Every week I hear stories from nursing mothers in which their doctors gave them incorrect information or bad advice about breastfeeding. It’s frustrating, because people want to feel that their doctors are knowledgeable and that their advice is trustworthy. People often feel that they have to follow a doctor’s advice. Unfortunately, this advice too often leads to shortened duration of breastfeeding when it is based on misinformation. How pervasive is this problem?

The 1995 Series

A series of studies published in 1995[1,2,3,4] looked at physicians’ knowledge and attitudes regarding breastfeeding. Both senior medical residents and practicing physicians were surveyed for this series in the fields of pediatrics[1,2,3], Ob/Gyn[1], and family medicine[1,4]. Overall, the results showed that physicians had poor general knowledge of breastfeeding and breastfeeding management, poor attitudes towards breastfeeding promotion, poor self-confidence in counseling patients with breastfeeding problems, and had received insufficient formal training on breastfeeding. This series also found that prior personal breastfeeding experience by physicians or their spouses predicted greater knowledge, attitude, and self-confidence compared to those without personal breastfeeding experience.

  • General Knowledge – While almost all agreed that breastfeeding enhances infant immune function, about a third of doctors surveyed were not aware that breastfed infants also have lower incidence of gastroenteritis and otitis media[4].
  • Breastfeeding Management – Generally, around half of medical residents surveyed and around a third of practicing physicians surveyed chose incorrect clinical management practices for breastfeeding. For example, in counseling a mother with perceived low milk supply, 40% of residents and practicing physicians chose incorrect advice. Around 40% of pediatricians and 60% of family physicians did not know how to manage an otherwise healthy 4-day-old breastfed infant with jaundice[1,4]. Almost 50% of both pediatricians and family physicians were not aware that supplementing with formula during the first 2 weeks of life is a cause of breastfeeding failure[2]. The percentage of physicians who recommended complete termination of breastfeeding for treatable lactation difficulties (including mastitis, insufficient milk supply, breast abscess, teething, frequent loose stools, baby not seeming satiated) was significant[2,4].

Percent of surveyed doctors who answered breastfeeding knowledge questions correctly, from National Assessment of Physicians' Breast-feeding Knowledge, Attitudes, Training, and Experience(1).

  • Attitudes – About 25% of doctors surveyed did NOT agree that exclusive breastfeeding is the most beneficial form of infant nutrition[4]. About 25% of family physicians did not feel that breastfeeding promotion was an important use of their time[4].
  • Self-confidence – Less than 50% of all residents and physicians surveyed[1] (and only 14% of pediatric residents[3]) rated themselves effective in counseling breastfeeding patients.
  • Training – More than half of practicing physicians rated their training as inadequate in preparing them to counsel breastfeeding patients[1]. Only 55% of medical residents recalled even one instance of instruction on breastfeeding, and fewer than 20% had at least 5 trainings on breastfeeding[1].
  • Personal Experience – Previous personal breastfeeding experience was a major determinant of improved clinical knowledge and improved self-confidence[1,3]. Those with personal breastfeeding experience chose the correct advice more often than their counterparts in managing mastitis by 14%, insufficient milk supply by 20%, and early supplementation by 8%. There were also 22% more physicians with personal experience than without who felt self-confident in their ability to counsel patients.
    *In this series, “previous personal breastfeeding experience” was defined as whether they or their spouse “had ever breast-fed an infant for at least 2 weeks. This time frame was not intended to represent successful breast-feeding experience, but rather an adequate length of time to initiate a diligent attempt at breast-feeding and to ensure first-hand understanding of common breast-feeding techniques and problem solving.” [4]

The 2004 follow-up

A follow-up study[5] was done 10 years later to determine how knowledge and attitudes of pediatricians had changed over a decade. In the follow-up study, more pediatricians in 2004 than in 1995 were found to have negative opinions and attitudes about breastfeeding. Fewer pediatricians in 2004 believed that the benefits of breastfeeding outweighed the difficulties or inconveniences. The chart below shows the percentage of pediatricians in 2004 and 1995 who recommended that mothers not breastfeed for various reasons. More pediatricians in 2004 recommended that mothers not breastfeed for unnecessary reasons, such as immaturity of the mother and inconvenience. Pediatricians in 2004 did have more personal breastfeeding experience compared to 1995, and personal breastfeeding experience did continue to be associated with better knowledge of breastfeeding management practices compared with non-experienced counterparts.

2004 vs 1995 pediatrician recommendations not to breastfeed, from Pediatricians and the Promotion and Support of Breastfeeding(5).

Other Studies

Other studies from other groups have also demonstrated a lack of knowledge about breastfeeding by medical professionals.

  • Growth Charts – A study from 2000[6]showed that while almost all doctors in the study frequently or always plotted infant growth at well-child visits, none reported plotting breastfed babies on a growth chart specifically for breastfed infants. Only 5% of study participants were even aware that breastfed infants grow at a different pace than formula-fed infants. This knowledge was related to personal breastfeeding experience: Only 2% of participants without personal breastfeeding experience answered correctly, while 12% of participants with breastfeeding experience knew this.
  • Drug Safety – A 2007 study[7] reviewed 10 resources that doctors and pharmacists commonly use to review drug safety information when prescribing medications to lactating mothers. These sources varied widely in their recommendations for safety of medications while lactating. When healthcare practitioners use sources with outdated and incorrect information for determining the safety of a medication, they are likely to inappropriately advise many mothers that their recommended medications are incompatible with breastfeeding, and therefore advise mothers to temporarily or permanently cease breastfeeding unnecessarily. LactMed was found to contain more extensive and current citations than the other resources studied. Out of 14 drugs in the probe, 11 were found to be safe when using LactMed, while some other sources deemed 2 or fewer drugs safe for breastfeeding mothers [see chart below].

Number of medications deemed safe while breastfeeding by various sources, from Lactation Safety Recommendations and Reliability Compared in 10 Medication Resources(7).

  • Personal Breastfeeding Experience – Recall that previous personal experience with breastfeeding was a major determinant in greater knowledge and confidence in counseling breastfeeding patients in the studies discussed above. Physicians’ personal experience as a predictor of breastfeeding knowledge was further investigated in a 2008 study[8]. The previous studies had divided the participants into two groups, those who had personal breastfeeding experience of at least 2 weeks, and those who did not. This study divided the participating physicians into four groups: those with no personal breastfeeding experience, those with less than 6 months of personal breastfeeding experience, those with 6-12 months experience, and those with greater than 12 months experience.
    .
    In this study, doctors who had less than 6 months of breastfeeding experience had knowledge levels similar to doctors with no breastfeeding experience at all, however they had poorer attitudes toward breastfeeding than all other groups. In addition, they were more confident and perceived themselves to be more effective than their knowledge and attitudes would indicate. 25% of participants with short breastfeeding experience agreed with the item – “Breastfeeding and formula feeding are both equally acceptable methods of feeding infants.” – compared with less than 5% of participants from the other three groups. 80% of participants with short breastfeeding experience agreed that – “Breastfeeding is incompatible with working outside the home.” – compared with less than 50% of other participants.
    .
    One possible explanation proposed in the report was that these participants may have a need to normalize and defend their own decision to stop breastfeeding before the recommended time, regardless of their reason for weaning. Agreeing that infant formula and breastfeeding are equivalent and that it is not possible to breastfeed and work outside the home enables these participants to justify decisions they may have already made regarding infant feeding. Conversely, those who have longer experience with breastfeeding also have a need to justify their decision to continue to breastfeed while participants without children may have an idealistic view of breastfeeding, not recognizing or understanding the difficulties that often arise. Alternatively, the group with short breastfeeding experience may have had lower breastfeeding attitudes before they became parents, which negatively influenced their breastfeeding duration once they did become parents.
  • Training – Because of the low level of knowledge about breastfeeding demonstrated by doctors, it is necessary for more training on this topic for residents and physicians. A 2011 study[9] showed that residents in pediatrics received only about 3 hours of breastfeeding training per year (9 hours over 3 years). Another study[10] showed that training doctors is an effective method of increasing breastfeeding success for their patients. After a training course, residents were more likely to show improvements in knowledge and confidence, and the infant patients of these residents were more likely to breastfeed exclusively for 6 months.

Final Thoughts

Physician attitudes and knowledge about breastfeeding seem to be improving over the last decade, and I look forward to seeing another update to the previous surveys. Adequate training for residents is now understood to be important. But it is apparent that there are still many physicians with poor attitudes and knowledge out there. As a patient, you expect your doctor’s advice to be appropriate, but in the area of breastfeeding there unfortunately seems to be a good chance that your doctor can actually hinder your breastfeeding success with misinformation. And it seems that one of the best ways to gauge your doctor’s knowledge might be to simply inquire as to whether the doctor’s own children were breastfed, and if so, for how long.

References:

1. Freed GL, Clark SJ, Sorenson J, Lohr JA, Cefalo R, Curtis P. National Assessment of Physicians’ Breast-feeding Knowledge, Attitudes, Training, and Experience. JAMA. 1995;273(6):472-476.

2. Freed GL, Clark SJ, Lohr JA, Sorenson JR. Pediatrician Involvement in Breast-Feeding Promotion: A National Study of Residents and Practitioners. Pediatrics. 1995 Sep;96(3 Pt 1):490-4.

3. Williams EL, Hammer LD. Breastfeeding attitudes and knowledge of pediatricians-in-training. Am J Prev Med. 1995 Jan-Feb;11(1):26-33.

4. Freed GL, Clark SJ, Curtis P, Sorenson JR. Breast-feeding education and practice in family medicine. J Fam Pract. 1995 Mar;40(3):263-9.

5. Feldman-Winter LB, Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians and the Promotion and Support of Breastfeeding. Arch Pediatr Adolesc Med. 2008;162(12):1142-1149.

6. Guise JM, Freed GL. Resident Physicians’ Knowledge of Breastfeeding and Infant Growth. Birth. 2000 Mar;27(1):49-53.

7. Akus M, Bartick M. Lactation Safety Recommendations and Reliability Compared in 10 Medication Resources. Ann Pharmacother. 2007 Sep;41(9):1352-60.

8. Brodribb W, Fallon A, Jackson C, Hegney D. The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of Australian GP registrars. Matern Child Nutr. 2008 Oct;4(4):264-74.

9. Osband YB, Altman RL, Patrick PA, Edwards KS. Breastfeeding Education and Support Services Offered to Pediatric Residents in the US. Academic Pediatrics. 2011;11(1): 75-79.

10. Feldman-Winter L, Barone L, Milcarek B, Hunter K, Meek J, Morton J, Williams T, Naylor A, Lawrence RA. Residency Curriculum Improves Breastfeeding Care. Pediatrics. 2010 Aug;126(2):289-97.