Pediatrician Competency in Breastfeeding Support Has Room for Improvement

The American Academy of Pediatrics (AAP) recommends breastfeeding as the preferred method of infant feeding. The protection, promotion, and support of breastfeeding are matters of public health policy and important roles for pediatricians.¹ In this issue of Pediatrics, Feldman-Winter et al² provide a summary and analysis of the data from 3 AAP Periodic Surveys of Fellows, conducted in 1995, 2004, and 2014, examining knowledge and attitudes of fellows of the AAP regarding breastfeeding. In examining the trends, the authors conclude that pediatricians’ recommendations and practices have become more closely aligned with AAP policy between 1995 and 2014; however, their attitudes about the likelihood of breastfeeding success have worsened, so continued efforts to enhance pediatricians’ training about breastfeeding are necessary.

Between 1995³ and 2014⁴ (most recent national data available), breastfeeding initiation rose from 60% to 82%, and 6-month breastfeeding rates for any (not exclusive) breastfeeding increased from 21% to 55%. These improvements in breastfeeding rates occurred across a backdrop of increased awareness regarding the importance of breastfeeding for women’s and children’s health outcomes while significant national initiatives promoted breastfeeding. In 2011, the US Department of Health and Human Services published “The Surgeon General’s Call to Action to Support Breastfeeding,”⁵ which established a national breastfeeding agenda with 20 action steps to encourage all segments of society to improve breastfeeding support. It called for all health professionals who care for women and children to receive education and training in breastfeeding and emphasized that basic support for breastfeeding should be considered a standard of care for pediatricians.

The Affordable Care Act included a provision covering breastfeeding counseling services and supplies and mandated breaks for milk expression for employed breastfeeding women.⁶ The Department of Health and Human Services’ “Business Case for Breastfeeding”⁷ provides resources and innovative approaches to support breastfeeding women in the workplace. The US Department of Agriculture Food and Nutrition Service's Special Supplemental Nutrition Program for Women, Infants, and Children enhances breastfeeding support by providing anticipatory guidance, counseling, pumps, and education for pregnant and breastfeeding women.⁸ 

Hospital breastfeeding practices have changed as well. The Joint Commission adopted the perinatal care core measure on exclusive breastfeeding as a quality measure. The Centers for Disease Control and Prevention instituted the biannual Maternity Practices in Infant Nutrition and Care⁸ surveys of maternity facilities in 2007. In that year, only 2.9% of births in the United States occurred in “Baby-Friendly”–designated facilities. By 2017, that number had increased to 21.8%, accounting for 869 000 births.^9,10 The Centers for Disease Control and Prevention have funded 2 major national initiatives with the aims to improve maternity care practices and to increase the number of Baby-Friendly designated hospitals in the US. "Best Fed Beginnings,"¹¹ a nationwide quality improvement initiative, resulted in 80% of enrolled facilities achieving designation as Baby-Friendly.¹² "EMPower Breastfeeding: Enhancing Maternity Practices" has used a model of breastfeeding content experts and quality improvement coaches to guide enrolled facilities in improving maternity care practices and achieving designation as Baby-Friendly.¹³ Baby-Friendly designated facilities must follow the “Ten Steps to Successful Breastfeeding.”¹⁴ Two of those steps include having a written breastfeeding policy routinely communicated to all health care staff and training all staff in the skills necessary to implement the policy. Pediatricians with privileges in newborn care must complete a minimum of 3 hours of education on breastfeeding management.

Residency training in breastfeeding is not universal. Freed et al¹⁵ identified deficiencies in pediatric residency training in a national survey published in 1995. A survey of pediatric program directors in 2006 to 2007 concluded that pediatric residents received an average of only 3 hours of breastfeeding training per year.¹⁶ The respondents reported that 67% of the pediatric residents have access to breastfeeding rooms, but only 10 programs had an official policy on breastfeeding accommodations for residents. Feldman-Winter et al¹⁷ previously documented that the implementation of a breastfeeding curriculum improved breastfeeding knowledge, practice, and confidence.

Positive trends from the Periodic Survey of Fellows series were noted by Feldman-Winter et al.² More pediatricians are affiliated with Baby-Friendly–designated facilities. They were more likely to recommend both exclusive breastfeeding and an early first postnatal visit by the fifth day of life. Pediatricians reporting that breastfeeding should be initiated within the first hour after delivery increased significantly from 44% in 1995 to 92% in 2014.

Some concerning trends from the 2014 Periodic Survey of Fellows were that pediatricians were less likely to believe that the benefits of breastfeeding outweigh the difficulties or inconveniences encountered and that younger pediatricians felt less confident in their ability to manage breastfeeding despite being more predominantly women and having more personal breastfeeding experience. Fewer than half of the respondents in 2014 advised that families should delay the introduction of a pacifier until breastfeeding is well established, and 17% reported not making any recommendation about infant feeding in the first month of life.

The authors² indicated that pediatricians or residents affiliated with Baby-Friendly hospitals would be receiving the required provider breastfeeding education. As the trend toward staffing hospitals with pediatric hospitalists increases, it is important to remember that ambulatory pediatricians also need breastfeeding education because they are responsible for the ongoing follow-up care of breastfeeding families. The maintenance of certification and lifelong learning skills should include breastfeeding as a core competency for general pediatricians.

Although the 2014 Periodic Survey of Fellows shows progress in many areas, the importance of routine integration of breastfeeding into all aspects of medical education cannot be overstated.^18,19 Pediatric residents, especially, should receive targeted breastfeeding education (including clinical skills practice) not only during newborn nursery experiences but also in continuity clinic and inpatient pediatrics, where follow-up and newborn readmissions occur. Breastfeeding education should be as routine in the curriculum as other preventive health strategies, such as immunizations. Residents must develop the skills to assess breastfed infants and their lactating mothers and be confident in managing clinical breastfeeding problems. The residents’ training programs should also provide a culture of support for residents who themselves are breastfeeding mothers because pediatric residents are the future providers, pediatric teaching faculty, and advocates for breastfeeding policy changes. Hopefully, by 2024, the Periodic Survey of Fellows will demonstrate that almost all practicing physicians have the breastfeeding knowledge, skills, attitudes, and confidence needed to provide competent breastfeeding support to their patients.

 
• AAP

  American Academy of Pediatrics