Breastfeeding and Lactation for Medical Trainees

The American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), the World Health Organization (WHO), and others recommend that infants exclusively receive breast milk for their first six months of life, with continued breastfeeding for at least the first year and beyond.^1-5 Breastfeeding provides benefits to infants, mothers, and society. Infants who are breastfed have reduced risk of several childhood illnesses, including ear and respiratory infections, allergies, asthma, and obesity. Breastfeeding is associated with a lower risk of sudden infant death syndrome (SIDS).⁶ Women who breastfeed have a lower risk of breast and ovarian cancer, type 2 diabetes, and hypertension.⁷ Businesses and institutions also benefit when their employees breastfeed. Successful breastfeeding results in lower medical costs for employees and their infants, lower absenteeism, lower turnover rates, higher productivity, and increased employee satisfaction.⁸ However, many women stop breastfeeding earlier than they intended due to lack of support from family, friends, and colleagues. Working outside the home is associated with shortened duration of breastfeeding,^9-11 and conditions in the workplace further impact this duration.^{12, 13}

Medical trainees are educated about the benefits of breastfeeding and taught to encourage and support their patients in their breastfeeding efforts. Yet when medical trainees choose to breastfeed, they often do not receive adequate support from their colleagues and institutions and many do not meet their breastfeeding goals.^{14, 15} Medical trainees face work hours and patient care demands that can make continued breastfeeding particularly challenging. Therefore, it is essential that medical educators, including medical schools, residency and fellowship programs, and healthcare facilities establish an environment that provides encouragement and resources for the successful continuation of breastfeeding. Programs with family-friendly policies, including lactation support, may be better able to recruit and retain residents, fellows, and young faculty physicians.

This information is provided to help medical schools, residency and fellowship programs, clinics, hospitals, and healthcare systems develop policies supportive of the needs of their breastfeeding medical trainees. Institutions developing a lactation policy should adapt and modify the key points provided as appropriate for their setting and resources. Key items needed include adequate lactation facilities, protected time for expression of breast milk or breastfeeding, and policies outlining roles and responsibilities to provide an environment of support for breastfeeding trainees.

Lactation Facilities

The regular expression and storage of breast milk is critical for the breastfeeding medical trainee. Expressing milk is necessary for the breastfeeding mother to maintain her milk supply, avoid pain, discomfort and health issues (e.g. mastitis), and provide milk to her infant for the time they are separated. Additionally, employers should provide reasonable break time from work and private facilities that are not bathrooms to allow for the expression of breast milk for up to one year after each child’s birth.

Whenever possible, medical trainees should be permitted and encouraged to directly breastfeed their infants during their break times if it doesn’t interfere with their duties. On-site childcare facilities maximize this opportunity for regular feeding and contact with their child. In situations in which direct breastfeeding is not possible, medical trainees should have access to a private, comfortable, and sanitary space for the expression of breast milk.

Medical schools and clinical training facilities must provide designated lactation rooms for medical trainees. The Accreditation Council for Graduate Medical Education (ACGME) lists the provision of lactation facilities, separate storage for breast milk, and protected time in their program requirements for residency training programs).¹⁶ Lactation rooms should be located in close proximity to trainees’ work or study area. The number of lactation rooms needed depends on the size of the facility or institution and the number of potential users of the lactation rooms. The general rule of thumb is that one space for milk expression is needed for every 50-100 female employees aged 18-45. However, this number will vary based on building size, number of buildings, work schedule, and job settings. In general, physician trainees should not be expected to share lactation rooms with patients or hospital guests. Resources are available for programs to find creative solutions for lactation space. The use of a private office or other private space is sufficient if it is comfortable, sanitary, private, and convenient for the trainee. A restroom or bathroom stall is not an appropriate space for the expression of breast milk.

The minimum requirements for lactation rooms include:¹⁷

Private – Trainees should be able to lock the door from the inside to ensure privacy.
Comfortable – The room should include a comfortable chair, an electrical outlet, appropriate lighting, and should be kept at a comfortable temperature. There should be a flat surface, such as a table or desk, to place breast pump and supplies.
Sanitary – Room should be kept clean. There should be access to a sink to wash hands as well as pump supplies.
Milk storage – Trainees should have access to a secure place (e.g. separate refrigerator or locker) to store expressed breast milk.
Pump Storage – Trainees should have access to a secure place to store their personal breast pump and supplies.

Additional considerations:

Computer work station in the lactation room – Medical trainees have demanding work and study responsibilities. Access to a computer would allow the trainee to continue their work or study while pumping.
Phone connected to the hospital or clinic system – This allows the trainee to respond to pages in a timely fashion or to alert a colleague or supervisor of any urgent patient care issue.
Hospital grade pump included in the lactation room– Providing a breast pump for trainees increases convenience as it frees them from having to carry and store their personal breast pump and minimizes the time needed to express breast milk. Any breast pump provided should be exclusively used in the designated lactation space and not shared by patients.
Lactation support – Providing access to professional breastfeeding support, such as lactation consultants, increases the culture of support for lactating trainees and increases their breastfeeding success.

Lactating trainees performing procedures in the operating room or the sterile procedure room may require lactation accommodations if procedures are prolonged. As consistent with hospital policy, trainees may either scrub out in order to directly breastfeed/express breast milk or may remain in the operating/procedure room and utilize a wearable breast pump as the human breast milk is not recognized as a bodily fluid requiring universal precautions.¹⁸ The decision to scrub out versus utilize a wearable breast pump is per the discretion of the trainee, in accordance with hospital policy. This is a personal decision that depends on multiple factors such as individual maternal lactation physiology, affordability of a wearable pump, the logistics of the specific procedure, and the educational experience of the procedure. The lactating trainee should inform her team of her specific needs for lactation accommodations. When determining a suitable time to breastfeed or express breast milk, should make a good faith effort to ensure patient safety and minimize impacts on her education and on her teammates.

Protected Time

Medical trainees will need to express breast milk every two to three hours to provide sufficient milk for the infant and to reduce the mother’s risk of developing engorgement, pain, or mastitis as well as to maintain the physiologic process of lactogenesis. In general, the trainee will need 20-30 minutes for milk expression. There is some variability in this time estimate, however, depending on the proximity of the lactation space, the quality of breast pump, access to pump and storage, and individual variations in time needed to express sufficient milk. Due to the demanding schedules of medical trainees - in particular their patient care responsibilities - finding protected break time for the expression of breast milk requires support from faculty, colleagues, staff, and administration. Break times may need to be scheduled in advance to ensure appropriate coverage of patient care responsibilities. In these cases, the trainee should work with their supervisor to determine an appropriate schedule and arrange for patient care coverage.

Medical trainees and supervisors should also discuss adjustments to return to duty after maternity leave that address reduced work hours, potential part-time or adjustment in schedules to avoid the most taxing rotations as the first ones after maternity leave. A flexible elective or board study rotation may be considered to enhance the likelihood of continued breastfeeding success.

Culture of support

Support from faculty, colleagues, staff, and administration is essential to encourage continued breastfeeding by medical trainees. To create a culture supportive of the needs of breastfeeding women, all employees must be regularly educated about the benefits of breastfeeding for both the mother and baby, the details of the lactation policy, and their responsibilities as outlined by the policy. Ways to disseminate this information may include training and materials provided during new staff orientation, yearly training programs for managers/supervisors, promoting it on the institution’s website, and including it under the benefits program. The policy should be included in any informational packets provided to all trainees, and revisited when a trainee is discussing family leave and health care policies to cover maternity benefits.

In addition to training and dissemination of policies to employees, the availability and location of lactation rooms should be publicized, along with whom to contact for more information.

Responsibilities

Policies should clearly outline roles and responsibilities of administration, supervisors, and trainees. Items that should be defined include the following:

Administration – The key administrator of the policy should be determined. This person will be responsible for ensuring regular education and promotion of the policy. Additionally, this person is responsible for conducting or delegating training of managers/supervisors. Finally, a clear process for receiving complaints should be developed with action plans documented to address those complaints.

Trainee – Trainees should inform their supervisor (clerkship director/academic dean/program director/department chair) that they will require accommodations to express breast milk. Ideally, this will occur during pregnancy, prior to maternity leave. The trainee and their supervisor should work together to determine a schedule that meets the trainee’s lactation needs while maintaining patient care responsibilities and/or classroom requirements. Medical student and resident/fellow schedules may need to be modified to ensure that the rotation schedule is conducive to continued breastfeeding or breast milk expression. Grades and/or evaluations should not be impacted negatively by any accommodations made to support breastfeeding. A culture of support for breastfeeding within the medical school or training program is imperative. The trainee should communicate schedule needs with colleagues and supervisors who may be impacted by the schedule. When using the lactation space, the trainee should clean up after each session and report any issues with the facilities to the appropriate person. The opportunity to meet with a lactation consultant prior to delivery and during breastfeeding can help the medical trainee prepare for breastfeeding, determine a realistic schedule, and manage any challenges that arise.

Supervisor – Supervisors (academic dean/program director/department chair) are responsible for being aware of the lactation policy and creating a culture of support for breastfeeding to promote trainee wellness. They must inform pregnant and lactating trainees about their options for expressing breast milk, including the lactation policy, location of lactation rooms, and who to contact to report concerns. Supervisors should work with the trainee to determine an appropriate lactation schedule. The supervisor should communicate with others, especially faculty, who will be affected by this schedule. The supervisor should communicate clear support for the trainee and ensure that there is a plan for patient care coverage.

References:

American Academy of Family Physicians. Family Physicians Supporting Breastfeeding (position paper). 2014. Accessed August 10, 2018.
American Academy of Family Physicians. Breastfeeding (policy statement). 2017.
Accessed August 10, 2018.
American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-841.
American College of Obstetricians and Gynecologists. Optimizing Support for Breastfeeding as Part of Obstetric Practice. 2016. Accessed August 10, 2018.
World Health Organization. Breastfeeding. 2018. Accessed August 10, 2018.
Centers for Disease Control and Prevention. About breastfeeding: Why it matters. 2018. Accessed August 10, 2018.
Feltner C, Weber RP, Stuebe A, Grodensky CA, Orr C, Viswanathan M. Breastfeeding programs and policies, breastfeeding uptake, and maternal health outcomes in developed countries. 2018.
United States Department of Health and Human Services OoWsH. Business Case for Breastfeeding.
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Mirkovic KR, Perrine CG, Scanlon KS. Paid Maternity Leave and Breastfeeding Outcomes. Birth. 2016;43(3):233-239.
Mirkovic KR, Perrine CG, Scanlon KS, Grummer-Strawn LM. Maternity leave duration and full-time/part-time work status are associated with US mothers' ability to meet breastfeeding intentions. Journal of human lactation : official journal of International Lactation Consultant Association. 2014;30(4):416-419.
Murtagh L, Moulton AD. Working mothers, breastfeeding, and the law. American journal of public health. 2011;101(2):217-223.
United States Department of Health and Human Services. Breastfeeding support: time and space solutions. Accessed November 16, 2018.
Dixit A, Feldman-Winter L, Szucs KA. "Frustrated," "depressed," and "devastated" pediatric trainees: US academic medical centers fail to provide adequate workplace breastfeeding support. J Hum Lact. 2015;31(2):240-248.
Melnitchouk N, Scully RE, Davids JS. Barriers to Breastfeeding for US Physicians Who Are Mothers: Barriers to Breastfeeding for US Physician Mothers: Letters. JAMA Internal Medicine. 2018;178(8):1130-1132.
Accreditation Council for Graduate Medical Education. ACGME common program requirements (residency). 2019. Accessed March 1, 2019.
United States Breastfeeding Committee. Federal Workplace Law. 2018.
Centers for Disease Control and Prevention. Perspectives in disease prevention and health promotion update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-case settings. 1988.

(COE) (May 2013) (2019 COD)