Supporting Families for Breastfeeding Success: A Case Study

Primary care support of breastfeeding requires listening, learning, and collaborating. What does that look like when caring for the breastfeeding dyad?

Consider this scenario:  A 4-day-old infant presenting to your office falling asleep at the breast, not feeding well, and down 12% from birth weight. The parents' goal is to breastfeed for one year. They do not want to supplement with formula.  How would you respond?

Common experiences

Below are instructions, that families shared with us, that the family received from their PCP prior to their appointment in our office: 

A) “You need to start giving 1-2 oz formula 8 times a day, otherwise you are giving your baby brain damage.”

B) “Keep feeding frequently. Your milk should be coming in, and I’ll see you in a week for a weight check.”

C) “Keep breastfeeding, but offer 2 ounces formula after each feeding.”

Decision A guarantees the baby gains weight (if the parents follow your advice), though it undermines the parents' self-efficacy, engenders a sense of failure, and increases the likelihood of breastfeeding cessation.

Decision B supports the concept of breastfeeding, though it ignores the 12% weight loss which medically requires an intervention. An infant that is 12% below birthweight needs sooner follow-up than one week. There is a risk of the infant losing more weight if milk supply does not increase, and we want to prevent dehydration, increased jaundice, and rehospitalization (see Protocol #3 from the Academy of Breastfeeding Medicine). Additionally, maternal milk supply needs to be evaluated, along with infant milk transfer, to determine if feeding frequency alone will support appropriate weight gain.

Decision C guarantees the baby gains weight, though it can increase the risk of weaning, and undermines the family’s breastfeeding goal by not providing education on steps to increase milk supply.

An alternative response that considers the breastfeeding dyad

Decision D: “Can you tell me more about your pregnancy and history? Also, I would like to watch a breastfeeding session today and then, after examining your baby and considering the history, we can decide on how to help your baby gain weight and support you in your goal to breastfeed.”

This approach supports breastfeeding by getting more history, evaluating a feeding, and evaluating if milk supply is increasing.

• Evaluating the breastfeeding dyad’s history identifies risks for delayed lactogenesis or low milk production.
• Examining the infant, and observing a feeding, evaluates the infant's ability to transfer milk from the breast.
• With the additional history and examination, we can determine if the milk is coming in and if the baby is having trouble getting it out.

With Decision D approach, if there are concerns, we are better informed to collaborate with the family to protect the goal of breastfeeding while also making certain their baby starts gaining.

Despite the improved care from Decision D, it is common for families to experience barriers and responses like A, B & C.

The main barriers to a breastfeeding supportive approach: time and education

Without improved breastfeeding medical education and solutions to address limited time during visits, families will continue to face barriers from their health care providers. Decision D takes time and education. The time to take a history and evaluate a feeding remains a barrier to appropriate primary care breastfeeding support, within most PCP practices. While there are supportive measures that can happen during brief encounters, a full evaluation does take time. If time is a factor, it is appropriate to screen and identify a plan which includes further evaluation. Options for this breastfeeding dyad could include:

1) Hand expressing after feeds and refeeding expressed breast milk, with follow-up the next day in clinic with more time set aside for further evaluation.

2) Referral to a lactation colleague. 

3) Team-based LC/PCP care in your office, with the lactation consultant available to spend the needed time to evaluate a feeding and milk supply. 

With team-based care you are equipped to routinely offer Decision D. 

Attitude matters

Families' perceptions of their health care providers' attitudes toward breastfeeding influences duration, so even if we have limited time and education, our support is critical. The families referred to my practice by their PCP, who identified the need for further support, are very thankful to their PCP for listening and pointing them in the right direction. Families without this support often wean or remain frustrated at their PCP. 

The Infant Feeding Practices Survey highlights the importance of physician support in initiating breastfeeding. In a study of pre-pregnancy obese patients, physician breastfeeding support was associated with an 8.5% increased probability of initiating breastfeeding and 12.5% increased probability of breastfeeding for six months.

Despite the importance of physician and health care provider attitudes, studies show that not all primary care providers think breastfeeding is their responsibility. A questionnaire sent to 1,429 pediatricians and 1,329 family physicians identified that just less than half thought evaluating breastfeeding was the primary care provider’s responsibility. Furthermore, only 5.1% of the pediatricians and 11.3% of the family physicians routinely observed a breastfeeding session.

Individualize breastfeeding support

By individualizing care, we can help increase confidence and support. The Office of the Surgeon General recognizes that our systems of care need to “guarantee continuity of skilled support for lactation between hospitals and health care settings in the community.” Our clinics are part of the continuity of care. 

Each family will define breastfeeding success in their own way.  We can be there to listen, offer support, and make certain our practices do not hinder the process. There are many approaches to caring for a newborn infant who has lost weight - some support breastfeeding and some do not. 

Let’s work together to create a system that supports each family to reach their individual vision of breastfeeding success. 

~ Ann M. Witt, MD, FABM, IBCLC