Breastfeeding Medicine Blog

The Burden of Proof

October is a busy month for me. I usually travel twice that month, once for the American Academy of Pediatrics Section on Breastfeeding Medicine meeting, and then again for the annual Academy of Breastfeeding Medicine meeting. One of my partners (who doesn’t have children) comes up to me and says: “Why are there so many meetings about breastfeeding? I mean we all know that’s the best thing for babies and we all should recommend it. How many meetings, research studies do you really need?” At first, I was stunned…not bad, not good, just surprised, I guess.

This reminds me of when I had invited Dr. Christina Smillie to Children’s Hospital of the King’s Daughters (CHKD)/Eastern Virginia Medical School (EVMS) to speak at our 1st Virginia AAP Breastfeeding conference in 2009. The first night I had her speak to the MPH school at EVMS. As Dr. Smillie always does, she gave a wonderful talk on the public health reasons, risks of death with sub-optimal breastfeeding, how breastfeeding is natural, etc. After 60 minutes of slides, statistics and videos, a male public health researcher raised his hand and asked: “So why isn’t everyone doing this…why aren’t BF rates at a 100%?” Dr. Smillie and I just smiled knowingly at each other.

After I thought about it, I explained to my partner that while there is so much new research/things discovered about breastmilk and its properties, I told her, that as a field, Breastfeeding Medicine is constantly battling critics and having to ‘prove’ our medicine. Whether it’s against the various industries, hospital systems, colleagues, or even other physicians, Breastfeeding medicine has to prove its worth. I was telling another ABM member about this conversation and I remarked at how I had attended an acne lecture at the AAP conference. As a general academic pediatrician, I wanted to get some new information, learn the research on various conditions that I commonly see in my practice. And it hit me like a ton of bricks. The dermatologist, while very knowledgeable and a good speaker, was quoting statistics from the 70’s and 80’s…that would be 1970/1980. Of course she spoke about the newer drugs being used, but the pathophysiology and meds/ointments used to treat this condition, well that data was over 25 years old!

This is not to say that other pediatric fields don’t have to do research and update their findings, but it was incredible to me! That would never be accepted within the BF medicine community. Other researchers/physicians, often via social media frequently attempt to debunk even the latest studies with strong findings.

Or if a physician has a bad experience, studies have shown that our personal breastfeeding experiences negatively affect our advice that we, as physicians, give to mothers/patients. That’s like me telling patients not to have a needed surgery since I had such terrible experiences with anesthesia.

So why does this happen? Why do folks not argue against the treatment of other medical conditions, such as acne, reflux, etc? It is because breastfeeding is personal, it is maternal and unfortunately, there is a lot of guilt attached to not being able to breastfeed and/or not meeting breastfeeding goals/expectations? Do we need to depersonalize the topic, make it less emotional? Is that even possible? Just like my partner or the public health researcher, it was like “duh…of course everyone should be breastfeeding.” Stepping out of your [breastfeeding] box, no matter what side of it you’re on, proves to be beneficial, to give perspective, to depersonalize it so one can see facts.

Ok, yes this may be oversimplifying the issue, as there are numerous facets (prenatal, hospital, postnatal, cultural, societal) to breastfeeding success, but the matter-of-factness of the health benefits of breastfeeding has been and continues to be proven. Period. And our goal as physicians is to give each and every mother the opportunity to give this to her baby. And there really should be no debating that.

“A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breasts, and security in the knowledge of her presence. Breastfeeding satisfies all three.” ~Grantly Dick-Read

Natasha K. Sriraman is a general pediatrician and a professor of Pediatrics at Children’s Hospital of The King’s Daughters/Eastern Virginia Medical School in Norfolk, VA.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Trust and test weights

“Nobody seems to trust test weights in our unit.  What are we doing wrong?”

To “test weigh” a baby means to measure how much milk she has transferred by simply weighing her — clothing, diaper and all — before and after breastfeeding.  Test weights are often used in term infants using precise scales such as the Medela BabyWeigh.  A few studies have supported the utility of test weights in preterm infants: these include a Swedish study favorably comparing babies cared for in NICUs using test weights vs NICUs that did not (earlier attainment of exclusive breastfeeding and earlier discharge) as well as a small study from the illustrious LCs at my own institution describing the development of a technique for accurately performing test weights.

It still seems, though, that NICU providers and even parents have a tendency to distrust test weights in premies learning to breastfeed.  Some of this distrust, especially for the providers, is probably a residuum of earlier studies using less precise scales and/or less consistent, accurate weighing techniques.  (It is true that we NICU folks tend to love our numbers, and we prefer that they have as many significant digits as possible.) I suspect another large part of the distrust has to do with the fact that premies who are learning to feed don’t consistently transfer the same volume of milk even when their feeding quality seems to be subjectively “good.”  As with learning to walk or talk, learning to feed is an incremental and not a linear process… but when numbers-focused, pattern-seeking people see “inconsistency” in the amount transferred, we think “that can’t be right.” Finally — just perhaps — part of the distrust might be with breastfeeding itself.  If we can’t measure it or control it, we can’t trust it. And if parents hear us expressing distrust of breastfeeding, they are probably more likely to distrust it as well.

Fortunately, a new study in the Journal of Pediatrics provides new support for the distrusting among us. This group took the breastfeeding out of the picture altogether: in a larger number of premies, using the protocol developed above, they performed test weights before and after gavage feedings.  (This means that the volume given was known, and the test weight was compared to the volume given.)  They found that 85% of the test weights were within + 5mL, which is clinically acceptable for older premies (>34 weeks).   I admit to glossing over the finer details here and encourage anyone who is interested to read the paper more closely.  But knowing that test weights do correlate with a known volume given by gavage, there is no reason we shouldn’t be able to trust them in measuring “unknown” milk transfer at the breast.

Bottom line: be consistent in your weighing procedure, use a good scale, and… trust the babies as they learn to breastfeed. If we trust the babies, we can empower their moms,  which is one of the most important parts of our job.  NICU moms need to be able to trust themselves and their babies, not just their NICU providers!

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine. 

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Short report on the Baby-Friendly Hospital Initiative Congress

Submitted on Behalf of the World Alliance for Breastfeeding Action (WABA) and the Academy of Breastfeeding Medicine (ABM)

Dr Felicity Savage, FABM, Chair of WABA.

Dr Rukhsana Haider, FABM, Co-Chair of WABA.


The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by WHO and UNICEF, with the aim of protecting, promoting and supporting breastfeeding in maternity facilities worldwide.  To be designated “Baby-Friendly”, facilities are required to follow the Ten Steps to Successful Breastfeeding and the Code of Marketing of Breastmilk Substitutes.

Since 1991, great progress has been made, and 20,000 maternity facilities world-wide have been designated Baby-Friendly. However, in the last decade, progress has slowed down, and the total number of designated facilities still represents less than one third of all maternities in the world. Also it has been difficult to maintain the necessary standards as the BFHI assessment procedure often lies outside normal hospital accreditation processes.

The 25th Anniversary of the launch of the BFHI seemed an appropriate time to review progress and consider the need for the development of revised or new guidelines.

The purpose of the Congress accordingly was to:

  • Celebrate achievements in improving quality of care for breastfeeding mothers
  • Examine the current status of the Baby-Friendly Hospital Initiative
  • Discuss new guidance on country implementation of the initiative
  • Form regional networks to improve country programmes in maternity facilities.

Congress proceedings

Over 300 participants attended, including representatives from Ministries of Health of 133 countries, and from 17 international organisations.

Day 1.

The opening had moving tributes to late Dr Audrey Naylor, and late Dr Miriam Labbok, both of whom had made major contributions to the development and implementation of the BFHI. There followed presentations on the latest evidence for the importance of breastfeeding, the history of the BFHI, country experiences, and the status of the BFHI in different regions.

An “Introduction to the updated guidance on protection, promotion and support of breastfeeding in maternity facilities” was presented by  Dr Laurence Grummer-Strawn. An update has become necessary because:

– there is clear evidence that implementing the Ten Steps increases breastfeeding rates, with a dose response relationship – the more steps that are followed, the less breastfeeding rates decline in the early weeks;

– yet there are serious challenges, including the voluntary nature of the BFHI, the question of ownership, and the costs and workload of training and assessment;

– the existing guidelines were developed in 2006-7, and WHO now has a new process for the development of guidelines, which includes detailed reviews of their evidence base.

The scope of the new guidelines will be for maternity facilities only, and will cover preterm and low birth weight infants.

They will comprise:

Guidelines on patient care: the process will be governed by the WHO Guidelines Review Committee, and developed by a Guidelines Development Group, with the inputs of 21 systematic reviews.

The Ten Steps will be discussed in November, and conclusions released in mid-late 2017.

Implementation guidance for national programmes:  this will be developed by an External Review Group, from case studies, key-informant interviews, a global survey and other key documents.

The principles driving the changes will be:

– integrated people centred health services

– improving quality of care

– strengthening of health systems

Key points are:

  • the BFHI should be the responsibility of every maternity facility, private and public, with countries establishing national standards of care;
  • it should be integrated with other health care improvements and quality insurance initiatives;
  • incentives to implement practices should be other than achieving designation;
  • regular internal monitoring of practices is crucial;
  • external assessment may still be required, but should be manageable with existing resources

Days 2 and 3.

A presentation on the Application of the Code in the BFHI, and a panel discussion on Capacity Building were included.

Much of the time was devoted to four presentations of Draft Updated Operational Guidance Topics for Implementation, each followed by discussion in 9 working groups, which were reported back in plenary sessions.

The Guidance Topics were:

–  1: Implementation in maternity facilities

–  2: Setting national health care standards

–  3: National implementation

–  4: National leadership and co-ordination

Reports from the 9 groups were extensive and varied and will be further discussed by the External Review Group in subsequent meetings, and considered in the development of new Guidance.

A summary of the discussions included the following key points:

  • Breastfeeding is the norm and needs to be mainstreamed – it is not a special extra;
  • The BFHI should be mainstreamed into other initiatives and policy and standards of care throughout a country;
  • There is a need for strong advocacy for both breastfeeding in general, and the BFHI;
  • Healthy and low birth weight babies must both be included in the initiative;
  • The public and private system must be involved;
  • The Code must be strong;
  • Mother friendly practices and the mother friendly community need to be linked in to the BFHI;
  • Training needs to be stronger with follow-up mechanisms, including supervision;

Operationalising, and the designation process are likely to be a challenge:

– government should be involved, but can sometimes  be a barrier;

– branding needs to be considered – and may require reconsideration of the title;

– new guidelines may make new issues apparent;

– electronic systems may be useful for evaluation.

The following simple recommendations were given to countries for proceeding while awaiting the new guidance and guidelines:

  • If your BFHI is already strong: carry on with what you are doing;
  • If you are struggling: try to work with networks such as professional associations and see if they can help move the initiative forward;
  • If the BFHI is controversial for you: it may be best to wait for the new guidelines. These may become available in late 2017.

Regional meetings were then held to discuss the development of regional networks to support implementation, followed by a closing session.

Further details of the presentations and the questions put to the discussion groups can be found at the following site:

The Baby-Friendly Hospital Initiative Congress was held October 24-26,  2016 at the World Health Organization Headquarters in Geneva, Switzerland.

Dr Rukhsana Haider, MBBS, MSc, IBCLC, PhD is Founder and Chair, Training & Assistance for Health & Nutrition (TAHN) Foundation, Chair, Civil Society Alliance for Scaling Up Nutrition, Bangladesh (CSA for SUN, BD), and Co-Chair, Steering Committee, World Alliance for Breastfeeding Action (WABA), Penang, Malaysia.

Felicity Savage is a paediatrician by training, who worked for a total of 18 years in Zambia, Indonesia and Kenya as a clinician in primary care, and was involved with the Baby Friendly Hospital Initiative from its inception. Felicity was an Honorary Senior Lecturer at the Institute of Child Health London, from 1979, where she founded the 4 (later 3) week Breastfeeding Practice and Policy (BFPP) course which continued  from 1992 to 2012.  In 1993 She joined the World Health Organisation in Geneva, specialising in the promotion of breastfeeding. With WHO, she co-ordinated the development of in-service courses on breastfeeding counselling and HIV and infant feeding.  She was part of the team that developed the Global Strategy on Infant and Young Child Feeding, and she edited a number of technical documents on different aspects of breastfeeding for WHO. Since retiring from WHO in 2001, Felicity has continued  to work as a freelance consultant, and Director of the Infant Feeding Consortium cic, based in Brighton UK, she particularly enjoys visiting countries where there are participants from BFPP courses, to help them to develop their plans for breastfeeding promotion and training.  She is now Chairperson of the Steering Committee of the World Alliance for Breastfeeding Action (WABA), which collaborates with the IFC to teach the 2-week course Breastfeeding Advocacy and Practice in Penang, Malaysia. She lives in Leeds in the north of England.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.


AAP New Policy Statement on Donor Human Milk for the High Risk Infant

While the birth of neonatology was in the late 1800s with the development of the incubator, it was only in the 1970’s when the modern NICU was established with the neonatal respirator. More advanced respirators and other technologic developments, including important medications such as surfactant and nitric oxide, have dramatically improved the outcome of preterm infants. Yet, one of the most important “new developments” to improve the care of these infants, is feeding an exclusive human milk diet. It is now clear that exclusive breastmilk decreases preterm mortality and the incidence of necrotizing enterocolitis, sepsis, BPD and ROP, while increasing infant brain volume and neurodevelopment in infancy, childhood and adolescence. 

Therefore, it is noteworthy that three AAP committees, the Committee on Nutrition, the Section on Breastfeeding and the Committee on Fetus and Newborn, the committee that writes policies for neonatologists, combined to write a policy statement supporting the use of pasteurized donor human milk in high risk preterm infants, with priority for those less than 1500 grams, when mother’s milk is not available. It states that the use of donor human milk in preterm infants is consistent with good health care. It recognizes that the use of donor milk is limited by its availability and affordability. It asserts boldly that the use of donor human milk should not be limited by an individual’s ability to pay. It urges health care providers to advocate for policies that assure reimbursement for its cost, while expanding the growth of milk banks by improving governmental and private financial support.


The policy states that donor milk for these high risk infants be obtained only from HMBANA and commercial milk banks that identify and screen donors, pasteurize milk and culture the post-pasteurization milk according to quality-control guidelines.  It discourages families from direct human milk sharing or purchasing from the internet due to the increased risks of infections and the potential exposure to contamination with medications, drugs or other substances. It recognizes, however, that current pasteurization methods destroy many bioactive components of donor milk and encourages the development of alternative sterilization methods that better preserve these factors. 

The statement states that the optimal feeding choice for preterm infants is mother’s own milk. Donor milk should be used when mother’s milk is unavailable or as a bridge or support while the mother’s milk is made available. It urges health professionals to encourage and assist mothers to pump or express milk and to provide their own milk whenever possible. But it also encourages providers to discuss with these families the high level of safety of milk obtained from milk banks and the tremendous benefits of human milk.

We can now envision a future where the overwhelming majority of high risk preterm infants will receive the low-tech, but very powerful, intervention of an exclusive diet of mother’s and/or donor milk. 

Donor Human Milk for the High-Risk Infant: Preparation, Safety and Usage Options in the U.S. This AAP policy will be published in the January issue of Pediatrics.

Larry Noble MD, FABM, IBCLC is a neonatologist and Associate Professor of Pediatrics at the Icahn School of Medicine at Mount Sinai and Elmhurst Hospital in New York City, the Secretary of ABM and Policy Chair of the AAP Section on Breastfeeding. He declares a hugh conflict of interest as one of the Lead Authors on this Policy Statement. You can follow him on Twitter @GalactoDoc

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.


Naturalizing Breastfeeding Through Filters

Every day since 2010, I spend a couple of hours reading and responding to posts in  a Facebook group of physician women who are breastfeeding/pumping/advocating called Dr. MILK (  And in the last 72 hours our group’s feed of 5200+ international physician mothers has exploded with dozens of deliciously gorgeous #brelfie pics of themselves nursing or pumping for their kids using the concept of the #treeOfLife breastfeeding selfie.

I completely derailed my entire Sunday evening of finishing newborn nursery charts and billing to create my own “Tree of Life” photo with dazzling filters, and I wanted to give credit to the person who came up with the idea.  So I did some serious journalistic Googling and found Cassie @keeponboobin (Instagram, Twitter) and tagged her in a series of posts of my own kids from 2012.  She wrote back in admiration of my edits (feigned blushing) and reposted my pics to her own account (as is customary in social media etiquette).  I asked her to be interviewed for this blog to explain how this viral campaign came to be and how it has changed the landscape of women fearlessly posting bare-breasted nursing photos.

The very FIRST tree of life pic!

The following are excerpts from our dialogue of her inadvertent campaign to #naturalizeBreastfeeding and give women confidence to share with the world their pride in making milk for their children.

How did this Tree of Life concept unfold?

“After celebrating my 12 month anniversary of nursing my daughter, I wanted to commemorate with a nursing photo that I could hang on the wall. I had recently learned about how breast milk was considered a living organism and that having fascinated me, I chose to try and incorporate that into our photo. We had a rough beginning when we started nursing, so this was something that was truly special to me. I came up with the idea to use Photoshop and create a flower, with the vines going from my breast to her brain. A metaphor for her ‘blossoming’ into this beautiful child. While nursing her one day, I took a photo of her on my cell phone and decided to play around with it, kinda work out the idea I had come up. “

“I was able to add a flower to the photo but didn’t really like the way it looked. That is when I decided to try a tree instead. I gave it a kind of artsy look through the app’s many filters they offer and just fell in love with it. I had originally intended to take a professional photo with my camera and do this all on the computer but I really loved what I had created.”

Cassie and her daughter @Keeponboobin

What is your breastfeeding story and journey?

I have a 13 month old and we are still currently nursing. My first goal was a year. Next goal is two years.  Unlike most nursing moms, I did not intend on breastfeeding. I saw breastfeeding as sexual. I was one of ‘those’ people who judged moms nursing in public. After my daughter was born, she was given formula for the first two days of life. On the third day, I was holding her and something in me just clicked. Like a maternal instinct had turned on. Next thing I know, I am asking for the lactation consultant and am trying to learn everything there is to know about breastfeeding during that hour consultation. However, we still had a rough beginning. My daughter has latching issues due to a posterior tongue tie and upper lip tie. We also dealt with colic pretty badly.

I was such an anti-breastfeeding person. Now, I am not only a huge breastfeeding supporter, but a lactation consultant student. I am about to start my clinicals and will be sitting for the exam next year!”

How did your one photo become a viral sensation trending on Facebook and Instagram?

“I had never shared a photo of my nursing my daughter before but I really wanted to share this beautiful photo with someone who I knew would appreciate it. I decided to share it in a breastfeeding support group that I have been a part of since my daughter was born. This amazing group of women have helped me through many tears and trials with my nursing relationship so I knew they would truly understand how special this photo was to me. When I shared the photo, I asked if anyone else wanted me to make one for them as well. I stayed up all night and edited one for every single person who wanted one and still am. To date, I have now edited over 700.”

A quiet moment with my two in 2012

Why does the filtered pic give women confidence and freedom to share widely?

“This was actually the first nursing photo I had ever publicly shared. I have taken a photo every month of nursing from since 3 days post birth but never had the courage to share it. However, I felt that an arty version would be less alarming to people.  I think that people feel that sharing a piece of art isn’t as alarming as sharing a regular nursing photo. I also think that women have a connection with these photos.  They are showing the emotion of the feeding relationship and the connection that so many of us feel everyday. I have received 100’s of messages from moms thanking me for giving them the courage to not only share their first nursing photo, but comfortable nurse in public today without feeling they are being judged”

You are tracking hashtags – what trends have you noticed?

There are women who have posted pumping tree of life, bottle tree of life, and gastrostomy tube tree of life pics.  All beautiful ways of showing how we nourish our children.  “The midnight overlay is the most popular of all the color options.”

Tandem nursing my two:  Caroline and George in 2012

Why use the term naturalize versus normalize for breastfeeding?

“Because breastfeeding is natural. It is what our breasts and body were designed to do. When you use the term normalize, that is implying that it wasn’t normal to begin with. It is normal, is it natural, and it is beautiful.”

I now follow @keeponboobin on Instagram and Twitter myself, and you can keep up with all the latest #brelfie #treeOfLife pics to see tens of thousands of mothers celebrating the ephemeral and mystical filter of providing your body’s milk for your child.  Women from all walks of life and all methods of delivering that milk to their children are finding a connection to this viral selfie movement.

Dr. MILK mothers and others have found courage through filters and edits to shout to the universe that we are proud of how we feed our children (this ain’t an exclusive club – every drop of your milk is precious)!  Ban the breast covers and download a photo editing app to reclaim your breasts as a source of love and provision – – not of objectification.

So go make your own (PicsArt free app -> sticker tree of life -> magic filters) and share away.  Scan in an old pic (gasp… a printed pic!) – – take a new pic – – just share and watch your friends and family be in awe of your “super powers” and beautiful art.

Laurie B. Jones, MD, IBCLC, is a pediatrician in Arizona and founder of Dr. Milk. You can follow her on Twitter @DoctorDrMILK


Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.