Why breastfeeding has made me a better geriatrician

Dr Sarah Blayney is a consultant geriatrician working in frontdoor frailty at University Hospitals Plymouth. She will be facilitating a breastfeeding drop-in session at the upcoming BGS Autumn Meeting in support of the Making BGS conferences family-friendly initiative.

Breastfeeding and geriatric medicine may not at first glance have much in common, but go looking and you will find some surprising parallels. We will explore this further in our drop-in session at the BGS Autumn Meeting in the family room on Thursday 7th November at 10.45am – come along to share your experiences.

As a naturally sourced, freely available intervention with a raft of proven health benefits to mother and baby,¹ it is no surprise that the NHS promotes breastfeeding. So why are UK rates shockingly low? I have learnt a lot in the two years since my daughter was born and the most important lesson was this: it is about so much more than just the milk.

Breastfeeding is the result of a complex and dynamic relationship between mother and baby. Like any complex process, it is unique to each pair and can be influenced by many external factors.^₂ It is nurturing and enjoyable for both when it works effectively but can become a source of physical pain and emotional angst for those who run into problems. The psychological effects of this may last for years.

Much as with medicine, I have enjoyed learning about the science³ but it is the human factors that really fascinate me. I trained as a La Leche League⁴ (LLL) Leader so that I could help other new mothers find the same empowerment through breastfeeding that I have found. The nature of these interactions has led me to reflect on how I care for my geriatric patients.

Peer support is powerful

I have seen mothers arrive at LLL meetings in tears but leave with their heads held high, thanks to the sharing of experiences and collective wisdom. It can be liberating to hear that others have gone through similar challenges; often as Leaders our job is to guide the conversation rather than to offer answers.

We should utilise more opportunities for peer support within medicine, such as Schwartz rounds or medical student tutor groups, aimed at debriefing the emotional side of practising medicine.

Success and failure are unhelpful words

So often we hear stories of bad advice, inadequate emotional support and unrealistic expectations. These undermine an effective breastfeeding relationship, and when added to unreasonable societal or cultural pressures, can be catastrophic for mum and baby. Yet there is no sense of ‘corporate responsibility’ for an unhappy outcome; the disappointment and the responsibility weigh only on the mother.

Setting individual goals and providing sufficient resources to achieve them is as relevant to the first few postpartum days as it is to recovery on the acute hospital ward.

It is alright not to breastfeed

The first time a new mum told me that she was switching onto formula, I felt a profound sense of failure. What could I have done differently to help her? But then I realised how little I knew about her life. Breastfeeding is a goal we can aspire to for all, but this does not mean it will be right for everyone: cow’s milk formula can offer an appropriate way of feeding for a family facing other pressures, or dietary intolerances (rarer) may require an alternative.

Sometimes we can feel a disproportionate sense of responsibility for what we perceive to be the best outcome for our patients. It is important to remember that we are only a part of this equation, and may need to adjust our expectations of what can be achieved or what our patients want.

Every mother and baby pair is unique

A mother knows her baby and family life better than any healthcare professional can. Similar breastfeeding principles will always apply, but there must be a willingness to look afresh from this mother’s perspective to be really effective in offering help. As a medical registrar I was fortunate to have training in the ‘Solution-Focused Approach’⁵(SFA). This encourages a different way of thinking to the traditional medical model of ‘diagnose and treat’: each patient is an expert in their own experience, and we offer medicine as a tool to help them reach their goals. The LLL approach has reinforced to me the utility of this method.

It may seem simply a nuance of expression, but I encourage reading further if you are really interested in genuine patient-centred care. My own experiences of using SFA in challenging clinical situations⁶ were strikingly relevant.

Intervention versus interference

The phrase ‘formula top-up’ is a misnomer: it is a substitute for breastmilk, not an addition. The implications for a mother’s supply as well as her confidence must be properly understood by those who advocate it. There are medical instances when it is necessary but too often it is ill-informed, sometimes a misguided attempt to be risk-averse and at worst a lazy substitute for good breastfeeding management. We should be supporting mothers and babies to ensure an effective latch and to promote techniques for increasing supply (such as skin to skin, feeding on demand, maternal nutrition and hydration).

Adequate inpatient hydration cannot be addressed by simply prescribing intravenous fluids. Complex science requires a multi-layered approach. We must continue to evaluate established practice, recognising risk and questioning our response to it.

The most important thing is to listen

New mothers are bombarded with advice and opinions, often well-meaning but just as often unhelpful. Finding the confidence to tread your own path is made possible by being listened to and given time to reach your own conclusions, something I have seen happen often at LLL meetings.

Our patients deserve the same breathing space to assimilate facts and opinions, ask questions and clarify their position before making a decision about their care.

Remember the ripple effect

My wise LLL mentor referred to this in one of our earliest conversations: that simple advocacy and the right nugget of knowledge imparted in a timely manner can make a difference well beyond what you can see.

As geriatricians we identify strongly as advocates for our patients, and as role models for our trainees. My LLL experiences have illustrated to me again how important this advocacy is, as well as reminding me to talk less and listen more.

The views expressed here are those of the author and not of the BGS or any other organisation referred to in this post.

References

1. Victora CG, Bahl RB, Aluísio JDF, Giovanny VA, Horton S, Krasevec, J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 2016;387(10017):475-490.

2. Rollins NC, Bhandari N, Hajeebhoy, N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016;387(10017):491-504.

3. Human Milk: Tailor made for tiny humans. Available at: www.human-milk.com.

4. La Leche League. What we do: La Leche League’s Mission and Philosophy. Available at: www.laleche.org.uk/what-we-do/#LaLecheLeaguesmissionandphilosophy

5. Visser CF. The origin of the solution-focused approach. International Journal of Solution Focused Practice 2013;10–17.

6. Blayney S, Crowe A, Bray D. Survival as medical registrar oncall - remember the doughnut. Clinical Medicine 2014;14(5):506-509.