Primum Non Nocere: Why ALL Physicians Should Learn The Basics of Lactation Care

As a physician who specializes in breastfeeding and lactation medicine, I frequently give lectures to various medical professionals on the basics of lactation care for their patients.

I work in this field every day, so the need for widespread education of my medical colleagues seems obvious to me. But I often find resistance to my offer – understandably, medical education must cover a vast array of topics, and is already crammed full. And physicians who are in practice are increasingly bombarded by tasks that leave too little time for patient care or keeping up with ongoing medical education, much less adding entirely new topics to learn. Additionally, when a subject hasn’t been taught for so long, it can be hard to see why it is now necessary. In my own training, I didn’t learn much about the actual ins and outs of lactation care either, so it didn’t occur to me until much later that it was so important either. I understand these hesitations, but I am on a mission to change the culture of lactation education and care in modern medicine. Primum non nocere applies here, as it does in all aspects of medical care and our oath to this profession. So let’s talk about why EVERY physician should learn the basics of lactation care.

First and foremost, physicians in almost all specialties will encounter lactating patients. They may not always realize it if they don’t ask about it, but they are seeing them nonetheless. They may be caring for the pregnant or lactating parent as an OB, primary care physician, or even a sub-specialist. Or perhaps they are a pediatric surgical specialist who sees infants, many of whom are ingesting human milk either at the breast or with pumped milk. Each of these patients may have concerns about their milk supply, how to properly pump and store milk day to day, whether the medicines and tests you order them or their child will affect breastfeeding, and how to manage chronic illness, acute care needs, and mental health with the unique demands of producing milk to feed their child. Lactation care is NOT only relevant to primary care and OBGYN, you will soon come to realize.

Don’t think you see many patients with lactation related care needs? Trust me – start asking, and you will likely realize just HOW MANY of your patients are affected in some way by lactation related concerns. You may even come to realize just how many you let down by not knowing to ask, or knowing how to refer them to proper resources for care. Don’t feel bad – just do better now that you know better.

Of course, knowing that many of our patients struggle with lactation related issues and need our advice about how to manage them doesn’t mean we actually know anything about how to properly help them. Many of us weren’t trained in even the basics of lactation. We learned about pathology like cancer that can occur in the breasts. We know the basics, that mammary tissue makes breast milk when needed, and there are ducts that lead to holes in the nipple where the milk is ejected. But we don’t know much beyond that – how to help with latch, how to form a differential diagnosis for nipple pain due to nursing, how to pump breast milk properly or even that there are different sizes of breast pump parts to fit different nipple sizes during pumping. Unfortunately this often leads us to not bring it up at all, or to give inaccurate or even harmful advice.

One common example of bad advice and mismanagement is when patients are often advised to “pump and dump” for a medication or procedure. Physicians often do not know how to access evidence based sources for these scenarios. Spoiler alert: it is very rare for pumping and dumping to truly be medically necessary, despite the frequent advice to do so in our usual medical resources for medication management.

We often don’t even realize the harm we do by defaulting to “pump and dump”, because we don’t know enough about the physiology and reality of lactation to realize the harm that this advice can cause. Truly, it is often harmful emotionally, even physically, to our patients. The gold standard of care is NOT pumping and dumping by default. Not even close. And there are actual easily accessible resources to help with this, we just have to be aware of them! It truly doesn’t take as much time as you may think to learn the basics and how NOT to mess things up for your patients in this regard.

But isn’t this what lactation consultants are for? Of course, lactation consultants are an invaluable resource for our patients in these matters. A good lactation consultant is worth their weight in gold. But there aren’t enough of them out there! And they aren’t the front line – as the physician, you will often see the patient first. They may not know how to find lactation consultant help, or it may not be quickly available to them. So if you as the physician don’t know how to recognize lactation related problems, determine when to refer out for care, how and who is best to refer to, and know how to give at least non-harmful and ideally somewhat helpful basic advice, then your patient may slip through the cracks and harm will occur.

As a physician AND lactation consultant myself, I know the differences in training and appropriate scope of care between these roles. Lactation consultants (IBCLC) are not physicians, and their scope of practice does not include making medical diagnoses or treatment plans. The IBCLE certification advisory board states:”The IBCLC certificant neither practices medicine nor diagnoses a disease or disease process unless the certificant is separately licensed or authorised to perform such procedures. An IBCLC certificant does: carefully assess, document findings, and refer appropriately as needed, to obtain a medical diagnosis and possible treatment.” This highlights the need for physicians to step up, seek out at least basic lactation care information, and be prepared to help lead the care team. This will lead to proper, more timely care. It will also improve the cohesiveness of the full care team’s management approach. Patients frequently tell me how confusing it is when they get conflicting advice from their doctors, lactation consultants, and even social media. The more we all learn about the actual evidence based care our patients deserve, the more we can reassure them and earn trust with actual cohesive, team-based care.

All physicians should have a basic foundational understanding of the anatomy, physiology, and pathophysiology of human lactation and feeding. These basics should have been covered in our basic didactic courses in medical school. Luckily, you can learn the basics in a very short time when you’re adding it to an already sound basis of general medical knowledge.

Beyond that, the needed knowledge will vary by specialty and patient population served by each physician. All physicians should know how to access evidence based medication and procedure related resources, and should have a basic understanding of the physiologic and pharmacologic factors that affect these recommendations. OB-GYN, emergency medicine, and primary care physicians (even those just seeing adults!) should add a basic knowledge of common problems related to lactation, such as nipple pain, milk production concerns, and mastitis to start. And a smaller number, like myself, will be needed to learn the full intricacies of lactation care at a sub-specialist level.

Luckily, there are evidence-based resources available to help physicians learn the basics of lactation care. And I am finding more often that this information is being included in medical school and residency curricula. Many programs even offer electives in lactation care now! I often recommend courses by IABLE as a starting point to learn the basics for both those in training or who have completed their training, though there are other options around of course.

Stay tuned for a future post where I will give you more information on resources to learn about lactation related care.Happy learning, my colleagues. I am excited to see a future where every physician recognizes the value in learning about the basics of lactation care and realizes how this will elevate their patient care.