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Establishing a Breastfeeding Medicine Practice or Academic Department


Key Points

  • Breastfeeding is unique in medicine as a process that occurs at the juncture of (at least) two interdependent physiologies, those of the lactating parent and of the child. Although much can be known about lactation by all types of providers, expert breastfeeding medicine providers have a role in treating complex problems facing lactating families.

  • There are increasing numbers of breastfeeding medicine clinics and programs at academic institutions. These programs vary widely in funding, billing, sponsoring department, and involvement with lactation consultants.

  • Some features common to building these programs include choosing a model type, business plan considerations, access, liability issues, and integration with community agencies and lactation consultants.

Practices that serve the medical needs of breastfeeding families are on the rise. At first, these practices were led by visionary physicians who noticed that the physiology and pathology of breastfeeding parents and infants were not being addressed by the medical field. 1 Parents and lactation consultants have long thought this to be true, and studies continue to document not only the poor support families receive from the health care system, but also the devastation brought on by policies and procedures that directly interfere with lactation.

A combination of factors has led to an expansion of both clinical sites devoted to serving breastfeeding and academic programs that also expand education and research surrounding lactation. These include rising breastfeeding rates, increasing percentages of women in medical fields, increasing complexity of pregnant patients and newborns, improved interdisciplinary support of patients, increasingly empowered medical students, and increased public health focus on breastfeeding as a human right. One survey of members of the Academy of Breastfeeding Medicine (ABM) and the American Academy of Pediatrics identified 32 academic breastfeeding medicine programs across 7 countries (25 of the 32 were in the United States); 75% of these were housed in pediatrics units. 2

Given the fact that this is a relatively new and expanding phenomenon, there is also a need for guidance surrounding the development of breastfeeding medicine practices and academic departments. Although significant differences exist around the world with respect to paying for health care, certain commonalities will be discussed here, to the extent possible.

Who is a Breastfeeding Medicine Provider?

Breastfeeding medicine providers may be initially trained in a variety of fields, but generally have the knowledge and expertise to address common and uncommon breastfeeding problems. There have been breastfeeding practices established by advanced-practice professionals (nurse practitioners, physician assistants), midwives, and physicians. Physicians may come from obstetrics and gynecology, pediatrics, family medicine, preventive medicine, surgery, or other fields. The ABM is a “worldwide organization of medical doctors dedicated to the promotion, protection, and support of breastfeeding,” and is developing a standard canon of knowledge to which an expert in breastfeeding may be held. In the absence of clear guidelines, a breastfeeding medicine provider should be up to date with standard breastfeeding knowledge and practices, have advanced knowledge of the anatomy and physiology of lactation and suck, and have extensive experience managing complex breastfeeding difficulties.

Choosing a Model Type

Good medical care surrounding breastfeeding can be provided in many ways. The type used in a particular community should take into account (1) what is feasible and sustainable; (2) the primary needs of the community, as identified by community activists and services, parents, lactation consultants, broad types of medical providers, students, and employees; (3) who the local champions are; (4) where the money is or should come from (business analysts, marketing directors, and office managers may have important input about the types of successful programs in a particular area); and (5) what already exists for parents and babies in the communities served. These factors may help determine which would be the most streamlined approach and where the barriers are likely to arise.

Needs Assessment

Given that those who control budgets are unlikely to be familiar with breastfeeding medicine programs, formal or informal needs assessment data are often useful in bringing attention to the needs of the community. A brief analysis may include strengths, weaknesses, opportunities, and threats/barriers (SWOT) analysis for such a program. 3 This may include data that are already available surrounding rates of disease, economic variables, marginalized communities, or access concerns. They should also include information about numbers of births and other important pregnancy variables such as maternal and infant mortality rates, maternal complications rates, and an estimate of the numbers of families who struggle with breastfeeding in a community. Standard numbers used may include the fact that worldwide 80% to 90% of women have reported at least one problem with breastfeeding 4 , 5 or that over 40% of women do not meet their breastfeeding goals. 6 , 7 If a neonatal intensive care unit (NICU) is part of the plan, data surrounding mother’s own milk use, donor milk use, costs of donor milk programs (if any), rates of necrotizing enterocolitis and bronchopulmonary dysplasia, length of stay, and breast milk/breastfeeding on discharge are numbers that are likely to exist. When considering an academic program, it is critical to break these numbers out by race or geography to ensure that marginalized populations are served equally. Tools to help guide needs assessments are widely available; an example is a free community needs assessment workbook by the Centers for Disease Control and Prevention. Global and local data on breastfeeding outcomes tend to be available from local health authorities. References useful for a needs assessment or business plan for the creation of a breastfeeding medicine practice or department are readily available on the web.

Types of Models

Different types of models may be used based on the needs of the community and the SWOT analysis, including the following:

  • A primary care physician with advanced training in breastfeeding who blocks time for breastfeeding/lactation medicine visits

  • A breastfeeding medicine provider embedded in a primary care practice or obstetric/midwifery practice

  • A stand-alone breastfeeding medicine clinic

  • A university-supported or academic breastfeeding medicine clinic

Types of Providers

Each type may include a variety of providers to meet the needs of the community, including a primary provider, such as a physician, midwife, or advanced care practitioner (nurse practitioner, physician’s assistant, etc.), and lactation consultants, lactation counselors, social workers/postpartum therapists, and occupational or feeding therapists. In some communities, home visitors, grant-supported trained counselors, peer counselors, doulas, massage therapists, chiropractors, acupuncturists, craniosacral providers, herbalists, or practitioners of traditional medicines may be part of a lactation community. Inclusion of these types of providers may enrich the tapestry of support for breastfeeding families. Getting paid for these types of providers will vary based on geography. There is one report of a “trifecta” model, in which good outcomes were seen with a provider, lactation consultant, and social worker who saw each dyad at each visit. 8 Other models have successfully included health care providers trained as lactation counselors. 9 Finally, many currently used models with two lactation consultants and one provider working a half day together, referring to a variety of other specialists as needed. For management of ankyloglossia, one report included an otolaryngologist working with a speech language pathologist, although breastfeeding outcomes were not reported. 10

Because the skills and credentialing for breastfeeding medicine providers is in development, and there exist many certification pathways for the other lactation supports, it is important to ensure that each provider has adequate training and safe practice to care for patients. 11 Specifically, lactation consultants should have their international board certification (IBCLC). For academic programs with NICU or complex care, nurses with advanced training (e.g., registered nurses) with an IBCLC should be strongly considered. Physicians should have, or be working toward, their Fellowship in the Academy of Breastfeeding Medicine (FABM) designation.

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