The Rights of Physicians and Future Physicians Who Are Lactating, Breastfeeding, or Chestfeeding: An American Medical Women's Association Position Article

Breastfeeding is a fundamental and biologically normal function with well-established benefits for both lactating parents and infants. Despite these benefits, physicians, particularly those in training, often face significant obstacles when attempting to meet their breastfeeding and pumping goals. In response to these challenges, the American Medical Women's Association (AMWA) and a diverse group of health care professionals have come together to advocate for comprehensive lactation support policies in medical learning environments and workplaces. This position article highlights the ethical necessity of comprehensive lactation support in medical educational and workplace settings, emphasizing the importance of not only providing physical accommodations but also fostering a cultural shift, educational initiatives, and policy reforms to empower lactating parents. It offers an examination of the difficulties encountered by lactating parents within medical environments and proposes guidelines for the formulation and enhancement of supportive policies. The position article envisions a future where medical professionals can thrive in both their careers and parenthood through collaborative efforts and a commitment to the key elements of Effective Lactation Support Programs in medical workplaces based on the following: (1) well-equipped lactation facilities, (2) customized work schedules, (3) mentorship and support networks, (4) lactation support in clinical settings, and (5) research and advocacy.

Transfer of Injected Triamcinolone into Human Milk of a Lactating Patient Suffering from Idiopathic Granulomatous Mastitis

Background: Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory condition of the mammary gland that presents as a painful mass, and it must be distinguished from both infectious mastitis and breast cancer. When diagnosed during lactation, it can result in significant distress and early weaning. Injection of triamcinolone has been used as a successful treatment method, but safety in breastfed infants has not been established. Methods: We present a case of a lactating patient who received a direct injection of triamcinolone (dosage 40 mg) in her breast to treat IGM after failure of oral corticosteroids. Breastmilk samples were expressed by the patient 0, 1, 4, and 24 hours after the procedure, and then daily for 1 week. All the samples were analyzed using liquid chromatography mass spectrometry. The patient was supported by a breastfeeding and lactation medicine clinic. Results: After injection of triamcinolone into the granulomatous mass, breast milk samples were collected and analyzed. No samples were found to contain triamcinolone. A temporary but significant decrease in milk production was noted after injection, though only a slight decrease had been noted with 6 weeks of systemic corticosteroids. With support, the patient rebuilt milk production and continued to breastfeed from both breasts. Conclusion: Triamcinolone was not found in any milk samples (≥0.78 ng/mL) following therapeutic injection of the affected breast. The patient was able to continue breastfeeding from the affected breast with intermittent symptoms.

Prenatal Provider Breastfeeding Toolkit: Results of a Pilot to Increase Women's Prenatal Breastfeeding Support, Intentions, and Outcomes

BACKGROUND

Breastfeeding rates for United States women with lower incomes fall below the government's Healthy People 2020 Goals. Breastfeeding recommendations combined with support from providers and peer counselors help women decide to begin and sustain breastfeeding, but peer counselor uptake is low.

RESEARCH AIM

To evaluate changes in referrals to Women, Infants, and Children's Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention.

METHOD

In this pre-post intervention study (2015-2016; upstate New York), providers implemented a Toolkit to discuss infant feeding recommendations and initiate peer counselor referral. We surveyed women pre- and post-implementation (after delivery; 1 month postpartum) about prenatal breastfeeding intentions, provider support, and breastfeeding outcomes. Analyses controlled for secular trends.

RESULTS

Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding support.

CONCLUSIONS

Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants' breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

Association of Human Milk Antibody Induction, Persistence, and Neutralizing Capacity With SARS-CoV-2 Infection vs mRNA Vaccination

Importance

Long-term effect of parental COVID-19 infection vs vaccination on human milk antibody composition and functional activity remains unclear.

Objective

To compare temporal IgA and IgG response in human milk and microneutralization activity against SARS-CoV-2 between lactating parents with infection and vaccinated lactating parents out to 90 days after infection or vaccination.

Design, Setting, and Participants

Convenience sampling observational cohort (recruited July to December 2020) of lactating parents with infection with human milk samples collected at days 0 (within 14 days of diagnosis), 3, 7, 10, 28, and 90. The observational cohort included vaccinated lactating parents with human milk collected prevaccination, 18 days after the first dose, and 18 and 90 days after the second dose.

Exposures

COVID-19 infection diagnosed by polymerase chain reaction within 14 days of consent or receipt of messenger RNA (mRNA) COVID-19 vaccine (BNT162b2 or mRNA-1273).

Main Outcomes and Measures

Human milk anti-SARS-CoV-2 receptor-binding domain IgA and IgG and microneutralization activity against live SARS-CoV-2 virus.

Results

Of 77 individuals, 47 (61.0%) were in the infection group (mean [SD] age, 29.9 [4.4] years), and 30 (39.0%) were in the vaccinated group (mean [SD] age, 33.0 [3.4] years; P = .002). The mean (SD) age of infants in the infection and vaccinated group were 3.1 (2.2) months and 7.5 (5.2) months, respectively (P < .001). Infection was associated with a variable human milk IgA and IgG receptor-binding domain-specific antibody response over time that was classified into different temporal patterns: upward trend and level trend (33 of 45 participants [73%]) and low/no response (12 of 45 participants [27%]). Infection was associated with a robust and quick IgA response in human milk that was stable out to 90 days after diagnosis. Vaccination was associated with a more uniform IgG-dominant response with concentrations increasing after each vaccine dose and beginning to decline by 90 days after the second dose. Vaccination was associated with increased human milk IgA after the first dose only (mean [SD] increase, 31.5 [32.6] antibody units). Human milk collected after infection and vaccination exhibited microneutralization activity. Microneutralization activity increased throughout time in the vaccine group only (median [IQR], 2.2 [0] before vaccine vs 10 [4.0] after the first dose; P = .003) but was higher in the infection group (median [IQR], 20 [67] at day 28) vs the vaccination group after the first-dose human milk samples (P = .002). Both IgA and non-IgA (IgG-containing) fractions of human milk from both participants with infection and those who were vaccinated exhibited microneutralization activity against SARS-CoV-2.

Conclusions and Relevance

In this cohort study of a convenience sample of lactating parents, the pattern of IgA and IgG antibodies in human milk differed between COVID-19 infection vs mRNA vaccination out to 90 days. While infection was associated with a highly variable IgA-dominant response and vaccination was associated with an IgG-dominant response, both were associated with having human milk that exhibited neutralization activity against live SARS-CoV-2 virus.

Milk From Women Diagnosed With COVID-19 Does Not Contain SARS-CoV-2 RNA but Has Persistent Levels of SARS-CoV-2-Specific IgA Antibodies

Background

Limited data are available regarding the balance of risks and benefits from human milk and/or breastfeeding during and following maternal infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Objective

To investigate whether SARS-CoV-2 can be detected in milk and on the breast after maternal coronavirus disease 2019 (COVID-19) diagnosis; and characterize concentrations of milk immunoglobulin (Ig) A specific to the SARS-CoV-2 spike glycoprotein receptor binding domain (RBD) during the 2 months after onset of symptoms or positive diagnostic test.

Methods

Using a longitudinal study design, we collected milk and breast skin swabs one to seven times from 64 lactating women with COVID-19 over a 2-month period, beginning as early as the week of diagnosis. Milk and breast swabs were analyzed for SARS-CoV-2 RNA, and milk was tested for anti-RBD IgA.

Results

SARS-CoV-2 was not detected in any milk sample or on 71% of breast swabs. Twenty-seven out of 29 (93%) breast swabs collected after breast washing tested negative for SARS-CoV-2. Detection of SARS-CoV-2 on the breast was associated with maternal coughing and other household COVID-19. Most (75%; 95% CI, 70-79%; n=316) milk samples contained anti-RBD IgA, and concentrations increased (P=.02) during the first two weeks following onset of COVID-19 symptoms or positive test. Milk-borne anti-RBD IgA persisted for at least two months in 77% of women.

Conclusion

Milk produced by women with COVID-19 does not contain SARS-CoV-2 and is likely a lasting source of passive immunity via anti-RBD IgA. These results support recommendations encouraging lactating women to continue breastfeeding during and after COVID-19 illness.

Who Makes the Choice: Ethical Considerations Regarding Instituting Breastfeeding in a Mother Who Has Compromised Mental Capacity

This case reports an ethical dilemma in which a mother who had recently delivered a baby through cesarean section after sustaining life-threatening injuries in a car accident did not have documented wishes whether she wanted to breastfeed. Her medical condition rendered her temporarily mentally incapacitated and critically ill, and the lactation medicine team was consulted about whether lactation choice should be preserved by pumping. Complicating considerations in this case were (1) lack of family or designated decision-makers available at the time of injury and emergent delivery, (2) lack of prenatal care, and (3) complex social situation, including prior history of illicit substance use, and state removal of other children into foster care. This case raises important ethical considerations regarding breastfeeding decision-making when a mother is incapable of making the decision, and if there is an intrinsic right for an infant to be breastfed in situations where maternal choice to lactate or to formula feed is unknown. Ultimately, the mother chose to discontinue breastfeeding once she was able to voice her own opinion. The issues discussed in this study may be relevant for future cases when providing guidance on the ethical argument to preserve maternal choice when a mother is critically ill and mentally incapacitated.

Using Brexanolone for Postpartum Depression Must Account for Lactation

On March 19, 2019, Brexanolone (Zulresso ™) was released as the first-ever FDA-approved medication specifically for the treatment of postpartum depression by Sage Therapeutics, Inc. Unfortunately, its use in breastfeeding mothers was not evaluated and is being restricted. An efficacious drug for postpartum depression stands to benefit many families. However, the lack of guidance for breastfeeding patients, and the resultant restrictions on breastfeeding by insurance companies is deeply troubling. Conversely, withholding this medication from a lactating mother is ethically problematic. From a public health perspective, we aim to foster continuous breastfeeding among depressed women while they are being treated for depression. We therefore aim to address concerns about Brexanolone's effects on the breastfed child, as exposed through breastmilk, as well as the impact this medication may have on lactation.

Characterization of SARS-CoV-2 RNA, Antibodies, and Neutralizing Capacity in Milk Produced by Women with COVID-19

Whether mother-to-infant SARS-CoV-2 transmission can occur during breastfeeding and, if so, whether the benefits of breastfeeding outweigh this risk during maternal COVID-19 illness remain important questions. Using RT-qPCR, we did not detect SARS-CoV-2 RNA in any milk sample (n = 37) collected from 18 women following COVID-19 diagnosis. Although we detected evidence of viral RNA on 8 out of 70 breast skin swabs, only one was considered a conclusive positive result. In contrast, 76% of the milk samples collected from women with COVID-19 contained SARS-CoV-2-specific IgA, and 80% had SARS-CoV-2-specific IgG. In addition, 62% of the milk samples were able to neutralize SARS-CoV-2 infectivity in vitro, whereas milk samples collected prior to the COVID-19 pandemic were unable to do so. Taken together, our data do not support mother-to-infant transmission of SARS-CoV-2 via milk. Importantly, milk produced by infected mothers is a beneficial source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness.IMPORTANCE Results from prior studies assaying human milk for the presence of SARS-CoV-2, the causative virus of COVID-19, have suggested milk may act as a potential vehicle for mother-to-child transmission. Most previous studies are limited because they followed only a few participants, were cross-sectional, and/or failed to report how milk was collected and/or analyzed. As such, considerable uncertainty remains regarding whether human milk is capable of transmitting SARS-CoV-2 from mother to child. Here, we report that repeated milk samples collected from 18 women following COVID-19 diagnosis did not contain SARS-CoV-2 RNA; however, risk of transmission via breast skin should be further evaluated. Importantly, we found that milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness as milk likely provides specific immunologic benefits to infants.

Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia

OBJECTIVES

There is debate among otolaryngologists and other practitioners about whether upper lip tie contributes to difficulty with breastfeeding and whether upper lip tie and ankyloglossia are linked. Our objectives were to evaluate the anatomy of the upper lip (maxillary) frenulum, to determine if the visual anatomy of the upper lip has an effect on breastfeeding, and to determine whether the occurrence of lip tie and tongue tie are correlated.

METHODS

A prospective cohort study of 100 healthy newborns was examined between day of life 3-7. Surveys were completed by the mother at the time of the initial exam and 2 weeks later. The maxillary frenulum was graded based on the Stanford and Kotlow classifications by two independent reviewers. Inter-rater reliability and relationships between tongue tie, lip tie, and the infant breastfeeding assessment tool (IBFAT) were calculated.

RESULTS

Inter-rater reliability showed fair agreement (κ = 0.302) using the Kotlow scale and better agreement using the Stanford classification (κ = 0.458). There was no correlation between the upper lip tie classification and breastfeeding success score. Lastly, there was a modest inverse correlation in the degree of tethering for the tongue and lip.

CONCLUSIONS

There was no correlation between maxillary frenulum grade and comfort with breastfeeding, pain scores, or latch. There was also no relationship between tip to frenulum length (tongue tie) and visualized lip anatomy, suggesting that tongue tie and lip tie may not cluster together in infants.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:E1701-E1706, 2021.

COVID-19 and human milk: SARS-CoV-2, antibodies, and neutralizing capacity

Background

It is not known whether SARS-CoV-2 can be transmitted from mother to infant during breastfeeding, and if so whether the benefits of breastfeeding outweigh this risk. This study was designed to evaluate 1) if SARS-CoV-2 RNA can be detected in milk and on the breast of infected women, 2) concentrations of milk-borne anti-SARS-CoV-2 antibodies, and 3) the capacity of milk to neutralize SARS-CoV-2 infectivity.

Methods

We collected 37 milk samples and 70 breast swabs (before and after breast washing) from 18 women recently diagnosed with COVID-19. Samples were analyzed for SARS-CoV-2 RNA using RT-qPCR. Milk was also analyzed for IgA and IgG specific for the nucleocapsid protein, receptor binding domain (RBD), S2 subunit of the spike protein of SARS-CoV-2, as well as 2 seasonal coronaviruses using ELISA; and for its ability to neutralize SARS-CoV-2.

Results

We did not detect SARS-CoV-2 RNA in any milk sample. In contrast, SARS-CoV-2 RNA was detected on several breast swabs, although only one was considered conclusive. All milk contained SARS-CoV-2-specific IgA and IgG, and levels of anti-RBD IgA correlated with SARS-CoV-2 neutralization. Strong correlations between levels of IgA and IgG to SARS-CoV-2 and seasonal coronaviruses were noted.

Conclusions

Our data do not support maternal-to-child transmission of SARS-CoV-2 via milk; however, risk of transmission via breast skin should be further evaluated. Importantly, milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness.

Prenatal Provider Support for Breastfeeding: Changes in Attitudes, Practices and Recommendations Over 22 Years

BACKGROUND

Prenatal care providers play a central role in breastfeeding outcomes. A survey on obstetricians' support of breastfeeding was conducted in 1993 in Monroe County, NY. Since the landscape of prenatal care and breastfeeding support has changed significantly in the past 2 decades, we repeated and extended this survey in 2015.

RESEARCH AIM

To determine changes in breastfeeding support by prenatal care providers over a 20 year period.

METHODS

We sent a 46-item on-line or paper questionnaire to all categories of prenatal care providers identified by an online search. A breastfeeding support score was created based on the prior survey, with a maximum score of 3. One point was awarded for: (1) personally discussing breastfeeding; (2) generally suggesting breastfeeding; and (3) commonly receiving questions from patients. Data were analyzed using Chi-square.

RESULTS

We had 164 participants (response rate 80%). More current participants, compared to 1993, reported discussing (97% vs. 86%, p < .001) and recommending (93% vs. 80%, p = .001) breastfeeding. Only 10% of 2015 participants gave infant formula samples, compared with 34% in 1993 (p < .0001). Improvement in the support score was seen, with 98% of current participants having high scores compared to 87% in 1993 (p < .001). Similar numbers reported receiving breastfeeding education, though more reported that the education was inadequate (54% vs. 19%, p < .0001).

CONCLUSION

Breastfeeding support improved significantly over time, even though breastfeeding education has not improved in quality or quantity. Improving education of prenatal care providers may help future providers be more prepared to support breastfeeding.

Bedsharing and Breastfeeding: The Academy of Breastfeeding Medicine Protocol #6, Revision 2019

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

ABM Clinical Protocol #30: Radiology and Nuclear Medicine Studies in Lactating Women

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

ABM Clinical Protocol #30: Breast Masses, Breast Complaints, and Diagnostic Breast Imaging in the Lactating Woman

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Mothers' Concerns for Personal Safety and Privacy While Breastfeeding: An Unexplored Phenomenon

BACKGROUND

Preliminary qualitative research in upstate NY shows new mothers are worried about safety while breastfeeding. Little is known regarding prevalence of these concerns and their effect on breastfeeding outcomes.

OBJECTIVES

(1) Determine frequency of breastfeeding safety and privacy concerns; (2) Explore their association with breastfeeding outcomes.

METHODS

Mothers were surveyed immediately and 1-month postpartum about breastfeeding goals; both surveys addressed privacy and safety concerns at home, work, and in public. Outcome data included breastfeeding intent, exclusivity, and duration. Breastfeeding/non-breastfeeding mothers were compared using Chi-square and multivariate analyses.

RESULTS

A total of 279 women enrolled. Of these 82.8% initiated breastfeeding; at 1-month 72% provided any breast milk, and 44% were exclusively breastfeeding. About 99% felt safe breastfeeding at home; 25% reported privacy concerns; and 5% felt "vulnerable or unsafe" while breastfeeding. At 1-month, 49% agreed there was a safe place to breastfeed/express milk at work (20% unsure). Non-breastfeeding mothers expressed more safety concerns outside home/at work: 18% breastfeeding versus 28% non-breastfeeding outside home; 27% breastfeeding versus 40% non-breastfeeding at work. Nearly 54% who reported feeling vulnerable/unsafe with breastfeeding initiated breastfeeding, compared with 86% not reporting this concern (p = 0.008). Fewer women initiating breastfeeding reported vulnerability/safety (3% breastfeeding versus 14% non-breastfeeding, p = 0.008) or privacy (22% breastfeeding versus 40% non-breastfeeding, p = 0.19) concerns. Associations held after controlling for age, race, parity, insurance, geography, and marital-status. Significant associations between initiation, privacy, and safety concerns did not extend to duration or exclusivity.

CONCLUSION

Many breastfeeding women reported safety and privacy concerns, especially outside the home and at work, which may influence breastfeeding initiation. Further study may identify methods to address these issues, potentially increasing breastfeeding rates.

Defining Tip-Frenulum Length for Ankyloglossia and Its Impact on Breastfeeding: A Prospective Cohort Study

OBJECTIVE

The purpose of this study was to investigate the normal lingual frenulum anatomy in newborns and to evaluate tip-frenulum distance as an objective diagnostic tool for identifying newborns at risk for anterior and posterior tongue tie and breastfeeding difficulty.

MATERIALS AND METHODS

The distance from the tongue tip to the insertion of the lingual frenulum was measured in a group of 100 healthy newborns to establish normative data. The presence of a visible or palpable cord was noted. Inter-rater reliability was assessed. Breastfeeding surveys including a maternal pain scale and Infant Breastfeeding Assessment Tool (IBFAT) were administered on days of life 2 and 14 to determine whether these findings predict breastfeeding difficulty.

RESULTS

Mean tip-frenulum length was 9.07 mm. Intraclass correlation coefficient between observers for tip-frenulum length was 0.82. A visible cord was identified in 21 subjects (21%). A palpable cord was identified in 59 subjects (59%). Unweighted κ coefficients for inter-rater reliability of visible and palpable cords were 0.91 and 0.47, respectively. Visible cord and shorter tip-frenulum distance were independently predictive of higher maternal pain scores. A positive correlation was identified between tip-frenulum length and IBFAT scores for mothers with two or more previous breastfed children.

CONCLUSIONS

Tongue tip-frenulum length correlated with maternal nipple pain, and was useful as an objective tool for identifying newborns at risk for ankyloglossia. Maternal breastfeeding experience appears to be an important factor in the link between tongue anatomy and breastfeeding difficulty. The presence of a palpable cord was variable across examiners, and should be interpreted with caution when evaluating newborns for posterior tongue tie.

ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

ABM Clinical Protocol #27: Breastfeeding an Infant or Young Child with Insulin-Dependent Diabetes

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Assessing the Efficacy of a Breastfeeding-Friendly Quality Improvement Project in a Large Federally Qualified Health Center Network

BACKGROUND

Provider attitudes can influence breastfeeding decision making, initiation, and duration, although much of this research has suffered from a "hospital-limited view."

OBJECTIVES

This study aimed to evaluate the effect of a Breastfeeding-Friendly Initiative (BFI) on knowledge and attitudes of providers and staff, as well as breastfeeding rates of patients within a large Federally Qualified Health Center network with no lactation consultants on staff.

METHODS

We evaluated breastfeeding rates before and throughout the BFI. In addition, surveys of 136 primary care providers and staff before and after they were exposed to a breastfeeding education module were assessed to measure changes in breastfeeding knowledge and attitudes.

RESULTS

Breastfeeding initiation and duration improved over the course of the BFI, with mean breastfeeding duration increasing by nearly 1 month following the education module compared with baseline rates (P = .01). Following participation in the breastfeeding education module, we observed a statistically significant improvement in provider and staff knowledge (P < .01) and attitudes (P < .01). These improvements were consistent across employment type, gender, geography, and personal experience as a parent.

CONCLUSION

Implementing a BFI in a large multispecialty primary care network was found to improve breastfeeding initiation and duration up to 1 year, with a further increase in breastfeeding duration of 1 month following a 45-minute staff education module. After exposure to this module, health care providers and staff across our network improved in breastfeeding knowledge and attitudes. Given that expectant and new mothers regularly come into contact with staff and providers in primary care, sound knowledge and positive attitudes toward breastfeeding appear to have had a favorable effect on mothers that correlates with improved breastfeeding duration.

Treatment of Narcolepsy with Sodium Oxybate While Breastfeeding: A Case Report

BACKGROUND

Sodium oxybate is used in the treatment of narcolepsy. Currently no published literature supports its safety during breastfeeding, although it has a favorable pharmacokinetic profile for minimizing exposure.

MATERIALS AND METHODS

We report a case of a 27-year-old primigravida with narcolepsy who was taking sodium oxybate for symptom control and contacted our Lactation Study Center for advice. Based on our current pharmacokinetic knowledge, she was advised to avoid breastfeeding 4 hours after a dose.

RESULTS

Follow-up phone interviews were done and the patient reported that the feeding schedule was manageable, and she was able to exclusively breastfeed for 6 months of her infant's life. Based on pediatric records, her infant's growth and development were excellent. There were no noted side effects of the medication for the infant.

CONCLUSIONS

This is the first report to our knowledge of breastfeeding during maternal therapy with sodium oxybate, which appears to be compatible with safe, exclusive breastfeeding when managed appropriately.

ABM Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Setting, Revision 2015

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.