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Letters from Maine

Advocating for reality

Publish date: February 6, 2018

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Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

^{©Lev Olkha/iStockphoto.com}

A recent article in the AAP News addresses this relationship between physicians’ personal experiences with breastfeeding and their clinical interactions with the mothers in their practices (“Facing barriers to breastfeeding may affect physicians’ advocacy for patients,” February 2018). The authors refer to a study in the Journal of Human Lactation reporting that in the group of 927 pediatric trainees who were surveyed, of which 421 had children and 346 breastfed their children, “1 in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for extended breastfeeding,” which was 6 months (J Hum Lact. 2015 May;31[2]:240-8). Twenty-five percent either did not have access to or were not aware of a private room where they could express milk or breastfeed. The resulting failure left the trainees feeling frustrated, depressed, and devastated. More than 90% of the respondents felt that their experiences affected their interactions with mothers in their practices.

In a different survey of American Academy of Pediatrics fellows, more of the 832 pediatricians responding reported having had a personal experience with breastfeeding in 2014 than of the 620 responding in 1995 (68% vs. 42%). However, it is interesting that fewer of the respondents in 2014 felt that any mother can succeed at breastfeeding (predicted value = 70% in 1995, PV = 56% in 2014; P less than .05), and fewer in 2014 believed that the advantages of breastfeeding outweighed the difficulties than among those surveyed in 1995 (PV = 70% in 1995, PV = 50% in 2014; P less than .05) (Pediatrics. 2017 Oct;140[4]. pii: e20171229). These results suggest that, as more pediatricians gained personal experience with breastfeeding, more may have realized that the American Academy of Pediatrics recommendations for breastfeeding are unrealistic and may contribute to the negative experiences of some women, including pediatric trainees.

An implied assumption in the AAP News article is that a pediatrician who has had a negative breastfeeding experience is less likely to be a strong advocate for breastfeeding. I would argue that a pediatrician who has witnessed or personally experienced difficulties is more likely to be a sympathetic and realistic advocate of breastfeeding.

Dr. William G. Wilkoff

Of course, my argument begs the question of exactly for what and for whom we are advocating. The quick reflex answer might be that, of course we are advocating for children because we have data supporting the benefits for them of exclusive breastfeeding for the first 6 months and extended breastfeeding for 1 year. However, many of us who have practiced pediatrics for more than a couple of decades have observed ample anecdotal evidence that overzealous advocacy for the current breastfeeding guidelines can result in casualties among women whose “failure” has left them depressed, frustrated, and less confident in their ability to mother.

We must walk that fine line between actively advocating for lactation-friendly hospitals and work environments and supporting mothers who, due to circumstances beyond their control, can’t meet the expectations we have created for them.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Advocating for reality

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