Blair, Ball and McKenna.

In creating the protocol, we rigorously reviewed all available evidence about risk. In addition, we put the current research and evidence into historical context, noting that solitary sleep and artificial feeding are related and were recent developments in human history. We noted that some marginalized and low-income populations have a higher rate of sudden infant death as well as a higher rate of artificial feeding, thus measures to increase breastfeeding and lower the exposure to hazardous circumstances in these populations are important.

“The welcome fall in unexpected deaths over recent decades has come about through risk reduction advice being closely aligned to the available published evidence. This protocol takes the same approach,” says Dr. Blair. 

Breastfeeding is important for safe infant sleep when bedsharing. “When bedsharing next to their mothers, breastfeeding infants sleep on their backs, and are naturally positioned away from pillows and objects that might obstruct their airways. Breastfeeding mothers form a protective position around their infant,” says Dr. Ball. Dr. Ball’s team provides detailed information for families through the Baby Sleep Information Source.

“Breastfeeding while bedsharing comprises a unique set of behaviors between mother and infant known as ‘breastsleeping,’ which also results in increased time breastfeeding compared to separate sleep,” notes Dr. McKenna.  Breastfeeding is associated with a lower risk of Sudden Infant Death Syndrome.

As the person charged with seeing the protocol through to fruition from writing to approval, I found the process of achieving consensus on the evidence and recommendations to be both challenging and rewarding. It required working closely with many people who held a variety of differing viewpoints and experiences on the topic and finding common ground. We are thus especially satisfied that this protocol represents the best evidence-based and practical recommendations for clinicians. We hope this protocol will be widely used.

Melissa Bartick, MD, MSc is an internist at Cambridge Health Alliance and Assistant Professor at Harvard Medical School. 

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.