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 Table of Contents  
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 163-168

Improving breastfeeding medicine in undergraduate medical education: A student survey and extensive curriculum review with suggestions for improvement

1 Department of Pediatrics, Creighton University School of Medicine, Omaha, NE 68178; Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ 85016, USA
2 Department of Pediatrics, Creighton University School of Medicine, Omaha, NE 68178; Department of Pediatrics, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI 53226, USA
3 Department of Pediatrics, Creighton University School of Medicine, Omaha, NE 68178; Department of Pediatrics, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA

Date of Web Publication19-Sep-2017

Correspondence Address:
Erin E Birmingham
Children's Corporate Center, 999 N. 92nd St., Suite 730, Milwaukee, WI 53226
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_180_15


Background: Breastfeeding education should be incorporated routinely into medical school curricula. Despite strong evidence supporting exclusive breastfeeding of infants, lack of physician education has continued to undermine the practice of breastfeeding. Protecting and supporting breastfeeding should be a public health priority as it has the potential to save billions of dollars in health care and also provide the most benefit to the newborn infant. The purpose of this article was to evaluate how the United States undergraduate medical institution incorporates breastfeeding medicine into its curriculum and to suggest modifications that will improve breastfeeding education at all undergraduate medical institutions. Methods: The authors performed an in-depth review of the undergraduate medical curriculum at the United States medical institution. Course requirements and lectures were compared with the 12 knowledge-based and 12 skill-based competencies that the authors suggest all medical students should possess. In addition, the authors sent out an electronic survey to 600 medical students at the same institution to assess current students understanding and comfort with basic breastfeeding topics. Results: Students in the preclinical years are only learning 3 of the 12 knowledge-based competencies and 1 of the 12 skill-based competencies. Students in the clinical years are learning 5 of the 12 knowledge-based competencies and 9 of the 12 skill-based competencies. Survey results showed that the majorities of medical students were not comfortable with basic breastfeeding medicine and guidance. Discussion: The authors recommend several curriculum changes to advance breastfeeding education. A more targeted breastfeeding curriculum in medical education will help to improve physician knowledge, practice patterns, and confidence in breastfeeding management.

Keywords: Breastfeeding, curriculum, educational intervention, medical student education/training

How to cite this article:
Gary AJ, Birmingham EE, Jones LB. Improving breastfeeding medicine in undergraduate medical education: A student survey and extensive curriculum review with suggestions for improvement. Educ Health 2017;30:163-8

How to cite this URL:
Gary AJ, Birmingham EE, Jones LB. Improving breastfeeding medicine in undergraduate medical education: A student survey and extensive curriculum review with suggestions for improvement. Educ Health [serial online] 2017 [cited 2022 Jan 23];30:163-8. Available from:

  Introduction Top

Breastfeeding has many demonstrated short- and long-term benefits for both mother and infant. The American Academy of Pediatrics, the World Health Organization (WHO), and the United Nations Children's Fund (UNICEF) have all recommend exclusive breastfeeding for the first 6 months of life with continuation up to 2 years or longer (unless medically contraindicated).[1],[2] Despite strong evidence supporting exclusive breastfeeding of infants, lack of physician education has continued to undermine the practice of breastfeeding.[3] This lack of breastfeeding not only affects the health outcomes of infants and mothers but also increases health care spending.[4] Protecting and supporting breastfeeding has the potential to save billions of dollars in health care and also provides the most benefit to the newborn infant. One study estimated that if breastfeeding goals had been met by the year 2010, there was the potential to save up to 3.6 billion dollars due to cost savings from the treatment of otitis media, gastroenteritis, and necrotizing enterocolitis alone.[5]

Clinician attitudes toward, experience with, and promotion of breastfeeding drastically impact the frequency and duration of breastfeeding in their patients. Studies have shown that patients are much less likely to continue exclusive breastfeeding for 6 months if providers recommend formula supplementation of healthy infants or if physicians feel that their advice about breastfeeding to their patients is unimportant.[1],[6] Mothers should be provided with evidence-based information and education regarding the benefits and practice of breastfeeding, starting in the prenatal period and continuing postnatally.[4],[7]

Studies have shown that a breastfeeding curriculum in postgraduate education improves breastfeeding care (including knowledge, practice, and confidence in counseling patients).[3] Regardless of a clinician's specialty, he or she should have a baseline understanding of the importance of breastfeeding and promote breastfeeding as a basic component of preventive health care.

At present, much of what a medical student learns about breastfeeding medicine is highly dependent on specific patient's encounters and the expertise of attending physicians, rather than a formal breastfeeding education curriculum.[8] The Academy of Breastfeeding Medicine recommends that breastfeeding education should be “incorporated routinely into medical school curricula,” and recommends the following:

“At a basic level, all medical students, and therefore physicians, should understand the scientific evidence for breastfeeding as the gold standard of infant feeding, understand evidence-based clinical management of normal mothers and newborns, and understand the societal context of lactation to provide health care that supports breastfeeding initiation and maintenance and avoids creating barriers.[9]

The WHO and UNICEF issued a joint statement reporting that all health-care providers should understand the physiology of breastfeeding, the nutritional aspects of breast milk, the mechanics of breastfeeding, and the psychosocial influences that impact the success of exclusive breastfeeding.[10] In addition, the United States Breastfeeding Committee and the Academy of Breastfeeding Medicine have each published guidelines outlining the basic understanding of breastfeeding that all clinicians, regardless of medical specialty, should have. [Table 1] and [Table 2] summarize these recommendations, specifically for undergraduate medical education.[6],[9] They outline both knowledge-based and skill-based competencies that should be covered in medical school curricula [Table 1] and [Table 2].
Table 1: Twelve knowledge-based competencies in breastfeeding care for undergraduate medical education

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Table 2: Twelve skill-based competencies in breastfeeding care for undergraduate medical education

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This report includes how breastfeeding care is taught at the United States Liaison Committee on Medical Education (LCME) accredited undergraduate medical institution. The goal of this report was to improve breastfeeding education so that every graduate of this undergraduate medical institution, as well as other medical schools across the country, has a baseline level of knowledge regarding breastfeeding and can confidently counsel his or her future patients.

  Methods Top

The authors performed an in-depth curriculum review of all 4 years at the United States LCME accredited undergraduate medical institution. We compared course requirements and lecture content in all 1st–4th years' courses to the core competencies listed in [Table 1] and [Table 2]. In addition, we sent out an online survey to all 608 undergraduate medical students in March 2015 assessing their perception of how breastfeeding care is taught, as well as their comfort with basic breastfeeding topics. The survey comprised 15 questions that evaluated students' knowledge of breastfeeding, exposure to breastfeeding education, as well as their confidence in counseling about various breastfeeding topics.

  Results Top

Curriculum analysis

Review of the preclinical undergraduate medical curriculum revealed that while several of the core competencies [Table 1] and [Table 2] are touched on, very few are taught in-depth, and most are not taught at all. The bulk of breastfeeding-related topics is taught during the endocrinology and reproductive system course during the M2 year. Although this course includes several lectures with heavy emphasis on basic anatomy and physiology of the breast, it does not delve into any other breastfeeding-related topics.

Students in the 3rd-year pediatrics clerkship are exposed to various breastfeeding topics such as obtaining a breastfeeding history, recommending breastfeeding over formula feeding, and the appropriate timing for introducing solid foods. We found that this clerkship addresses knowledge-based competencies 6, 7, 9, 10, and 11 [Table 1] and skill-based competencies 1, 6, 7, 9, 10, 11, and 12 [Table 2].

Analysis of the obstetrics and gynecology clerkship revealed that while many clerkship objectives and lecture topics are related to pregnancy, very few of them specifically address breastfeeding topics. For example, although there are lectures about the physiology of pregnancy during this clerkship, a review of lecture content revealed that breastfeeding is not addressed.

There is a 4th year “Breastfeeding Medicine” elective offered to students which allows extensive exposure to breastfeeding, including shadowing international board certified lactation consultants and physicians, attending breastfeeding support groups, completing online breastfeeding modules, and presenting an in-depth breastfeeding topic of choice. This course addresses all of the 12 knowledge-based and skill-based competencies. However, only students who choose to take these courses benefit from the exposure to breastfeeding care. Therefore, most medical students receive instruction and education about breastfeeding only during the first 3 years of medical school.

Overall, our extensive curriculum review showed deficiencies in teaching breastfeeding medicine. Our analysis revealed that students in the preclinical years are learning 3 of the 12 knowledge-based competencies and 1 of the 12 skill-based competencies. All students in the M3 year learn 5 of the 12 knowledge-based competencies and 9 of the 12 skill-based competencies, primarily during the pediatrics clerkship.

Student survey results

A total of 137 students responded to the study, with 26 students (19%) from the 1st year class, 25 students (18.2%) from the 2nd year class, 26 students (19%) from the 3rd year class, and 60 students (43.8%) from the 4th year class (overall response rate of 22.5%).

Ninety-nine percent of respondents correctly answered that breastfeeding is the gold standard for infant feeding, and 93% of respondents correctly answered that most infants (even those with special health-care needs) can breastfeed. Overall, however, respondents indicated that they have not had adequate exposure to breastfeeding medicine and do not feel confident in their knowledge of the topic. Furthermore, 64% of students responded that they had not received any formal education about breastfeeding.

Most of the respondents indicated that they were lacking confidence in counseling patients about specific breastfeeding care topics. In response to the question “How confident do you feel about counseling a family about the benefits of breastfeeding?” on a scale of one to 10, one being “Not confident at all” and 10 being “Extremely confident,” 68% of all students reported a confidence level of 5 or less. Using the same scale, students were asked to report their confidence in counseling a family about the contraindications to breastfeeding; 80% reported a confidence level of 5 or less.

When asked about their comfort level with various breastfeeding topics and skills: 64% of students rated their comfort with the physiology of lactation as 5 or less; 91% rated their comfort with assessing infant latch as 5 or less; and 37% of 4th year respondents answered “Not comfortable at all” to this question. Finally, 85% of respondents rated their comfort level with counseling mothers about establishing/maintaining milk supply and discussing common breastfeeding problems as 5 or less, while 47% of 4th-year students rated comfort level as one or two.

  Discussion Top

Our results demonstrate that, in general, current students are not adequately prepared to counsel patients about breastfeeding. Importantly, the responses of the 4th-year students were very similar to those of the first-, second-, and third-year students, further indicating that confidence with breastfeeding topics is not increasing as training progresses.

During the 4 years of medical school, students should have ample opportunities to learn breastfeeding knowledge and skills. We suggest the following simple, but important, proposals for improving breastfeeding education in the undergraduate medical curriculum. [Table 3] provides an outline for the proposed breastfeeding medicine curriculum. This table includes lecture material that is currently taught, as well as suggestions for lecture material, course requirements, and supplemental material to be added to various courses [Table 3].
Table 3: Suggested breastfeeding medicine curriculum for undergraduate medical institutions

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Breastfeeding education in the preclinical years is lacking, and lectures devoted exclusively to the knowledge-based competencies of breastfeeding care [Table 1] should be added to the preclinical curriculum. These preclinical years are a time for medical students to develop a basic level of understanding of breastfeeding. In addition to the breastfeeding care topics that are already taught, we propose several additions to the preclinical (M1 and M2 years) curriculum including the infectious disease, endocrine and reproductive system, host defense, and behavioral medicine courses.

During the clinical years (M3 and M4), students should put into practice the knowledge they have acquired during the first 2 years as well as develop new, valuable skills related to breastfeeding medicine. Students have the most exposure to infants and mothers during the pediatrics and obstetrics and gynecology clerkships, therefore the authors recommend that the breastfeeding core competencies are taught and reiterated during these two rotations. Fourth-year electives teaching breastfeeding-related topics serve as supplemental material for students interested in solidifying their understanding of breastfeeding care.

Our recommendations would ensure that all 12 knowledge-based and all 12 skill-based breastfeeding care competencies are taught during the first 3 years of undergraduate medical education. Most of these recommendations could also be implemented at undergraduate medical institutions across the country. Creating a breastfeeding curriculum that spans across the first 3 years of medical school will ensure that each student, regardless of future discipline, will have a basic understanding of breastfeeding. As a result, we aim to graduate physicians who are knowledgeable, skilled, and prepared to counsel their future patients about breastfeeding.

This study is one of the first to evaluate medical students' confidence with breastfeeding medicine, as well as recommendations for a breastfeeding curriculum in medical schools. The limitations of the study are that the number of completing medical students was small, and the study was only inclusive of one medical school. It would be very informative to survey medical students at different institutions across the US with various breastfeeding curriculums to see if one curriculum has shown to be more effective than another. Further study recommendations would also be to resurvey students after implementation with the above-recommended curriculum.

  Conclusion Top

Despite strong evidence supporting exclusive breastfeeding of infants, lack of physician education has continued to undermine the practice of breastfeeding.[3] A more targeted breastfeeding curriculum in undergraduate medical education will improve knowledge, practice patterns, and confidence in breastfeeding management and will increase rates of exclusive breastfeeding in patients.


The authors wish to thank Creighton University School of Medicine Faculty and Students for their participation in this report.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Taveras EM, Li R, Grummer-Strawn L, Richardson M, Marshall R, Rêgo VH, et al. Mothers' and clinicians' perspectives on breastfeeding counseling during routine preventive visits. Pediatrics 2004;113:e405-11.  Back to cited text no. 1
Horta BL, Bahl R, Martines JC, Victoria CG. Evidence on the long-term effects of breastfeeding, systematic reviews and meta-analyses. Geneva: WHO; 2007. Available from: [Last accessed on 2015 Sep 15].  Back to cited text no. 2
Feldman-Winter L, Barone L, Milcarek B, Hunter K, Meek J, Morton J, et al. Residency curriculum improves breastfeeding care. Pediatrics 2010;126:289-97.  Back to cited text no. 3
United States Breastfeeding Committee. Core Competencies in Breastfeeding Care for All Health Professionals. Washington, DC: United States Breastfeeding Committee; 2009. Available from: [Last accessed on 2015 Sep 15].  Back to cited text no. 4
Weimer JP. Economic Benefits of Breastfeeding: A Review and Analysis. Food Assistance and Nutrition Research Report No. 33813. Washington, D.C: US Department of Agriculture; 2001.  Back to cited text no. 5
Taveras EM, Li R, Grummer-Strawn L, Richardson M, Marshall R, Rêgo VH, et al. Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics 2004;113:e283-90.  Back to cited text no. 6
World Health Organization. Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva: WHO; 2009. Available from [Last accessed on 2015 Sep 15].  Back to cited text no. 7
Ogburn T, Espey E, Leeman L, Alvarez K. A breastfeeding curriculum for residents and medical students: A multidisciplinary approach. J Hum Lact 2005;21:458-64.  Back to cited text no. 8
Academy of Breastfeeding Medicine. Educational objectives and skills for the physician with respect to breastfeeding. Breastfeed Med 2011;6:99-105.  Back to cited text no. 9
World Health Organization, UNICEF. Protecting, Promoting, and Supporting Breastfeeding: The Special Role of Maternity Services. Geneva: WHO/UNICEF; 1989. Available from: [Last accessed on 2015 Sep 15].  Back to cited text no. 10


  [Table 1], [Table 2], [Table 3]

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