Abstract
The commonly used caution “Primum non nocere”—“above all, do no harm,” applies to many aspects of breastfeeding education and practice.
We all know the potential harm from the improper use of formula as a substitute for breast milk and the deceptive marketing practices of formula companies. However, there are many other activities that disrupt and sabotage breastfeeding. The Baby-Friendly Hospital Initiative has identified many, but it is not a complete list.
I offer a partial list of additional potential harms. Some have a direct impact on breastfeeding, whereas others may be more subtle and some are controversial and may not apply to your practice. I would encourage our readers to add their list.
Lack of Golden Hour Education
I had many opportunities to have a student or resident present at a delivery. I would challenge them to observe, both during and after the delivery, the activities that disrupt or encourage breastfeeding and watch the magic of newborn self-attachment. Few took me up on this valuable education and I believe must be promoted as a necessary part of medical education.
Epidurals
Epidural anesthesia has revolutionized pain control during labor. However, there remains inadequate information and education of mothers on the potential harms that epidurals can have on breastfeeding. 1 As recommended by ABM Clinical Protocol #15, Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017, more studies need to be done on safety of analgesics used in deliveries and their impact on breastfeeding. 2 Reliable safety information must be developed for the education of mothers.
Visitors
Family support is crucial to the initiation and continuation of breastfeeding. However, I have seen large number of well-intentioned relatives and friends at deliveries, postpartum, and visiting the home after delivery and do not understand their potential for disrupting breastfeeding. Many offer their uneducated infant feeding recommendations that can be equally as harmful. This issue must be part of prenatal education as well as community education.
Vigorous Suctioning
Vigorous suctioning on low-risk, normal vaginal birth with normal fluid, has no benefit. 3 While improving, in some hospitals, it is still a common practice. Some habits and procedures are hard to break, but this one, if done improperly, has the potential for harm to breastfeeding.
Protocols
Protocols are necessary for safety and protection of our patients. Many are followed to get the appropriate boxed checked in the electronic medical record (EMR) and it has become a challenge to overcome the fear of the protocol. Weighing the baby, eye drops, vitamin K, heel sticks, and the “warmer” are all sometimes necessary procedures but can be delayed to allow breastfeeding to get started. Close observation, skin-to-skin contact, and a little colostrum have been shown to go a long way to prevent some of the harms caused by the “protocol.”
Automated Blood Pressure Monitor
The automated blood pressure monitor continuously attached to the mother especially after delivery can be disruptive to trying to get the baby latched. I personally have removed them to allow the mother to get in a better position to hold the baby. It is an annoyance that could be done intermittently and not for staff convenience.
Disruptive Technology: Electronic Medical Records
Physicians and nurses used to use two hands to treat the mother and baby as patients. Gradually one hand left the patient and the other was charting in the electronic medical record. Now a considerable amount of “patient care” time is spent with both hands entering data. Although some of the information is important, how much better would care be if we spent time face to face, observing, listening to, and educating the mother–baby dyad and families?
Nipple Shields
Before the invention of silicone, I suspect primitive nipple shields were used as last resorts and very specific conditions. Current soft silicone nipple shields should be used in specific conditions, but in many cases are used too early, too frequently, and sometimes without proper education or indications. We have all seen cases wherein nipple shields were started for no clear reason and have only served to disrupt breastfeeding.
Maternity Leave
I believe this is a major disrupter to breastfeeding at least in the United States. Too many times I have had mothers not want to start or continue breastfeeding because they must return to work in just a few weeks. There are several examples throughout the world that extended maternity leave has reduced the harm of early return to work and should be further evaluated and applied where appropriate. 4
Paternal Breastfeeding Education
One of the major influencers of breastfeeding is the committed support of the baby's father. 5 Not involving the father prenatally has potential harm. We have many opportunities at prenatal visits to educate fathers on breastfeeding and we must take the time to accommodate them. More is being done in prenatal education in this regard, but the invitation, education, and encouragement by maternity care physicians can have a significant impact on the success of breastfeeding.
As physicians, we should be aware of the many direct and subtle ways that breastfeeding is affected and educate ourselves and our colleagues to “above all, do no harm.”