The Breastfeeding Mother and the Pediatrician

Abstract

An estimated 70% of mothers in the United States initiate breastfeeding annually. Mothers often discuss breastfeeding problems with their infant’s pediatrician. Pediatricians may feel unsure about their role when assisting the nonpatient, breastfeeding mother. By having practical solutions and support systems in place to anticipate and tend to breastfeeding mothers’ needs, pediatricians can be instrumental in preventing early weaning. The purpose of this article is to provide practical suggestions to outpatient-based pediatric health care providers when assisting the breastfeeding dyad.

An estimated 70% of mothers in the United States initiate breastfeeding annually.¹ Thus, approximately 3 million of the more than 4 million infants born in the United States each year will be breastfed for some period of time.² Breastfeeding mothers often need encouragement and support, yet pediatricians report feeling inadequately trained in breastfeeding management and may need guidance in the care of breastfeeding mothers.^3–8 The American Academy of Pediatrics is currently in the process of developing an office-based breastfeeding training curriculum with the goal of providing pediatricians with an improved skill set.⁹ The purpose of this article is to provide practical suggestions to pediatricians to help them optimally support and care for breastfeeding mothers.

Competencies Involved in Treating Breastfeeding Mothers

Although pediatricians may not be accustomed to treating adult women within their traditional scope of practice, it is recommended that they provide medical advice and care to breastfeeding mothers.¹⁰ Maternal breastfeeding problems may be identified in any of the clinical settings in which pediatricians commonly practice: outpatient offices, hospital inpatient wards, maternity hospital nurseries, emergency departments, and urgent care clinics. Pediatricians should be adept at describing the content of breast milk, recommend the frequency and duration of breastfeeding, assess breast milk intake by the infant, and, in the rare circumstance, discuss with mothers the contraindications to breastfeeding. Pediatricians also should be able to identify when infants have not effectively and properly latched on to the breast and have a working knowledge of available breast-pumping equipment that might aid the struggling mother. Background information that the pediatrician should obtain before treating adult women includes understanding the scope of his or her medical license and being aware of any potential restrictions imposed by the malpractice insurance carrier when treating adults. In addition, the pediatrician should be mindful of cultural practices specific to the patient population in his or her geographic area and understand state-specific breastfeeding laws.

Breastfeeding in Various Pediatric Settings

One of the most important components of managing problems with the breastfeeding mother-infant dyad is to have effective systems in place to anticipate and immediately tend to breastfeeding mothers’ needs.^11,12 Breastfeeding support should be viewed as a group effort that includes the staff with whom the physician works. Even though pediatricians may not traditionally see themselves as having a physician-patient relationship with adult women, they can serve as advocates to ensure adequate support systems for breastfeeding mothers. The following strategies may improve support for breastfeeding mothers at various locations in the health care system.

Outpatient Office or Clinic Setting

• Discourage supplying free formula and display educational material in waiting and examination areas.¹³

• Advertise that the practice is a breastfeeding-friendly practice and encourage mothers to breastfeed in the office.^12,14

• Provide pregnant women in the practice with educational material and a list of resources on breastfeeding. Also recommend that the expectant mother and her partner participate in a breastfeeding class before delivery.^15–18

• Discuss with all mothers their goal for how long they want to breastfeed and encourage them to provide exclusive breast milk for about 6 months.¹⁰

• Have a telephone triage system in the office to address breastfeeding-related telephone calls.^19,20 Identification of office staff members with breastfeeding knowledge to address such telephone calls could be helpful.

• Employ a lactation consultant who will preferably work in coordination with office staff members who triage breastfeeding-related telephone calls.^19,21–23 Involvement of a skilled lactation consultant may be especially helpful for mothers with problems with latch since patient support for such issues can be especially time intensive. Although lactation consultants will not be reimbursed for their services at the same professional level as a physician, they often can bill commensurate with their background.²⁴ If the infant has been provided clinical care by the physician at that visit for another indication, the lactation support visit potentially can be associated with the physician professional fee where appropriate.²⁵

• Designate a room within the office space for breastfeeding support. Ideally, this room should have a sink, a comfortable chair with arms for the mother to sit, clean towels and linens, pillows for the mother to support the infant and her arms, and breastfeeding supplies. Such a room can be used for lactation consultations as well as for mothers to pump breast milk, especially if their breasts are engorged.

• Maintain a stock of breastfeeding supplies in the office for the mother. Depending on health insurance coverage practices in the area, costs of breastfeeding supplies may be reimbursed by the infant’s health insurer if the mother is not separately registered as a patient. These supplies should include a breast-pumping kit compatible with the office’s electric breast pump, a hand pump for the mother to take home, nipple shields, breast shells, and breast milk storage bottles and labels.

• Have current reference material on breast-feeding available, especially for nurses and other office staff members designated to support breastfeeding mothers.

• Keep updated information material on electric breast pump rental locations and support groups within the local community. This list is best compiled and maintained by the office staff working with breastfeeding mothers and is updated with feedback from mothers who tried the suggested services.

• Keep educational materials or flip charts in each office room illustrating proper latch techniques.

• Keep office systems in place to enable mothers of all breastfeeding infants to obtain a prescription for vitamin D, with appropriate information material as per the policy recommendation of the American Academy of Pediatrics.^10,26

• Provide breastfeeding mothers who plan to return to work with practical advice on how to continue breast milk feeding during separation from their infants.

• Congratulate every mother on her decision to breastfeed!

Inpatient Pediatric Hospital Wards

• Advocate that the hospital invest in a sufficient number of breast pumps and breastfeeding supplies for use by all mothers of infants admitted to inpatient wards. To estimate the number of pumps that are needed, we recommend multiplying the number of infants younger than 1 month admitted to the facility over the previous 12 months by the breast-feeding initiation rate in the area.¹

• Advocate for the availability of lactation support service to assist mothers of breastfed infants who require hospital admission. The lactation service should include trained lactation personnel, preferably those with experience assisting mothers of sick children. Dedicated lactation support is especially crucial in neonatal intensive care settings, where nurses or dietitians may have limited time to spend with the mother.^23,27–31

• Ensure that there are private areas available in the hospital for mothers of hospitalized infants and children to express breast milk.

• If expressed milk is to be stored in a central location, the hospital should have a self-explanatory breast milk bottle-labeling procedure in place as well as a policy on handling situations in which an infant is fed the wrong mother’s milk.³²

• Remind all house staff, nurses, and other inpatient ward personnel that if the infant is well enough, he or she can be fed at the breast. Tools to measure the infant’s intake of breast milk can include a scale sensitive enough to measure body weight before and after each feed.

• Ensure that the hospital has protocols in place to dispense donor milk from a central location.

• Have a partnership with a milk bank in the event of infant death. When an infant dies in the hospital and there is stored milk that the mother has pumped, donation to a milk bank ensures that the milk is not discarded. This donation process can be part of the hospital-sponsored grieving protocol for the family.³³

• Develop an affiliation with the closest hospital-related family housing since breastfeeding and breast-pumping mothers in various post-partum stages may spend a significant amount of time there. Work with the director of each facility to ensure that maternal lactation needs are supported, including having readily available breast pumps cleaned and in working order and providing clear instructions for safe storage and transport of milk to and from the hospital.

• Have breastfeeding references available on each inpatient unit, particularly those describing the compatibility of maternal medications and breastfeeding.

Maternity Hospital/Postpartum Unit

• Be aware of whether the maternity hospitals with which you are affiliated have met the requirements of the Baby-Friendly Hospital Initiative.³⁴

• Support each mother’s decision to breastfeed.

• Have all breastfeeding mothers make an appointment for outpatient follow up in a pediatric primary care provider’s office within the first 3 days following discharge.¹⁰

• Confer with lactation consultants on the post-partum units about any anticipated difficulties by breastfeeding mothers of infants to be followed in your practice

• Ensure that there are reference books available on each postpartum unit, particularly those that describe the compatibility of maternal medications and breastfeeding.

Emergency Department or Urgent Care Center

• Support each mother’s decision to continue breastfeeding, even if the reason for the emergency may be related to breastfeeding difficulty (eg, infant dehydration or hyperbilirubinemia).

• Have an electric breast pump available for mothers to express their milk if the infant is too ill to feed at the breast.

• Have lactation consultative services available to properly assess the breastfeeding dyad before discharge or soon thereafter.

• Have current reference material readily available, particularly material that describes the compatibility of maternal medications and breastfeeding.

When to Register the Mother as a Patient

Registering the breastfeeding mother of a patient in a pediatric office or hospital setting may be an uncommon but prudent approach when assisting breastfeeding mothers. Ideally, each time a mother-baby dyad is seen by a pediatrician and maternal breastfeeding issues are extensively discussed, a medical record for the mother should be generated. A medical record generated for the mother is important not only for communicating information with other health care providers but also for documenting potential health issues of the mother that may affect breastfeeding or may be contraindications to breastfeeding. If the pediatrician examines the mother’s breasts and nipples or recommends the use of breastfeeding equipment or medications for the mother, such information should preferably be recorded in the mother’s chart. The pediatrician is not obligated to treat the maternal medical conditions; however, he or she might need to consult with the mother’s physician to communicate the need for such care. By having any maternal history and physical examination findings recorded in the mother’s own chart and not the infant’s chart, there will not be risk of violation of parts of the Health Insurance Portability and Accountability Act.³⁵ The mother’s chart can be either physically located next to or electronically linked to the infant’s chart, to make it easier to locate.

Prescribing Medications for the Mother

The pediatrician may be uncomfortable with prescribing medications for an adult woman and may recommend that the mother call her own physician’s office. While this can be an appropriate measure, it does present one more hurdle for the tired mother of a newborn who is trying to breastfeed. With experience caring for the breastfeeding dyad, the pediatrician may become comfortable treating maternal conditions such as (1) candidasis of the mother’s nipples when an infant has oral candidiasis, (2) localized bacterial infection of the mother’s nipples due to trauma from the infant’s sucking, and (3) low milk supply. Any medication recommended for the mother should be documented in the mother’s own medical record. Having the mother register as a patient before writing a prescription will enable the pediatrician to document any pertinent past medical history, allergies, or potential contraindications to and side effects of medication use, as well as to document follow-up care.

When to Bill for Care Provided to a Breastfeeding Mother

Clinical care provided by a pediatrician to the breastfeeding mother of an infant is reimbursable. The American Academy of Pediatrics has published information with typical International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for both the infant and mother.²⁵ Since clinical encounters involving breastfeeding-related issues may be lengthy, this information from the American Academy of Pediatrics additionally discusses billing criteria based on visit duration. When both the mother and infant are registered as separate patients, there will be 2 co-payments collected at the time of service as well as 2 insurance payments for the time involved. Billing for only the infant may lead to underpayment of the pediatrician for the clinical care provided.

Conclusions

Providing clinical support to the breastfeeding dyad may be time-consuming and involves addressing issues regarding both the mother and the infant. Pediatricians often find themselves providing advice and treating the breastfeeding mother as a patient even though the medical care of an adult woman is generally perceived to be outside the scope of a pediatrician’s practice. By developing appropriate knowledge and skills, as well as by developing support systems to anticipate and attend to the needs of breastfeeding mothers, pediatricians can help increase breastfeeding duration and exclusivity.