Tribute to Dr. Ruth Lawrence and the Pediatrician’s Role in Breastfeeding Protection,Promotion,and Support

To the Editor:

I cannot think of another individual who has done more to advance the field of breastfeeding medicine than Ruth Lawrence, MD. As a member of the American Academy of Pediatrics (AAP) “Work Group on Breastfeeding” from 1996 to 1997, Dr. Lawrence authored one of the early and transformative policies on “Breastfeeding and the Use of Human Milk.” ¹ This statement highlighted “the need” for breastfeeding. The United States had been tracking breastfeeding rates by using data from the commercial milk formula industry, and breastfeeding rates in the United States were recovering from an all-time low of around one in three mothers initiating breastfeeding throughout the 1970s. ² The “need” was not obvious to most pediatricians; Dr. Lawrence and colleagues spelled out in this policy why pediatricians should care about doing more to increase breastfeeding.

Throughout the 1990s, Dr. Lawrence advocated for a permanent structure within the AAP to harness the importance of educating pediatricians about how to protect, promote, and support breastfeeding. The Work Group, with funding from the U.S. federal government, launched a multiyear project titled Breastfeeding Promotion in Pediatrician’s/Physician’s Office Practices (BPPOP). ³ This project identified over 800 interested pediatricians, family physicians, and obstetrician/gynecologists (OB/GYN) around the country who wanted to get more involved and learn more about breastfeeding. The project also brought together each of the state’s WIC Breastfeeding Coordinators with a pediatrician, a family physician, and an OB/GYN physician in the state to begin collaborative efforts to support breastfeeding. Many statewide breastfeeding coalitions were born out of these collaborations. In the midst of the project, with the momentum of so many AAP members, and with the advocacy of Dr. Lawrence and colleagues, the AAP Section on Breastfeeding (SOBr) was launched. The section, under the direction of Betty Crase, International Board-Certified Lactation Consultant (IBCLC), the first Section Manager, was established with BPPOP participants as its inaugural members. The AAP Work Group transitioned into the Executive Committee of the Section on Breastfeeding, and many of the BPPOP participants became Chapter Breastfeeding Coordinators (CBCs). The CBC was a designation given by the state chapter president to lead state-based activities that supported breastfeeding. The CBCs reported activities to the SOBr and could inspire breastfeeding champions to adopt these activities and spread the work nationally.

The SOBr emerged with strong collaborations and partnerships with peer support organizations. They held an annual AAP La Leche League International (LLLI) physician’s education conference. As the NJ CBC, and first Education Committee Chair of the SOBr, I was honored to share the Section page of AAP News with Dr. Lawrence when she was Chair of the SOBr, in an article celebrating LLLI’s 50th anniversary. ⁴ Dr. Lawrence recognized the value of peer support, but at the time there was much work to be done to diversify the workforce in order to provide equitable access to trained peer support that reflected all communities, particularly in Black/African American communities. Dr. Lawrence was instrumental in the creation of the United States Breastfeeding Committee (USBC), formed in 1998 in response to the Innocenti Declaration of 1990, of which the United States Agency for International Development was a co-sponsor. It is the USBC that ultimately held the space for community organizations including peer support workers who represent diverse communities using an equity lens.

Dr. Lawrence valued having a permanent section on breastfeeding within the AAP. She strongly believed in the importance of physicians carrying the torch to protect, promote, and support breastfeeding and that especially pediatricians should be equipped with the knowledge, attitudes, and skills needed to perform these functions. She did not think doctors should be IBCLC as that was considered a credential for those who were not physicians. The IBCLC began in the early 1980s as a profession emerging from LLLI with the recognition that there were professionals who acquired knowledge and skills and needed an internationally recognized credential, yet many possessed lay education. ⁵ She set the stage for an interprofessional collaborative approach to breastfeeding and the use of human milk where the physician would know the anatomy and physiology at the medical level, and lactation consultants and others could support mothers on a more practical basis. Interestingly, she was conflicted on the value of the Baby-Friendly Hospital Initiative but strongly supported the World Health Organization’s Ten Steps to Successful Breastfeeding and advocated for organizations to adopt the Code of Marketing of Breastmilk Substitutes. Ultimately, it was physician education about breastfeeding that drove her passion and led to the publication of her landmark book, Breastfeeding: A Guide for the Medical Profession, now in its ninth edition.

Personally, I always appreciated seeing how Dr. Lawrence balanced her role as a devoted wife to Bob (Dr. Lawrence, an OB/GYN) and a mother of nine successfully breastfed children while ascending the ranks of professorship at a major academic medical center, overcoming sexism and any other isms that stood in her way. She strongly opposed the idea that she was from the “Silent” Generation, but in fact, she is part of the Greatest Generation! She owes much of her success to her own resilience, having survived the Great Depression and tragic loss of her father at a young age. She has been a trailblazer as the first female pediatric resident at Yale School of Medicine in New Haven, full Professor of Pediatrics, Obstetrics and Gynecology, and a neonatologist and toxicologist at the University of Rochester. Trained as a chemist, she started one of the first centers for toxicology at the University of Rochester in 1958. While Dr. Lawrence is certainly a trailblazer in the field of breastfeeding medicine, she is also a perfect example of a lifelong learner, a lesson we continue to reinforce to the next generation of physicians.