Defending breastfeeding

I think I have been quiet on here longer than I have been for well, ever. I am doing a family practice rotation and trying to set up elective rotations and plan for applying to residency. I am also just busy and tired out in general. I can’t write about much of what I see day to day without discussing my patients or my attending physicians and residents in a way that might be ethically questionable.

But, I do want to write about something that happened today.

A patient came in with a complaint that wasn’t life threatening or earth shattering. My attending physician wanted to treat it empirically. The patient is breastfeeding exclusively. The physician, without even looking up the medication, told her to stop breastfeeding.

I usually don’t challenge what my attending physician recommends. The patient said she would do what she always does, and call her baby’s pediatrician. When we did look up the medication, it did not have a contraindication for breastfeeding, but had a typical “well, we just don’t know if this is safe” disclaimer. This wasn’t a book specifically dedicated to medications and lactation. There are books like this available.

I told the attending physician that the patient was exclusively breastfeeding, and breastfeeding is hard enough to pull off in this society as it is. I said that, barring a contraindication during breastfeeding, most medications are safe, and a little research on the topic and possible alternatives may be a good idea. The attending said that, in today’s litigious society (which is the topic of many lectures by many attendings), we just can’t take those kinds of chances these days. She apparently tells any breastfeeding patient to stop breastfeeding with any medication.

I hope I can take these kinds of chances one day. I respect my attending physician’s choices in balancing her medicolegal risk and the way she cares for her patients, but I hope to be able to strike my own balance one day that is more supportive of breastfeeding.

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33 Comments

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33 responses to “Defending breastfeeding

  1. doctorjen

    Wonder why your attending doesn’t feel similar medico-legal concerns over the increased risk stopping breastfeeding presents? And why would a family doc not own a copy of Medications in Mother’s Milk? (which has a useful rating system for the relative safety of medications.) Or at least check the AAPs recommendations? (you can access Tom Hale’s forums online to look at medications – he is the auther of Medications in Mother’s Milk http://www.infantrisk.com/content/webforum) .
    As a family doc myself (and a member of the Academy of Breastfeeding Medicine) this makes me so sad. If you think it wouldn’t create a problem, maybe you could direct this family doc to our own national organization’s breastfeeding position statement, complete with recommendations that almost all maternal medications are safe in breastfeeding. (http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html) I’m sad that you aren’t getting to see what I’ve always felt was a great part of being a family doc – I treat mothers and babies, so can manage medication situations and breastfeeding problems by addressing both the mother and child without the poor mother having to search out info for her baby from another provider.
    I hope the mother in your story gets better advice from her ped, at least.
    I know I’m preaching to the choir here, but geez, this just sucks.
    On a different note – I’m making the move from private practice to residency faculty in July this year, so hopefully I can help turn out family docs who know better!

    • MomTFH

      Thanks so much for replying! I questioned writing about it, but I thought it was a reasonable post about an important issue. The patient is a medical professional and was luckily a good advocate for herself who was well informed on breastfeeding. But, not every patient would dare challenge a physician.

      Thanks for all the resources. And, good luck in your transition to academics!

  2. doctorjen

    I’m glad the patient was able to advocate for herself, but you’re right, so many can’t. That’s why I suggested directing your attending to AAFP’s position paper – since you won’t always be there to help her! But I know how it is to be the student, and certain things can be only pushed so far, and other things you have to file under “I’ll NEVER practice this way” and move on.

    • MomTFH

      I’m tempted to print it out, but I may be asking her for a letter of recommendation. I think it will just be one of those learning opportunities.

  3. Wow, it’s hard enough to continue breastfeeding when you are being questioned by your doctor peers (i.e. pressured to quit), but your own doctor? Sheesh.

    • MomTFH

      I know! It’s bad enough when your peers and / or family tell you to quit, but when your doctor insinuates that it’s risky, that’s really discouraging.

  4. Karen

    I have been cumulatively breastfeeding for 10 years of the last 20. I have had multiple surgeries and procedures and been ill etc….and required medications.
    I either go armed with Tom Hale’s book or just do what I want, knowing that what has gotten into my milk has little to no bioavailbility or is at such a level as to induce no effect on my child or at worst a little sleepiness. There is just no convincing some people that weaning or even pumping and dumping just.isn’t.necessary the vast majority of the time.
    I should be on a statin but that is contraindicated when nursing. I’ll start it when my baby weans but I am not weaning him for that purpose.

    Thankfully, the main physicians I see are either a) educated on medications and breastfeeding or b) willing to learn.
    I saw my rheumatologist when my last baby wasa 3 months old. We sat there with Hale’s *together* and came up with a plan. I am probably the only lactating woman that she has as a patient but she is willing to take the time to get a bit educated about it.

    • MomTFH

      Karen, it is wonderful that you are so educated and engaged, and your health care practitioners have been such good partners with you.

  5. ouch. that is so sad.

    I will share with you my personal story of a doctor unexpectedly supporting my breastfeeding. I had appendicitis when my son was 9 months old. When the anesthesiologist came to see me before I went into the OR, I asked him how many hours it would be before I was able to breastfeed my baby safely. He said he would get back to me, went and looked up the medications he was going to give me and came back and said he was doing something a little different than he usually did so that I would be able to breastfeed right away after surgery, that the medications would metabolize out of my body very quickly, and the amounts passing on to my baby would be very minimal and not unsafe.

    He then came to see me just before I was transferred out of post-op recovery and asked where my baby was. I told him that my baby was waiting with my husband in my room upstairs and I would nurse him when I got there. He was disappointed and said “I really wanted to meet your baby and I also wanted to tell my colleagues that I was able to give a mother medications that allowed her to breastfeed immediately after surgery!”

    I made sure to express my appreciation!

  6. Olivia

    It is so sad and frustrating that so many doctors practice in fear of being sued. I don’t know what can be done about it, but I wish more docs were strong enough to really put the patient first.

    Recently, my 2 yr old went to the dentist and she has a couple of cavities. The dentist listed breastfeeding at night as one of the probable causes and said she should be weaned right away. The hygienist followed that up with ,”She two, she doesn’t need to breastfeed anymore.” My husband was the one with her, and he did his best to defend our breastfeeding, but he really fest attacked as a bad parent for allowing her to still be nursing.

    • MomTFH

      As far as I know, it’s having a bottle throughout the night that is linked to dental caries. That, and sharing utensils with parents. Not breastfeeding. But, I may be mistaken.

      • Olivia

        No, everything I’ve read says that breastmilk alone doesn’t cause cavities.

        • Look up Dr. Brian Palmer, an expert on breastfeeding and dental issues. One fun fact is that breastmilk has components which actually protect against cavities, including (IIRC) lactoferrin, I think (again, off the top of my head on its name). The danger in bottlefeeding w/r/t cavities is twofold, one, the lack of procective substances and two, the fact that using an artificial nipple causes milk to “pool” in the mouth – I believe this is of particular concern at night feeds.

  7. Sara

    My sister was just telling me that she helped to take care of some preemie twins who are now several months old. The mother had started breastfeeding, but was told that her milk was “too thin”, and then was told after she developed PPD that she would need to wean to take the meds anyway.

    It made me really sad, because as a former preemie twin myself (31 weeks), I attribute my mother’s determination to breastfeed my sister and I for our stellar health and lack of any developmental delays. Today’s society does make breastfeeding SO hard sometimes.

    • MomTFH

      Good for your mom! I am sure it was hard work on her part.

      That is sad about the preemie twins. How can they tell her milk is “too thin”? There may be many reasons that the babies might have had issues gaining weight, but I somehow doubt completely suspending breastfeeding was the best answer.

      • Oh, but pediatricians used to have mothers express some milk so they could swirl it in a cup, look art it and declare whether it was “rich” enough. SERIOUSLY. No distinction between foremilk and hindmilk – and of course most mothers’ initially expressed milk is going to be the relatively watery, sugary foremilk. Oh, to think of the number of moms and babies who were rejected based on nothing.

        Perhaps this doc learned this in medical school way back in the day.

  8. You are not mistaken about dental caries. Pacifiers are also implicated in the spread of S. mutans and other culprits. There are other factors involved as well, but breastfeeding is not one of them. It is, however, “deviant” in the eyes of some people, and anything that is different is always suspect.
    Good for you for standing up for responsible medical practice! I’m sure it wasn’t easy to do. But it was the right thing.

  9. MAN. This really, really bums me out, thginking of how often this happens to (a) a patient who’s not a good, informed advocate for herself and (b) with an observing medical student who doesn’t question what happened, and goes on to practice the exact same way. No attempt to even see if there was an alternate medication, even though chances are the one chosen was fine anyway? I could cry.

    I’m-a go rend my garments.

  10. (Sorry for the commentpalooza, this one just obviously struck my padawan IBCLC2B nerve.)

  11. StorkStories

    SO glad you advocated for her. I can’t speak for how it must feel to challange the attending in your current role/shoes but I do it all the time in mine with a gentle information sharing approach. A “would you consider letting the babies doctor make the final determination on this based on this info..X..Y..Z”.
    I was also going to let you know about the Dr. Hales infantrisk site which i see you already got in the comments.
    Good for you!!

    • MomTFH

      Thanks! I challenged her very tactfully, I hope, and I plan on providing the resources on my way out the door. After I get my letter of recommendation, I hope.

  12. StorkStories

    Also have you all seen the bestforbabes blog yesterday about an MD’s admission of lack of lactation knowledge?
    http://www.bestforbabes.org/talk-breastfeeding-with-your-ob-an-obs-advice-2

  13. oldmdgirl

    No information does not equal “safe.” The patient was right to call her pediatrician. The internist was right to be conservative, and I’m inclined to agree with her given that you didn’t say what the drug was.

    Comparing not breastfeeding to the possible effects of some drug? Come on now. It’s not like formula is poison. It is made for human consumption as a food product. Drugs by contrast are MADE to perturb human biology. That is why they work.

    • MomTFH

      Thanks for your input. Different practitioners are obviously going to have varying ways of responding to these challenging situations.

      I am going to have to disagree with your saying who was “right” in this situation. First of all, you don’t have all the information, and I am not going to disclose all of the information. “Right” is a strong word. Reasonable? Maybe, but I disagree. Secondly, what I would think would be most “right” would be to follow expert and evidence based standard of care. Doctorjen linked to the AAFP publication on the topic above. Let me quote:

      “Special Breastfeeding Issues
      MEDICATION AND SUBSTANCES
      Almost all prescription and over-the-counter medications taken by the mother are safe during breastfeeding. Several resources are available to help estimate the degree of drug exposure an infant will receive through breastmilk.23-25 The National Library of Medicine provides an easy-to-use online source for information on the use of drugs in lactation; it is available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Physicians must weigh the risks of replacing breastfeeding with artificial feeding against the risk of medication exposure through breast milk. Even a temporary interruption in breastfeeding carries the risk of premature weaning, with the subsequent risks of long-term artificial feeding. Generally, it is recommended that breastfeeding should be interrupted if the mother ingests drugs of abuse, anticancer drugs, and radioactive compounds.23 Among antidepressants, cardiovascular medications, immunosuppressants, and many other classes of medications, certain drugs are preferred over others for lactating women.26 In a particular class of medications it is best to choose a drug that has the least passage into breast milk, has fewer active metabolites, and/or is used locally rather than systemically.24,25,27

      Given that there is continuously new information on medications and their effect on breastfeeding, family physicians are encouraged to use reliable and up-to-date resources for advising their patients and advocating for them. Suggested references include those that are regularly updated such as Hale’s Medications and Mothers’ Milk, local or state-wide pregnancy risk hotlines, or the Academy of Breastfeeding Medicine evidence-based protocols (http://www.bfmed.org).

      Physicians should counsel patients before ordering medications or procedures. Often, patients will be counseled inappropriately by well-meaning health care professionals to “pump and dump” or stop breastfeeding based on old information or package inserts. Family physicians should be aware of up-to-date information and advocate for patients to continue breastfeeding safely.”

      Now, let me assure you, this was not a life saving medication. This was not even a necessary medication. The condition it treated was not even definitively diagnosed in this patient. It was not chemotherapy, radioactive, a drug of abuse, a psychosomatic treatment or hormonal. There are actually better choices that are less systemic that would have been more appropriate to recommend, even if the patient was not breastfeeding, based on the algorithm for her presenting symptoms that I found on UpToDate.

      The physician did not bother looking it up at all before insisting that the mother stop breastfeeding, and only found the “no information” information when I asked her to look it up once the patient said she would not suspend breastfeeding. She did not choose a source with comprehensive information on medications and lactation. She did not suggest that she call the baby’s pediatrician. That was the patient’s idea.

      When I looked up the medication on Toxnet, it stated that it was minimally excreted in breast milk, and this actually has been researched. It also said it was safe during lactation. Here is the synopsis, with the name of the drug redacted:

      “[Medication] and its active metabolite are minimally excreted into breastmilk. An informal consultation group to the World Health Organization concluded that a single oral dose of [medication] can be given to lactating women.[1]”

      Furthermore, in the details about the research done on lactation pharmokinetics, ” The authors estimated that a fully breastfed infant would be exposed to less than 0.1 mg/kg of [medication inactive metabolite] over a 36-hour period following a maternal dose of 400 mg and even less of [medication].[2] This translates into an infant dosage of less than 1.5% of the weight-adjusted maternal dosage.”

      I’d like to add that this medication is primarily used in pediatric populations, and has an excellent side effect profile.

      So, it isn’t that there was no information. There was good information in the appropriate places, which the physician did not check even after I suggested it.

      And, the baby would not be getting formula as a replacement. The mother assured me that they had tried to give the baby formula in the past, and it would flat out refuse it. The physician did not discuss this with the mother; I did. I have a history in lactation consulting. “Stopping breastfeeding” isn’t as easy as it sounds. She was pumping three times a day at work to keep up with her baby’s needs, and had no extra pumped breastmilk to spare. She most likely was going to avoid taking the medication at all if it would involve her having to stop breastfeeding. Luckily her baby’s pediatrician seems to be a supportive, educated resource on safety of medication during lactation. She said she would be happy to drop off her screaming, hungry baby with the family physician and have her try to feed her formula and console her when she refused. I didn’t think the situation warranted that, and I am hoping her pediatrician doesn’t, either.

      No one said formula was poison. The AAFP rightly discusses switching to artificial feeding of infants as having risks, which are well documented. It should not be done lightly, and may be less “safe” or “right” than breastfeeding while taking a medication.

  14. Alison

    I’m late to the party, but I wanted to add my experiences with nursing and medication use. I take a few daily meds for chronic conditions — meds that are vitally necessary for my continued functioning and ability to care for my children. One of them is widely considered safe for breastfeeding, and the other is in a class that is considered risky. Both my doctor and the pediatrician recommended not nursing my baby at all, even the first few days when little or no medication makes it into the collostrum.

    But after researching the second med, I discovered that, due to a combination of extremely low oral bioavaliablity (50%) bioavailability and other factors. My doctor even refused to believe that most meds diffuse out of the stored breastmilk in my body at roughly the same rate as it left the plasma, insisting that any drug that got into the milk stayed there. I finally had to fib to him and promise to pump and dump a couple hours after my once-daily dose and just partially nurse the baby. With the agreement of the pediatrician (who didn’t realize the other doc’s insistence on pump-and-dump, or she would probably have been reluctant), I timed the dose of medication during my son’s longest nursing gap (right after bedtime) and have had absolutely no problems.

    Am I proud to have fibbed to the doctors? No, of course not, but I feel that I made the best choice I could for both my and my baby’s health. There were some very important reasons he needed breastmilk, not just my vanity or being stubborn. It’s just sad that these two highly-trained, caring, and generally excellent doctors were somewhat ignorant about breastfeeding and had difficulty in accepting the (peer-reviewed) data I brought them.

  15. Alison

    For some reason, part of my comment got deleted the first time. Here’s the full version):

    I’m late to the party, but I wanted to add my experiences with nursing and medication use. I take a few daily meds for chronic conditions — meds that are vitally necessary for my continued functioning and ability to care for my children. One of them is widely considered safe for breastfeeding, and the other is in a class that is considered risky. Both my doctor and the pediatrician recommended not nursing my baby at all, even the first few days when little or no medication makes it into the collostrum.

    But after researching the second med, I discovered that, due to a combination of extremely low oral bioavaliablity (less than 10%), rapid metabolism, and low solubility in breast milk, my baby would be receiving less than 0.5% of the weight-adjusted dosage, an amount which is utterly negligible for the baby in the case of this med. Yet, I faced significant opposition from both doctors because they had “always heard” that this class of medicines was “bad” for breastfeeding, regardless of the fact that the other meds in the class were very different due to high (more than 50%) bioavailability and other factors. My doctor even refused to believe that most meds diffuse out of the stored breastmilk in my body at roughly the same rate as it left the plasma, insisting that any drug that got into the milk stayed there. I finally had to fib to him and promise to pump and dump a couple hours after my once-daily dose and just partially nurse the baby. With the agreement of the pediatrician (who didn’t realize the other doc’s insistence on pump-and-dump, or she would probably have been reluctant), I timed the dose of medication during my son’s longest nursing gap (right after bedtime) and have had absolutely no problems.

    Am I proud to have fibbed to the doctors? No, of course not, but I feel that I made the best choice I could for both my and my baby’s health. There were some very important reasons he needed breastmilk, not just my vanity or being stubborn. It’s just sad that these two highly-trained, caring, and generally excellent doctors were somewhat ignorant about breastfeeding and had difficulty in accepting the (peer-reviewed) data I brought them.

    • MomTFH

      Thanks for sharing. No, your comment didn’t get deleted, I think it just got caught up in my new commenter / spam filter.

      I think you did excellent research and were a good advocate for yourself. Your physicians weren’t necessarily practicing evidence based care. And, even when weighing evidence, practitioners and patients / people can be risk averse or intervention averse to difference degrees. That is what informed consent is all about.

  16. MomTFH

    Here’s an update, everyone. I showed the doc the LactMed / ToxNet site, including the entry on the drug in question. I bookmarked the page under her favorites. I also brought up the page with the AAFP statement (thanks doctorjen!) and left it up, without saying anything. Passive aggressive? I prefer to call myself nonconfrontational. I was sort of pretending I was looking up different things and just didn’t close the window.

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