Breastfeeding and Lactation Support for Medical Trainees

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, breastfeeding parents, and society. Children who are breastfed have reduced risk of conditions including ear and respiratory infections, type 1 diabetes, asthma, and obesity. Breastfeeding is also associated with a lower risk of sudden infant death syndrome.⁶ People who breastfeed have a lower risk of breast cancer, ovarian cancer, type 2 diabetes, and high blood pressure⁷

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 parents stop breastfeeding earlier than they intended due to lack of support from family, friends, and colleagues. In addition, studies have shown an association between length of maternity leave and breastfeeding duration.^9,10  For example, evidence indicates that people who take three months or more of paid or unpaid maternity leave are likely to initiate and continue breastfeeding.¹¹ Returning to work within three months of delivery is associated with a shorter than intended duration of breastfeeding, particularly among people returning to full-time work.¹² Conditions in the workplace can further impact employees’ breastfeeding duration.^13-15

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. Consequently, many do not meet their breastfeeding goals.^16-18 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, to establish an environment that provides encouragement and resources to support  the successful continuation of breastfeeding by medical trainees. Programs with family-friendly policies that include lactation support, may be better able to recruit and retain residents, fellows and young faculty physicians.

The AAFP and AAP recognized the need to support and guide institutional change regarding breastfeeding by medical trainees. They collaborated to provide a repository of resources that can be modified and adapted by medical schools, residency and fellowship programs, clinics, hospitals and health care systems as appropriate, including a step-by-step guide to help institutions either create a breastfeeding and lactation policy that meets the needs of their trainees or strengthen their existing policy.

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 components needed to provide breastfeeding and lactation support for medical trainees include adequate lactation facilities, protected time to express breast milk or breastfeed, and policies outlining roles and responsibilities to create a culture of support for breastfeeding.

Lactation Facilities

A medical trainee should be permitted and encouraged to directly breastfeed their infant during their break times whenever possible. On-site childcare facilities maximize opportunities for trainees to have contact with and feed their children on a regular basis. If direct breastfeeding is not possible, medical trainees should have access to a private, comfortable, sanitary space where they can express breast milk.

For breastfeeding medical trainees, being able to regularly express and store breast milk is critical. Expressing milk necessary to maintain their milk supply, avoid pain, discomfort and health issues (e.g., mastitis), and provide milk to their infant during time apart. Under the Providing Urgent Maternal Protections for Nursing Mothers Act, or PUMP Act, which was signed into law on December 29, 2022, employers of all sizes are required to give a lactating employee a reasonable amount of break time to express breast milk for up to one year following their child’s birth.¹⁹ Employers must also provide a clean, private lactation space that is free from intrusion and is not a bathroom. These protections apply regardless of the employee’s gender.

Medical schools and clinical training facilities must provide designated lactation rooms for medical trainees. The Accreditation Council for Graduate Medical Education lists the provision of lactation facilities, separate storage for breast milk and protected time to express milk in their program requirements for residency training programs.²¹ Lactation rooms should be located in close proximity to trainees’ work or study areas.

The number of lactation rooms needed depends on the size of the facility or institution and the number of potential users of these rooms. A general rule is that employers need to have one space for milk expression for every 50-100 women between 18 and 50 years of age they employ.²² However, this number will vary based on factors including number of buildings, building size, work schedules, and job environments. 

In general, physician trainees should not be expected to share lactation rooms with patients or hospital guests. The use of a private office or other private space is sufficient if it is comfortable, sanitary, and convenient for the trainee. Bathroom stalls and private restrooms are not appropriate spaces for expressing  breast milk.

The minimum requirements for lactation rooms include the following:^19,21-23:

• Private – While lactation areas do not have to be permanent, trainees should be given options such as an existing office, closet, storage area, or screened space to ensure privacy and prevent intrusion by the public or coworkers.
• Comfortable – The room should include a comfortable chair, an electrical outlet, and appropriate lighting. It should be kept at a comfortable temperature. A flat surface (e.g.,, table, desk, to hold a a trainee’s breast pump and supplies should be available.
• Sanitary – The room should be kept clean. It  should allow access to a sink so trainees can wash their hands and pump supplies.
• Milk storage – Trainees should have access to a secure place (e.g., separate refrigerator or locker) to store expressed breast milk.  
• Pump Storage – Trainees should have access to a secure place to store their personal breast pumps and supplies.

Programs may also consider offering the following:

• Computer workstation in the lactation room – Medical trainees have demanding work and study responsibilities. Access to a computer in the lactation room allows them to continue their work or study while extracting breast milk.
• Phone connected to the hospital or clinic system – This allows the trainee to respond to pages in a timely fashion or to alert a colleague or supervisor of any urgent patient care issue.
• Hospital grade pump included in the lactation room– Providing a hospital-grade breast pump for trainees increases efficiency and convenience. It minimizes the time a trainees needs to express breast milk and frees them from carrying and storing a personal breast pump. It should not be shared by patients.
• Lactation support –Offering access to professional breastfeeding support, (e.g., a lactation consultant) improves, the culture of support for lactating trainees and increases their likelihood of breastfeeding successfully.

Lactating trainees performing procedures in the operating room or the sterile procedure room may require lactation accommodations during lengthy procedures. Human breast milk is not recognized as a body fluid that requires universal precautions.²⁴ Therefore, depending on hospital policy and their own discretion, trainees may either remain in the operating or procedure room and utilize a wearable breast pump or scrub out so they can directly breastfeedor express breast milk. This is a personal decision that depends on multiple factors, including the logistics and educational experience of the specific procedure, individual lactation physiology and the affordability of a wearable pump. Medical trainees should inform their team of their specific needs for lactation accommodations. They should make a good-faith effort to ensure patient safety and minimize impacts on their education and teammates when determining a suitable time to breastfeed or express milk.

Protected Time

Lactating medical trainees will need to express breast milk every two to three hours to provide sufficient milk for their child, maintain the physiological process of lactogenesis and reduce their risk of developing engorgement, pain, or mastitis. In general, a person who is breastfeeding will need approximately 15 to 20 minutes at least twice during an eight-hour shift to express breast  milk.^25,26 However, the amount of time required may vary depending on the proximity of the lactation space, the quality of breast pump, how easily the breast pump and milk storage can be accessed, and how long it takes individual trainees needed to express sufficient milk. Due to medical trainees’ demanding schedules and patient care responsibilities, finding protected break time to express 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.

When discussing return to duty after maternity leave, medical trainees and supervisors should consider schedule-related factors that can impact breastfeeding. They should address the possibility of reduced work hours or a part-time schedule, as well as potential schedule adjustments to avoid the most taxing rotations immediately after maternity leave. A flexible elective or board study rotation may be considered to enhance the likelihood of continued breastfeeding success.

Culture of support

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 parents, institutions should regularly educate all employees about the benefits of breastfeeding for both the parent and child. In addition, institutions must inform employees about their breastfeeding and lactation policy (including details about employees’ responsibilities according to the policy).

This information may be disseminated in a variety of ways, such as incorporating  materials and p training programs for managers/supervisors. The breastfeeding and lactation policy can also be highlighted as part of an institution’s benefits program and featured on its website should be included in any informational packets provided to all medical trainees. It should also be revisited when a trainee is discussing family leave and health care policies that cover maternity benefits.

Responsibilities

A breastfeeding and lactation policy should clearly outline roles and responsibilities of administration, supervisors, and medical trainees. Points that should be addressed should include the following:

• Administration – The institution should determine a key administrator who will be responsible for ensuring regular education and promotion regarding the breastfeeding and lactation policy. This person must either train managers/supervisors on the policy or delegate this responsibility to someone else. The administration should develop, a clear process for complaint submission and documentation of action plans to address complaints.
  
  
• Supervisor – Supervisors (i.e., clerkship direction/academic dean/program director/department chair) are responsible for being familiar with the breastfeeding and lactation policy, and creating a culture of support for breastfeeding to promote trainee wellness. They must inform pregnant and lactating trainees about the details of the policy, including the options for breastfeeding or expressing breast milk, the lactation policy, location of lactation rooms, and how to report any concerns. They also play a significant role in promoting trainee well-being by creating a culture of support for breastfeeding within the medical school or training program.
  
  
• Supervisors should work with each trainee to determine an appropriate lactation schedule. They should also communicate with others who will be affected by this schedule, particularly faculty. The supervisor should communicate clear support for the trainee and ensure that a plan for patient coverage is in place.

• Trainee – Medical trainees should inform their supervisor (i.e., clerkship director/academic dean/program director/department chair) that they will require accommodations to breastfeed or express breast milk. Ideally, this conversation will occur during a trainee’s pregnancy prior to maternity leave. Opportunities to meet with a lactation consultant prior to delivery and breastfeeding can help the medical trainee prepare for breastfeeding, determine a realistic schedule and manage any challenges that arise.

A trainee and their supervisor should work together to determine a schedule that meets the trainee’s lactation needs while also allowing them to maintain their patient care responsibilities and/or fulfill classroom requirements. Medical student and resident/fellow schedules may need to be modified to ensure that the rotation schedule is conducive to continued breastfeeding or breast milk expression. The trainee should communicate schedule adjustments to all colleagues and supervisors who may be impacted by them.

When using the lactation space, the trainee should clean up after each session and report any issues with the facilities to the appropriate person. Recognizing the Diversity of Families

The AAFP recognizes that the language traditionally used around lactation and parenting is highly gendered and often presupposes a heteronormative, two-parent family structure. Many transmasculine people use the term “chestfeeding” because it is better aligned with their gender identity. The AAFP encourages the use of language that is appropriate for each individual and avoidance of any assumptions about a person’s gender identity, sexual orientation, partner status or family makeup when providing lactation support and counseling.

References:

1. American Academy of Family Physicians. Breastfeeding, Family Physicians Supporting Breastfeeding (position paper). January 2022. Accessed May 30, 2024.
   https://www.aafp.org/about/policies/all/breastfeeding-position-paper.html
2. American Academy of Family Physicians. Breastfeeding (policy statement). October 2023. Accessed May 30, 2024.
3. Meek JY, Noble L; Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988 .
4. American College of Obstetricians and Gynecologists. Breastfeeding your baby. Frequently asked questions. July 2023. Accessed May 30, 2024. https:\www.acog.org\womens-health\faqs\breastfeeding-your-baby
5. World Health Organization. Infant and young child feeding. December 20, 2023. Accessed May 30, 2024. https:\www.who.int\news-room\fact-sheets\detail\infant-and-young-child-feeding
6. Meek JY, Noble L. Technical Report: breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057989.
7. Feltner C, Weber RP, Stuebe A, et al. . Breastfeeding programs and policies, breastfeeding uptake, and maternal health outcomes in developed countries. Agency for Research and Quality (US); July 2018. AHRQ Publication No.: 18-EHC014-EF.
8. United States Department of Health and Human Services Office on Women’s Health. Business Case for Breastfeeding.  https://womenshealth.gov/breastfeeding/breastfeeding-home-work-and-public/breastfeeding-and-going-back-work/business-case
9. Navarro-Rosenblatt D, Garmendia ML. Maternity leave and its impact on breastfeeding duration among postpartum women review of the literature. Breastfeed Med. 2018;13(9):589-597. 
10. Bettinelli ME, Smith JP, Haider R, et al. ABM position statement: paid maternity leave-importance to society, breastfeeding, and sustainable development. Breastfeed Med. 2024;19(3):141-151.
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12. Mirkovic KR, Perrine CG, Scanlon KS, et al. Maternity leave duration and full-time/part-time work status are associated with US mothers' ability to meet breastfeeding intentions. J Hum Lact. 2014;30(4):416-419. 
13. Hilliard E, Schneidermann A. Prevalence of ‘Mother/Infant Friendly Worksite Designations’ and state laws regulating workplace breastfeeding support in the United States. J Public Health Policy. 2020;41(1):70-83.
14. Vilar-Compte M, Hernández-Cordero S, Ancira-Moreno M, et al. Breastfeeding at the workplace: a systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women. Int J Equity Health. 2021;20(1):110.  
15. U.S. Department of Health and Human Services. The Surgeon General’s call to action to support breastfeeding. HHS, Office of the Surgeon General; 2011. 
16. French PT, Dickmeyer JJ, Winterer CM, et al. Breastfeeding advocacy: a look into the gap between breastfeeding support guidelines and personal breastfeeding experiences of faculty physicians. Breastfeed Med. 2022;17(3):239-246.  
17. Melnitchouk N, Scully RE, Davids JS. Barriers to breastfeeding for US physicians who are mothers. JAMA Intern Med. 2018;178(8):1130-1132. 
18. Ortiz Worthington R, Adams DR, Fritz CDL, et al. Supporting breastfeeding physicians across the educational and professional continuum: a call to action. Acad Med. 2023;98(1):21-28. 
19. U.S. Department of Labor. FLSA protections to pump at work. Accessed July 16, 2024. https://www.dol.gov/agencies/whd/pump-at-work  
20. United States Breastfeeding Committee. The PUMP Act explained. Accessed May 30, 2024. https://www.usbreastfeeding.org/the-pump-act-explained.html 
21. Accreditation Council for Graduate Medical Education. Common program requirements (residency). July 1, 2023. Accessed May 30, 2024. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2023.pdf 
22. Office on Women’s Health. Location for breaks. February 22, 2021. Accessed July 16, 2024. https://www.womenshealth.gov/supporting-nursing-moms-work/break-time-and-private-space/location-breaks 
23. Office on Women’s Health. What employers need to know. May 23, 2023. Accessed May 30, 2024. https://www.womenshealth.gov/supporting-nursing-moms-work/what-law-says-about-breastfeeding-and-work/what-employers-need-know
24. Centers for Disease Control and Prevention. Perspectives in disease prevention and health promotion update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR. 1988;37(24);377-388. 
25. Slusser WM, Lange L, Dickson V, et al. Breast milk expression in the workplace: a look at frequency and time. J Hum Lact. 2004;20(2):164-169. 
26. Office on Women’s Health. Time for breaks. February 22, 2021. Accessed July 16, 2024. https://www.womenshealth.gov/supporting-nursing-moms-work/break-time-and-private-space/time-breaks  

 (COE) (May 2013) (October 2025 COD)