In the News

An Open Response to Dr. Amy Kennedy’s Article Breast or Bottle – The Illusion of Choice NEJM April 20, 2023

We see and hear you and are so sorry you endured these experiences. We are physicians practicing breastfeeding and lactation medicine, and we acknowledge the overwhelming lack of support for families after birth. Many of us have come to this field after experiencing our own similar challenges, and we would like to offer a different perspective. We propose that health care systems and policies must change to support breastfeeding dyads in reaching their goals as recommended in evidence-based guidelines from reputable medical societies such as the World Health Organization (WHO), the Academy of Breastfeeding Medicine (ABM), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, and the European Society for Social Pediatrics and Child Health (ESSOP). This letter identifies several places where the system failed and delineates opportunities for improving support for lactating parents and their infants without changing evidence-based clinical guidance. These guidelines are not a demand on mothers – they are meant to be a call to action for health care systems and policymakers to support families.

System failures start with a lack of prenatal education. Dr. Kennedy’s statement that she had no idea what she was getting into indicates a lack of prenatal breastfeeding support. Many of us felt similarly unprepared for our first breastfeeding experiences. A 2017 Cochrane Review showed that many different forms of prenatal breastfeeding education increased the odds of exclusively breastfeeding and increased the length of time dyads breastfed. Recent research affirms that parents find prenatal breastfeeding education helpful. Therefore, after the physician or other health care worker screens for a feeding plan, every family should receive education and anticipatory guidance about their infant feeding plan as an essential part of their prenatal care.

Next, we see that not having support on the weekend resulted in a missed opportunity for early intervention and managing breastfeeding challenges. This illustrates the frequent lack of support from lactation-knowledgeable physicians, nurses, and lactation consultants immediately after birth. We propose that the onus should be on the hospital system to emphasize and support breastfeeding and lactation education and policy so families can receive quality breastfeeding care regardless of when they give birth.

Third, Dr. Kennedy’s story highlights the inconsistent information and lack of full-scope lactation care available in the outpatient setting. In her case, the highly intensive act of triple feeding was recommended without an endpoint or further evaluation for underlying problems. It is well known that many physicians and other health care workers may lack the knowledge and experience to support lactating parents, as lactation education is minimally (if at all) included in medical education or residency. Inappropriate and inconsistent recommendations lead to poor care and traumatic experiences. Similarly, evaluation and management of medical issues related to lactation are often not done or delayed contributing to increased stress to the lactating person and suboptimal management of these conditions. Close follow-up and diagnostic ability are crucial to improving experiences and outcomes in the postpartum period.

Finally, difficulty breastfeeding is associated with an increased risk of peripartum mood and anxiety disorders (PMADs), and the American health care system does a poor job of supporting mental health. Dr. Kennedy notes feelings of stress, anxiety, and hopelessness and ultimately had to advocate for herself at six months postpartum. Multiple health care team members did not promptly identify or address these issues. The onus should not be on the one struggling, who may not recognize the problem or be able to overcome the stigma of asking for help. Early and frequent screening and treatment should be standard and is a grade B United States Preventive Services Task Force (USPSTF) guideline. Breastfeeding and PMADs are intricately linked – successful identification and treatment of PMADs improves breastfeeding outcomes, and successful breastfeeding reduces the risk for PMADs. Services for both are vital.

Dr. Kennedy’s story resonates with so many and represents a failure of the systems meant to support the mother and infant. Breastfeeding and Lactation Medicine is an emerging field that will help fill some gaps in care through earlier assessment, support, and management of medical issues that may contribute to breastfeeding difficulties. We believe with increased accessibility, education of the entire health care team, and enhanced patient support, families can have empowered and satisfying experiences instead of the traumatic and stressful ones that many dyads currently face. For this reason, we emphasize the need for standardized education about lactation during medical education, including board certification, protocols, and standards of care. The North American Board of Breastfeeding and Lactation Medicine (NABBLM) is striving to establish physician leaders to help close gaps in care using evidence-based medicine.

Many of us have also had extremely challenging, painful breastfeeding and postpartum experiences, and we applaud Dr. Kennedy for openly sharing her difficult journey. We agree that change is much overdue, and our health care system must move from providing an illusion of choice to real support for birthing people, infants, and their families postpartum – including high-quality breastfeeding and lactation care.

Respectfully submitted,

Doctora Milk

on behalf of the Doctors Practicing Breastfeeding Medicine and Dr. MILK – full author list

Logo for the North American Board of Breastfeeding and Lactation Medicine

Lead Authors:

Kristina Lehman MD, FABM, IBCLC – Associate Professor at The Ohio State University Wexner Medical Center, Owner at LehmanMD
April A Castillo MD, MPH, IBCLC – Assistant Clinical Professor at the Renaissance School of Medicine, Stony Brook University
Nithya Natrajan, MD, CLC, FAAFP – Physician Owner, Blossoming Mamas: 4th Trimester Care; Medical Content Expert, IABLE
Ashley E. Wofford Leong MD, MPH, IBCLC – Physician Owner, Sage MD
Cherec Morrison, MD, IBCLC – North Carolina Department of Health and Human Services
Evelyn Pietrandrea Laskowski MD, FAAP, IBCLC – Assistant Professor, Oakland University William Beaumont School of Medicine, Pediatric Hospitalist, Corewell Health Beaumont Children’s
Bailey Adams MD, CCFP, BSC, IBCLC – University of Alberta
Mariah Davis MD, IBCLC – Methodist Physicians Clinic
Julia Selezneva, MD MS IBCLC – General Pediatrician at Stanford Children’s Health
Allison Reiter, MD – Kaiser Permanente
Fiorella B. Castillo, MD, MSPH, CLC – DBP Fellow at CHAM
Sally Wineholt MD, IBCLC – Cayuga Family Medicine
Liza Goldman Huertas, MD, IBCLC – Breastfeeding Medicine of Connecticut
Julia Tanguay DO FAAP – Pediatrician at Centura Health NorthCare Pediatrics
Jennie Baker Scoggins, MD, IBCLC – Pediatric Partners of Augusta

We are all Doctora MILK and we co-author the article