Working with Your Child's Doctor
By Janice Berry
Westerville OH USA
From: NEW BEGINNINGS,
Vol. 16 No. 6, November-December 1999, pp. 196-199
In December 1997, the American Academy of Pediatrics (AAP) published a groundbreaking statement on breastfeeding that included new recommendations and guidelines. To assess pediatricians' educational needs in the aftermath of this statement, the AAP recently sent a survey to 1,602 of its active Fellows. The survey's results reflect what some mothers already realize - that doctors' recommendations on breastfeeding may differ markedly from those of the AAP.
For instance, when asked about feeding healthy full-term babies during the first month, only 65% of the survey's respondents said they recommend exclusive breastfeeding for that brief but critical time period. The AAP statement, conversely, recommends exclusive breastfeeding for approximately the first six months. In addition:
- Although the AAP statement extensively documents the superiority of human milk, a startling 45% of surveyed pediatricians view breastfeeding and formula-feeding as equally acceptable methods of feeding. Another 17% aren't sure.
- Nearly equal proportions of pediatricians agree and disagree about whether formula-fed babies are just as healthy in the long run as breastfed babies.
- A surprising 22% routinely recommend some form of supplementation (water, glucose water, or formula), although the AAP discourages supplements "unless a medical indication exists."
This research appears to show that pediatricians as a group have yet to incorporate the most current medical research on breastfeeding into their practices. And although 77% expressed confidence in their ability to manage common breastfeeding problems, those respondents were not necessarily the most informed regarding breastfeeding. Statistics on pediatricians outside the US aren't available, but anecdotal evidence from LLL members indicates that a supportive health care provider can be hard to find no matter where you live.
Why do so many physicians express only lukewarm support for breastfeeding? This is puzzling, since the scientific evidence in favor of breastfeeding is overwhelming. Part of the explanation is that, simply put, doctors are human. One study showed that most health care providers depended on their personal experience - or their spouse's - when assisting patients (Freed). Alicia Dermer, MD, a family physician who also teaches medical students, says "Any guilt or sense of failure they may feel about their or their spouses' infant feeding choices could affect their feelings about breastfeeding promotion. For some physicians to enthusiastically embrace the AAP's recommendations to breastfeed for at least a year, for example, they may have to reconcile their own feelings about their children not being breastfed, or being breastfed for only a short time."
Some doctors are hampered by inadequate education. Just 58% of doctors responding to the survey received any education about breastfeeding management while in medical school or residency. It can be difficult for doctors to keep current with research on breastfeeding and myriad other topics. Much of the information health care providers get about breastfeeding comes from publications distributed by formula company sales representatives, which are readily available yet often dwell on possible problems or contain subtle inaccuracies.
No matter what the cause is, a doctor's lack of knowledge about managing breastfeeding can have an adverse effect on mothers and babies. THE WOMANLY ART OF BREASTFEEDING points out, "A doctor who has little opportunity to learn about breastfeeding may be readily inclined to take the baby off the breast when treating either you or baby. Such a move is rarely necessary." The AAP survey proved this point. Pediatricians were asked when they would recommend against breastfeeding, and many cited situations such as mastitis, nipple problems, jaundice, and low weight gain. These problems can be treated without stopping breastfeeding.
Choosing a Doctor
So how do you find a physician who will be helpful to you as you breastfeed your baby? It's best to begin the search during pregnancy and talk with several care providers before selecting one. Family physicians may also care for babies. Dawn Hubbell-Staeble of Bowling Green, Ohio, USA, states, "We had a good relationship with our family practitioner, so we chose to take our newborn to him rather than the pediatrician our older child had seen. Our family practitioner knows our family and realizes breastfeeding is a priority. Also, he isn't worried about the growth of my tall, slim son, because he knows my husband's growth history." Nurse practitioners or other types of health care providers may also provide well-baby care.
THE WOMANLY ART OF BREASTFEEDING suggests making an appointment for a consultation with a prospective doctor. Many doctors don't charge for such visits. Make a list of questions about breastfeeding and health care issues that are important to you.
When you go for the appointment, take note of the materials in waiting and examining rooms. Are there up-to-date printed resources that encourage and inform breastfeeding mothers?
When you meet a doctor, try to build rapport before you begin asking questions. A positive approach works best. The idea, explains Linda Smith, a La Leche League Leader and lactation consultant from Dayton, Ohio, USA, "is not to confront or challenge the doctor, but to gauge the level of support for breastfeeding in that office, both in theory and in practice."
Smith suggests, "I might ask what resource the doctor would consult - or to whom he or she would refer me for a breastfeeding-related problem or question. We can't expect doctors to know everything about breastfeeding, but we can expect them to consult expert resources and, if there is a problem, to refer clients to an International Board-Certified Lactation Consultant (IBCLC)." Ask if the doctor refers mothers to La Leche League Leaders and meetings for support and information. See the sidebar for additional breastfeeding-related questions you may want to ask.
Possible interview questions for potential health care providers:
One mother took a copy of the December 1997 AAP guidelines (which include 110 references) with the important parts highlighted, and gave it to doctors she interviewed, asking if their recommendations were in line with each highlighted recommendation. By letting the doctors keep the copy, she also managed to educate everyone she interviewed. Reprints of these guidelines can be ordered from LLLI.
Many parents have worked hard to find a breastfeeding-friendly doctor, realizing that this approach may minimize time, effort, and conflict in the long run. However, finding health care providers who understand and value breastfeeding is not always possible. Insurance companies, health maintenance organizations, or governments may limit the choice of doctors. Living in a rural area can limit choices because there may be fewer doctors to choose from. Low income or lack of insurance coverage may also limit options.
Some mothers-especially those with limited choices-worry about how to work with their children's doctors and other health care providers to keep their children healthy while preserving the breastfeeding relationship. In this situation, some parents look for a doctor they can rely on to give them sound medical advice and trusts them as parents to make the best decisions for their children. Meg Hill of Germantown, Tennessee, USA, explains, "My children's doctor was my partner in their health care and I made sure he understood that issue up front. I did not seek, nor did I accept, his advice on discipline, parenting, or nutrition. After more than 20 years of working together, we still have a good relationship and he has always respected my children, my decisions, and me." Meg decided she would seek support for her choices on breastfeeding, nutrition, and discipline from other sources.
It can help to know for yourself what you want from your child's health care providers. Do you need advice on parenting issues, or solely medical advice? As Cecilia Miller of Jacksonville, Florida, USA, says, "I keep in mind that health care providers are problem-solvers by profession, so I don't bring up issues unless I want their advice."
It's not always necessary to engage in a dialogue when you disagree with your doctor on parenting or breastfeeding issues. If you get advice that doesn't suit you, you can simply say something mild, such as, "That's interesting. I'll give it some thought." Meg Hill says, "I found it helpful to deflect questions that didn't pertain to my child's health. When the doctor asked about night nursing, I mentioned that we were doing great and getting plenty of sleep, rather than giving specific details."
Although you may opt to ignore certain parenting advice, honesty - the basis of a trusting relationship - is essential when a medical issue is at hand. Doctors base their treatment recommendations on what you tell them, so withholding information can inadvertently lead to medical advice that is inappropriate for your child. Also, many doctors view honest feedback as on-the-job training that helps them refine the advice they give over time.
When you're working with health care providers, it helps to be confident and trust your instincts. You know your child better than anyone and you have the right to make decisions you're comfortable with. It helps to have a positive approach and remember that you all have the same goal - preserving your child's health.
Rather than simply reacting to what happens at your appointments, make plans about what you will say and do. Here are some positive, proactive ideas:
- When you go for well-baby check-ups, talk about how you and your baby are benefiting from breastfeeding and your positive feelings about it. Many doctors deal with breastfeeding only when there is a problem, so they may not realize how often it goes well and how enjoyable it can be for all concerned.
- Do your homework. Confidence comes from knowing what you want and why. Feel free to turn to La Leche League Leaders. While Leaders do not give medical advice, they can provide breastfeeding information, help you think through the situation and your options, and locate information to help you make decisions about your child's care.
- Mention to health care providers any community resources, such as LLL, that have helped you with breastfeeding.
- Provide information when the opportunity arises. Cecilia Miller says, "I have often taken the time to discuss issues with my children's doctor or write to him later and provide him with additional facts. He has always accepted my gentle, informed suggestions, and I hope that I've helped future patients." Another mother often brings an article or two that the doctor might find interesting when she comes for well-child visits.
You never know what long-term effects your breastfeeding dialogues may have. When Paul Fleiss, MD, started his career as a pediatrician, he says he knew nothing about breastfeeding. In those days, he told moms, "Breastfeed or bottle-feed, there is no difference" - advice he wishes he could take back. He remembers the first time a mom came to him with a six-month-old who got nothing but breast milk. Horrified, he threw up his hands and said, "You must give him food or he'll be undernourished!" The mother said, "Doctor, just look at this baby." He did, and saw a very healthy breastfed baby. Then she invited him to an LLL meeting and he went. Today, Dr. Fleiss is a member of the LLLI Health Advisory Council and a renowned breastfeeding expert and supporter.
How to Talk So Health Care Providers Will Listen
When speaking with health care providers, it helps to follow guidelines that apply to most interpersonal communication:
- Remain calm. It sometimes helps to lower your tone of voice and speak slowly.
- Make eye contact, which demonstrates sincerity and resolve.
- Be firm, tactful, and friendly - not hesitant, defensive, or antagonistic.
- Look for areas of agreement.
- Use "I" messages, such as "I feel strongly about ...."
In a complex or difficult medical situation, it may help to present a united front by having both parents present. If this isn't possible, you can still include the other parent verbally ("My husband and I feel that...").
La Leche League International's BREASTFEEDING ANSWER BOOK offers many suggestions you can apply when speaking to health care providers, including the following:
- Think through your approach in advance, if possible. You may wish to practice out loud.
- Be clear about your feelings and goals. Stating them initially keeps you from being on the defensive and makes it easier for your health care provider to adapt advice to your preferences. You might say, for example, "Our family has a history of allergies and I feel strongly about exclusive breastfeeding. Are there treatment options that allow for continued breastfeeding without giving formula? "
- Ask for a complete explanation of any proposed treatment, including the reasons for the advice, the alternatives, and the possible result if you don't follow this advice.
- Repeat what you've heard in your own words. This can prevent confusion and show the impact of the other person's words on you.
- Make statements in a positive way - for example, 'I'd like to try encouraging my baby to breastfeed more often before considering supplements," rather than "I don't want to give supplements."
- Try the "broken record" technique if a disagreement arises - simply restate your basic position calmly and quietly at each opportunity. For example, "I appreciate your concern about her health, but now that she's breastfeeding well, I'd like to monitor her weight for another week before we consider other options."
- Keep in mind that although the doctor is a medical expert, the ultimate responsibility for a child's health lies with you. You can reflect this by asking, "You'd like my permission to... " or stating, "If I'm understanding correctly, your recommendation is..."
Remember that you can always call the doctor back if you don't have the time or composure to get the facts straight during an office visit.
If you get breastfeeding information that doesn't sound correct, you may wish to ask for references - especially when supplementation or weaning is recommended. You might say, "I hadn't thought of that. Could you please suggest some reading or articles to me so our family can read them and better understand your position? I don't want to make this decision until we've reviewed the research." Asking for references can also help if your child develops an unusual condition or illness. Being an informed consumer helps you get better care.
If, despite your best efforts to work with your child's doctor, you've still getting advice you're not comfortable with, consider your options. You have the right to:
- Seek a second medical opinion, perhaps with a health care provider more experienced with breastfeeding.
- Refuse treatment.
- Find a new doctor.
- Speak with your insurance company or health maintenance organization, especially if you're unsatisfied with the quality of medical care you've received and have limited options.
It's not always easy to find health care providers who understand and support breastfeeding. Still, many parents have been able to preserve their breastfeeding relationships and work successfully with the health care providers they have. Some parents have even taken steps to help their doctors become more breastfeeding-friendly.
There are reasons to be optimistic about the future: The Academy of Breastfeeding Medicine, a worldwide organization of physicians, is working to promote, protect, and support breastfeeding and facilitate optimal breastfeeding practices. Many groups, including La Leche League, offer materials and training to educate health-care providers. And, the American Academy of Pediatrics is introducing a new program to assist pediatricians in gaining more knowledge about breastfeeding. (See related article.)
If you run into problems or need more information in making informed decisions, don't hesitate to call your local La Leche League Leader.
American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk (RE9279). Pediatrics 100, 6: 1035-1039, 1997, http://www.aap.org/policy/re9729.html.
Freed, G.L., et al. National assessment of physicians' breast-feeding knowledge, attitudes, training, and experiences. JAMA 273, 6: 472-476, 1995.
La Leche League International. THE WOMANLY ART OF BREASTFEEDING. Sixth edition. Schaumburg, IL: LLLI, 1997.
Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK. Revised edition. La Leche League International: Schaumburg, IL: 1997.
Schanler, R.J., O'Connor, K.G., and Lawrence, R.A. Pediatricians' practices and attitudes regarding breastfeeding promotion. Pediatrics 103, 3: e35, 1999, http://www.pediatrics.org/cgi/content/full/103/3/e35.