The American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), the World Health Organization (WHO), and others recommend that infants exclusively receive breast milk for their first six months of life, with continued breastfeeding for at least the first year and beyond.1-5 Breastfeeding provides benefits to infants, mothers, and society. Infants who are breastfed have reduced risk of several childhood illnesses, including ear and respiratory infections, allergies, asthma, and obesity. Breastfeeding is associated with a lower risk of sudden infant death syndrome (SIDS).6 Women who breastfeed have a lower risk of breast and ovarian cancer, type 2 diabetes, and hypertension.7 Businesses and institutions also benefit when their employees breastfeed. Successful breastfeeding results in lower medical costs for employees and their infants, lower absenteeism, lower turnover rates, higher productivity, and increased employee satisfaction.8 However, many women stop breastfeeding earlier than they intended due to lack of support from family, friends, and colleagues. Working outside the home is associated with shortened duration of breastfeeding,9-11 and conditions in the workplace further impact this duration.12, 13
Medical trainees are educated about the benefits of breastfeeding and taught to encourage and support their patients in their breastfeeding efforts. Yet when medical trainees choose to breastfeed, they often do not receive adequate support from their colleagues and institutions and many do not meet their breastfeeding goals.14, 15 Medical trainees face work hours and patient care demands that can make continued breastfeeding particularly challenging. Therefore, it is essential that medical educators, including medical schools, residency and fellowship programs, and healthcare facilities establish an environment that provides encouragement and resources for the successful continuation of breastfeeding. Programs with family-friendly policies, including lactation support, may be better able to recruit and retain residents, fellows, and young faculty physicians.
This information is provided to help medical schools, residency and fellowship programs, clinics, hospitals, and healthcare systems develop policies supportive of the needs of their breastfeeding medical trainees. Institutions developing a lactation policy should adapt and modify the key points provided as appropriate for their setting and resources. Key items needed include adequate lactation facilities, protected time for expression of breast milk or breastfeeding, and policies outlining roles and responsibilities to provide an environment of support for breastfeeding trainees.
The regular expression and storage of breast milk is critical for the breastfeeding medical trainee. Expressing milk is necessary for the breastfeeding mother to maintain her milk supply, avoid pain, discomfort and health issues (e.g. mastitis), and provide milk to her infant for the time they are separated. Additionally, employers should provide reasonable break time from work and private facilities that are not bathrooms to allow for the expression of breast milk for up to one year after each child’s birth.
Whenever possible, medical trainees should be permitted and encouraged to directly breastfeed their infants during their break times if it doesn’t interfere with their duties. On-site childcare facilities maximize this opportunity for regular feeding and contact with their child. In situations in which direct breastfeeding is not possible, medical trainees should have access to a private, comfortable, and sanitary space for the expression of breast milk.
Medical schools and clinical training facilities must provide designated lactation rooms for medical trainees. The Accreditation Council for Graduate Medical Education (ACGME) lists the provision of lactation facilities, separate storage for breast milk, and protected time in their program requirements for residency training programs).16 Lactation rooms should be located in close proximity to trainees’ work or study area. The number of lactation rooms needed depends on the size of the facility or institution and the number of potential users of the lactation rooms. The general rule of thumb is that one space for milk expression is needed for every 50-100 female employees aged 18-45. However, this number will vary based on building size, number of buildings, work schedule, and job settings. In general, physician trainees should not be expected to share lactation rooms with patients or hospital guests. Resources are available for programs to find creative solutions for lactation space. The use of a private office or other private space is sufficient if it is comfortable, sanitary, private, and convenient for the trainee. A restroom or bathroom stall is not an appropriate space for the expression of breast milk.
The minimum requirements for lactation rooms include:17
Lactating trainees performing procedures in the operating room or the sterile procedure room may require lactation accommodations if procedures are prolonged. As consistent with hospital policy, trainees may either scrub out in order to directly breastfeed/express breast milk or may remain in the operating/procedure room and utilize a wearable breast pump as the human breast milk is not recognized as a bodily fluid requiring universal precautions.18 The decision to scrub out versus utilize a wearable breast pump is per the discretion of the trainee, in accordance with hospital policy. This is a personal decision that depends on multiple factors such as individual maternal lactation physiology, affordability of a wearable pump, the logistics of the specific procedure, and the educational experience of the procedure. The lactating trainee should inform her team of her specific needs for lactation accommodations. When determining a suitable time to breastfeed or express breast milk, should make a good faith effort to ensure patient safety and minimize impacts on her education and on her teammates.
Medical trainees will need to express breast milk every two to three hours to provide sufficient milk for the infant and to reduce the mother’s risk of developing engorgement, pain, or mastitis as well as to maintain the physiologic process of lactogenesis. In general, the trainee will need 20-30 minutes for milk expression. There is some variability in this time estimate, however, depending on the proximity of the lactation space, the quality of breast pump, access to pump and storage, and individual variations in time needed to express sufficient milk. Due to the demanding schedules of medical trainees - in particular their patient care responsibilities - finding protected break time for the expression of breast milk requires support from faculty, colleagues, staff, and administration. Break times may need to be scheduled in advance to ensure appropriate coverage of patient care responsibilities. In these cases, the trainee should work with their supervisor to determine an appropriate schedule and arrange for patient care coverage.
Medical trainees and supervisors should also discuss adjustments to return to duty after maternity leave that address reduced work hours, potential part-time or adjustment in schedules to avoid the most taxing rotations as the first ones after maternity leave. A flexible elective or board study rotation may be considered to enhance the likelihood of continued breastfeeding success.
Support from faculty, colleagues, staff, and administration is essential to encourage continued breastfeeding by medical trainees. To create a culture supportive of the needs of breastfeeding women, all employees must be regularly educated about the benefits of breastfeeding for both the mother and baby, the details of the lactation policy, and their responsibilities as outlined by the policy. Ways to disseminate this information may include training and materials provided during new staff orientation, yearly training programs for managers/supervisors, promoting it on the institution’s website, and including it under the benefits program. The policy should be included in any informational packets provided to all trainees, and revisited when a trainee is discussing family leave and health care policies to cover maternity benefits.
In addition to training and dissemination of policies to employees, the availability and location of lactation rooms should be publicized, along with whom to contact for more information.
Policies should clearly outline roles and responsibilities of administration, supervisors, and trainees. Items that should be defined include the following:
(COE) (May 2013) (2019 COD)