Abstract
Background
The lack of breastfeeding training among physicians who indirectly attend to mothers providing this type of feeding to their babies could lead to its inadequate suspension. There are no impactful scientific publications addressing knowledge about breastfeeding among medical professionals who are not usually in contact with it, such as surgeons, nephrologists, internists, or cardiologists. The aim of this study is to evaluate the knowledge of physicians who are not directly involved in breastfeeding regarding its compatibility with drugs or diseases and related issues, as well as the available resources to consult its compatibility. The study also aims to analyze whether knowledge varies according to the center Baby Friendly Hospital Initiative (BFHI) accreditation, specialty (medical/surgical/medical-surgical), and job position (resident/attending).
Methods
This was a multicenter and cross-sectional observational study conducted in Spain, between October 2023 and February 2024. All physicians from hospitals or health centers in the country were included, resulting in 418 surveys. The questions were grouped into blocks: the first block included demographic data; the second block included general knowledge about breastfeeding; the third block included compatibility with diseases and drugs; and the fourth block included resources for consultation.
Results
Although 87% (365/418) of the physicians treated women who were breastfeeding at least once a year, they reported having limited training in breastfeeding, especially basic issues, and compatibility with drugs. In cases of doubt, 57% (238/418) reported seeking a reliable source. BFHI accreditation, specialty, or job position had little influence on the results. Nevertheless, we observed a higher percentage of correct responses in BFHI paediatric care centers and hospitals.
Conclusions
The results of this study highlight the lack of training in breastfeeding issues among professionals who are not in direct contact with breastfeeding women. This knowledge gap is particularly evident in basic questions about breastfeeding and its compatibility with various medications. This emphasizes the importance of investing in breastfeeding promotion and education across all clinical settings, not only among paediatricians or obstetricians, but throughout the entire healthcare system. Encouraging a multidisciplinary approach can significantly improve support for breastfeeding women and ultimately benefit maternal and infant health outcomes.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13006-025-00752-2.
Keywords: Breastfeeding, Drugs, Disease, BFHI
Background
Physicians play a fundamental role in promoting this practice and educating mothers about its benefits, offering support to overcome any issues that may arise and thus preventing the interruption of breastfeeding due to a lack of information [1, 2].
The knowledge about breastfeeding among paediatric residents is acceptable and has been increasing in recent years [3, 4], especially among residents in hospitals accredited by the Baby-Friendly Hospital Initiative (BFHI) [4]. However, healthcare professionals not directly involved with breastfeeding do not have a satisfactory level of knowledge, positive attitudes, or support skills related to breastfeeding [5]. Some studies have demonstrated that breastfeeding training among physicians and medical students is limited [6], resulting in many of them not delving deeply into or gaining practical experience in this topic [7]. Only 33% of healthcare professionals who regularly participate in examinations of healthy infants for up to six months have received direct breastfeeding training at some point in their careers [8]. Fewer than 20% of physicians attending pregnant women discuss breastfeeding, and fewer than 30% do so beyond three months postpartum [9].
Currently, there are no impactful scientific publications addressing knowledge about breastfeeding among medical professionals who are not usually in contact with it, such as surgeons, nephrologists, internists, or cardiologists. In general, there is a low level of knowledge about the safe use of medications during the breastfeeding period [10]. This can lead to the inappropriate suspension of breastfeeding by healthcare professionals due to potential pharmacological incompatibility or related to certain diseases, who, in the interest of protecting the infant or adequately treating the mother, make this decision without relying on scientific evidence.
The main objective of this study was to assess the knowledge of physicians who are not directly involved with breastfeeding regarding their understanding of breastfeeding compatibility with common diseases and frequently prescribed drugs. The secondary objectives are to study the knowledge these physicians have about breastfeeding-related issues; to evaluate their knowledge of the available resources for consulting the compatibility of certain diseases/drugs with breastfeeding; and, finally, to assess whether the level of knowledge differs among these physicians on the basis of the institution where they provide care (BFHI accredited versus nonaccredited centers), their specialty (medical/surgical/medical-surgical), and professional category (resident/attending).
Methods
This is a multicentric, cross-sectional study conducted through the distribution of an individual and anonymous questionnaire, which could be completed via a QR code or a link disseminated through various social networks and other electronic means. The study was carried out in Spain between October 2023 and February 2024.
To facilitate this, at the center where the project investigators provide care and through the continuing education unit and the teaching committee, the questionnaire was distributed to the professionals included in the study. To achieve participation from other centers, specialists from various hospitals and primary care centers (PCCs) across Spain were contacted via email sent from the medical associations of each province, as well as to the teaching committees of other hospital centers.
The study included all attending physicians and resident physicians working in the participating hospitals or primary care facilities, resulting in a total of 495 responses. The study excluded professionals who had a direct relationship with breastfeeding (36 obstetricians and 29 paediatricians), those who did not have direct patient contact (2 microbiologists, 3 pathologists, 1 biochemist, and 3 clinical pharmacologists) or those whose specialty made it unlikely to treat mothers of reproductive age (3 geriatricians), resulting in 418 surveys (84%).
The questionnaire consists of 44 questions divided into 4 sections. The first section covered the demographic data of the respondents; the second section included questions related to general knowledge of breastfeeding extracted from the WHO-UNICEF Competency Assessment Tools document [11]; the third section comprised questions related to prevalent diseases and the most frequently prescribed medications in our region; and the fourth section consisted of questions aimed at evaluating knowledge about the resources available to check the compatibility of certain diseases or medications with breastfeeding.
To select the diseases and medications for the third section, a series of consensus questions were developed by the researchers on the basis of a list of prevalent diseases, and the most frequently prescribed medications were considered on the basis of the Annual Report on Pharmaceutical Provision in the National Health System [12]. Regarding the fourth section of questions about reliable information sources to determine the compatibility of certain diseases and medications with breastfeeding, responses were considered correct if the physicians mentioned the website e-lactancia which is grounded in scientific publications and professional experience [13] or consultation with a paediatrician.
To determine the BFHI accreditation status of hospitals and PCCs, the registry of accredited healthcare centers available on the official BFHI website was accessed.
The demographic variables collected included sex, age, workplace, specialty, job position, experience, previous children, and type of feeding offered during the breastfeeding period. Additionally, questions were included to understand the frequency of breastfeeding that these women attended by these physicians, as well as their breastfeeding training during their professional life.
A subgroup analysis was conducted on the basis of the BFHI accreditation status of the participating center (in any of its phases or not accredited), specialty (medical, surgical, or medical-surgical), or professional category (resident or attending).
A descriptive analysis of categorical variables was performed via absolute and relative frequencies; for numerical variables, the mean and standard deviation or median and the 25th and 75th percentiles were used, depending on the normality assumption. The incidence was estimated along with its corresponding 95% confidence intervals.
Univariate analysis was conducted via the Mann‒Whitney U test for numerical variables and the chi‒square test or Fisher’s exact test for categorical variables, as appropriate. The significance level was set at 0.05. The statistical package used was Stata/IC v.17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC).
Results
Table 1 shows the demographic characteristics of the study participants (first block of questions). The mean age of the participants was 42.2 ± 11.8 years; the majority were women (304/418; 73%), attending physicians (313/408; 77%), medical specialists (350/416; 84%), and working in BFHI-accredited centers (251/418; 64%).
Table 1.
Demographic characteristics of study participants
| n | % | |
|---|---|---|
| Sex (n = 418) | ||
| Male | 113 | 27 |
| Female | 304 | 73 |
| Job position (n = 408) | ||
| Attending physician | 313 | 77 |
| Resident | 94 | 23 |
| Specialty (n = 416) | ||
| Medical | 350 | 84 |
| Medical-surgical | 29 | 7 |
| Surgical | 36 | 9 |
| BFHI hospital/primary care center (n = 418) | 251 | 64 |
| Work experience (n = 415) | ||
| <5 years | 103 | 25 |
| 5–10 years | 84 | 20 |
| 10 years | 227 | 55 |
| Children (n = 418) | 270 | 65 |
| breastfeeding in those with children (n = 418) | 249 | 92 |
| Frequency of attending to women who breastfeed (n = 418) | ||
| Never | 36 | 9 |
| Occasionally per year | 229 | 55 |
| Weekly | 100 | 24 |
| Unknown | 36 | 9 |
| Has received specific training on breastfeeding (n = 418) | 117 | 28 |
BFHI: baby friendly hospital iniciative; breastfeeding. The results are presented as absolute values and percentages
Tables 2 and 3 present the responses to the various questions related to basic breastfeeding knowledge (second block of questions), as well as its compatibility with medications and diseases (third block of questions).
Table 2.
Absolute number and percentage of correct responses regarding basic breastfeeding issues
| N | % (95%CI) correct answers | |
|---|---|---|
| 1. Administering formula in the first hours of life can interfere with breastfeeding. (n = 413) | 315 | 76 (72; 80) |
| 2. The recommended duration for exclusive breastfeeding is 6 months. (n = 417) | 230 | 55 (50; 60) |
| 3. The recommended duration for breastfeeding is two years or more. (n = 415) | 61 | 15 (11; 18) |
| 4. The recommended initiation of breastfeeding is immediately after birth. (n = 417) | 331 | 79 (75; 83) |
| 5. breastfeeding is important for mothers because it reduces the risk of breast and ovarian cancer. (n = 409) | 379 | 93 (90; 95) |
| 6. It is advisable to discuss early and exclusive breastfeeding with a pregnant woman. (n = 408) | 363 | 89 (86; 92) |
| 7. Breastfeeding within the first 2 h of life, if the baby is ready, is important because it promotes the onset of milk production. (n = 414) | 389 | 94 (92; 96) |
| 8. To prevent breast engorgement, the mother should respond promptly to the baby’s hunger cues. (n = 410) | 253 | 62 (57; 66) |
| 9. The baby will receive all the nutrients it needs with exclusive breastfeeding. (n = 414) | 385 | 93 (90; 95) |
| 10. The normal breastfeeding pattern for a newborn during the first days is: feedings lasting 10–30 min, at least 8 times a day in the first months. (n = 411) | 217 | 53 (48; 58) |
| 11. Rooming-in for 24 h is beneficial for breastfeeding because it helps the mother learn to recognize and respond to the baby’s feeding cues. (n = 415) | 411 | 99 (98; 100) |
| 12. The use of pacifiers prevents the mother from noticing the baby’s subtle hunger cues, which can delay feedings. (n = 413) | 280 | 68 (63; 72) |
The results are presented as absolute values and percentages
Table 3.
Absolute number and percentage of correct answers on medication and disease compatibility with breastfeeding
| N | % (95%CI) correct answers |
|
|---|---|---|
| Medications: | ||
| 1. Valproic acid (anticonvulsant) is compatible with breastfeeding. (n = 410) | 111 | 27 (23; 31) |
| 2. Metamizole (analgesic) is not compatible with breastfeeding. (n = 411) | 230 | 56 (51; 61) |
| 3. Lorazepam (anxiolytic) is compatible with breastfeeding. (n = 412) | 123 | 30 (25; 34) |
| 4. Simvastatin (lipid-lowering agent) is compatible with breastfeeding. (n = 402) | 207 | 51 (47; 56) |
| 5. Ciprofloxacin (antibiotic-quinolone) is compatible with breastfeeding. (n = 408) | 120 | 29 (25; 34) |
| 6. Topical corticosteroids are compatible with breastfeeding. (n = 407) | 349 | 86 (82; 89) |
| 7. Iodine-based radiological contrast is compatible with breastfeeding. (n = 408) | 122 | 30 (25; 34) |
| 8. Internal radiation therapy/brachytherapy is not compatible with breastfeeding. (n = 407) | 283 | 69 (65; 74) |
| 9. Breast augmentation surgery is compatible with breastfeeding. (n = 410) | 234 | 57 (52; 62) |
| 10. Blood transfusions are compatible with breastfeeding. (n = 411) | 365 | 89 (86; 92) |
| Diseases: | ||
| 11. Maternal HIV infection is not compatible with breastfeeding. (n = 410) | 177 | 43 (38; 48) |
| 12. Hepatitis B infection is compatible with breastfeeding. (n = 411) | 217 | 53 (48; 58) |
| 13. Multiple sclerosis is compatible with breastfeeding. (n = 413) | 405 | 98 (97; 99) |
| 14. Diabetes mellitus is compatible with breastfeeding. (n = 414) | 411 | 99 (98; 100) |
| 15. Hypothyroidism is compatible with breastfeeding. (n = 414) | 404 | 98(96; 99) |
| 16. Inflammatory bowel disease is compatible with breastfeeding. (n = 413) | 406 | 98 (97; 100) |
| 17. Depression is compatible with breastfeeding. (n = 412) | 399 | 97(95; 98) |
| 18. Systemic lupus erythematosus is compatible with breastfeeding. (n = 411) | 385 | 94 (91; 96) |
| 19. Hypercoagulable states are compatible with breastfeeding. (n = 412) | 389 | 94 (92; 97) |
| 20. Glaucoma is compatible with breastfeeding. (n = 414) | 403 | 97 (96; 99) |
HIV: human inmunodeficiency virus, breastfeeding. The results are presented as absolute values and percentages
Finally, regarding the source to consult in case of doubt about the compatibility of a medication or disease with breastfeeding, 238 of 415 (57%) responded a web-based resource for consultation, grounded in scientific publications and professional experience [13] or consultation with a paediatritian.
Results based on BFHI accreditation
No differences were observed in the demographic characteristics between the two groups. Likewise, no differences were observed in the correct responses across the various blocks of questions based on the BFHI accreditation of PCCs and hospitals (Supplementary Table 1), except for those reflected in Table 4.
Table 4.
Absolute number and percentage of correct responses by BFHI accreditation status of workplace
| BFHI N = 250 |
NO-BFHI N = 143 |
p | |
|---|---|---|---|
| The recommended duration of breastfeeding is two years or more. | 45 (18%) | 15 (10%) | 0.045 |
| breastfeeding within the first 2 h of life, if the baby is ready, is important because it promotes the initiation of milk production. | 229 (92%) | 138 (97%) | 0.039 |
| Metamizole (analgesic) is not compatible with breastfeeding. | 128 (51%) | 90 (64%) | 0.016 |
| Hypothyroidism is compatible with breastfeeding. | 248 (99%) | 134 (95%) | 0.008 |
Breastfeeding. The results are presented as absolute values and percentages
With respect to the reliable source of documentation used to assess breastfeeding compatibility, no differences were observed between BFHI-accredited PCCs/hospitals (n = 135/220; 61%) and non-BFHI-accredited PCCs/hospitals (n = 92/132; 70%) (p = 0.504).
Results based on specialty
No differences were observed in the demographic variables. Compared with other professionals, professionals from medical specialties reported more frequent attention to women who were breastfeeding in relation to their specialty (p < 0.01). Nevertheless, most physicians, regardless of their specialty, reported encountering breastfeeding women at least once a year.
No differences were observed in the correct responses across the various blocks of questions based on specialty (Supplementary Table 2), except for question number 3 (the compatibility of lorazepam with breastfeeding), where correct responses were more frequent in medical specialties [n = 115/346 (33%)] than in medical-surgical [n = 3/15 (20%)] and surgical specialties [n = 5/36 (14%)] (p < 0.004). Additionally, physicians with a medical specialty consulted the most reliable resources more frequently [n = 213/314 (68%)] than those with a medical-surgical specialty [n = 10/26 (38%)] or surgical specialty [n = 15/31 (48%)] (p < 0.001).
Results based on job position (attending physician/resident physician)
With respect to demographic variables, attending physicians more frequently had children [n = 234/313 (75%) vs. n = 26/94 (28%) (p < 0.01)], had more than 5 years of work experience [n = 289/313 (92%) vs. n = 16/94 (17%) (p < 0.001)], were older [45 ± 11 years vs. 31 ± 7 years (p < 0.001)], and were less likely to work in BFHI-accredited centers [n = 171/292 (59%) vs. n = 74/94 (79%) (p < 0.001)]. No differences were observed in the rest of the variables.
Table 5 shows the responses where differences were observed on the basis of the job position of the participants. The remaining results are reflected in Supplementary Table 3. Regarding the source of documentation used to assess breastfeeding compatibility, no differences were observed between attending physicians [n = 185/285 (65%)] and resident physicians [n = 52/80 (65%)] (p = 0.452).
Table 5.
Absolute number and percentage of correct responses with significant differences based on job position
| Attending physicians N = 313 |
Residents N = 94 |
p | |
|---|---|---|---|
| The administration of formula in the early hours of life may interfere with breastfeeding. | 247 (79%) | 62 (67%) | 0.017 |
| Breastfeeding within the first 2 h of life, if the baby is ready, is important because it promotes the initiation of milk production. | 296 (95%) | 84 (89%) | 0.040 |
| To prevent breast engorgement, the mother should respond promptly to the baby’s hunger cues. | 200 (65%) | 48 (51%) | 0.013 |
| The baby will receive all the nutrients needed with exclusive breastfeeding. | 296 (95%) | 81 (87%) | 0.006 |
| Valproic acid (antiepileptic) is compatible with breastfeeding. | 93 (30%) | 16 (17%) | 0.013 |
| Topical corticosteroids are compatible with breastfeeding. | 267 (88%) | 74 (80%) | 0.045 |
| Breast augmentation is compatible with breastfeeding. | 168 (55%) | 62 (67%) | 0.029 |
| The transfusion of blood derivatives is compatible with breastfeeding. | 281 (91%) | 76 (82%) | 0.010 |
| Maternal HIV infection is not compatible with breastfeeding. | 121 (40%) | 52 (55%) | 0.007 |
| Hepatitis B infection is compatible with breastfeeding. | 172 (56%) | 38 (40%) | 0.008 |
| Glaucoma is compatible with breastfeeding. | 305 (98%) | 88 (94%) | 0.072 |
Breastfeeding. HIV: human inmunodeficiency virus. The results are presented as absolute values and percentages
Discussion
The results of this study highlight the lack of training in breastfeeding issues among professionals who are not in direct contact with it. This knowledge gap is particularly evident in basic questions about breastfeeding and its compatibility with various medications. Moreover, a significant number of participants do not consult appropriate information sources when they are in doubt.
A recent study conducted in Croatia revealed that healthcare professionals lacked supportive skills related to breastfeeding [5]. Healthcare professionals have a duty to promote breastfeeding and prevent its interruption due to a lack of information. In our study, most of the participating physicians had limited knowledge about the compatibility of breastfeeding with commonly prescribed medications, while knowledge about its compatibility with prevalent diseases was significantly higher. This is similar to the findings of Al-Sawalha NA et al., where 80% of healthcare professionals reported a low level of knowledge regarding the safe use of medications during the lactation period [10].
With respect to general knowledge about breastfeeding, we observed results similar to those of a recent study conducted with family physicians and nurses in Nigeria [14]. In that study, only 24% of the participants had attended a breastfeeding training program, and 51% of the participants reported that breastfeeding should be initiated immediately after birth [14]. In our study, 79% (331/417) of the participants responded correctly to this question. However, the Nigerian study participants performed better in some areas, such as the recommended duration of exclusive breastfeeding, with 90% answering correctly compared with 55% (230/417) in our study. They also had better knowledge about the harmful use of pacifiers during the first weeks of life, with 93% answering correctly, compared with 68% (280/413) in our research.
More training in breastfeeding is necessary, as is greater dissemination of reliable consultation resources, to ensure that no physician inappropriately discontinues breastfeeding due to uncertainty about compatibility with a drug or disease. In our study, many of the participating physicians had not received specific training, despite frequently attending to women who breastfeed. Our results are similar to those obtained in studies conducted in Australia and Chile, where only 50% and 33% of respondents, respectively, had received direct training on breastfeeding at some point in their careers [6, 8].
The worst results were obtained for questions related to drug compatibility, where eight questions were incorrectly answered by 30% of the participants and four by more than 70%. Although knowledge regarding compatibility with diseases was greater, 57% (233/410) of the physicians in our study believed that HIV was compatible with breastfeeding in our setting. However, traditionally the recommendation was to replace it with pasteurized donor human milk from a milk bank or commercial infant formula, as this eliminates any risk of transmission to the infant [15]. Nevertheless, the recommendation to contraindicate breastfeeding is currently controversial, and recent guidelines suggest considering the resumption of breastfeeding if the parental viral load is undetectable upon retesting [16].
Additionally, the knowledge of this group of physicians about the available resources for checking the compatibility of certain diseases and drugs with breastfeeding was also limited, as the sources they used were not always appropriate. In our study, 57% (238/418) of professionals used reliable tools to check compatibility. These results can be compared with those of a study conducted in Australia in 2007, where 62% of participants relied on their personal experience with breastfeeding to make such decisions [6]. A possible solution to this lack of training could be to inform all physicians about the available resources for checking the compatibility of certain diseases and drugs with breastfeeding.
BFHI accreditation is a strategy for promoting breastfeeding that has proven effective, with evidence showing that professionals in these centers have greater knowledge about breastfeeding [17–20]. A study conducted in our setting revealed that knowledge about breastfeeding among paediatric residents in BFHI-accredited centers was superior to that of residents in other specialties [4]. However, in our study, which included residents without direct involvement in breastfeeding, we did not observe better knowledge based on affiliation with a BFHI-accredited center. This may be because the professionals directly involved and in contact with breastfeeding benefit from the training provided in the accredited centers.
In our study, we found that knowledge about general breastfeeding issues and their compatibility with medications or diseases among medical specialists was similar to that of other specialties, with medical specialists performing better on only one question about breastfeeding and drug compatibility. However, differences were observed in the resources used to seek information when in doubt, with 61% (213/350) of medical specialists providing a reliable source. This may be due to the more holistic view of the patient typically held by medical specialists than by surgical specialists, who are possibly more focused on techniques or procedures. It is also feasible that, because of their specialty, medical specialists interact more frequently with professionals directly related to breastfeeding.
Finally, the overall level of knowledge observed in our study was greater among attending physicians than among residents, likely because of their greater professional and personal experience. Personal experience with breastfeeding may have influenced their responses.
Within the limitations of the study, data collection through a questionnaire inherently introduces selection bias among participants, thereby reducing its external validity. Although the sample size is large, it cannot be considered representative of the entire medical population, which may render the conclusions drawn less reliable. The responses could be influenced by the time each participant answered the questionnaire, their personal experience with breastfeeding, or a greater likelihood that those with more knowledge would respond. Another limitation of the study is that the question regarding the compatibility of HIV with breastfeeding does not consider data on viral load or maternal treatment, which may lead to misinterpretation by researchers. Additionally, it is possible that some physicians who received the questionnaire consulted a source of information to answer the questions, which could limit the conclusions derived from the results obtained.
Conclusion
Most doctors who do not have direct involvement with breastfeeding have limited knowledge about basic issues related to breastfeeding, as well as its compatibility with various medications; and the sources of information they referred to in case of doubt were not adequate. Our results emphasize the importance of investing in breastfeeding promotion and education throughout the entire healthcare system. Encouraging a multidisciplinary approach can significantly improve support for breastfeeding women and ultimately benefit maternal and infant health outcomes.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors would like to acknowledge the contributions of all the individuals who participated in our survey. Additionally, we express our gratitude to the anonymous reviewers for their constructive feedback, which greatly enhanced the quality of this manuscript.
Abbreviations
- BF
Breastfeeding
- BFHI
Baby-Friendly Hospital Initiative
- HIV
Human immunodeficiency virus
- MRs
Medical residents
- PCCs
Primary care centers
- UNICEF
United Nations Children’s Fund
- WHO
World Health Organisation
Author contributions
All authors: Have participated in the conception and execution of the work.Have participated in the writing and revision of the text.Have approved the final version that, if applicable, would be published.Additionally, the authors declare: The content of the article is original, has not been previously published, and has not been submitted for publication/consideration.The study was approved by the Ethics Committee of Puerta de Hierro-Majadahonda University Hospital.
Funding
This research received grant from BFHI (Baby-Friendly Hospital Initiative). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Supplementary Materials
Data Availability Statement
No datasets were generated or analysed during the current study.