Memo for GPs: when a breastfeeding mother walks in

You may have seen the Lancet series on breastfeeding that was published last week [1] and you may have seen the headlines that announced the UK was the “world’s worst at breastfeeding” [2].

It’s a time when those of us in breastfeeding support feel both energised by the Lancet’s affirmation that breastfeeding matters in all countries: “Our systematic reviews emphasise how important breastfeeding is for all women and children irrespective of where they live and of whether they are rich or poor”. [3] And also disappointed that the media’s emphasis was on UK ‘failure’ and it quickly turned to the ‘failure’ of individual women. [4]

As Dr Rollins stated at the launch of the Lancet papers, we need a different focus: “This is not about individual mothers either succeeding or failing. This is not about one lobby group winning over another; it´s not about our individual comfort zone or fashion; it´s about the survival and health of women and children today and in future generations” [5].

These are big issues and they require big thinking and money. At a time when money is hard to find. Health visiting and community breastfeeding support have moved to local authority funding from NHS England and these are the same people looking to save significant chunks from their budgets. There is a local authority in London threatening to decommission health visiting services in 2017. Peer support services are being slashed – even the ones run by volunteers [6]. Children centres are closing and the few groups run by volunteers are struggling to find places to meet [7] Infant feeding coordinator positions are being lost. There is no breastfeeding lead or national committee on breastfeeding in England and the post of Welsh lead has just been cut.

Things are about to get very real for GPs in the world of breasts. Imagine a mum giving birth and being discharged by the community midwife (already stretched and unable to give sufficient time to breastfeeding support) and then when breastfeeding goes pear-shaped after 10 days, the GP is her only port of call. If I had a pot of money to spend on breastfeeding support in the UK right now, I would spend it on talking to GPs about breastfeeding. In a country where the infant feeding survey is cancelled, helplines running on a shoestring, health care professionals being trained by formula companies [8], I’d still spend it on talking to GPs. If I had unlimited time too, I would buy every GP a coffee and say, ‘Can I just have five minutes of your time to tell you a handful of things that will change lives?’

Health care professional bashing is a national pastime. Right after the breath where we say how proud of the NHS we are. But please don’t imagine that those in breastfeeding support don’t get how hard this is. You have ten minutes to talk a mother who is presenting with complex issues wrapped up in emotions and sleeplessness with a chaser of internet research. You have to be a generalist and the lactation bit really wasn’t a focus in your training. We understand that and we’d like to correct that but now you are in your surgery and working a day that doesn’t give you time to go to the toilet, we get that ship might have sailed.

Before you move onto your next webpage, please skim this one. I am an IBCLC, International Board Certified Lactation Consultant. That means I took two 3 hour exams after a thousand hours of supporting breastfeeding mothers. And I recertify every 5 years after a further 75 hours of education in lactation. I am chair of a national charity (www.abm.me.uk) that helps to run the National Breastfeeding Helpline and have spoken to more than 3000 mothers myself on that helpline. I run three drop-in groups in North London and have done for seven years. I visit mums in their home and spend all day texting, emailing and phoning to discuss breastfeeding issues. I don’t know everything but I do know what is likely to walk through your surgery door and what will be helpful for you to say to them.

Mothers need help with medication. They want to continue breastfeeding and treat their other conditions. They don’t want to stop breastfeeding for even a day. That’s like asking them not to be a mother when breastfeeding really matters to them. It is hard to get reliable information on the compatibility of breastfeeding and medication as manufacturers will have rarely paid for the necessary licensing for breastfeeding mums and the responsibility is pushed back on to you. Luckily in the UK, we have other people who will take that responsibility. The Breastfeeding Network runs the Drugs in Breastmilk helpline: https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/. The factsheets on this site give a summary of the main medications for a range of conditions. The compatibility of anti-depressants and breastfeeding may be especially relevant to some of the new mums you see: https://www.breastfeedingnetwork.org.uk/antidepressants/ Research has shown that ending breastfeeding can increase risk of postnatal depression so supporting mums to use medication that is compatible is an important role of the GP [9]. As well as using the factsheets, you or the mother can contact the helpline directly to speak to a specialist pharmacist. The ‘Breastfeeding and Medication’ page can also be found on Facebook: https://www.facebook.com/breastfeedingandmedication/info?tab=page_info. Messages are answered by trained volunteers

Mums walk in the door with mastitis. Let’s just check first it’s not a blocked duct that can be resolved with good self-help measures. A blocked duct means firmness and even tenderness in the breast but the mother feels generally well and there is no pyrexia. This can be resolved with increased drainage of the breast, warm compresses on the firm area and massage. An electric toothbrush is handy for massaging the affected area. The mother may benefit from using different positions to help with draining the breast effectively or pumping after a feed if there is concern the baby is not feeding well. If infective mastitis is suspected, antibiotics should be accompanied by increased drainage and the massage and warm compresses. If a mother does not continue to breastfeed frequently, it is more likely she will go onto to develop an abscess. Antibiotics are required if a mother's symptoms are severe and a bacterial infection is evident but not simply because a breast is firm and uncomfortable, not least because the dyad may go onto develop nipple and breast thrush as a consequence. https://www.breastfeedingnetwork.org.uk/wp-content/dibm/BFN%20Mastitis%20feb%2016.pdf

​Mums will walk in with sore and damaged nipples. This may sometimes be the entry point for the staph aureus which is the common cause of mastitis. ​The most common cause of nipple damage will be positioning and attachment issues. Of course, in the ideal world, you’ll be referring a mother to a breastfeeding support group, a lactation consultant or a trained health visitor. However there are things that take less than three minutes to point out that could make all the difference. Is the mum leaning forward to ‘put’ the breast in the baby’s mouth or moving the breast unnaturally (so then inside the baby’s mouth it springs back into its natural position and gets trapped against the baby’s hard palate)? Damage is likely to be caused by nipple abrasion against the hard palate usually because the baby does not have enough breast tissue in its mouth. The baby’s gape is important. And when the baby gapes, we want to maximise the space of their tongue on the breast. Their chin should be making close contact, the baby’s body close, the baby not likely to drift if mum’s arms get tired. We want the baby to take a large mouthful of areola below the nipple. This lactation consultant explains how simply leaning back can make all the difference and the fact we falsely believe a mother should sit bolt upright is often the problem:
 
“In the commonly used cradle, cross-cradle, and football/rugby holds, mothers and babies must fight the effects of gravity to get babies to breast level and keep their fronts touching. If gaps form between them (which can happen easily with gravity pulling baby’s body down and away), this disorients baby, which can lead to latching struggles. The pull of gravity makes it impossible for a newborn to use his inborn responses to get to his food source and feed…In these positions, gravity can transform the same inborn feeding responses that should be helping babies into barriers to breastfeeding. Head bobbing becomes head butting. Arm and leg movements meant to move babies to the breast become pushing and kicking. Mothers struggling to manage their babies’ arms and legs in these upright breastfeeding holds have often told me: “I don’t think I have enough hands to breastfeed.” http://www.mothering.com/articles/natural-breastfeeding/

Videos from Nancy Mohrbacher show a powerful alternative: https://youtu.be/rHXolgD4r44

And this image from Nancy Mohrbacher may help

Latching issues can also cause vasospasm and blanching of the nipple. It can also be responsible for neuralgia deeper in the breast. A mother with Raynaud’s syndrome may experience nipple pain when breastfeeding is otherwise going well. She may find applying warm dry compresses after a feed helpful and in severe cases nifedipine can be prescribed: http://www.raynauds.org/2011/02/08/help-for-pregnant-breastfeeding-moms/

If it’s not an issue of latching, you may be prescribing topical antibiotic cream or considering treatment for thrush: https://breastfeeding.support/thrush-on-nipples/
 
Thrush will usually develop after a period of pain-free breastfeeding. If a mother is getting misshapen nipples after a feed and the nipples appear to show mechanical damage, latching will remain the primary focus. Even in the absence of symptoms, both members of the dyad will need thrush treatment if one is suffering. Miconazole oral gel is not licensed under four months due to a risk of choking but mums can be taught to apply the gel safely and it is shown to be more effective than nystatin suspension. Deeper breast pain is often connected to neuralgia but ductal thrush is a possibility. The pain will develop as the breast empties and peak shortly after a feed (or pumping session) has finished. Fluconazole is not licensed for breastfeeding mothers. However it’s worth noting that the amount that gets through in milk is 0.6mg/kg/day. The amount that can be given to a baby within the license is 6mg/kg/day (Dr Thomas Hale).
 
A mum experiencing constant nipple pain and damage despite support with positioning and attachment and may also have a baby who struggles to stay attached, feeds for excessively long and may feed frequently, isn’t putting on weight adequately, could have a baby with ankyloglossia (tongue tie).  An overview here: http://www.cwgenna.com/ttidentify.html. Posterior sub-mucosal tongue ties can be particularly difficult to identify on first look. You should have a referral pathway that gives you access to a tongue tie clinic locally: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/support-for-parents/tongue-tie/

 A Mother may come for help when they suspect they have low milk supply. Is there anything you can do? It is worth noting that many mothers lack confidence and perceive themselves to have a low milk supply when they are experiencing normal breastfeeding. You can find out more in Low Supply 101 here.
 
If a mother’s breasts are feeling softer, if they no longer leak, if their baby is not sleeping for extended periods, if their baby is cluster feeding – all that can be normal. As can a mum whose body does not respond to a breast pump and they find it hard to trick their bodies in achieving the surge of oxytocin needed for the milk ejection reflex when a plastic pump is all that’s there to stimulate it.
 
However if a mother is showing further signs and her baby is experiencing faltering growth, she may be asking you to help. Has she already received good quality breastfeeding support? Has her baby’s positioning and attachment been checked? Is she feeding regularly and not switching sides too quickly (but also not staying on one side beyond the point the baby is transferring milk because someone has mistakenly told her a baby MUST feed for 30 minutes). Could she benefit from hiring a double hospital grade pump to help boost supply? Is she in the process of reducing her use of formula and giving her milk production a chance to develop?
 
What else could be happening?
 
The impact of thyroid dysfunction on low supply can be devastating and a significant minority of mothers experience thyroid issues post-partum: https://www.llli.org/breastfeeding-info/breastfeeding-and-thyroidism/
 
Some mothers, perhaps those with insufficient glandular tissue, may be asking you for a prescription of domperidone. This is an off-label use of the drug and there have been some concerns with using it for lactation in the last few years. Some research indicated a link between domperidone and cardiac issues. However the issues were among patients over 60 who had cardiac problems, who were taking other medication which caused arrhythmia or were taking a dose of domperidone greater than 10mg three times a day. https://www.breastfeedingnetwork.org.uk/wp-content/dibm/BfN%20statement%20on%20domperidone%20as%20a%20galactogogue.pdf
Research has shown that domperidone causes a steady increase in milk supply over a placebo. As the Breastfeeding Network specialist pharmacist notes, “We do not have research suggesting that domperidone causes risks to otherwise healthy, young women who are breastfeeding.”
 
Metoclopramide is sometimes prescribed as an alternative prolactin-booster but we need to be aware this is known to increase risk of depression and should only be given for short periods.

Breastfeeding doesn’t feel like a ‘choice’ for many of the women seeking your help.  For lots of mums, it is a choice and it might be a choice that they decide not to go for.  That is of course up to them and their families. But for many of the desperate women in pain and struggling, this is one of the most important things they will ever do in their lives. To discuss moving to formula instead of looking at the root of their problems or to discuss your personal views about formula feeding is a waste of precious minutes. You may have struggled with breastfeeding yourself, or watched your partner struggle. It can be difficult to empathise with the woman sitting in front of you who appears to prioritise breastfeeding beyond what you consider logical. It may make you feel uncomfortable about your own choices. Other healthcare professionals may get a chance to debrief their own breastfeeding experience but you rarely do.
 
Do not doubt that there are women who seek your help who would literally have a toe amputated if it meant that they could solve their breastfeeding problems. And they’d be happy for you to do it right there and then. And that’s about the level of pain they are experiencing right now, but still they persevere. ‘Why don’t you give up?’ is what they are already being told by mothers-in-law and friends and sometimes partners when they cry at 3am. They are asking for your help because that isn’t the way they want to go. When their nine month old is on a nursing strike and is suddenly refusing the breast, they want you to check for an ear infection before you talk about formula. They get it’s an option. Ending breastfeeding and using formula really isn’t a secret. If you don’t know the answers, then it’s valuable to have a sense of what is available to you locally in terms of signposting. Your local health visiting team should have information available on local support groups and drop-ins. What leaflets does the local post-natal ward give out? There are four charities in the UK that offer breastfeeding support: the NCT, the Breastfeeding Network, the Association of Breastfeeding Mothers and La Leche League. Is there a local La Leche League meeting near you?
 
If you aren’t familiar with local drop-ins, mums can also speak to breastfeeding counsellors through the National Breastfeeding Helpline: 9.30-9.30 365 days a year on 0300 100 0212. All the charities have their own separate helpline too.
 
If a mum needs more specialist care, a lactation consultant may be useful. An IBCLC may be attached to the local hospital or they can find one at www.lcgb.org.

 They may also be women breastfeeding past 12 months and even 2 years and 3 years. They are doing that because they are meeting their child’s needs and their knowledge of the constituents of breastmilk and its continuing immunological benefits may possibly supersede yours. If you are personally uncomfortable with it, it’s not a conversation you need to have. Do you believe that breastmilk ‘loses its benefits’ as time goes on? What is your evidence-base for that belief? Can you find its source? 

It looks as though the role of GPs in lactation support is likely to become even more significant in the coming years. There are places where you can access more training. UNICEF have an e-learning package that you may find useful: http://www.unicef.org.uk/BabyFriendly/Resources/Training-resources/E-learning-for-GPs/ Or here from BMJ learning: http://learning.bmj.com/learning/module-intro/breast-feeding.html?moduleId=5003232 

You can also find free videos here: http://www.health-e-learning.com/resources/free-lectures?lang=en
Shadowing a lactation consultant or a breastfeeding counsellor at a support group will also be a valuable way to spend some time.
 
As the Lancet series says, ‘breastfeeding is generally thought to be an individual’s decision and the sole responsibility of a woman to succeed, ignoring the role of society in its support and protection.’ [10]. Those of us who talk to breastfeeding women every day know we cannot underestimate the impact of just 10 minutes of contact with a well-informed GP. The effect is felt in her immediate relief as she walk away from the surgery and in the lifelong impact on her and her baby’s health.

Notes:
[1] http://www.thelancet.com/series/breastfeeding
[2] http://www.bbc.co.uk/news/health-35438049
[3] Victora, C.G. et al (2016) Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475–90.
[4] https://heartmummy1980.wordpress.com/2016/02/03/are-you-strong-enough-to-change-the-world/
[5] https://www.facebook.com/DrJackNewman/
[6] http://www.essexchronicle.co.uk/Essex-County-Council-cut-support-breastfeeding/story-28078350-detail/story.html
[7] http://www.bbc.co.uk/news/uk-england-wiltshire-34983055
[8] http://www.babymilkaction.org/archives/7167
[9] http://www.cam.ac.uk/research/news/breastfeeding-linked-to-lower-risk-of-postnatal-depression, http://www.ncbi.nlm.nih.gov/pubmed/25138629
[10] Rollins, N.C. et al (2016).  Why invest, and what it will take to improve breastfeeding practices? Lancet 2016; 387: 491-504.

Cover image: crocheted breasts used by lactation consultants and breastfeeding supporters in conversations with mums. These were made by AnatomicalknitsbyLGD on Etsy.