For new physician parents, navigating the care of a young child and the return to work can be challenging. For physicians in training or early in their careers, providing breastmilk and maintaining an adequate breastmilk supply can be difficult to balance with clinical demands. Busy clinic schedules, long days in the operating room, and limited control over your own schedule can make breastfeeding seem logistically impossible. After obtaining exempt IRB approval, an anonymous Qualtrics survey link was sent to a well-known online physician group — PMG (Physician Mom's Group on Facebook) and to several listservs of physicians in an effort to solicit input from physician-mothers. As part of the survey, we specifically asked these physician moms for practical advice and "life hacks" to pass along to new physician parents. Much of their advice centered around the challenges of breastfeeding and pumping. 897 women participated in the survey and 650 offered advice for new moms. Below is a summary of the advice they had to pass along.

1. Fed is best

The current recommended duration of exclusive breastfeeding by AAP is "about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer." Of the participants in our survey who had a child while in training, 23% reported breastfeeding or pumping for 6–12 months and 26% reported breastfeeding or pumping for 12 months. This is lower than national breastfeeding rates as observed in the National Immunization Survey by the CDC from 2015 in which 24.9% of U.S. mothers reported breastfeeding exclusively for 6 months and 35.9% reported continued breastfeeding at 12 months.

This is not entirely surprising given the findings of a recent study in JAMA Internal Medicine by Melnitchouk et. al that demonstrated the significant barriers to continued breastfeeding for physician-mothers. With our current societal pressures on breastfeeding, it is easy to feel like you have failed your child if you are unable to produce sufficient breastmilk. One mom eloquently states "the pressure to breastfeed when you are unable can be very isolating." The onus is on physicians to educate regarding breastfeeding recommendations and benefits but also remain supportive of all moms and their feeding choices.

2. Invest in a good breast pump — Consider buying an extra one to leave at work

If you plan on pumping for a long period of time, you will spend many, many hours with your pump; survey respondents had lots of suggestions for reducing the stress related to pumping at work. Having a pump that is efficient and functions well is critical. To find the best pump check out Amazon reviews or Consumer Reports for comparisons. If you have access to a hospital grade pump, these are more efficient and typically pump more milk in a session than a portable electric pump; this could be for the office or at home. If you don't have a hospital grade pump, consider buying an extra portable pump to leave in the car or at work so you cart around fewer supplies. Rechargeable battery powered pumps allow you to pump whenever and wherever you need, including in the car. Additionally, many women find that having an extra set of pump parts is convenient when there is limited time for sanitizing parts and they function as a safety measure if a pump part were to break or malfunction.

Some physicians mastered the skill of hand-expressing breast milk and found it faster and easier, as you don't need to rely on equipment. Below are links to resources on hand expression:

Hand Expression

"Hand expression is a useful skill for any nursing mother. It can relieve breast fullness, stimulate milk production" via breastfeedingusa.org. Click here for a video about hand expression.

3. Negotiate for pumping breaks with your boss

Blocking out time to pump in clinic can decrease stress and can pay for itself in the long run. If you need to, remind your employer that breastfeeding has many known benefits for both mom and baby, including decreased infections for children, meaning fewer days of sick leave for you. In addition to negotiating breaks in your clinic schedule, ensure you have a private space to pump. As shown by Melnitchouk et al. having an accommodating schedule and dedicated space to pump results in more mother's reaching their breastfeeding goal. Furthermore, providing "reasonable break time" and a private non-bathroom space for lactating mothers is mandated by The Patient Protection and Affordable Care Act of 2010. Know your rights and demand better conditions for the workplace.

4. Supplies for pumping can make it less of a struggle

Many moms recommended Freemies and hands-free pumping bras to allow you to do other things while pumping (i.e. eat a snack and look at pictures of your baby or alternatively, write clinic notes). Participants also recommended having extra pump parts — this will reduce the number of things to be cleaned each day and keeping an extra set at work will come in handy if you forget parts at home or if a part were to break. One mom recommended pumping into sterile urine cups if you forget supplies at home. Using a specially designed pump part bag, 'A Pumparoo', with wet and dry compartments, makes transporting and storing parts in community refrigerators more efficient and less messy. Some physician moms reported creating a community stash of pump parts at the hospital in case one of them forgot parts at home. 

5. Understand the basics of breastmilk storage

Breastmilk can be stored for up to 5–8 days in the refrigerator, and 6–12 months in the freezer. See below for storage recommendations from the Academy of Breastfeeding Medicine. 

See table below for storage recommendations from the Academy of Breastfeeding Medicine. Link to full article is here.

It is recommended that fresh milk is used first. Breastmilk should be heated slowly in a water bath to avoid overheating. Breast milk warmers are easy to find online and are incredibly useful. Frozen milk should be used within 24 hours of thaw and should not be left at room temperature for more than 2 hours. Additionally, fresh milk should not be added to previously refrigerated milk to avoid rewarming. One useful tip is to refrigerate breast pump parts between pumping sessions, this way you don't have to bring multiple sets of pump parts or clean the parts between pumping sessions. Throughout the course of the day and week this can save a lot of time. The CDC has very detailed instructions on cleaning pump parts: 

How to Keep Your Breast Pump Kit Clean: The Essentials
"Providing breast milk is one of the best things you can do for your baby's health and development." via www.cdc.gov

6. Hydrate and bring snacks to help maintain a healthy breastmilk supply

Making breastmilk burns an incredible number of calories (approximately 20 calories/ounce of milk), and provides a variety of health benefits for the postpartum mom such as decreased lifetime ovarian and breast cancer risk. To generate milk, adequate caloric and fluid intake is needed. There are many recommendations about foods and beverages that can increase breastmilk supply. Some of those foods include oatmeal, spinach, garlic, fenugreek, brewer's yeast, and papaya. Evidence about the efficacy of each of these foods varies, but healthy snacks and adequate hydration is key. Mother's milk tea contains fenugreek which has an association with increasing supply. For those who take fenugreek supplements beware — it can make you smell like maple syrup. 

7. Understand the logistics of building a breastmilk supply and challenges that can come with bottle-feeding

Starting to pump a few weeks before you return to work can help to build up an adequate supply. Pumping only prior to breastfeeding your baby will lead to a supply of mainly foremilk (less fatty, bluish color), while pumping at the end of feedings will lead to having more hindmilk (more fatty, yellow/creamy color). As the breast is emptied, the milk will have a higher fat content (hindmilk). Having a mix of pumped milk from pumping sessions before and after feedings will lead to a similar composition of milk that your child gets while nursing. For moms struggling with clogged milk ducts, adding lecithin supplements (3600mg-4800mg per day) can decrease occurrence and can be used as needed.

Practice giving a bottle before the first day you return to work as some newborns struggle with a bottle the first few times they try. Having a caregiver other than the mom give the bottle can help the infant successfully take a bottle. Additionally, holding the baby using a piece of clothing that has mom's scent may also help the baby accept the bottle. There are numerous bottle and nipple combinations. Some babies will have a preference, so it can lead to a period of trial and error to figure out what works. Different nipples have different flow rates gauged to your child's age, with a faster flow for older infants.

8. Be kind to yourself

Breastfeeding can be very challenging, especially in the early days. For many women, it is difficult to establish a breastmilk supply and it is very common for infants to struggle with latching. Stress from breastfeeding can be a source of depression and anxiety. However, there is also an association with exclusive breastfeeding and decreased rates of postpartum depression. Physicians have often found themselves successful in most things in life and when faced with the challenge of breastfeeding, they can feel like a failure. Accepting imperfection is definitely part of parenthood. For many moms in our survey, once they ceased breastfeeding and pumping their schedule became less stressful.

9. Find other physician parents that are facing similar struggles

Dr. Milk and PMG (Physician Moms Group) on Facebook offer support and can be a resource if you have questions. Parents who work at your institution can also provide resources — information about lactation rooms, lactation consultants or work policies around pumping. Finding a physician-parent mentor to guide you through this experience can be invaluable. They can serve as both a guide and advocate for you. You can pay it forward in the future to pass along advice once you accumulate it. Finding or creating a community of support is key for new parents.

Bev Gray is an obstetrician-gynecologist and Residency Program Director at Duke University Medical Center. Follow her on twitter @DrBevGray. Rebecca Meekins is an FPMRS Fellow at Duke and Allison Puechl is a Gynecologic Oncology Fellow at Duke. Follow her on twitter at @AlliePuechl. Sarah Dotters-Katz is an assistant professor in Maternal-Fetal Medicine at Duke. All are physician moms of young children and have spent significant time with their pumps. The authors have no conflicts of interest.