C.B. Rosen-Carole

Despite the large body of evidence concerning practices and behaviors that support breastfeeding and the positive effect of residency and primary care curricula on breastfeeding rates, there remains no information concerning the appropriate and complete education of medical students. It is imperative to ensure that every health care provider graduates medical school with a basic understanding of breastfeeding. The following guide was created in order to support the development of such a curriculum:

Learning objective/transfer goal

By the end of medical school, medical students should have a basic understanding of the histology, anatomy, physiology, pathology, pharmacology, public health and clinical issues surrounding breastfeeding; be able to understand relevance of this knowledge to clinical scenarios; and begin to apply this knowledge in clinical decision-making (see Chapter 23 ). (C.B. Rosen-Carole)

The following topics should be included:

• 1.
  

  Histology : The histology of the breast, including the acinar cells, ductal cells, and hormonal stimuli of milk release. Impact of breast milk on the newborn gut cells.

  
  
• 2.
  

  Anatomy : Location of the milk ducts, their proximity to surgical incision sites. Surgeries and surgical sites with varying impacts on breastfeeding. Suspension ligaments. NO lactiferous sinuses. Role of the interstitial spaces that fill with fluid during engorgement to prevent release (“let down”) of milk.

  
  
• 3.
  

  Physiology : Seeing the newborn and mother as a “dyad” biophysically during the first year of life. Normal hormonal stimulation of milk ejection, mechanisms of milk expression by mechanics of neonatal tongue, and differences with milk ejection by artificial methods (hand expression and pumps). Impact of breast milk on the newborn gut, biomes, hormones, and digestion.

  
  
• 4.
  

  Pathology : Mastitis causes and prevention, and appropriate management of breast abscess while not interrupting ductal tissue. Few contraindications to breastfeeding. Infant malformations associated with difficulty breastfeeding. Diseases impacted by breastfeeding. Genetic and epigenetic influences of breast milk.

  
  
• 5.
  

  Pharmacology : Impact of artificial infant formula on newborn gut, especially premature gut. Risks of artificial infant formula and proposed mechanisms (e.g., changed microbiota leading to increased inflammation, increased permeability of mucosal membranes, decreased host defenses, and increased infection). Breast milk fortifiers and their role in growth and nutrition of premature babies (both human- and cow-milk-based fortifiers). Considerations of the transfer of medications into human milk. Determining the safety of medications for breastfeeding. Role of certain medications in decreasing breast milk production.

  
  
• 6.
  

  Nutrition and immunology : Nutritional impact of breastfeeding and breastmilk as species-specific. Co-factors for absorption, presence of cells, and immunoglobulins for immunologic support. Colostrum as first nutrition and first vaccine.

  
  
• 7.
  

  Public health : Breastfeeding as a health disparities and access issue. Low rates of breastfeeding and impact on cost of health care and burden of disease.

  
  
• 8.
  

  Primary care clerkship preparation : How to discuss breastfeeding in a supportive manner with families, the importance of breastfeeding education and physician recommendation. The basics of a good latch and positioning.

Curriculum design considerations:

• •
  

  Material included should meet the highest standards of evidence-based medicine. Involving a physician with advanced training in breastfeeding medicine is recommended, if available, for this process.

  
  
• •
  

  Curricula should be designed by a multidisciplinary team, including basic science and clinical faculty (obstetric, pediatric, family medicine, surgical, etc.), medical student leaders, patients, and administrators. This is likely to improve buy-in, humanism, and applicability to all parts of the curriculum.

  
  
• •
  

  Each phase of the medical school curriculum should include some information on breastfeeding: basic science, preclinical, and clinical years.

  
  
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  Material should be considered for inclusion in an integrated manner with other course topics (e.g., a discussion of the role of breastfeeding in breast cancer prevention could be included in a problem-based-learning cancer case or in a traditional lecture on breast cancer).

  
  
• •
  

  Dedicated sessions on breastfeeding should be considered to focus on the clinical skills necessary for the clinical years (e.g., latch, positioning, motivational interviewing).

  
  
• •
  

  In schools that utilize a systems-based integrative model, or modular, problem-based learning, a case/unit on breastfeeding should be strongly considered or should be included as a teaching point of a related case (e.g., bronchiolitis, diabetes, etc.).