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Evidence-Based Strategies for Common Clinical Questions

April 2019

How to Become a Stronger Advocate for Breastfeeding 


Author: Kristin Streiler, MD | Chief Resident, Children’s Mercy Kansas City

Column Editor: Rupal Gupta, MD | Medical Director, Operation Breakthrough Clinic | General Academic Pediatrics | Assistant Professor, UMKC School of Medicine

The American Academy of Pediatrics recommends exclusive breastfeeding for about six months.1 Benefits to infant health include reduced risk of respiratory infections, gastrointestinal infections, otitis media, sudden unexplained infant death, obesity and a myriad of other conditions. Benefits to maternal health include decreased risk of cardiovascular disease, diabetes and breast cancer, among others. These proven benefits have led the AAP to advocate for breastfeeding as the norm for infant feeding.1

Even though evidence supports breastfeeding as the norm, practice has yet to catch up with recommendations. While the CDC’s 2018 Breastfeeding Report Card showed that 83% of infants had ever breastfed—meeting Healthy People 2020 goals—the gap lies in continuation and exclusivity of breastfeeding, rates of which remain below Healthy People 2020 targets. Breastfeeding rates in Kansas and Missouri hover near those targets.2 Pediatricians can improve a mother’s chance of success by identifying those who require additional support (and when), and learning what type of support is most beneficial.

While all mothers should receive support during breastfeeding, certain demographic groups and critical time periods warrant additional support. The CDC’s 2018 Breastfeeding Report Card notes that the most critical times for requiring breastfeeding support are the first few days of life (while breastfeeding is being established) and when mothers return to work.2 According to the CDC, initiation and continuation of breastfeeding varies by socioeconomic group and age, with the lowest rates occurring among non-Hispanic black women younger than 20 years, and the highest rates occurring among white women ages 30-34 years.3

Sattari, et al., found that physician mothers represent an unexpectedly high-risk group. While their rates of initiation are very high and socioeconomic factors suggest a high likelihood to continue breastfeeding, their observed rates of continuation of breastfeeding are low.4 Two studies surveying a combined total of 1,850 physician mothers found initiation rates ranging from 80-94%, with a precipitous decrease to only 15-21% continuing to breastfeed at six months.5,6,7 Supporting physician mothers who are breastfeeding is crucial not only for them, but also because their successful personal experiences are a strong predictor of their continued advocacy and anticipatory guidance about breastfeeding.8 Thus, pediatricians must learn evidence-based ways to support breastfeeding for not only mothers of patients, but also for their physician colleagues.

Supporting breastfeeding mothers begins with following AAP recommendations that pediatricians promote breastfeeding in hospitals and help families prioritize the practice during early weeks postpartum.1 Providing lactation support and space for parents or staff to breastfeed or express breast milk in the office is important to many mothers. It also sets an example of comprehensive support for breastfeeding. In addition to providing space and time for breastfeeding mothers, it is important to ensure they understand health insurance benefits mandated by the Affordable Care Act for breastfeeding. Insurance plans must provide support, counseling and equipment (including breast pumps) before and after birth.10 Finally, many mothers discontinue breastfeeding because of their own medications or based on poorly-informed advice from other health care professionals about maternal medications. Thus, it is crucial pediatricians know how to verify the safety of maternal medications during breastfeeding. The National Library of Medicine’s LactMed (freely available online) is the most up-to-date resource about transmission of maternal medications to breastmilk and possibly to the infant.11

Supporting physician colleagues begins with recognizing challenges they face. Miller and colleagues surveyed 1,500 resident physician mothers and showed that about 50% of mothers stop breastfeeding when they return to work because their work schedule interferes with breastfeeding.7 Eighty percent of resident physician mothers felt there was insufficient time for expressing milk.7 Arthur and colleagues surveyed 350 attending physician mothers and noted that the three major factors influencing breastfeeding cessation were returning to work, diminished milk supply, and lack of time to pump.5,6

The federal Fair Labor Standards Act requires employers to provide non-bathroom space and “reasonable time each such employee has need to express [breastmilk],” yet the CDC found that fewer than half of all employers meet these standard.2,10 Advocating for institutional change, such as designating convenient and well-equipped spaces for expressing milk, blocking time throughout the day for expressing milk, and updating or creating policies that increase the length of maternity leave are critically important to support physician mothers.4,8,9 Worldwide, employer-based comprehensive lactation support programs have been shown to increase continuation and exclusivity of breastfeeding. These programs make common sense, improve employee morale, and increase the proportion of women employees achieving Healthy People 2020 milestones.8,9

Advocating for every child to have a healthy start by supporting breastfeeding as the norm for infant feeding ought to be an important part of every pediatrician’s practice. Supporting a mother’s ability to breastfeed her child should start at the bedside and continue in the boardroom, where important practice management decisions are made.


1. Policy Statement: Breastfeeding and the Use of Human Milk. American Academy of Pediatrics Section on Breastfeeding. Pediatrics 2012; 129;e827.

2. Breastfeeding Report Card, United States 2018. Centers for Disease Control and Prevention. Online resources: Accessed 18 March 2019.

3. Healthy People 2020 Maternal, Infant, and Child Health Objectives. Centers for Disease Control and Prevention.

4. Physician Mothers: An Unlikely High-risk Group—Call for Action. Sattari, M et al. Breastfeeding Medicine 2010; 5(1).

5. The Employment-related Breastfeeding Decisions of Physician Mothers. Arthur, CR et al. J Mississippi State Med Assoc 2003;44:383-387.

6. Personal Breastfeeding Behaviors of Female Physicians in Mississippi. Arthur, CR et al. South Med J 2003;96:130-135.

7. Breastfeeding Practices Among Resident Physicians. Miller, N et al. Pediatrics 1996;98:434-437.

8. Employer-based Programs to Support Breastfeeding Among Working Mothers: A Systematic Review. Dinour, L and Szaro, J. Breastfeeding Medicine 2017;12(3).

9. Outcomes of a Hospital-based Employee Lactation Program. Spatz D, et al. Breastfeeding Medicine 2014;9(10).