untitled

pISSN: 2234-8646 eISSN: 2234-8840

https://doi.org/10.5223/pghn.2017.20.3.147

Pediatr Gastroenterol Hepatol Nutr 2017 September 20(3):147-152

PGHN

Review Article

PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY & NUTRITION

Important Role of Medical Training Curriculum to Promote

the Rate of Human Milk Feeding

ong Joo Kim

Department of Pediatrics, Hanyang University College of Medicine, Seoul, Korea

The rate of human milk feeding has been decreasing despite the diverse efforts of many physicians and nurses,

as well as numerous professional organizations and various international health institutions. The number of physi-

cians and nurses who can provide proper guidance for human milk feeding and offer appropriate knowledge and

techniques to allow the most beneficial and convenient manner of breastfeeding is quite deficient. It is suggested

that physicians and nurses be trained to teach and educate about the medical importance of human milk feeding

to lactating mothers. This can be accomplished through systemic changes in medical education and clinical practice.

However, the curricula of medical schools in Korea do not provide enough education and training to effect an increase

in human milk feeding. The author strongly recommends that the educational objectives for medical schools and

resident training offer more education and training concerning so that they are well aware of breastfeeding basics

and techniques, and have ability to solve lactation-associated clinical problems.

Key Words: Human milk, Breast feeding, Medical education, Curriculum

Received：August 23, 2017, Accepted：September 20, 2017

Corresponding author: Yong Joo Kim, Department of Pediatrics, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu,

Seoul 04763, Korea. Tel: +82-2-2290-8390, Fax: +82-2-2297-2380, E-mail: kyjoo@hanyang.ac.kr

his is an openaccess article distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits

unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION

Many physicians are well aware of the benefits of

human milk feeding. It is well-known that human

milk-fed infants correlate with higher IQ than for-

mula-fed infants as documented from a meta-analy-

sis study [1]; this may be one of the most attractive

advantages of human milk. Other benefits include

that milk is species specific, so human breast milk is

evolved for human infants and must be regarded as

the standard. It is associated with improved outcomes

in childhood health, maternal health and public

health. Most antenatal pregnant women commit to a

goal of exclusive breastfeeding (BF), but the rate of

BF even during the first 6 months remains quite low

despite the aggressive and sincere efforts of the World

Health Organization (WHO), and the United National

International Children’s Emergency Fund (UNICEF).

To enhance appropriate human milk feeding just after

birth, WHO and UNICEF initiated the “Baby-Friendly

Hospital Initiative” (BFHI) in 1991 (Table 1) [2]. The

Certificate of BFHI is awarded according to a hospi-

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Pediatr Gastroenterol Hepatol Nutr

Table 1.

Ten Steps to Successful Breastfeeding Organized by World Health Organization (WHO), United National International

Children’s Emergency Fund (UNICEF)

Every facility providing maternity services and care for newborn infants should

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in the skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4. Help mothers initiate breastfeeding within a half-hour of birth.

5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.

6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

7. Practice rooming-in allow mothers and infants to remain together-24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial nipples or pacifiers (also called dummies or soothers) to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic.

Adapted from WHO, UNICEF. Baby friendly hospital initiative: revised, updated and expanded for integrated care. Section 1:

background and implementation. Geneva: World Health Organization, 2009 [2].

tal’s fulfillment of the “Ten steps program for BFHI”.

The American Academy of Pediatrics (AAP) endorsed

the Ten Steps program in 2009, and promotes adher-

ence to these 10 steps in order to enhance the rate of

BF initiation after birth, the proper duration of BF

during infancy, and a commitment to exclusive BF

(EBF). Most hospitals with maternity practices are

managed under BFHI, but the mean score for ex-

ecution of all Ten Steps was only 65% [3,4]. Even

worse, studies have shown that 58% of participating

hospitals erroneously advised lactating mothers con-

cerning BF-related problems and baby care [5]. By

implementation of the AAP recommendations based

on the initiative began by the WHO and UNICEF, the

rate of BF in USA has been greatly increased: ever hu-

man milk feeding, the rate is 81.1%, and EBF continu-

ing to 6 months stands at 22.3% by a CDC survey tak-

en in 2014-2015 among 2013 births [6].

On the other hand, the rate of EBF at the age of 1

month in Korea is 52.6%, at 3 months 47.2%, and then

it drops sharply down to 9.4% according to a recent

government report from 2015 [7]. In 2015, the

Ministry of Health and Welfare of South Korea set

2020 health project goals which include achieving a

66.8% BF rate at the age of 6 months [8]. This may be

an even more difficult goal since a more recent Korean

government report from 2016 showed a much lower

rate of EBF in Korea. The rate of EBF at 1 month of age

was improved at 55.8% but then radically falls to the

bottom with a rate of only 5.6% at 6 months old [9].

THE IMPORTANCE OF SUPPORT FOR

BREASTFEEDING BY MEDICAL

PROFESSIONALS

A national survey conducted through telephone

interviews with 1,229 women with children less

than 3 years old in the States showed that the en-

couragement of BF by physician or nurses inspired

BF initiation in 74.6% of mothers, whereas only

43.2% of those women who had not been encouraged

by their healthcare givers did BF [10]. This study

strongly indicates the importance of support and ed-

ucation for BF by physicians and nurses.

Since a nationwide survey of pediatrician’s atti-

tudes concerning BF was conducted in 1995, pedia-

tricians have explored the promotion and support of

various methods and protocols for BF, and have con-

ducted many studies concerning the benefits related

to human milk. Owing to these efforts, the overall

rate of BF in the States has jumped from 59% in 1995

to 81.1% in 2013 at the time of birth, and from 22% in

1995 to 51.8% in 2004 at the age of 6 months [11,12].

During this period, another nationwide survey of

United States pediatricians performed in 2004, re-

ported that more of them had received education

about the successful management of BF while in

medical school or during their pediatric residency in

the period before 2004 than those trained before

1995. Pediatricians trained until 2004 recommended

EBF more strongly than those trained before 1995

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Yong Joo Kim：Medical Education and Haman Milk Feeding

Table 2.

General Implementation Strategy for the Breastfeeding Residency Curriculum Provided by American Academy of Pediatrics

Step 1 Gain buy-in from other key faculty and residency and hospital administration

Step 2 Train faculty to be able to teach about breastfeeding and consider assessing the quality of care in your hospital for

breastfeeding mothers and babies.

Step 3 Determine length of time that you will expect residents to participate in the curriculum

Step 4 Develop an implementation plan that includes the length of time you have decided upon for residents to complete the

curriculum and how you will keep track of their progress.

Step 5 Review the resources that have been shown to be most helpful in teaching the residents about breastfeeding care.

Step 6 Consider formal evaluation of the curriculum by testing the residents before they receive breastfeeding education and

after they have completed the program.

Step 7 Consider having a kick-off event to introduce and celebrate breastfeeding support and education

Step 8 Implement the curriculum. Work through each activity with the residents and be sure to evaluate and document their

progress

Step 9 Continually train and update faculty on breastfeeding.

Step 10 Periodically re-assess the progress of the hospital in reaching optimal breastfeeding rates.

Adapted from American Academy of Pediatrics. Breastfeeding: implementation strategies [15].

and were more likely to follow supportive hospital

policies [13]. Since the national survey in 1995, pe-

diatricians have been more receptive to efforts that

increase the rate of BF, to receive education about

BF, and to set up hospital policies for BF. But, those

efforts have gradually faded, as noted in the survey

performed in 2004. Pediatricians continue to dis-

courage mothers from stopping or giving up BF with

no absolute contraindications rather than those seen

in the 1995 survey. The major reasons for which

many pediatricians do not recommend BF were hu-

man immunodeficiency virus (HIV)-infection of the

mother, drug abuse by the mother, medication taken

by the mother, the mother’s opposition to BF, in-

fected nipples, too young age of the mother, in-

adequate nipples of the mother, inconvenience, slow

weight gain of the baby, healthy jaundice in the in-

fant, and cracked nipples. None of these reasons are

an absolute contraindication for BF, and even a

mother’s HIV infection does not necessarily block BF

if a baby’s health issue is more serious, especially in

a developing nation or locale.

THE IMPORTANCE OF BREASTFEEDING

EDUCATION FOR MEDICAL STUDENTS

AND HEALTHCARE PROVIDERS

Since the 2004 survey, additional educational re-

sources and materials have been developed to in-

crease physician support for BF, which includes the

Breastfeeding Handbook for Physicians, a joint pub-

lication of the AAP and the American College of

Obstetricians and Gynecologists. At national meet-

ings of the AAP, the American College of Obstetricians

and Gynecologists, and the American Academy of

Family Physicians, diverse educational sessions have

been offered. In addition, a multispecialty BF resi-

dency curriculum has been initiated as a major

priority. The policy for the Breastfeeding Residency

Curriculum for pediatric residents offered by AAP in-

cludes providing training in more than one rotation,

throughout the residency, with pre-tests and post-tests

before and after BF medicine education, and Resident

Care Evaluation through the Accreditation Council

for Graduate Medical Education Core Competencies

[14]. The AAP suggests that beginning this General

Implementation Strategy is the best way to accom-

plish the curricular objectives. A summary of this

strategy is introduced in Table 2 [15].

Most physicians, not only pediatricians, have op-

portunities to meet and support lactating mothers

both in and out of the hospital. Setting aside con-

sultations which concern a variety of lactation-asso-

ciated problems and troubles, it is strongly encour-

aged that physicians do their best to encourage BF to

mothers under any circumstances as much as possible.

Therefore the education of BF medicine needs to be

executed in medical school and nursing school.

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Pediatr Gastroenterol Hepatol Nutr

Fig. 1. Stepwise correct

answer about Baby-Friendly

Hospital Initiative among

medical and nursing students.

Modified from Kakrani et al.

(Int J Prev Med 2015;6:40

[16].

Kakrani et al. [16] have studied the awareness about

the Ten Steps for successful BF policy among medical

students and nursing students in India. They were

well aware about step 2 (training), step 6 (no supple-

ment), step 7 (rooming-in), and step 9 (no paci-

fier).The students gave the least correct answers con-

cerning step 10 (community support), step 8 (cues),

step 1 (written policy), and step 3 (pre- and post-natal

information). There was no difference between the

male and female respondents except in two steps

(Fig. 1).

The Academy of Breastfeeding Medicine pre-

sented a statement concerning inclusion of BF medi-

cine in the educational objectives for undergraduate

and graduate medical education curriculum in 2011

[17]. The statement strongly suggests that medical

students learn about BF medicine, which includes

the anatomy, endocrine control and physiology of

breast and mammary glands, biochemical and im-

munological aspects of human milk, and the influ-

ence of BF on individual health and social issues. It

also suggests that medical student have multiple op-

portunities during clinical training to participate in

solving BF-associated problems and in supporting

and encouraging BF. In order to achieve these goals,

education needs to be set up as block rotations, with

case- and system-based learning in preclinical learn-

ing, and clinical rotations at mother-child clinics in

pediatrics, obstetrics, and family medicine.

It is also remarkable to find that some medical

schools in the States provide a system and facility for

their lactating students. Taylor et al. [18] faculties in

the department of Clinical Curriculum of the Medical

School of Brown University, have tried to find good

support guides for parent students, and reported

some suggestions. One main suggestion was to in-

stitute a formal policy regarding BF and workplace

support.

EDUCATIONAL METHODS FOR

BREASTFEEDING MEDICINE IN

MEDICAL SCHOOL AND RESIDENCY

TRAINING PROGRAM

There are recommended educational methods for

BF education in the medical school.

Multidisciplinary approach

A successful multidisciplinary approach was set up

for the BF curriculum for residents and medical stu-

dents based on the Wellstart Lactation Curriculum

Guide [19] at New Mexico University [20]. This cur-

riculum was implemented by faculties from the ob-

stetrics, pediatrics, and family medicine departments

and includes interactive teaching sessions, opportune

discussions of BF issues during all clinical rounds, and

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Yong Joo Kim：Medical Education and Haman Milk Feeding

the inclusion of lactation-supporting personnel in

meetings with patients. The didactic sessions covered

4 topics; anatomy and physiology of lactation, com-

mon problems confronted by lactating mothers, com-

mon problems in BF babies, and the promotion and

support of BF. Medical students were required to at-

tend all 4 didactic sessions during their clinical rota-

tion in obstetrics. One educational effort evaluated as

very fruitful was the provision of self-study modules,

composed of various topics of 15-pages, which were

placed in newborn nursery and delivery rooms.

Interactive learning sessions, clinical practice

which includes visiting lactating mothers, and prob-

lem-solving operated by lactation professionals are

not currently set up in Korean medical school

curriculum. These teaching methods are strongly

recommended to medical school faculties.

Web-based learning

The internet site at www.BreastfeedingBasics.org,

developed by the faculty at Case Western Reserve

University and available since April 1999, offered free

BF education for health care providers and students.

There are 7 modules: (1) benefits and barriers of BF,

(2) anatomy and physiology of mammary glands, (3)

growth and development in the breastfed infant, (4)

BF around the world, (5) the BF couple, (6) breast-fee-

ding issues in term infants, and (7) human milk and

drugs. Each module indicates clear learning ob-

jectives; offers didactic information including pic-

tures, radiologic findings, and case studies; and in-

cludes a pre- and post-test composed of three question.

The effectiveness was studied and reported in 2012 by

Lewin and O'Connor [21]. More than 15,000 health-

care providers and medical students studied BF medi-

cine through the content offered at “Breastfeeding

Basics” between April 1999 and December 2009. Their

pretest and posttest score significantly increased (p

＜0.001) for all the modules, and suggests that this

online education offers time- and cost-effectiveness

compared to offline education. This web site of

www.breastfeedingbasics.org is not available cur-

rently, but web-based BF training and educational re-

sources are also provided through several recently de-

veloped web-based learning tools, which are

www.wellstart.org by UCSD Medical Center and

Vermont College of Medicine, Tulane Knowledge to

Practice Program, Supporting and Promoting

Breastfeeding in Health Care Settings by Tulane

University Mary Amelia Women's Center, Supporting

and Promoting Breastfeeding in Health Care Settings

by University at Albany School of Public Health.

Problem-based workshop

In 1998, a project for a skill-based experiential cur-

riculum to be integrated into residency education

was initiated at the University of Wisconsin-Madison

[22]. Second- and third-year residents at the depart-

ment of family practice were enrolled and they re-

ceived baseline examinations and Objective Structured

Clinical Examinations (OSCEs) over a 2 week period.

In 30 days, the intervention group attended a 4.5

hour BF workshop. After another 30 days, the inter-

vention and the control groups again completed the

paper examination and OSCE. The workshop was a

4.5-hour time block during a regularly scheduled

conference period. The scores for the OSCE after in-

tervention were significantly higher than the control

group for assessing feeding position and latching

and for offering support for sore nipples. The residents

in the intervention group reported feeling more con-

fident in BF-related problem-solving (p＜0.001).

Problem-based learning (PBL) is current practice

in most medical schools in Korea. If medical schools

incorporate BF medicine into the basic learning ob-

jectives of PBL and OSCE, medical students will have

more opportunity to study BF medicine.

CONCLUSION

A well-rounded BF education for medical students

and residents through various educational modal-

ities integrated into clinical rotations would lead

medical professionals and medical students to in-

crease support for lactating mothers and provide

healthcare givers confidence to solve BF-related

problems. Better support by the faculties of medical

school and the health care system is needed to make

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Pediatr Gastroenterol Hepatol Nutr

the promotion of BF for infants successful.

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