Breastfeeding medicine subspecialty requirements

BFM Subspecialty Content

Theme

Category

Details

Learning Objectives/

Demonstrated Achievements

Public Health/Systems-Based Practice

Recommendations from different national and international groups (WHO, ABM, other national depending on country of practice (eg. AAP, ACOG, AAFP, Healthy People targets, etc…)

• Health benefits of breastfeeding for mother and infants.
• Exclusive breastfeeding for about 6 months and
• Continued breastfeeding with complementary foods during the 1st/2nd year or as long as mutually desired
• Physiologic and biologic mammalian weaning

• List the benefits of breastfeeding for mother and infants.
• Understand in detail evidence for at least one of these benefits.
• Understand the rationale for risks-based language and how the data changes in these cases
• List should be comprehensive of systematic reviews, mothers, infants and communities, and include some, but not necessarily all, most recent findings
• Name the length of time exclusive breastfeeding is recommended.
• Know WHO and ABM recommendations, along with national recommendations of country of practice, if any
• Cite the recommended length of continued breastfeeding, and why
• Describe the evidence for the benefit of breastfeeding beyond one year

Ethical Principles

Informed consent

• Avoid coercion, undue influence
• WHO code of marketing
• Health Equity: providing breastfeeding medicine care equitably in one’s community, community engagement for collective impact

• Demonstrate an understanding of the WHO code of marketing of breastmilk substitutes
• Describe ways formula companies undermine informed consent
• List 3 ways your practice addresses health equity (eg. locations, translation services, data tracking, insurances accepted, images inclusive of demographics served, etc…)

Breastfeeding rates

• In practicing country

• Across continents with a minimal understanding of at least 2 other country-specific programs and rates

• Name the overall and exclusive breastfeeding  rates in country of residence, where available. If not available, determine which methodology would be best suited to approximating such data in country or locality of practice (ie. randomized chart review, community health worker survey, etc…)
• Recall what socio-economic, racial, education groups are most and least likely to breastfeed

Role of the National and International Support programs, including IBFAN, WABA, and country-specific (eg. WIC: Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program) in supporting breastfeeding

• Food/formula support
• Role of these programs in breastfeeding support
• Role of free formula in undermining breastfeeding

• Name and describe 2 international organizations devoted to infant nutrition and maternal child health
• Describe how national programs support breastfeeding (eg. WIC). If none exist, choose a program from another country with similarities to learner’s and analyze how it supports breastfeeding and may be used in learner’s locality.
• Relate role of WIC in providing nutritional support for breastfeeding mother and formula for infant if needed

Other Support

• Role of support groups
• Supportive communities
• Baby friendly hospitals and/or state-sponsored breastfeeding friendly recognition for hospitals
• Community outreach and advocacy

• List support groups or locations available to families to support breastfeeding locally in area of residence. If none exist, as above, choose a program from another area with similarities to learner’s and analyze how it supports breastfeeding and may be used in learner’s locality. Take steps to make contact with that group.
• Recall at least 2 additional avenues of support for families in community of area of interest
• Describe the different levels of support provided by: groups, peer support, family support, medical support, tech/texting/online support

Role of national/state supports/policies

• Public breastfeeding 
• Maintenance of lactation while separated from infants, ie. at work
• Pumping at work, current data
• Government assistance for, or insurance coverage of pumps 
• Paid maternity/parental leave
• On-site childcare
• Providers should play an active role in education, changing hospital practices, community efforts, or supportive legislation

•  Analyze a case from provider’s patient panel who was impacted negatively by a policy or lack thereof - suggest management strategies for this patient - suggest policy changes to alter outcomes in future cases
• Describe local and national laws surrounding time and space for mothers to express milk at work, if any exist. If so, ensure access to patients of such information

Outside supports

• Knowledge and tracking of support network local to the trainee
• Maintenance of referral lists and distribution
• Positive and at least yearly interaction with community providers of support services, more as needed
• Knowledge of local/state breastfeeding coalitions and their activities

• Visit one local support, or potential local support if none exist
• Achievement: 1-page reflection on visit/meeting with local support service
• Describe any local/national/international recognition for “breastfeeding friendly” businesses, childcare centers, medical offices etc.

Human milk banking

• Basic guidelines for screening, processing, pasteurization methods, distribution and typical uses of banked milk
• Different models of milk banking: not-for-profit, for profit, government sponsored
• Issues of equity and fairness in distribution of human milk
• Issues of religion in the use of other’s milk (milk siblings, donor pooling)
• Informal human milk sharing: risks vs. benefits, how to increase safety; any local groups (ie. Eats on Feets, Human Milk for Human Babies (HM4HB))

• Describe the 3 current models of human milk banking
• List 2 risks of purchasing informally donated human milk
• Create an educational tool for patients based on the ABM statement on informal milk sharing. If one already exists, demonstrate its use.

Medical Knowledge and Patient Care

Protocol and organization use

• Knowledge of ABM protocols
• Demonstrate use of at least 4 clinical protocols

• Knowledge of and use of other breastfeeding education and consulting platforms, either national or international (eg. MyABM member community, mentors, country-specific groups, IABLE)

• Present a weekly case to a local group of learners (Lactation, fellows, etc…Can use resources like IABLE, other curricula)
• Describe the use of the ABM protocol for maternal pain in a clinical case of the learner’s choice
• Mentor sign-off on the observed use of 4 protocols in practice

Prenatal 

• Appropriate counseling on Breastfeeding knowledge/confidence, benefits, and how to get started
• Knowledge of at least 1 evidence-based curriculum for prenatal counseling/support
• Knowledge of racial differences in breastfeeding rates
• Engaging and educating fathers/partners and other family members
• Knowledge and use of websites, printed materials and other resources for patient education (avoid advertising / giving formula)
• Able to counsel on tandem feeding/ breastfeeding while pregnant (e.g. nipple soreness, decrease in milk supply, weaning rates in 1^st/2^nd trimester, no increased risk of SAB or preterm delivery, high risk of anemia, some risk of low birth weight)

• Able to perform prenatal breast exam, understands the importance and timing of breast changes in pregnancy (e.g. colostrum, masses). Able to differentiate pathologic processes or anticipate potential sources of concern (Inverted nipples, nipple piercings etc.) and initiate appropriate counseling or management.  
• Understand the importance of physician knowledge and counseling on breastfeeding rates
• Identify Comorbidities
• Understanding the role of breastfeeding laws and supports in creating plans to breastfeed or not
• Understanding the Gentle Cesarean

• Discuss when in the life-cycle mothers make decisions around infant feeding and name at least 4 prominent influences on decision-making.
• Discuss the role of bias, limited access, formula marketing and stigma in a person’s decision to breastfeed.
• Explore learner’s own life experience that may cause bias surrounding breastfeeding
• Describe three conditions which would be identifiable on prenatal breast exam and what expectant management/early intervention could be done to improve outcomes.
• Be able to educate physicians involved in prenatal care on their role in counseling and what the best approach may be
• Be able to identify conditions that may compromise breastfeeding efforts (PCOS, Breast surgery, Unsafe medications) and be able to provide counseling or referral
• Be able to provide education on local breastfeeding laws protecting breastfeeding in public, breast pump coverage, and pumping at work

Birth practices impact on breastfeeding

Understanding the impact of birth practices and methods on breastfeeding:

o   Intrapartum antibiotic use

o   Induction / Augmentation Methods

o   Operative Delivery (Vacuum / Forceps)

o   Intrapartum Pain Medication - Nubain, Epidural

o   C-section and the microbiome

o   Lactogenesis onset

o   Infant separation and impact on skin to skin, lactogenesis and supply

• Compare C-section rates at different hospitals in area, where available
• Compare breastfeeding scores of the same hospitals (eg. via mPINC score)- is there a correlation?
• Compare breastfeeding rates at discharge for babies born via non-emergency cesarean vs vaginal at learner’s institution.
• If not available, describe methodology to collect a local estimate (ie. randomized chart review), then work to systematize this review to yearly.

NICU

• Be aware of the latest research surrounding the use of human milk and donor milk and outcomes on NEC, BPD, ROP, cardiac volume, feeding tolerance, neurodevelopment
• Neo Baby Friendly Hospital Initiative and challenges it has faced with roll-out
• Evidence for health outcome differences between mother’s own milk, donor milk and formula
• Different types of pasteurization and their effects on human milk components
• Research basis of colostrum and early human milk feedings
• Understand the importance of hand expression in first hours after birth to optimizing long-term milk production 

Parental outcomes

• Be familiar with Kangaroo Care and all related research by Nils Bergman, especially early sensory processing needs as foundational to later development and the central role of breastfeeding in this.
• Understand effects of high-risk deliveries on milk production trajectories, insofar as it is known
• Be sensitive to competing priorities in a NICU parent’s time for milk expression
• Know potential parental mental health outcomes associated with a NICU admission

After discharge

• Review the evidence surrounding targeted fortification for growth of infants discharged from the NICU
• Understand the different options for fortification and weaning from fortification

• Explore differences in the amount of support for breastfeeding mothers of babies in NICU vs postpartum ward at various hospitals in the learner’s area
• Analyze the differences between local sources of donor milks, risks vs. benefits
• Describe the minimum amount of milk a mother of a premature infant should be expressing by 1 week and 1 month postpartum
• Describe the effect of skin to skin on maternal cortisol levels

Sleep

• Understanding the research behind the co-sleeping debate
• Understand and explain the factors associated with safer sleep
• Understand and explain the incidence of, timing of, and causes of SUPC 
• Role of BFHI in sleep patterns
• Understanding the impact of sleep on postpartum depression

•  Demonstrate how to counsel parents regarding safer sleep while breastfeeding

Postpartum mothers

Understand patient experiences in the postpartum period such as: 

• Exhaustion
• Stress
• NICU experiences
• Breast changes
• Body changes, what is normal and when is it abnormal (vaginal bleeding, blood pressure, urine/fecal loss)
• Depression screening and referral/management
• Breastfeeding Confidence/Education

Understand the Immediate Postpartum conditions listed below and their relationship with breastfeeding

• Perineal lacerations
• Uterine Contractions
• Surgical Site knowledge
• Baby blues / Fatigue
• Maternal Infection
• Postpartum Depression/Anxiety
• Nipple wounds
• Nipple yeast overgrowth
• Hormone levels and sex
• Fertility
• Anesthesia Effects / Safety

 Obstetric Comorbidities 

• Pre-Eclampsia / Gestational Hypertension
• Unplanned/Emergency C-Section 
• Gestational Diabetes
• Obstetric Hemorrhage / Sheehan Syndrome
• Retained placenta
• Insufficient Glandular Tissue
• Shoulder Dystocia / Nerve Injury 
• Operative vaginal delivery 
• Infant birth injury
• Prolonged labor, failed induction of labor or arrest disorders

Knowledge and management of common conditions

• Polycystic Ovary Syndrome
• Thyroid abnormalities and how they can affect breast development and lactogenesis
• Pregestational diabetes
• Delayed lactogenesis 
• Maternal Substance Use, Recreational Drug Use and Drug Addiction/Abuse

Management of Common Complications

• Lack of maternal knowledge / confidence
• Breast Engorgement – frequent feedings, cold packs, mild analgesics
• Nipple Pain – Assess latch, breast milk application, nipple shields, pump flange fit, use of pump
• Perceived or actual low milk supply – Most commonly due to inadequate breast stimulation
• Failed lactogenesis 2 (limited evidence for medications or herbals)
• Poor milk transfer
• Poor weight gain with or without poor milk transfer
• Breast Infections and bacterial dysbiosis
• Formula supplementation in the hospital
• Nipple Vasospasm
• Nipple blebs
• Overactive let down
• Oversupply
• Mastitis/abscess
• Plugged duct(s) - acute and recurrent
• Lactation induction
• Galactogogue use
• Care of breastfeeding in context of adoption, fertility and LGBTQ families
• Mood, trauma, social support problems
• Infections (Bacterial, Viral, Fungal)
• Chronic diseases/cancer
• Medication management (Medication use, timing, evaluation)
• Maintenance of breastfeeding in high-risk conditions of the mother or infant
• Breastmilk management in the context of procedures, imaging or surgeries
• Ankyloglossia/Tongue Tie affect on the mother

• Describe the three most common reasons mothers stop breastfeeding before reaching their goals

• Describe appropriate scenarios for nipple shield use, and possible complications
• Demonstrate how to teach  reverse pressure softening to a mother with breast engorgement

• Demonstrate how to assess and improve latch, hands-off methods
• Teach a parent how to tell when their newborn is swallowing
• Demonstrate how to help a mother find the best fitting pump flange
• Teach a mother how to use breast compressions
• Describe treatment options for vasospasm of the nipple
• Relate the latest research on the microbiome of the breast.

• Discuss the work-up of a mother with delayed lactogenesis
• Recite options for treatments for nipple wounds and the available research behind each
• Recall the incidence of postpartum depression, and explore the routine use of screening tools locally
• Demonstrate when and how to collect a breastmilk and nipple wound culture
• Recite the most common pathogens causing infectious mastitis, and the appropriate antibiotics to treat empirically
• Define delayed lactogenesis for primips vs multips
• Discuss considerations for recurrent mastitis and possibility of using prophylactic TMP/SMX

Birth control

• Describe Lactational Amenorrhea and criteria required for efficacy
• May be successful for up to six months
• Requires full or nearly full breastfeeding
• Ovulation returns prior to first menses but pregnancy risk still low
• Knowledge of non-hormonal contraceptives and efficacy (e.g. Copper IUD, Condoms, Diaphragm, Tubal Sterilization)
• Knowledge of hormonal contraceptives 
• potential impact on breastfeeding 
• When to initiate
• Understand the theoretical risk of reduced duration and potential delay of lactogenesis due to the required withdrawal of progesterone  
• For each contraceptive method, know efficacy, factors affecting efficacy and common side effects
• Timing of Mirena or Nexplanon placement
• POPs are commonly used, but require faithful administration with little room for delayed administration.
• Be aware of available resources that can help with counseling such as bedsider.org, CDC  medical eligibility app or chart for contraceptive use
• Awareness of any country-specific based racial implications of birth control choices and impact of discrimination in healthcare
• Ethical and religious or political considerations in contraception and potential discriminatory impacts

• Understand and be able to counsel on the  risks and benefits of the various forms of birth control in a breastfeeding mother
• Name 2 reasons the literature surrounding breastfeeding and contraceptives is difficult to interpret.

Immediate care of newborns

• Knowledge of Newborn Complications
• Positional difficulties such as Torticollis
• Cleft lip and palate
• Transient tachypnea of the newborn
• Meconium Aspiration 
• Subgaleal hematoma
• Cerebral palsy
• Neonatal seizures
• Congenital defects
• Congenital Heart Disease
• Hypotonic infant
• Fractured clavicle
• Neurologic injury
• Hypoglycemia - including those at high risk
• Indications for supplementation
• Methods of supplementation
• Identify concerning findings and be able to provide anticipatory guidance, manage or refer as appropriate
• Prematurity (NICU vs. late-preterm)
• Slow weight gain
• Suck dysfunction
• Jaundice (AAP policy, BF with phototherapy) 
• Ankyloglossia effect on the child
• GERD
• Food intolerances and allergies
• Dehydration management
• Child abuse/neglect
• Tandem feeding effects
• Concerns and benefits of breastmilk use in complicated infant/child conditions (eg. diabetes, cancers, immunosuppression)

•  Demonstrate how to teach parents the various methods of supplementation
• Recite the indications for supplementation

Absolute, transient and relative/partial contraindications to breastfeeding

• Infant with:
• Galactosemia
• Maple Syrup Urine Disease
• PKU (may require assessment in NICU)
• Mother with:
• HTLV1/2
• HIV (depending on country)
• Active untreated TB
• Recreational drug use such as cocaine
• Certain maternal medications 
• Chemotherapy
• I-131 treatment vs diagnosis

•  Able to name relative/partial and absolute contraindications of breastfeeding
• Know how to monitor/manage transient contraindications and support mothers and infants until able to breastfeed if desired
• Counsel a family on the literature, risks, and uncertainty surrounding marijuana use in breastfeeding.

Risk Factors for Breastfeeding Failure

• Breast surgeries and types of incision least and most likely to cause breastfeeding difficulties
• Breast Cancer – Breast radiation reduces breast milk > Higher Na and lower fat concentration
• Childhood leukemia with intracranial irradiation
• ?history of infertility?
• History of prior breastfeeding failure

• Mammary hypoplasia
• Expecting a child with an anticipated difficulty feeding from the breast (cleft palate, NPO as in TEF, extreme prematurity)
• Lack of changes in breasts during pregnancy
• Extremely large or long nipples
• Maternal illness requiring medication that other HCP may tell mother she cannot breastfeed

• Describe physical characteristics associated with mammary hypoplasia
• Name 6 maternal conditions associated with breastfeeding failure
• Demonstrate counseling a pregnant woman who has had breast reduction surgery

Medication Safety

• Pharmacology of medication transfer to milk ( e.g. protein binding, bioavailability, molecular weight, timing, etc)
• Evidence based resources available to physicians and patients
• InfantRisk, LactMed, mothertobaby.org, Hale’s Milk and medications book
• Know the most commonly used medications and the impact on breastfeeding
• Ibuprofen – First line, Relative infant dose 0.2-0.6% infant dose
• Toradol – Infant dose after IV is unknown, but likely low in colostrum
• Opioid Analgesics - Central Nervous System Depression, PO or IV has higher transfer to milk than neuraxial 
• Codeine – Active metabolite (Morphine), Polymorphisms can result in ultra-rapid metabolization, Excessive sedation or depressed respirations
• Tramadol – Similar to Codeine, No published reports of toxicity in breastfed infants
• Oxycodone 
• Hydromorphone
• Vaccinations – Most are safe
• Iodinated Contrast / Gadolinium – May breastfeed uninterrupted
• Anesthesia – May breastfeed when stable, awake, and alert enough to hold infant
• Sleep Aids
• Galactogogues – Metoclopramide, Domperidone, Fenugreek, etc
• Opioid use disorder therapy: Methadone, Buprenorphine
• Cannabidiol Oil, topical or ingested 
• Assessing the newborn/infant for signs of toxicity
• Maternal anxiety/depression medications

•  Counsel a family on a complicated medication regimen
• Describe considerations for opioid use for mothers postpartum
• Discuss reasons why use of medications for a mother of a premature neonate will vary than for an older term infant

Lactation support skills

Understanding/Supporting Normal Breastfeeding Physiology

• Appropriate latch and suck
• Positioning and alignment
• Institute breastfeeding within 30-60 minutes; Skin-to-skin
• Frequency / duration 
• Newborn / Infant sleep patterns 
• No food or drink except breast milk
• Rooming in 
• Breastfeeding on demand
• Pacifier Use
• Block feeding versus dual breastfeeding
• Knowing situations when Ten Steps should be adapted to maintain health of infant and mother

·       

• Discuss hospital policies that are supportive of breastfeeding
• Name 3 hospital based practices which limit breastfeeding success and what alternatives exist. Cite literature.
• Describe 2 different situations which would require an adaptation to the Ten Steps to Successful Breastfeeding and how breastfeeding may be supported in these situations.

Logistics of Breast Pumping

• Learning and manipulating a breast pump
• Breast pump flange size 
• Common skin findings with frequent pumping
• Timing of pumping sessions
• Strategies to manage pain with pumping 
• Importance of pressure and frequency in output
• Types of pumps; Common brands available in country of practice
• Hand expression
• Electric versus manual  pump
• Pumping in the hospital
• Pumping at home
• Pumping at work
• Pumping colostrum versus milk

•  Demonstrate appropriate use of a breast pump (setup, let down phase, pressure vs. frequency)
• Describe pressure differences between pumps (manual, passive, electric, hospital)

Assessment of intake

• Flaherman’s publications on early weight loss, Newborn Early Weight Loss (NEWT) tools
• Pre and post feed weights, how to, usefulness of, risks of
• Estimation of supplementation amounts, different methods (ie. pre/post weight, Flaherman’s ELF studies, etc...)

• Cite the calculations for estimated intake of a one month old infant who has poor weight gain, and supplementation estimates
• Plot an infant’s growth in the first 72h on NEWT curves, describe this method for indicating (or not) supplementation
• Name 4 behaviors of a hungry child who is not satisfied ar the breast

Infants and Children

Newborn

• Normal newborn
• Growth
• Weight loss
• (Pediatricians using correct growth chart)
• Intake and output
• Frequency of feeds
• Behaviors
• Sleep Patterns (Falling asleep at breast)

• Accurately plot a baby’s growth and determine whether it is adequate
• Discuss normal weight loss
• Discuss differences in WHO vs. CDC vs. Fenton vs. NEWT growth charts

Infants

• Vitamin D supplementation
• Introduction of culturally acceptable age appropriate complementary foods
• Know local requirements for iron supplementation based on prevalence, risk factors, etc. 
• Understand when and how mothers in learner’s community return to work. Refer to above for education and resources.

• Correctly time and prescribe vitamin D or iron
• Correctly counsel families on appropriate intake of maternal vitamin D which results in adequate infant stores
• Discuss reasons for and against iron supplementation for exclusively breastfed infants, preemies, older children

Toddlers

• Mutually desired weaning
• Dental concerns
• Healthy maternal-infant attachment

•  Discuss the conflicting literature around dental issues during breastfeeding and the importance of dental hygiene for all children

Older nurslings

 Mutually desired weaning

Bottle feeding/other feeding types

• Nipple Confusion/preference

-     Role of tongue tie, hypotonia, clefts in bottle vs. breast preferences

• Finger, cup
• Paced bottle feeding
• Exclusive breast milk pumping, vs. triple feeding, vs. pumping with frequency of feeds
• Storage of EBM

• Able to counsel the patient on when / how to introduce a bottle or other forms of feeding
• Able to counsel on proper storage of human milk

Prematurity and NICU

• Instituting pumping or hand expression, within 1 hour of delivery
• Breast milk decreases NEC, Retinopathy of prematurity, Late-onset sepsis, BPD, readmission rates
• Breast pump extraction of colostrum – often doesn’t work!
• Hand expression / Spoon feeding
• Assess maternal anxiety/depression (heightened in NICU)
• Know steps of the NeoBFHI

•  Name 4 illnesses of premature neonates that are positively impacted by a human milk diet
• Discuss sources of donor milk for intensive care units and their differences
• Discuss the role of skin to skin in the parental/child bonding and wellbeing/health
• Name 1 program supportive of breastfeeding in a NICU

Malformations

• Ankyloglossia 
• Cleft palate
• Cleft lip
• Hypotonia (eg down sy)
• prematurity

•  Describe in detail the conflicting literature around ankyloglossia and why full clinical conclusions are difficult to reach
• Name 1 intervention that may help a family whose infant has a congenital malformation to breastfeed

Weaning

• Definition
• Why
• How
• Medication support for weaning
• Night weaning
• Behaviors misunderstood as weaning
• Maternal emotion / depression during weaning

•  Describe 3 methods of weaning

Procedures/devices/

interventions

Devices

• SNS/lact aid/home made
• Nipple shields
• Shells
• Sticky pads/Soothees
• Pumps and fittings

•  Demonstrate appropriate setup and use of a supplemental nursing system (SNS)
• Name 2 possible indications for SNS use

Creams and lotions

• Evidence or lack of
• Lanolin
• Breastmilk
• “triple nipple”
• Steroids
• Antifungals
• Antibiotic creams
• Others

•  Discuss components, alternatives, pros and cons of triple nipple cream use

Procedures

• Therapeutic breast massage
• Frenotomy
• Breastmilk culture

Optional: breast biopsy, breast imaging, occupational/feeding therapies.

•  Name 3 reasons learner would consider referral for breast imaging and/or biopsy in a breastfeeding parent
• Name 2 reasons for a breastmilk culture
• Demonstrate competence with therapeutic breast massage, signoff by supervisor
• Demonstrate competence with frenotomy, signoff by supervisor
• Demonstrate competence with Breastmilk culture, signoff by supervisor 

Physical exam

Mothers (Breast)

• Preconception, intrapartum and postpartum breast exam
• Breast anomalies: hypoplasia, surgeries, gigantomastia, asymmetries, clogged ducts vs mastitis vs cysts. Early cancer signs, mastalgia management
• Nipple anomalies: inversion classifications, milk blebs/blisters, eczema/atopy, friction effects, bruises, cracks, herpes diagnosis and management, role of trauma and pain disorders, specific problems with pumping, candida infection, vasospasm. Assessment, diagnosis and management of nipple pain.

•  Demonstrate a complete breast exam
• Name and cite treatments for 3 nipple conditions which may result in a nipple rash besides infant latch damage

Babies

·      Infant oral cavity:

o  Mucus membranes

o  Palate

o  Tongue function and classification of ankyloglossia (Hazelbaker and Coryllos)

o  Oral thrush

o  Normal newborn oral structures and anomalies

·      Infant suck 

o  Suck/swallow/breathe evaluation and suck dysfunction

o  Preferences vs behaviors vs dysfunction

·      Infant behavior, normal, preterm, developmental delay

o  Identification of abnormal behavior, tone, neurodevelopment

o  Referral to primary provider with concerns

·      Infant skin tone, dehydration

• Correctly type and score function (Coryllos and Hazelbaker ) of three infants with breastfeeding problems
• Discuss difficulties in assessment and evidence for “lip ties” or maxillary frenula which affect breastfeeding

Safety/risks and risk mitigation

Culture of safety

• Know the reasons for risk mitigation
• Culture of safety: open discussions, time outs, risk reporting

•  Report 1x/year on near miss/miss/patient safety concern

Areas of high risk

• Caring for mother and baby and others outside of “original” scope of practice
• Breast cancer
• Mastitis
• Tongue tie
• Maternal mood/anxiety disorders (risk of early weaning, medications)

•  Name 2 risks for mother and 2 for infants which could be challenging for breastfeeding medicine providers

Risk mitigation

•  Discuss how these risks could be mitigated

Practice-based learning and improvement

Billing and practice management

• Billing mom and baby, others
• Patient responsibility for charges
• Working with LC, LC billing
• Workflow in the solo, group practice. Single specialty or multispecialty operation
• Business case for breastfeeding

•  Discuss local billing practices, how to get paid for clinical breastfeeding work
• If insurance coverage is not possible, discuss how BFM services can be made possible for low-income or high-risk patients

Working with other provider types

• LCs
• RNs
• Other physicians
• Hospital systems
• Other clinics
• Therapists
• Mental health
• Body workers
• Chiropractors
• Others…

•  Discuss components of positive interdisciplinary training and worksites
• Name 3 local provider types with which the learner may work 

Quality Improvement

•  PDSA cycles (plan do study act), Design of Interventions
• Importance of data and feedback
• Engagement of staff     

• Design and implement at least 1 QI project in learner’s environment
• Describe 1 cycle of change (using PDSA or other methodology)

Interpersonal and communication skills/Professionalism

Communication skills

•  Tools for efficient communication
• Feedback on communication and growth/observation

• Name and describe the use of at least 1 tool for empathic and efficient communication with patients and famlies (ie. Engage, Empathize, Educate, Enlist, or Motivational Interviewing, etc…)

Professionalism

•  Appropriate method of examining mothers’ breasts (when MD not her doctor, ie. Peds)

• Describe process of informed consent
• Describe conflict resolution with interdisciplinary concerns

Systems Based Practice - Supporting Normal Physiology

Gross Anatomy

• Embryonic development of mammary glands
• Fetal and prepubertal development of mammary glands
• Pubertal Development
• Anatomic location
• Corpus Mammae - parenchyma and stroma
• Nipple and Areola
• Blood supply
• Lymphatic drainage
• Innervation

• Describe the development of the mammary gland with critical time periods

Microscopic anatomy

• Mature mammary gland
• Prepartum mammary gland
• Lactating Mammary gland
• Post-lactation regression of mammary gland

• Describe the relationship of lactocyte development and apoptosis with milk supply and hormone signaling

Hormonal control of Lactation

• Embryogenesis
• Mammogenesis
• Lactogenesis I, II, III
• Prolactin and Oxytocin
• Feedback inhibitor of lactation
• Neuroendocrine control of milk ejection

• As above
• Discuss the process of induced lactation and how it corresponds with the stages of breastfeeding hormonally

Synthesis of Human milk

• Mammary Secretory Cell
• Intermediary Metabolism of mammary gland

• As above

Involution

• Weaning  
• Apoptosis

• Discuss the cellular process of weaning and breast shape changes