Parenting is always an experiment so why not collect the data?
GPIFN

What do GPs know about breastfeeding? A Q&A with the GP Infant Feeding Network (part 1)

The GP Infant Feeding Network (GPIFN) is a network of trained individuals, including General Practitioners, who have volunteered their time to work on quality improvement in the field of Infant Feeding.

We were lucky to have several GPIFN volunteers join us for this Parenting Science Gang Q&A. Because this was our busiest ever chat (we generated 10,000 words in an hour!) it’s been split into two parts.

Here is part one: on the GPIFN, what GPs learn about breastfeeding while training, some research ideas and information on how we can support the work of the GPIFN.

Louise Santhanam: Hi everyone- I’m Louise Santhanam, I’m currently a Salaried GP (employed by a practice) in south London and I set up the GP Infant Feeding Network in late Feb 2016 with lots of support from the Infant Feeding community and a number of interested GPs and other HCPs who helped to establish our learning community. I personally have an interest in perinatal (pregnancy and postnatal) mental health and am part of the London Clinical Network which works to improve maternal mental health care in the capital.

Clare Nia Hi. I am a GP partner, member of GPIFN and mum of three. I started a pilot project in Norwich to have a GP breastfeeding champion in every practice

Jane Raja: Hi! I am a GP trainee in Yorkshire (meaning I’ve been a doctor for 7 years and am part way through my specialty training). I’m a member of GPIFN and I have one son and another baby due in the spring. I have a particular interest in paediatrics and child health and the important role that good infant feeding support plays there.

Robyn Powell I am an A&E doctor with a special interest in breastfeeding medicine. I am passionate about breastfeeding and its many benefits and I hope to be involved in changing our culture and how we view breastfeeding over my career. I am working on educating doctors, particularly in the Emergency department, as we do see a lot of infant feeding issues which are not recognised. I am also a mum of three.

Rosi Marsh Hi, I’m another member of GPIFN although here unofficially as I’m also a member of Parenting science gang. I’m a GP trainee in London. I used to work in paediatrics for a number of years before retraining as a GP. I also have 3 children.

What does the GP Infant Feeding Network do?

Louise Santhanam: We started off with an online discussion group, and we continue to share news, research and discuss general clinical topics on this. From this we developed a ‘community’ of active members who contributed to the idea of developing a resource specifically for General Practice, to address the common issues which come up for GPs.

We worked on the website for about 1 year and obtained the material for each topic partly through the discussions in the online forum. Over the last two years the active members who have formed the ‘Team’ have also been meeting their local Infant Feeding clinical representatives, making connections with the large UK infant feeding and breastfeeding support organisations and sharing info with GP colleagues online and in person.

When we launched our website in April 2017 we therefore had lots of support to disseminate it and it has travelled literally across the globe (but mostly around the UK!).

We are also working to make contact with the Royal Colleges (the medical bodies which develop medical training curricula), as we hope to impress on those that write the curriculum that breastfeeding and infant feeding in general is an important topic for all our patients and to integrate learning where relevant to ‘normalise’ it for doctors.

PSG F: It’s been an amazing resource and support network to those of us in the trenches in Infant feeding.

How do the GPIFN support health care professionals?

Louise Santhanam: When we set up the online forum it was intended to encourage GPs and our Primary Care HCP colleagues like Practice Nurses and GP Pharmacists to become interested in infant feeding issues and educate.

We were pleasantly surprised to get a lot of interest, but also from our colleagues who are Midwives, Health Visitors, other Medics, Pharmacists, Speech and Language Therapists, Dietitians and many others. We have welcomed anyone who is an interested HCP to our group for discussion and education, but have had to keep a clear aim of improving GP education, because this is a gap that we seek to address.

We would be very pleased to see other HCP groups develop their own networks and work with established structures like the Baby Friendly Initiative and the Mother Support organisations so that those professions can address any specific learning needs that apply to their roles.

We also know that lots of other HCPs use our website www.gpifn.org.uk which collates medical information from reliable sources on a range of topics- which is great! The more HCPs referring to trusted materials (particularly on the safety of drugs in breastmilk) the better!

How much time is given to breastfeeding in GP training and what scope is covered?

Jane Raja In short – none. There is no guarantee that a doctor training as a GP will have any formal training in breastfeeding. The curriculum does include breastfeeding problems but this does not mean there will be a formal teaching session in it.

The curriculum is far too long for it to be possible for there to be a formal training session on everything. Instead it means trainees should either attend a formal teaching session (if one is run on their training programme – most don’t), or else read around this topic in their own time. Some trainees will read around this topic more than others and come away with a much more detailed understanding. It is covered in the exam syllabus but this usually relates to questions about mastitis and about prescribing.

A lot of medical teaching and training in general is based around experience on the job – some doctors have the opportunity to work in paediatrics or obstetrics as part of their training and will gain experience there. I’m quite lucky that when I finish my training I’ll have worked as a paediatric doctor for 3 years due to some previous training prior to switching to GP, and have spent 6 months in obstetrics and gynaecology.

However it’s perfectly possible to become a GP without having done any of these rotations where one would naturally come across lots of breastfeeding related issues to prompt learning. (I should add – doctors who have plenty of experience and knowledge relating to infant feeding will naturally know less than some of their colleagues about, say, ophthalmology or dermatology, compared to those who have spent months working in those fields.)

PSG C: Wow. Are you aware of any other medical area that receives a similar treatment like breastfeeding in the GP curriculum? I’m just wondering if it’s given low regard because it’s a mostly mother’s issue and mothers generally have low value in society.

Clare Nia: In fairness as GPs we have to cover basically everything that can go wrong with a person of any age. And our training is only 3 years! So, most things get a quite cursory mention! But there is a feeling that breastfeeding can be “dealt with” by midwives and health visitors. Which is fine, until a mum turns up at our door with questions.

The GP’s job is not to be an expert on anything, but to know the limits of our knowledge and where to send people when we reach those limits. And the difficulties arise when people don’t admit they know nothing, or do, but haven’t a clue where to signpost people for help.

I don’t know about other areas but where I am, specialist support for feeding in the NHS is pretty limited.

Jane Raja: I think many of the more specialist areas are not usually covered in depth, and people then go on to do extra training courses after they finish training if they wish to pursue an interest in that area. For example, prescribing for substance misuse. Contraception (we all have training in this of course but there are more in-depth courses that can be done for those who wish to fit coils for example, or specialise in family planning).

Ophthalmology – again we are all expect to cover basic issues but there will be some GPs who go on have a more formal interest in this and will purchase additional equipment etc to enable them to provide a more specialist service to their patients without needing a hospital referral.

There will certainly be many topics on the curriculum where I doubt there is a formal teaching session in most areas, simply because the curriculum is so big that most of it has to be covered via clinical contact.

We are encouraged to reflect on consultations afterwards so if patients feel that their GP has not demonstrated adequate knowledge then it is actually a helpful thing to signpost them to information and resources so they can update themselves.

I know when I’ve seen patients with very rare diseases in the past I’ve been quite open with them that I don’t know much about their condition and they are usually able to signpost to some really useful resources. It’s very helpful. (Obviously breastfeeding is not all that rare but I think the point still stands that most doctors are fairly happy to be signposted to information on areas they don’t know much about.)

PSG C: I wish a day’s peer support crash course could be offered to GPs as a compulsory part of their curriculum. Breastfeeding is such a foundational aspect of the physical and mental health of mothers and babies, and their families.

Rosi Marsh: Yes, there are other medical areas like this. GPs are generalists, so cannot cover every area in their training. They need, ideally, to have an idea of what they don’t know in order to refer/ask for help at appropriate times and they need to know how to respond to urgent issues such as emergencies that need immediate hospital admission or suspected cancer diagnoses and have a grasp of most common simple issues. Beyond that, it is possible to have differing areas of expertise in different areas. My feeling is that the problem with infant feeding is that not all doctors know what they don’t know in this area and often assume that their culturally derived experience represents medical experience.

Jane Raja: I think so too. I don’t think GPs need to know everything – that would be impossible – but knowing where to signpost someone (whether that be another GP in the practice, or someone external) is key.

What breastfeeding topics are covered as part of a GP’s training?

Rosi Marsh: There is no set content to GP training, rather a curriculum which each trainee aims to cover through either clinical practice or through taught elements or through self-teaching. Infant feeding is referred to in this curriculum, but mostly with reference to infant problems such as faltering growth. There is no specific requirement to learn about the mechanics of normal breastfeeding.

Is there is room to work to improve initial training alongside your work reaching those currently practicing?

I recently did a training session for GP trainees and, as part of that, asked for feedback about what training they had previously received. About half not had any breastfeeding training at any point (undergraduate, post-graduate, in clinical placements) so I think it is fair to say that there are some GP trainees who will not receive formal training in breastfeeding. This is reinforced by the number of GPs in GPIFN who share the experience of learning much of their feeding knowledge once they have their own children.

We hope that there is room to improve this. Through our network we are trying to share training materials and promote the idea of those interested training colleagues, as often the training exposure of doctors does depend on the experience, expertise and interest of colleagues. We are also working with various organisations to try to make infant feeding a more established part of curriculums.

Are you working with training universities and organisations of relevant professionals to include your work in their relevant programmes?

Louise Santhanam: Yes we are working on this. It’s in the early stages, so it would be premature to say too much, but this is on the agenda. It has taken almost 2 years to build up awareness and relationships with the various relevant organisations to get to this point, and I personally see it could even be a career’s worth of work!

PSG C: So exciting!

Who decides what GP qualifications cover?

And who decides training on the job? Is it something like self-directed CPD or does the NHS require GPs to update their knowledge with specific training?

Clare Nia: Before completion of GP training there is a curriculum which is set by the Royal College of GPs. After training it’s basically self-directed CPD. There’s a few compulsory things like safeguarding and life support but generally you follow your own interests or try to improve on your own identified weaknesses.

Rosi Marsh: The content to be learnt is decided by the Royal College of GPs who compile the curriculum. However, the content to be learnt doesn’t necessarily describe what clinical areas are covered in any one training programme. Each trainee may be exposed to different clinical specialties during training. They will all work at least 16 months in GP practice as trainees however, so in this role they ought to be able to see a broad range of what presents to GPs.

Some things are only seen rarely, and so there may be gaps in the curriculum which trainees need to fill. Sometimes there are set teaching sessions which may cover these, and other times the trainee will need to find training materials themselves e.g. By doing online training modules or reading around an area.

Each trainee needs to record and evidence having covered the whole curriculum on a portfolio. However, this applies only to coverage of each of the broad curriculum areas rather than specifics (e.g. General area of Child health vs specific area of faltering growth in infants). GP trainees have to pass a written and clinical exam which requires broad knowledge of all areas of medicine which could present to GPs. They also have various assessments by professionals in practice who assess their work directly with patients.

Robyn Powell I can’t comment on GP’s training, but for A&E doctors, we have a curriculum set by the Royal College of Emergency Medicine and then we have to build a portfolio. There is no self directed learning for trainees and infant feeding is not a requirement completion of training.

Louise Santhanam As Rosi says, some of the learning is shaped by what comes up in your day to day practice as a trainee. It also depends on what your Trainer thinks is important to cover and what your GP Trainee colleagues are raising. We know that a lot of GPs who have had their own children, or contact with children through family member start to realise the significance of these issues when they experience them first hand. I wrote a bit for our website on this issue too: GP Education

Barriers to progress

We all know that the level of breastfeeding training that GPs and other health care professionals get could be massively improved. It’s a no-brainier to everyone here I’m sure!

What do you think are the main barriers to doing this? Why isn’t it prioritised more especially when there’s evidence that it improves health and saves money?

Jane Raja 

I think some of the barriers simply relate to a lack of time and other competing topics and issues – often the larger topics such as cardiovascular disease, respiratory disease, contraception etc get a lot of priority in training sessions. And then there are hot topics like sepsis.

As part of my training programme I’ve been lucky to have a placement at a Unicef Baby Friendly Initiative hospital where there’s compulsory training in breastfeeding for all doctors. However not all doctors get the opportunity to work in paediatrics as part of their training, and having worked in several other paediatric departments before as a paediatric trainee, I’ve never received training of this kind previously.

The exams we have to sit do have questions on breastfeeding sometimes, but these almost always relate to prescribing, or mastitis.

I think another part of the problem is that infant feeding issues are often seen to be a soft topic which is best delegated to health visitors and midwives. Obviously, health visitors and midwives do also deal with these problems but there are many instances where we know that a GP also needs to have a good understanding.

I also think the evidence we have on the amount of money saved by breastfeeding vastly underestimates it. We (the NHS) spend £80 million a year on paracetamol prescriptions which people could be buying for 20p in Tesco. I don’t believe that breastfeeding only saves half as much. More evidence would I think help a stronger case be made.

We (the NHS) spend a huge amount of money on a vaccination programme because we know it saves countless lives and huge amounts of money. It’s much easier and more straightforward to prove that though…

Louise Santhanam I agree with Jane on this, and much of the problem is time/competing interests. It’s also to do with the way we have traditionally looked at breastfeeding/infant feeding and seen it as a non-medical issue.

The way we have tried to present it through our website is to show how the topic has wide reaching impact on a number of different areas. The emerging research on the microbiome and immunology is important as well as the links with feeding issues and perinatal mental health. There is also a lot of developing research on bonding and neurodevelopment. We see support for the early years as integral to preventative health, but unfortunately the distribution of healthcare funding does not currently reflect this.

Robyn Powell I am an Emergency Medicine doctor (A&E) and in my experience, the majority of my colleagues don’t seem to believe the evidence or maybe it’s that they are not aware of it. They are very bound up in the societal change of the last fifty years or so (not breastfeeding) and don’t seem to understand that breastfeeding is as much an effective public health strategy as accident prevention in the home. My feeling is that more/good strong research into how breastfeeding prevents/shortens the duration of common A&E presentations would be useful and help break down barriers. A&E doctors are very science based so that is the way into our hearts and minds.

PSG A:  As a medical student, I’ve found that people come to university with their minds already made up about breastfeeding. And there’s no effort made to teach them anything to change that. It’s been one of the most emotive subjects that we’ve discussed. I’m only just through pre-clinical, so I wondered if this is still the case up through all the levels of training?

Jane Raja: It’s certainly an emotive topic, I don’t think that changes post qualification. I think one of the barriers faced when it comes to infant feeding is that many, many GPs and other doctors have had their own experiences of infant feeding – possibly including some very good or very poor support – and it can be really hard for doctors to separate these issues from their clinical practice. I think it’s important that we are able to do so as clinicians, but I really appreciate that for colleagues who had a very emotionally painful time with their own children, this may be very difficult.

PSG A:  I can absolutely understand why people with their own experiences have “baggage” (for want of a better word), but on my course (post-grad, accelerated) there were only 2 of us with children and we’d both breastfed. The people who seemed to take the most offence were the early 20s, never even considered having children… they seem perfectly happy to accept that age, BMI, gender etc (often things that you can’t control) are risk factors for so many different things, but when I said that formula feeding is a risk factor for ear infections, respiratory infections and SIDS, apparently that’s being judgemental. If people are so convinced of that at the start of their training, how do you get past it later? (This may be a rhetorical question!)

Where do you see the biggest hurdles in getting more GPs up to date (or just generally knowledgeable) about breastfeeding?

And what has been easy so far?

Clare Nia: My breastfeeding champion scheme has worked quite well so far because it’s a trickling down of knowledge. We ask each champion to do one online module and then they came to a 2 hour talk. We then asked them to present that talk back to their colleagues. I gave them all the resources they needed. It needed to be easy for them to do it!

PSG B: Is that scheme across the whole GPIFN or just locally?

Clare Nia: Just in Norwich at the moment. Though we’ve made the business case public and are more than happy for anyone to copy it anywhere in the country/world!

PSG B: It needs to be everywhere!

Louise Santhanam One of the biggest hurdles I think is that GPs are not easy to contact. Once we qualify we work in different surgeries, some work in out of hours, some work in urgent care centres, and everyone is busy!

Sending emails is not often a useful way of spreading info as everyone gets hundreds of emails, and many GPs are not able to attend training days due to Surgery work commitments, or perhaps because their working timetable does not permit it.

That’s one of the reasons why we appreciate the chance to engage our GP Trainee colleagues like Jane Raja and Rosi Marsh who still have regular training education sessions, and to work towards the GPs of the future seeing this issue differently.

 

What is the most common type of breastfeeding enquiry that you get?

Clare Nia: We see a lot of mastitis. And queries about the safety of medication in breastfeeding. But I think the biggest impact I have is when I can tell people something is normal. e.g. Cluster-feeding or frequent night feeds. So many mums think this means they don’t have enough milk. So, it’s nice to be able to tell them it’s normal, it’s hard but it will pass and it will get easier, and that the best thing they can do is just keep on feeding responsively.

PSG D: In my doctor’s surgery, we rarely get to see the same doctor twice in a row. Do you have problems with seeing people who have what you regard as a “normal” complaint that they have had less useful advice about previously?

Clare Nia: Yes sometimes. Though mostly from well-meaning relatives! Generally, midwives and health visitors give good advice, better than us GPs. The problem is for good or ill our advice is often perceived as “superior” so when GPS give one piece of bad advice it undoes a lot of the good work the other HCPs have done. My main message to the GP Champions is that if you don’t know the answer to a question, don’t just make something up!

Jane Raja There are often also a lot of concerns about reflux and possible allergies in baby, often these are an opportunity to help share information about normal infant behaviour and signpost to appropriate information, because sadly many mums think something is wrong with a baby who doesn’t like to be put down, or who wants to feed “too frequently”. Obviously sometimes something is wrong, but that’s what needs to be worked out, and it can take time to do that.

Research

If you could wave a magic wand and get any research commissioned tomorrow, what would it be?

Clare Nia: We all know breastfeeding is important. I would like research on which interventions, both on a one to one and public health scale, have actually led to increased feeding rates. I think it has been done here and there but the results are never totally conclusive. But if we are doing things and potentially investing money in them then they should be evidence based.

PSG D: Do you think there are HCPs who don’t value BFing very highly? Is there any research that could be done that would motivate them to develop their own knowledge base?

PSG B: There are many HCPs that have their own personal experiences with feeding and I think this has a huge influence :-/

Clare Nia: Personal experience always has an impact and if someone has had an awful experience with breastfeeding

Rosi Marsh: There is so much about breastfeeding that could be researched further and give us more concrete information about advantages.

I agree with Claire that knowledge about which interventions helped, and by how much, would be useful.

It would be helpful to have better data on how many women have physiological difficulties with feeding (there are various figures quoted on this and my impression is that it isn’t well studied or known). This would give a better idea of how high we could aim as a society.

And it would be useful to know more about the physiology and pathophysiology of breastfeeding. Very little is known about, for example, how to investigate true low milk supply and links to metabolic or hormonal problems such as impaired glucose tolerance. This is more in the realm of endocrinology than in that of general practice. But as it stands there is little research base to tap when expert advice is needed by general practice doctors.

On a much simpler level, it would be great just to know how many mothers are breastfeeding accurately. Now that the infant feeding survey is no longer running we cannot be sure what the status quo is, or what outcome changes result from any policy changes. GPIFN has been vocal in the need to reinstate this.

Louise Santhanam: I would love to see:

  1. Parents own views on what they think are the areas where they found advice from HCPs confusing/conflicting and the attitudes that were not supportive. This could help to inform future educational curriculum development
  2. The outcomes of a targeted education programme like Clare Nia has set up, but also of more brief interventions which might be rapidly helpful to a large number of doctors or HCPs. It would be good to see if the impact of a learning module or using a website (like the GPIFN website!) actually changes practice, not just for GPs but also the experience of parents/patients.

Rosi Marsh: These are much more concrete and grounded aims than my grand research ideas and therefore probably much more practical and important!

Robyn Powell: From my point of view, it would definitely be how we can use breastfeeding in disease prevention and management. For example as a comfort/pain killers during procedures (there is some evidence about this but more is always good), breastfeeding in gastroenteritis /ear infections / chest infections etc.

How can we support the GPIFN?

On a very practical level, how can non-health care proressionals help GPIFN? What is the best way to spread the word about you?

Louise Santhanam:  Yes! Please share our website with your GP, Health Visitors or your Infant Feeding Lead. We have a downloadable flyer that you might like to show them.

Beyond this there could be scope for anyone who is part of a formal breastfeeding support group trying to contact local Surgeries to offer to do a training session for the Surgery. Also you can follow on Twitter @GP_IFN

PSG I: So what would be the best way to approach our local GP surgeries to get them involved?

Clare Nia: 
This You Tube Video sort of explains what we did in a Norwich and might be a good way to get started. Though actually I wouldn’t approach an individual surgery [about this approach] rather than go to public health or the CCG. Unless you can find a GP who is passionate about it in your local area and then see if they will kick start a scheme.

 

Thank you to the GPIFN for a very interesting Q&A. Part two coming soon … 

 

 

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