Observe the Latch: A Missing Link in Physician Training!

Physical diagnosis is a central component of medical education. As medical students, our physical diagnosis course provided us with in-depth knowledge and skills to perform a medical history and a comprehensive physical examination. We used and perfected these skills during the remainder of our medical school and postgraduate education and even in practice. I am sure that most of you reading this will agree that our education on the topic of breastfeeding management was lacking. Specifically, a significant missing link in our physical diagnosis education was observing breastfeeding and understanding the importance of obtaining a good infant latch.

Medical students and residents learn a lot about obstetrics, perform deliveries, care for neonates, and examine countless infants. With the help of the Academy of Breastfeeding Medicine, along with many other associations and organizations, I believe an increased awareness of the importance of breastfeeding has developed. However, given the public health significance of breastfeeding, it should be a concern that physicians-in-training are given few opportunities to provide primary care, direct observation, and hands-on breastfeeding management. They have not observed the latch.

A recent survey of residents entering family medicine residencies evaluated the experience in 69 procedures acquired in medical school. ¹ The survey included obstetrical procedures, but breastfeeding management and helping with the latch were missing. Experiences varied depending on the school and motivation of the student; however, it was generally noted that insufficient procedure experience in medical school is a problem. In my experience with medical students, lack of experience in active breastfeeding management is almost nonexistent.

Many, maybe most, physician educators have not clinically observed normal breastfeeding or developed an understanding of what a proper latch should be. The lack of emphasis or support to observe the act of breastfeeding is a detriment to the education of students and residents. Personal experience of physicians with breastfeeding (self or partner and >26 weeks) does provide an increased level of breastfeeding knowledge. ² Using this peer knowledge and practical experience may be helpful to share with other students and residents.

Breastfeeding needs to be observed. For patients with asthma, we listen to lungs and observe and show the proper use of an inhaler. For patients with diabetes, we teach, observe, and educate patients on the proper use of insulin injections, foot examinations, and diet. Why should breastfeeding be any different? We spend considerable time watching the clock, the scale, and documenting voluminous data in our electronic records, but we need to spend more time observing baby and mother and learn how they breastfeed.

Mothers, especially primipara mothers, may need intense physical and emotional support and encouragement for breastfeeding. Physician ambivalence due to lack of knowledge or training can be very disruptive to starting breastfeeding. I would suspect this is also true for many nurses and physician extenders who work in hospitals and outpatient clinics. Although lactation counseling and support may be available, physician observation, knowledge, support, and reassurance in a timely manner can be the difference between success and failure.

There are many other opportunities to learn about proper latch. Many videos exist depicting skin to skin, breastfeeding positions, proper latch, and hand expression. In this digital age, high-fidelity simulation mannequins that deliver physiologic responses are being used to train medical students in many other clinical management skills and show a positive impact. ³ High-fidelity simulation may be an area that could be adapted to introduce students and faculty to breastfeeding and proper latch. However, nothing replaces the actual clinical experience of direct observation of breastfeeding, listening to mothers' concerns, examining the baby, and observing the latch.

A mother and father recently brought in their 4 days old, 37.5-week infant, delivered vaginally but complicated by HELLP syndrome. Mother was given a pump and nipple shield the first day, was told to breastfeed no >10 minutes at a time, and was frustrated with a crying baby. A nurse and lactation consultant helped her, but when asked, no physician, resident, or physician assistant observed the latch. She was not shown hand expression and was frustrated with the nipple shield. With a little help that included observing the latch, positioning, asymmetrical latch, hand expression, lots of reassurance, getting rid of nipple shields and pump, and close follow-up, each time observing the latch, the baby is well on her way.

To be effective in counseling and support, medical students, residents, and educators must observe breastfeeding. Helping a mother with a latch, including hand expression, is a skill, a procedure, not learned in a book or just by watching a video or a simulation; it is a clinical skill that must be developed with real patients and taught by educators who have experience and knowledge in that area. Spending some time with a lactation consultant, observe breastfeeding and latching in the delivery room, and observing the latch on follow-up visits in the office can lead to a rewarding experience for baby, mother, and the physician.