Paediatric training on breastfeeding

To the Editor; I recently sent around a mailing to colleagues quoting what one fourth-year resident in paediatrics, having consulted with me by e-mail about certain breastfeeding issues, had to say about her paediatric training on breastfeeding. Here, from her e-mails, in a nugget, is what she said. “Teaching of breastfeeding at University of xxxx and at xxxxx Hospital? Exactly what teaching are you referring to? I do not recall a single lecture or problem-based learning case or anything.” And “I have had whole lectures on the components and makeup of one million different formulas (normal, premie, soy-based, partially or totally hydrolyzed, etc).” I was not surprised by what this resident had to say. After all, my work now consists exclusively of helping breastfeeding mothers breastfeed, and what I have heard mothers say about what paediatricians advised them regarding breastfeeding beggars the imagination. In 21 years of working with breastfeeding mothers, I have asked thousands whether their baby's doctor ever observed the baby breast-feeding. Only a few said yes. And yet, one can learn a tremendous amount by simple observation. One can see whether a baby is latched on well and whether the baby is getting milk. It is easy. Look at the video clips at to see the distinct pause in the chin of the baby at the breast. This pause says, “I just got a mouthful of milk.” The longer the pause, the more milk the baby got. The pause can be seen even on day 1, though not as dramatically. Once an observer knows this, he or she knows that breastfeeding by numbers is an absurdity. Per cent weight loss is misleading, and leads to undue confidence in some cases and unnecessary interventions in others. “Feed the baby at least eight to 12 times a day” makes no sense. A baby who feeds well will wake up when he's hungry. A baby who feeds so poorly that we are concerned he will get dehydrated should not be woken up to feed more frequently. What's the point of the baby getting nothing eight times a day instead of five? The point is to fix the breastfeeding not to wake the baby up more frequently to feed poorly more frequently. Twenty minutes on each side is meaningless. If the baby breast-feeds well, he may have had enough in 20 min on just one side. A baby who ‘nibbles’ for 20 h will not get enough. Are paediatricians aware of how to evaluate a breastfeeding? Do they learn this in their training, something that takes 15 s to see and then understand? Paediatricians lean on these numbers and the scales (which are sometimes inaccurate, and comparing different scales is useless) because they do not know about breastfeeding, and so numbers offer them security – false security. This is part of an e-mail I received recently from a new mother. “She had lost a considerable amount of weight and was admitted into the [a world-class Canadian paediatric] hospital. She was put through a battery of various tests to determine what may have been the cause for such an amount of weight loss (1 lb). After four days of hospitalization, it was determined that I was not producing enough milk.” This is appalling. If someone, someone who knows, had just watched the baby at the breast, they could have told immediately that the baby was not getting enough milk (which is not the same as the mother not producing enough; it is quite possible that her situation represented the usual situation, not that the mother was not producing enough, but that the baby was not getting the milk that was available). Four days of hospitalization at great cost could have been avoided, and the real problem, inadequate breastfeeding, could have been addressed, often without supplementation, in fact. This case is not unique, not by a long shot. Consider this: articles are frequently published on dehydration in breastfed babies. Breastfed babies do not get dehydrated. Babies get dehydrated if they are only pretending to breastfeed. They are not breastfeeding simply because they have the nipple in their mouths anymore than a baby who is sucking a bottle with a clogged nipple hole is feeding, and the fact that so many cases of dehydration occur is a black mark on our hospital system, in which most of the staff have no idea of how to help mothers establish breastfeeding. Consider this: most mothers could produce all the milk the baby needs, but most are failed by our system. They could have produced enough if given good help and information. Consider this: most mothers who have sore nipples do not need to have developed sore nipples. Simply helping the mother latch the baby on well will prevent and treat most sore nipples. Most mothers in Canada succeed in breastfeeding in spite of the ‘help’ they get because most women will produce more than enough milk, and when you produce more than enough milk, you can often overcome any problem. The Canadian Paediatric Society needs to do more to encourage teaching about breastfeeding to paediatric residents and to emphasize breastfeeding support strategies for practising paediatricans. Now is the time to get breastfeeding on the curriculum of medical schools and into the training of paediatricians, not just ‘breastmilk contains x g% protein, y g% fat, just like formula’, but important, practical stuff, so paediatricians can really do what they should be doing to help mothers and their babies maintain good health. Or, they should not advise mothers about breastfeeding at all, and leave it to those who know.

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