Sunday, December 21, 2014

Mock clinical exams boost pediatric residents’ comfort in addressing breastfeeding

AUGUSTA, Ga. – A simulated clinical experience guiding future pediatricians through interactions with breastfeeding moms appears to put the doctors at ease with the sensitive and important health topic, researchers say.

“We showed that their confidence and comfort increased with the OSCE (Objective Structured Clinical Examination) interventions,” said Dr. Kathryn McLeod, a pediatrician and educator at the Medical College of Georgia at Georgia Health Sciences University who developed the three simulated patient exams.

Breastfeeding education typically falls to pediatricians who often see mothers and babies several times before a baby is six months old.  “Our residents have book knowledge about breastfeeding but they do not have hands-on knowledge on how to help mom’s breastfeed,” she said. “It’s an embarrassing examination for a lot of residents, especially males, watching moms breastfeed infants.” It can be embarrassing for moms to ask for help as well, McLeod said.

In the OSCEs, pediatric residents interacted with moms who’d been taught to model three common breastfeeding obstacles: sore nipples, a perception of a poor milk supply and a jaundiced baby. The moms gave residents immediate, face-to-face feedback on their history-taking, style, skill and professionalism. Training was first given in the second year then repeated in the third year.

The experience increased residents’ self-reported confidence in helping mothers breastfeed, going from 18.1 to 22 points out of a possible 25 Breastfeeding Attitudes and Behavior assessment score. While their comfort level dipped in the interim, the second course in their third and final year of residency re-boosted the score to 22.2. A second group of residents receiving the more traditional lecture and video in their first and second year experienced a smaller confidence boost.

The findings were reported in a poster presentation at the American Academy of Pediatrics National Conference in New Orleans, Oct. 20-23.

Breastfeeding is considered a win-win for mother and baby. It enhances a baby’s protection from infection and reduces the risk of obesity, Sudden Infant Death Syndrome, childhood leukemia and type 1 and 2 diabetes. Additionally, breast milk is easily digestible, reducing the incidence of colic and enhancing food tolerance, since whatever the mother eats flavors the milk. For mothers, it decreases the risk of type 2 diabetes, breast and ovarian cancer and postpartum depression. Still breastfeeding can be technically challenging for already exhausted moms trying to fit it into their hectic schedules, which is why optimal physician support is so important, McLeod said. She is now finalizing videos that mimic the OSCE scenarios, which will be shown to first-year residents, in the hopes of getting them off on the right foot.

Third-year resident Dr. Shannon Myers agrees that the first year is a great place to start. Myers was a second-year resident on maternity leave and breastfeeding her firstborn, Christian Alexander, when McLeod offered the OSCEs. Myers opted to take them anyway.  “We as physicians must be comfortable discussing breastfeeding. It is so important to the child’s initial development and growth,” Myers said. “If pediatricians aren’t going to do it, who is?”

Her own experience provided additional, invaluable insight. “I have been where they are and know the struggles,” said Myers, who juggles an 80-hour work week to ensure that she and husband Paul Myers provide their child the love and support he needs. “I say, ‘Let’s do this day by day, let the goal be that this day you are going to breastfeed your baby every three hours.’” For those on the fence, she may even pull out an extra incentive: “I tell them it will take that baby weight right off.”

The cost and time it takes to continually recruit breastfeeding moms and train them for the OSCEs prompted McLeod to turn the realistic exam scenarios into videos. She’ll move forward with assessing their impact and plans to share the OSCE scripts and videos with colleagues across the country through the Association of American Medical College’s MedEdPORTAL.

In Georgia, about 71 percent of mothers have ever breastfed, a percentage that drops to 41 percent at six months with only 13 percent exclusively breastfeeding.  The American Academy of Pediatrics and other groups recommend breastfeeding exclusively to age 6 months and supplementing with other foods and liquids until age 1.  “We are good with initiation, but duration is a problem,” McLeod said. Just that day, she had gotten a call about a mother who quit breastfeeding after just 48 hours.

McLeod, who has been teaching residents about breastfeeding a dozen years, used a GHSU Educational Innovation Institute research fellowship to develop the hands-on curriculum. Classes were taught in MCG’s Clinical Skills Center where medical students get their first clinical experience with standardized patients mimicking a wide variety of maladies. The American Academy of Pediatrics developed a breastfeeding residency curriculum about five years ago.

One comment

  1. As an educator in a Family Medicine Residency program, I applaud Dr. McLeod. This is an excellent approach to educating medical students and residents about this crucial subject. I would just like to correct a subtle but important point in the article. The author states: “The American Academy of Pediatrics and other groups recommend breastfeeding exclusively to age 6 months and supplementing with other foods and liquids until age 1.” In actual fact, the recommendation is to continue breastfeeding to AT LEAST one year of age and then nurse for as long as mutually desired by the mother and the child. This is an important distinction because the traditional AAP recommendation for those babies who are formula fed is to switch to cow’s milk at one year of age (because cow’s milk doesn’t contain iron and is therefore not a good choice for a bottle-fed infant before one year of age but is OK after that when the child is getting good sources of iron from their food.) I frequently hear from mothers who are frantically trying to wean their child from the breast onto cow’s milk on the advice of their doctor, a family member or friend. It’s as though the mother’s milk suddenly turns to water on the child’s first birthday. I have to reassure them that this recommendation is for formula-fed children, not breastfed. There is no advantage to cow’s milk when a child is regularly nursing. Mother’s milk is an excellent source of all the child’s nutrients for as long as the child nurses. It also continues to boost the child’s immunity, so they would actually be depriving the child of further immune benefits by switching to cow’s milk. Breastfeeding for as long as the child and mother wish also has important health benefits for the mother, including a decrease in the risk of breast cancer of 4-28% for every year that a mother breastfeeds throughout her life. Not to mention the ease with which a nursing mother can calm and soothe an unhappy toddler. Many mothers miss the ease with which they used to make things better once their child has weaned.
    Alicia Dermer, MD, FABM, IBCLC
    Clinical Associate Professor
    UMDNJ-RWJ Medical School
    Department of Family Medicine

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