Estimated reading time: 8 minutes
Mary In-Ping Huang Cobb, MD, Durham, NC, USA
Photo: Janae Marie Photography
I have chosen to write for Breastfeeding Today because of the commitment of LLLI to advancing breastfeeding around the world.
Four months ago when I returned to work as a fourth-year neurosurgery resident after having a baby, I knew the odds of continuing to breastfeed were against me. I could barely find enough time to fulfill my surgical, clinical, and administrative duties throughout a normal day. Now I had to fit in several sessions of breastfeeding while getting enough rest at night.
There is a lot of data on the statistics and barriers to continuing to breastfeed when women return to work, but little practical information is available on how actually to make it work. The first months after returning to work were probably some of the most stressful times I’ve had in my residency. Finding the appropriate work/life balance while maintaining the standards demanded of my program was difficult. I now feel more stable. Several colleagues have asked me how I’ve managed it, so I decided to share ten practical tips that helped me and my family make breastfeeding work for us.
There is a lot of data on the statistics and barriers to continuing to breastfeed when women return to work, but little practical information is available on how actually to make it work.
I am now a Post Graduate Year (PGY) 5 neurosurgery resident, starting my second year as an enfolded neurointerventional fellow, currently training at Duke University Hospitals.
Exclusive breastfeeding is recommended by the American Association of Pediatrics and the World Health Organization for six months, with continued breastfeeding up to two years and beyond1, 2. Breastfeeding is initiated by 79.2% of new moms, but only 49.2% of them continue breastfeeding at six months, and 27% at 12 months3. With women making up almost half of the workforce (45.3%), one of the most common reasons for the discontinuation of breastfeeding is return to work4,5.
As a PGY4 neurosurgery resident, being pregnant was not that difficult. We are trained to work hard through fatigue. Carrying around a progressive amount of baby weight was bearable. What I did not expect was how difficult it was to go back to work after a month of maternity leave.
Similar to national rates, 80% of resident-moms initiate breastfeeding, but the discontinuation rates drop off much quicker. Half of resident-moms discontinue breastfeeding upon return to work, but an even greater drop occurs by six months with only 15% continuing to breastfeed6. Common reasons for discontinuing breastfeeding include lack of preparation and the demand of a rigorous residency work schedule6-10. Of those who continued to breastfeed, 79% felt there was insufficient time to pump during work, and 42% felt there was no appropriate place at work to pump6.
Most resident-moms feel there is support from their attending physicians and colleagues (54–80%)6,8, but the logistics of making it work are hard. In this profession, there is no room for compromise in quality of patient care or meeting the demands of an intense residency training program.
My baby boy is now five months old. He was born weighing over nine pounds, and continues to grow up happy and healthy. As I approach the six-month breastfeeding goal, I would like to share:
Ten tips on how I make it work
1. Get help at home.
When I started the residency, my husband and I hired a housekeeper to do deep cleaning twice a month. We now have her come every day. She does the day-to-day tidying (dishes, laundry, putting away toys, preparing bottles and lunches for the next day, and cleaning and putting together the breast pumping parts for the next day). This allows my husband and me to spend the little time we have during the week together to play with our baby boy, eat, study, and go to bed. It is not cheap but well worth it.
2. Have meals prepared.
We found a specialty food shop that prepares ten meals a week, Monday through Friday for a couple, with a main course, sides, bread, salad, and dessert. We pick the food up on a Monday evening, put it in the fridge, and my husband heats up each day’s meals in the oven when I’m about to come home. This saves us time from shopping, cooking, or picking up take-out daily. Lactating women require extra calories 11. With an increase in appetite, and less time to get lunch at the cafeteria, I take these leftovers to work with me the next day to eat between cases while working or breastfeeding.
3. Set up space at work.
By US law, employers are required to provide a place for lactating women to breastfeed12. At Duke University Hospitals, there are lactation rooms scattered throughout the hospital. I emailed the lactation coordinator for badge access, and downloaded the Google calendar app on my iPhone for reservations. Most of the other lactating women at Duke reserve the rooms in advance. With limited time between cases, I check the calendar while walking up to the lactation rooms and reserve one on the spot. If they are full, I go to a nearby private bathroom, sit on the floor, and pump there. Some people are lucky enough to have their own office, or share space. With an inconsistent pumping schedule, I felt it was too much work to coordinate this on the spot.
4. Rent a hospital grade pump.
There are several pumps on the market. I switched after finding one that almost doubled my milk supply in the same amount of time. This is crucial with limited time between cases and even more so after long cases, when milk supply backs up, the breasts are engorged, and it takes a couple of pumping sessions to alleviate the pressure and pain.
Some of the lactation rooms provide a hospital grade pump, but because these rooms aren’t always open, I rented my own backup. I have two of them, one to keep at work, one for home that I bring in the car when traveling to an off-site hospital. Priced at $180 each to rent for 90 days, these pumps are retailed at $1300–$2500, and not worth the purchase. The membrane cap and tubing also need to be purchased separately.
5. Free up your hands while pumping
Experts recommend pumping every 3–4 hours, for 15–30 minutes at a time. Most breast pumps require the mom to hold plastic cups against the breasts with both hands throughout the pumping session. There are “hands free” options, but they require a special type of bra that requires time to change into. With an already tight schedule, the best product I found was invented by an emergency physician mom, milk collection cups that fit inside your bra, with connector tubing from these cups to the pump. When I pump in the car, nobody can tell. And the set up and take-down is quick. I purchased four of them, so I had backup in case the extra parts didn’t get clean on time during the week. With hands free, I bring my laptop to work, keep it with my pumping supplies, and am able to work while pumping. Between cases, I place orders, write notes, check in on labs and imaging, make phone calls, and prepare for the next case.
6. Wipe, don’t wash
To save time, there is no need to wash and dry the collection cups between pumps. Milk can stay safe in a cooler for up to 24 hours while you work13. I use baby-safe accessory wipes to wipe off the excess milk on my breasts and the top of the collection cups after each pump.
7. Tighten storage
Inside a cooler bag, I have a tupperware to keep the collection cups upright (with the top off for quicker access), and a 32-ounce wide mouth Mason jar. I tried multiple containers for milk storage. Mason jars have a rubber liner that keeps the milk watertight, with a big enough spout to catch the extra when pouring milk from the collection cups into the container. I then purchased a pourable spout attachment, which I keep in the fridge at home, to make the exchange of milk from the Mason jars to the baby bottles mess free.
8. Backup human milk
Getting extra milk from a mother I know locally has been really helpful when my milk supply was low. Taking the galactagogue fenugreek, as well as finding the time to nurse my baby more helped boost my supply. See Milk Sharing in An Age of Social Media and LLLI Milk Donation Policy.
9. Feed the baby in a comfortable position
When I first started breastfeeding, holding a baby in football or cradle position while supporting the nipple was hard on my hands and wrists. I developed carpal tunnel in both hands, and de Quervein’s tenosynovitis in my left hand. As a surgeon, I could not afford to have my hands compromised. My hands felt better after using a nursing pillow that wraps around my waist. Pillows don’t necessarily fix latching issues but getting comfortable makes breastfeeding easier.
10. Get sleep at night
I have not had a full night of rest since my baby was born, but I feel well rested. Contrary to the advice of the AAP14, I co-sleep with my baby on my side. I feel a strong maternal instinct that helps me be aware of where he is at night. When he is hungry, I gently turn to the side, guide him to feed, and I fall right back asleep. I switch from my right to left side several times overnight. We have a king size bed, and I purchased a side rail so there is a safe barrier between me and the edge of the bed. I found this to be much more restful than waking up in the middle of the night and feeding the baby upright in another room. Frequent feedings during the night keep up my milk supply. With the little time I get to be with my baby, it keeps us bonded as well.
Breastfeeding benefits both mother and infant. For the infant, human milk reduces the rates of infection, allergies, obesity, diabetes, leukemia, lymphoma, SIDS, and infant mortality2. For the mother, benefits include a more rapid involution of the uterus, return to pre-pregnancy weight; and a reduction in postpartum blood loss and a lifetime risk of developing cardiovascular disease, breast cancer, ovarian cancer, and rheumatoid arthritis2. With strong data supporting the benefits of breastfeeding, it is my hope that these practical tips can help resident-moms who return to work continue breastfeeding.
- World Health Organization, Unicef Global strategy for infant and young child feeding (2003).
- Breastfeeding and the Use of Human Milk. Policy Statement from the American Academy of Pediatrics. 2012;129(3):e827-841.
- CDC report card – Breastfeeding Report Card. United States 2014.
- US Department of Labor Statistics. Household Data Annual Averages. Employed persons by occupation, sex, and age.
- Biagioli F. Returning to work while breastfeeding. Am Fam Physician 2003;68(11):2199-2207.
- Miller N. et al. Breastfeeding practices among resident physicians. Pediatrics 1996;98(3 Pt 1):434-437.
- Wyatt, S. Challenges of the working breastfeeding mother. Workplace solutions. AAOHN J. 2002;50(2):61-66.
- Orth, T. et al. Breastfeeding in obstetrics residency: exploring maternal and colleague resident perspectives. Breastfeed Med. 2013;8(4):394-400. doi: 10.1089/bfm.2012.0153. Epub 2013 Apr 30.
- Walsh, A. et al. Motherhood during residency training: challenges and strategies. Can Fam Physician 2005;51:990-991.
- Sattar, M. et al. Breastfeeding intentions of female physicians. Breastfeeding Medicine 2010:5(6):297-302.
- Greiner, T. The breastfeeding mother’s diet. Breastfeeding Today May 2010.
- Pregnancy Discrimination Act of 1978.
- Hamosh, M. et al. Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk. Pediatrics 1996;97:492–498.
- AAP. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Technical Report. Pediatrics 2011;128 (5): e1341.