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There’s no money to study breastfeeding or provide care. There are packs of angry influencers and others on social media ready to vilify anyone who addresses it in clinical terms. Perhaps most dispiriting of all is that breastfeeding is so misunderstood in the medical community; problems encountered during breastfeeding are too often misdiagnosed and mistreated.

That’s according to a group of mostly female experts who, despite these obstacles — and also because of them — are persisting in their quest to further a novel lactation subspecialty in women’s health, offering physicians board certification.

Defining the Who and What of Lactation Medicine

“Essentially, we cover the care and management of lactation and breastfeeding, including any lactating parents/mothers and/or their children,” Casey Rosen-Carole, MD, said in an interview. “This means we diagnose and treat lactation difficulties.”

Rosen-Carole oversees two breastfeeding medicine fellowships, one in-person and another online, at the University of Rochester in Rochester, New York, the only academic center to offer a board-certified lactation medicine fellowship program.

There is no “typical” clinical practice in lactation medicine, although the most typical profile of a physician who also offers lactation medicine is that of a pediatrician or a family medicine practitioner. Those in the field cut across a few specialties and often have other subspecialties.

Katrina Mitchell, MD, for example, is a breast surgeon who also specializes in lactation medicine. “My clinic is totally atypical,” she said in an interview about her surgery clinic with a lactation medicine consultancy attached. “Breast surgeons normally would have a clinic that is all about cancer. I see everything, including other benign breast diseases.”

Mitchell, who trained at MD Anderson in Houston, co-wrote the American Society of Breast Surgeons’ guide to “oncolactation,” a term she said she originated. “Breast surgeons especially don’t have any education in lactation in their fellowship or specialty training,” she said.

It’s not uncommon for a physician to obtain lactation expertise at a teaching hospital and then leave academia to start their own clinic to meet demand for lactation services, according to one specialist who did just that.

“I wouldn’t say that everybody has left academic medicine, but many have gone out and created private clinics because that’s harder to do in academic centers where there is not so much emphasis on women’s health,” Cindy Rubin, MD, a pediatrician and lactation consultant in Westchester, Illinois, said in an interview.

Rubin founded the Loyola Center for Breastfeeding at the Loyola University Medical Center in Chicago before leaving to start her own private practice, although she still teaches breastfeeding medicine at Loyola as an adjunct professor.

“Now we’re going in the other direction, trying to build more academic centers so there is more research,” Rubin said.

Movement Gains Momentum

The movement to standardize the field goes back to 1990, when family medicine physician Anne Eglash, MD, had her first child. “I put my baby to the breast, but I realized that I hadn’t had any education about it,” she said. “I wanted to know why more doctors weren’t involved in it.”

Eglash, now a clinical professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin, trained after her epiphany to become a lactation consultant and began to research the history of breastfeeding.

She learned about La Leche League’s role in the 1950s of reclaiming breastfeeding in the United States after the Industrial Age. Succeeding generations saw women largely abandoning it, primarily due to the pressures of work and exacerbated by a corporate campaign to assert formula’s superiority over breast milk.

“Pediatricians were learning their nutrition from [formula makers], and they started to understand that they knew what was in formula, but they didn’t know what was in breast milk,” Eglash said.

La Leche League had been instrumental in helping standardize lactation consulting beginning in the 1980s when consultants began needing to pass an exam to earn a consulting credential. This support for breastfeeding women only went so far, however.

“Lactation consulting is counseling; I recognized that right away. I thought, we need to bring this into the field of medicine because these women deserve diagnosis and treatment,” Eglash said. “Lactation consultants cannot practice medicine.”

This led Eglash and a handful of others across relevant specialties — including the late John Queenan, MD, a luminary of maternal-fetal medicine and the deputy editor of Obstetrics & Gynecology (The Green Journal) — to found the Academy of Breastfeeding Medicine in 1995. Although they sought to define a scope of practice and leadership in lactation medicine, over time, Eglash realized there was still a gap.

“We were not going to get physician specialists in the field unless they got physician-level training,” Eglash said.

Physician-Level Expertise

So Eglash founded the Institute for the Advancement of Breastfeeding and Lactation Education in 2014 and was instrumental in founding the North American Board of Breastfeeding and Lactation Medicine (NABBLM), which began offering board certification in late 2023.

There are currently 166 board-certified lactation medicine specialists in the United States, according to Karen Bodnar, MD, a pediatric hospitalist and head of Lactation Medicine at Inova, a health system in metro Washington, DC. She is also a co-founder and president of NABBLM.

Meanwhile, also in 2014, Rosen-Carole was the first fellow to enter the University of Rochester’s breastfeeding medicine fellowship, founded by neonatologist Ruth Lawrence, MD, author of “Breastfeeding: A Guide for the Medical Profession,” now in its ninth run.

Lawrence is largely considered the “mother” of the medical field of lactation, thanks to her efforts beginning in the late 1950s to help the medical community understand and normalize breastfeeding at a time when it was mostly stigmatized.

As Lawrence’s successor, Rosen-Carole seeks to expand the program. She said that although she has had only two fellows in person, the online fellowship program — which is aimed primarily at post-residency physicians — has graduated 11 fellows to date, currently has 12 enrolled, and already has seven more students enrolled for next year.

“The largest obstacle for the in-person fellowship is recruitment,” Rosen-Carole said. “Fellows in medical training have lower salaries, and at the end they are not graduating into a field with a strong hiring track.”

No Money, No Mission

The lack of money for breastfeeding specialists is a legacy of the formula industry, according to all experts interviewed for this story. Formula makers’ dominance over infant nutrition began as more women went to work in factories by the end of the 1800s and into the 20th century. Working mothers fed their babies unpasteurized cows’ milk, which brought on diarrhea and eventually killed many of them, according to Eglash. Formula was developed as a safer alternative to diluted cows’ milk.

“There were public health efforts to try and increase breastfeeding, but this came at a time when there were doctors specializing in the new field of pediatrics, who were taking away the care of infants from the midwives who understood the importance of breastfeeding,” Eglash said.

The public health efforts failed, according to Eglash, as pediatricians began to rely upon formula makers for their understanding of nutrition. When the medical community saw formula’s effectiveness at preventing infant starvation, they lost interest in breastfeeding and even described it as passé.

“There was skepticism about breast milk, and then there was this [idea] about how American women had evolved out of their ability to make sufficient breast milk,” Eglash said.

Today, although interest in lactation medicine continues to grow and breastfeeding rates have slowly been trending upward over the past century, the legacy of corporate dominance over infant nutrition has been hard to break.

“The majority of our information about breastfeeding actually comes from the dairy industry right now. There is very little human research,” Rubin said. “It’s about ‘how do we prevent our cows from getting mastitis?’”

“There’s money and lobbying for studying formula, but there is no money for breastfeeding your kids,” Rachel Watson, International Board Certified Lactation Consultant (IBCLC), a private lactation consultant in London, England, said in an interview. “And that’s why so many doctors have no idea about it.”

Social Media Mash-Ups

Watson was a medical librarian until she could not find the support she needed while breastfeeding; then she became a lactation expert herself.

Watson took a 1000-hour credentialing route available to nonmedical personnel through the IBCLC Commission, a spin-off of the credentialing organization founded by La Leche League in the 80s. After working alongside Rachel Yang, MD, a breast surgeon and lactation consultant in greater San Francisco, Watson decided to open her own practice in her native United Kingdom.

Despite her lack of medical credentials, Watson is a proponent of strict standards for lactation consultants and worries about the raft of misinformation women find online due to a lack of widely available evidence-based knowledge in the field.

“Where do mums turn? They go to social media, where if you do a quick search on mastitis, you will get completely wrong information,” she said.

In addition to potentially harmful counsel, Watson said that going online also exposes one to the pressure to adopt unnecessary behaviors such as producing freezers full of breast milk. “There are all these ads for breast pumps. They create this sense of need, like, of course, mums have to pump,” she said.

Pumping is not truly necessary much of the time in the United Kingdom, according to Watson, citing how mothers in the United Kingdom who breastfeed during their year-long maternity leave typically do not pump because they are not separated from their baby. In the United States, however, pumping is part of the culture, since maternity leave in the United States is typically only 8 weeks, making storing extra breast milk a necessity, if it doesn’t dissuade the mother from pumping at all, she said.

Correcting misinformation can lead to personal online attacks, however, making true medical experts unwilling to wade into the fray, the experts interviewed for this story acknowledged.

Mitchell recalls in a forthcoming book about breastfeeding, to be published in August by Simon & Schuster, how strange some online advice can be.

“The breast is a very metabolic organ; if you get red or have a fever, put ice on it to relieve the pain,” said Mitchell.

Meanwhile, she writes in the book that a patient reported to her that she’d been given the exact opposite advice and was told to treat her swollen and painful breasts with “Crock-pots of scalding washcloths and heating pads on high.”

Some of her patients, Mitchell said, have ended up with site trauma and other wounds from following online advice. “It’s just nuts,” Mitchell said in the interview. “There is no medical evidence for any of this.”

Other bad online advice Mitchell cited to Medscape Medical News included breast gymnastics (massage), rubbing nipples with bacon, and walking around naked to air out the breasts.

‘Do Doctors Even Know What the Breast Is for?’

Lack of medical understanding is not limited to online forums. Doctors are also ignorant about the anatomy and mechanics of the breast, thanks to over a century’s worth of wrong or no teaching about the breast, according to Watson.

“Let’s say you sprain your ankle. It goes red and swells, and you’re all chilly and sort of feverish. You elevate it. No one will give you an antibiotic for it,” she said. “But that is what happens all the time with breasts. It blows my mind how many doctors do not have a basic understanding of the breast as an organ, with its function being to lactate. If they don’t know that, then what do they think a breast is for? This is why we need this medical specialization.”

Bodnar said one of the most important basic tenets of lactation medicine is that it teaches there is a patient dyad, not just one patient. She said that often, patients come to her with breastfeeding issues after another physician’s advice has failed.

In some cases, “there was no assessment made of whether the baby empties milk well,” Bodnar said. “Or, does the pump empty milk well? Very often, one or both is doing a crummy job, but if you don’t assess and diagnose, you can’t make a plan that will help make things better.”

Lactation education can also help with prevention, according to Mitchell.

A common complaint in breastfeeding is abscesses, “but these are 100% preventable,” Mitchell said. “I’ve never had one of my patients who’s under my care from the beginning have an abscess because I am telling them that if they get engorged or they get red and if they have a fever, just put a lot of ice on your breast. And I can take care of the complications.”

Rubin says she is optimistic that now the tide is turning in lactation and breastfeeding specialists’ favor. “There are people who are trying to create academic departments, and there is starting to be a demand for it in hospitals,” she said. “I think we’re going to have a lot more patient access to physicians who are knowledgeable about breastfeeding in the next 10 years,” she said.

All experts interviewed for this story reported no disclosures.