Breast health with Dr Justice Reilly

If you are breastfeeding, your breasts are going to be central to your success! Changes in breast health, from nipple damage and infection to breast cancer, can impact heavily your breastfeeding journey. In the most extreme cases, they can force a breastfeeding parent to stop nursing before they are ready.

In this episode, I’m joined by Dr Justice Reilly, an IBCLC, medical doctor and expert in all things breast health. We talk about breast cancer screening and treatment while lactating, abscesses and other breast health concerns, and how to look after your breasts during nursing and beyond.

My new book, ‘Supporting the Transition from Breastfeeding: a Guide to Weaning for Professionals, Supporters and Parents’, is out now.

You can get 10% off the book at the Jessica Kingsley press website, that's uk.jkp.com using the code MMPE10 at checkout.

Follow me on Twitter @MakesMilk and on Instagram  @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com

Find out more about Dr Justice at her website https://breastmed.co.uk/ and @breastmed on instagram

Resources mentioned - 

Breast imaging recommendation in pregnant and lactating women - RAD Magazine Article by Justice and Sau Lee Chang https://www.radmagazine.com/scientific-article/breast-imaging-recommendation-in-pregnant-and-lactating-women/

Breastfeeding course for medical students (unfortunately no longer free): https://www.futurelearn.com/courses/an-introduction-to-breast-feeding-for-medical-students

Amma Birth Companions https://ammabirthcompanions.org/

Mummy's Star Charity https://www.mummysstar.org/

Spectrum (spectrumlactation.org) and @spectrumlactation on instagram

Katrina Mitchell’s website https://physicianguidetobreastfeeding.org/

ABM Clinical Protocol #34: Breast Cancer and Breastfeeding https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/Protocol%20%2334%20-%20English%20Translation.pdf

Breastfeeding for Doctors https://breastfeedingfordoctors.org/

This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.

Transcript

Hi. I'm Emma Pickett, and I'm a lactation consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time, because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end. And I'm big on making sure parents get support at the end to join me for conversations on how breastfeeding is amazing. And also, sometimes really, really hard. We'll look honestly and openly about that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk.

Emma Pickett  00:46

Today, I'm very excited to be joined by Dr. Justice Reilly. She is one of the very few doctors in the UK who was also a board certified lactation consultant. So she has a background as a breastfeeding counsellor and a breastfeeding support volunteer. But she's also a medical doctor who specialises in breast health based in Glasgow so you can see why I would want to talk to her today because she's sort of the dream combination of a variety of skills that we really, really need to hear more about. We've recently been working together on a project called spectrum lactation. You can find out more about spectrum on Instagram and on our website. And I'll put those links in the show notes and we will talk a little bit about spectrum lactation today. But first of all, I'm going to pick justices brains on the subject of lactation and breast health. If she doesn't mind me using an expression like pick your brains, maybe I shouldn't use an expression like that to a medical doctor because you immediately think of surgery and literally picking brains. Thanks very much for joining me today justice.

Dr Justice Reilly  01:44

It's really a pleasure to be invited. 

Emma Pickett  01:47

I'm not going to say something cheesy, but I do love your accent. Oh, say something cheesy. I'm allowed to say that because I'm half Scottish. My dad is Scottish. So I'm allowed to say that without sounding completely patronising. tastic crazy from so originally from Stirling, Stirling and then Aberfeldie and Stirling.

Dr Justice Reilly  02:05

Oh, great. Have you been up to like Loch Tay and that kind of Trossachs area?

Emma Pickett  02:10

I have. Yeah, unfortunately, he's not there right now. He actually moved to France. So he's a traitor to the Scottish cause. But you know, for most of my life that was it was trips up to Scotland and spending time with them in Scotland and visiting my granny and Sterling. I don't know if you noticed, we've just lost half our listeners. So my granny my granny lived just right at the base of the castle. So you know Stirling castles on this big cliff she was she was a you could literally chuck a paper doll from the castle down to her house at the bottom of the castle. So I have a very soft spot for Stirling.

Dr Justice Reilly  02:40

Yeah. I grew up not far from there at all. So that was like the big smoke for me, Stirling. And so yeah, good memories. 

Emma Pickett  02:49

Cool. Right. So the three people who are still listening, thanks for sticking with us who don't care about Scotland. We're going to talk about breast health and breastfeeding. Can I ask a little bit about your professional journey? Were you always focused on lactation? Or did you start your career as a doctor? Without that necessarily being at the front of your mind? What's the sort of order that your interests developed?

Dr Justice Reilly  03:13

No, not really interested in breastfeeding at all. I mean, I think I've always been interested in child health and women's health. But that was very much in the background. I wanted to be an end surgeon when I was at uni, and then worked for four years had our first baby. And this was 10 years ago. So I'm not saying Facebook groups, and Instagram didn't exist, but I just wasn't really aware of that. Plus, we were relatively young. And I think among our peer group, when we had our eldest, so we were 27. So we didn't really have a point of reference, we weren't really, we didn't have friends around us who'd had babies who were telling us to do it this way, or that we're, our families don't live nearby. So it was really just us kind of muddling through and finding out what worked, because I'd been to Glasgow uni for medical school. And I didn't appreciate this at the time, but they do have a very strong public health focus. Because historically, it's an area of huge inequality. And in some areas, huge deprivation. And we had a focus block actually on breastfeeding, not just the importance of human milk, but things like who caused compliance. We had a lab session where we were invited to taste formula. There was more of an appreciation, I think of the political landscape, and it's something that I didn't probably take in at the time, but really, around the time I was having my eldest, it did kind of come back into into my mind. And I think for my husband, he was just always, he's not medical, but for him. He's He's very sporty. He's very nutrition and health focused and had grown up. He's 10 years older than his brother. So have you seen Brett? So eating and for him, it was the normal way to feed a child, which, obviously no, knowing what we do as lactation consultants about the kind of psychosocial aspects of breastfeeding was a huge advantage to us. And we did have a lot of challenges. But again, it was just us kind of working towards breastfeeding, because we both had a strong appreciation for it. And it worked really well. And when I went back to work, I think that's when I was starting to really question my clinical practice, because I was seeing babies who were coming in with, you know, chronic ear infections, or needing grommets or their tonsils and adenoids taken out. And it wasn't until that point that I really questioned the causes and the associations to that. So beyond having to answer questions in an exam, you know, you have to kind of have an appreciation of what the causes are. But it really solidified for me that actually, breastfeeding wasn't something that was just nice for me and my family, it was something with huge kind of public health and social inequality, consequences and repercussions and that weren't being addressed. So I think it was actually only when I returned to work that I started feeling quite passionate about it. And also because I recognise the real and systemic barriers to me continuing to breastfeed, and to my colleagues continuing to breastfeed, you know, by that point, I was very aware of the fact that we were supposed to, ideally, breastfeed or give your milk to baby for the first two years of life. And that really doesn't seem to be supported by society in general, when people are going back to work much earlier than that. And the expectation is that you just get thrown into the water, you're doing night shift, you're doing a long, long day separated from your baby. And yes, maybe you can find a toilet or a cupboard to express but there wasn't this policy in place necessarily. So it did, it made me personally very passionate about it. And it was only when I had my second child that I then became aware of breastfeeding for doctors, they only just kind of formed at that point. I know you've had Vicki Thomas on speaking as well. So she was one of the founding members along with Robin Powell and Sophia Reynolds and Natalie Shankar, Gabrielle colour and in Ireland. And it was really nice, just being in that online peer support Facebook group, but also recognising, I'm not the only person seeing this. I'm not the only person thinking the world is mad that we're not supporting something. So key to health. And in many ways, we're actively working against women and families who want to breastfeed. So that was really a galvanising point for me. At the same time that I had my second baby, I was also training to be a little ECI lead leader. Because that charity, you know, along with all the other major breastfeeding charities are really picking up the slack, I think, from the support that's needed in our culture in our society in the UK. So I felt like I had some knowledge and some expertise to give. And it wasn't something I felt like I could use as a doctor, if that makes sense. So it was a really nice outlet for me. It still is,

Emma Pickett  08:20

Breastfeeding for Doctors seems to be a very special organisation doesn't I mean, the work that you're doing is so powerful. I mean, not only are you supporting individual doctors to reach their breastfeeding goals, which has a massive ripple effect, but you're also you know, joining the dots and then helping to make a change on a societal level. I mean, it's, it's such a valuable organisation. So thank you for being part of it. And thank you very much to Vicki and Robin and Sophia, and all the founding. Just incredibly useful. What you're saying about your medical school is interesting. So you sounded like you did more Glasgow than most doctors I've spoken to in the UK. I mean, that sounds like it's a pretty unusual programme. If you're already talking about, you know, industry and conflict of interest and formed, is that still carrying on in Glasgow today is that is the Glasgow public health angle and the breastfeeding angle still strong

Dr Justice Reilly  09:07

It is actually I was at the European Academy of breastfeeding medicine conference in Croatia, and the lead clinician is actually professor of Paediatrics is still pushing forward that course, obviously, during the times of COVID, parts of it had to go online, but it's still developing. And Glasgow uni also developed a UNICEF accredited sort of a short course for medical students, but it's available online to anyone. 

Emma Pickett  09:37

Wow, that's, that's great. Let's put that link in the show notes for sure. Because lots of doctors would be desperate for that. 

Dr Justice Reilly  09:42

Yeah. And it's just again, just your luck, isn't it that that that was something that hugely shaped me and I didn't realise it at the time. But to know that, again, there's this this wider aspect or at least wider implications to it. I mean, I think before I even became a breastfeeding advocate, I was an advocate of the the Nestle boycott because of that. So, yeah, it was massively influential. And it's funny where, you know, these chats and counters can take you some time.

Emma Pickett  10:09

But yet, when you went back to work, as a doctor, you you were really struggling to maintain your lactation where your barriers were you facing? 

Dr Justice Reilly  10:17

Well, I mean, don't get me wrong, I had a hugely supportive team, I went back to the team that I'd been pregnant with. And so there wasn't that same barrier of, you know, you having to earn your colleagues trust and, you know, even learn their names or the computer passwords and things like that. I think the barrier was just that they didn't have many trainees who had breastfed, they had plenty of female trainees. But I think maybe the ones that had gone back maybe had stopped breastfeeding in preparation for return to work. And I think perhaps it was a little bit naive. But yeah, I hadn't really made any inroads into that, because she was still feeding day and night. And actually, we really enjoyed it. So my thought process was, I can go back to work, the feeds that she's that she's missing, you know, I knew she would be fine with her dad and getting cuddles overnight. But I would just express, you know, for the missed feeds. The reality was that I think I didn't feel empowered enough to say to my colleagues, I need to step away, I need you to hold the bleep, I need to go and express some milk in a toilet, even if I wasn't having to store that milk and take it home, you know, for my own comfort and to maintain lactation. So what ultimately happened was I did a run of nights. And I basically tanked my supply I did four nights in a row. And coming back together over the weekend, she was furious, and she was breastfeeding lots and my supply came back up. I think because it had been so robust, because we'd fed for over, you know, over the year. But when I also went back to work, it coincided with her teething, she was quite late to get her first teeth through, then, of course, at 13 months, they get through the MMR vaccine. So again, she, that that also impacted how frequently she wanted to feed. So she brought my supply back. But there was this huge mood shift as well, that came with, you know, having no milk one week, and then a fuel supply again the next week. So that was a bit of a learning curve as well as just to actually maybe needed to be a little bit more protective of it. And again, I don't want to bash my colleagues, because plenty of them had said to me, Oh, I breastfed my child until they were 18 months. And it was it's the proudest thing I'd ever done. Or, you know, it's it's so nice to see that, that you've really enjoyed being at home with your baby. And they were very positive about the fact that had a child. I think part of it was maybe me internalising those surgical kind of cliches of you just keep going and you. You don't, you don't you don't see anything. And you just you know, the priority is the patient and the system. So maybe it was it was me because I do remember being hugely uncomfortable at the operating table leaking into my breast pads. And maybe there was superfluous you know, there plenty of trainees like happy to scrub in, but I just didn't feel comfortable. I didn't feel like I could see, I need to step away. Which, you know, if it was my daughter telling me this are my friends, I would obviously help them advocate for themselves in any way. And I think that's maybe why I've been so delighted with the work that breastfeeding for doctors are doing and even the work that the big breastfeeding charities are doing, because they do help people navigate that I think it just at a time not to say that that information wasn't available, but I just wasn't aware of it. 

Emma Pickett  14:00

Yeah. And what you're saying about that, that barrier being internal, I think is really interesting. There are I think that's so common for lots of women, even if you've got that friendly person two desks away in your office who says oh, yeah, breastfeeding is great. To get through all the sort of cultural noise. They're all the stuff you've internalised for so long to actually say Hang on, I do have to step out of this meeting, I you know, I do have to step away from this operating theatre. That's an extra extra hurdle, an extra thing that feels scary, it's and for you who have you know, obviously you're so articulate so educated in in this environment. The fact that even you couldn't do that is really demonstrates how much work we've got to do to make sure that people feel safe to do that. And, and, and that probably means explicit policies and explicit training. And, you know, it's got to be more than just relying on kindness and bravery. We can't rely on the bravery of the lactating parent to make this stuff work. So you were a presumably when you're on the operating theatre, that's adenoids and tonsils and all part of the NT work and you've now I moved away from EMT stuff. And you're now describing yourself as a breast health doctor or breast Doctor, tell me about typical working week at the moment what's happening for you right now professionally.

Dr Justice Reilly  15:10

So the way I kind of stepped away was that I just find the whole kind of process of EMT training just super overwhelming. I think as well, a huge part of it was I fell out of love with it, it was kind of everything I want everything in anything I wanted to do. And then, actually, that conflict, which I think a lot of people feel when they have a baby at home, was just for me too much. So I actually stopped working for about 18 months, I had another child, and then got a job in breast screening. Around the same time I was, I've completed my love actually leak peer support training. So by that point, I was very much in women's health. And then, like yourself work towards that ibclc. So it was, it was a bit of a Yeah, for road less travelled, I think. But now, I think I've maybe got a better balance in that I'm always there for school pick up. And you know, I don't have to stress about the holidays, because I'm working independently, I still get to do my peer support and voluntary work, which is hugely important. Usually in a week, I'll have one clinic, I'll have one or two home visits. And then I'll have an afternoon, where I'll open virtual appointments. As you know yourself, you'll get emails that come in through the week that are probably best handled by someone else. And you know, I'm happy to provide information, I'm more than happy to provide information if it means that the get seen quicker or by a more appropriate person. But that takes up a wee bit of time as well. And then through the week, I'll either have a little bit to League meeting, or we'll have Scottish breastfeeding, collaborative meeting, European Academy of breastfeeding medicine, I'm on the kind of policy and information team for them. And we often have spectrum meetings kind of dotted around the place. I also do some teaching for AMA birth companions, which is a really great charity in Glasgow, and they support vulnerable people in pregnancy and that first year postpartum. So if you know if you imagine you're someone who is especially impacted by austerity, maybe you're not entitled to Universal Credit in this country, because you're not yet a citizen. So if you're an asylum seeking person, and money is very tight, and breastfeeding becomes very important for not just the health of the baby, but you know, your economic position as well. So I think that's, that's really nice work. And actually, just a shout out to them. I think I've learned so much more than I've given because in terms of cultural competency, equality and diversity training, everything I've learned in terms of supporting people who are not like EU has come from them, actually. And they have a very robust training programme. And I really wish that we had something simpler within the NHS that doesn't feel so much like a tick box, and is really kind of compassion driven, and driven by the needs of the service users. So I feel like I do lots of little things here and there. And but ya know, week, no week is the same. And I imagine it's the same for you as a lactation consultant.

Emma Pickett  18:29

You see, you do lots of little things. You see, you do lots of some very big things that really do help people's lives. And I, I have we sort of shared a mother that we were both talking to, at some point just before Christmas, I know what an impact you make it in some people's lives at the most difficult time of their lives. I mean, some people you work with had been treated for breast cancer or other breast health issues like an abscess, and it's, you know, it must be great for them to talk to someone who's a doctor and also a lactation specialist. That's just the magic combo. Do you mind if we just talk about some of the conditions that you might support a parent? So let's imagine somebody has an abscess? What's the sort of process that that they'll go through in the UK if they have a suspected abscess talk us through the sort of what they can expect in their treatment?

Dr Justice Reilly  19:15

Yeah, so if they have a breast abscess will usually be quite sick and it will usually present a septic so their heart rate will be fast, their temperature will be high, and they may not be eating or drinking plus, you know, looking for the source is usually quite clear. And if it's if it's breast sepsis, sometimes they'll if the phone 111 They'll go straight to a&e, if they go via their GP, they'll go straight to a&e. It really depends on that hospital whether there is a breast team and this is where things can get a wee bit dicey because sometimes people will be hanging around for a long time in a&e Or we'll have a general surgeon kind of prod at it with a needle Without an ultrasound without that kind of specialist breast radiologist present. And, you know, sometimes that is the thing that needs to be done, but it's really difficult without looking at the abscess with an ultrasound. And to know whether it's, it's, you know, a liquid thing that is ready to be drained or if it's a flagman, which is a kind of harder lump, which is very, very painful if you stick a needle into it. So I think different people have different experiences in Scotland, we can we tend to manage them quite well, I would say, in terms of how people are followed up. But the thing about an abscess is that it's an infection. It's a collection of pus that is walled off. So often, by sticking a needle in it and taking the pus out, there's still a bit of a cavity there. And it will tend to maybe fill up a wee bit more again. So we call that serial drainage when you know, they need to come back every two or three days and have have poor posture trained. And obviously, that can be really distressing. And getting out of the house when usually we have a young baby as well. And difficult to make appointments difficult to get anywhere for a certain amount of time. But when you're also dealing with things like hospital car parking, and, you know, do you bring your baby? Do you not bring your baby and that kind of uncertainty and you're feeling rubbish? It can make a lot of people just feel like what is this all about? Why is this? Why is this the norm kind of thing. But usually what will happen is that over the course of maybe three, four appointments, the amount of past that's drained is reduced. So it might go from 20 mils to 10 mils to five mils to a couple of mils and then we can leave it alone. For some people. If that abscess kind of comes to a head, we would say if if it's self discharges through the skin, and they might need more treatment under general anaesthetic and it might be more involved. But generally they're caught early because like I say, it's usually something that's quite obvious identify the source of sepsis. If anything, we're probably maybe too happy to prescribe antibiotics, when someone gets the first little niggle of a of a tender breast. There is evidence to say that actually, you know that conservative management in the first 24 or 40 hours is really important in not overdoing it, you know, we used to hear people would be getting their electric toothbrush out and really digging into the inflamed area. Or they'd be massaging it with a comb or their knuckles. We now know that actually trying to reduce the inflammation with things like cold packs, not touching it feeding responsibly, but not trying to overdo it. So again, if people have been pumping excessively and really driving that oversupply and hyper lactation that in itself can promote more inflammation in the breast. And I think it's sometimes tricky to manage, because we are adopting that kind of pumping culture. I feel like in the UK, from the US, yeah, it's a different set of circumstances, people usually have more than two weeks maternity leave in this country. But also, you know, people start expressing early for lots of reasons. And maybe they've had no no option but to. And I think the problem can sometimes be when they're presented with a pump early on, it's maybe not been fitted correctly, they've not been given a plan to then move to direct feeds, if that's what they want to do, then they can quite easily, you know, drive themselves into an oversupply, and that will increase the risk of mastitis and abscess. So a lot of the kind of treatment is actually in the history taking and working out what actually happens because although mastitis and abscesses are fairly common, you've probably all met someone who's breastfed that's had that happen to them. It's actually not normal, you know, ought not to happen. I kind of used this example of when I was doing a peer support breastfeeding support group with the AMA clientele and everyone in that, in that Zoom meeting was from kind of West African countries. So there were about 810 people. And we were talking about different breast problems or breastfeeding issues. And I'd mentioned the status and everyone kind of glazed at the screen. And I said, you know, you know, as a wrestler to get hot or hard or tender, and still no one had a clue what I was talking about. Because although although there were certain challenges that they were experiencing, the status wasn't one because they were all directly feeding. They were all responsively feeding. And I'm not to say everyone from those countries, you know, doesn't experience my status. But within that cohort, I thought it was really interesting that no one had even heard of it. So yeah, I think a lot of it is to do with how we manage lactation in the UK. 

Emma Pickett  24:59

Yeah, I do. Have you recognised that concept of over pumping? I think also these are one piece silicon pumps in inverted commas that people are using from birth and thinking, you know, you just pump the other breast automatically. Gosh, there's no people pumping from birth thinking that's what they're supposed to do to drive their supply. Yep. So you dip into hyper lactation, you dip into mastitis, you get an infection, you ended up with abscess not normal, as you say not not the state shouldn't be normal. But that is a pattern that I've definitely seen more mastitis, I think, in the last few years, and I did at the beginning of my experience as a lactation consultant, for sure. And that would fit with what you're saying about that, that pumping culture. So when somebody has an abscess in the UK, needle aspiration under ultrasound, is the norm, it seems to be that the in the US they're putting in drains and incisions and drains more commonly is that, is that my impression? Or do you see drains being fitted in the UK?

Dr Justice Reilly  25:47

we do but they tend to be inpatient drains, so maybe they've had that wind kind of washed out in theatre. And then they're still an inpatient on IV antibiotics and hospital. I know. Katrina Mitchell in California, who's a breast surgeon and also an ibclc, and has a wonderful amount of resources. on her website, she has written up for cases where the insert of flexible panels strain into the breast and obviously, it has to be angled in such a way that it will still be able to leak the fluid. But what that means is that you're changing the dressing within a bra, rather than that person coming back and forth so frequently, because the past the fluids will come out of the path of least resistance. So that's why if it's very tense, and there's not an exit route, it will rush through the skin. And some people if they're very superficial, or if they're very close to the nipple, they will experience pass through the nipple, because that for that area is the path of least resistance. So by putting in a soft, flexible dream, it can help, it can help the bus move out without having to serially pierce the skin put a needle limit. 

Emma Pickett  27:01

So ideally, somebody is continuing to breastfeed while they have an abscess. Is there ever a time when that's not recommended or not advisable or too challenging?

Dr Justice Reilly  27:10

I think I think there are definitely times where it's too challenging, you know, emotionally, pain wise, a lot of people will associate them choosing to breastfeed with them, though being in this situation of having an abscess. And they feel very trapped when they give and get the bit the information or the advice to actually continue to breastfeed because it's very good for the breast microbiome. And it's you don't want to then shut off lactation in a really abrupt way. Because then that will also increase inflammation, and encouragement. So it can it can be really conflicting. If someone really wants to continue, of course, there are ways that we can, we can support that. And sometimes that means breastfeeding from the affected breast. Sometimes that means actually weaning down the affected breast and breastfeeding from one breast you can talk about uniquely being there are plenty of people out there that that will breastfeed from one breast for a variety of reasons, and will make her feel supply from that one breast. So I think as long as someone knows what their options were, they can kind of make peace with their decision. And ultimately, it has to be their decision. They're the one that has to look after their baby. But I think where it's really challenging is where, you know, it'd be sitting in a little lychee League meeting, and someone will, will come in and they'll say, oh, yeah, I had to stop breastfeeding, because I had an abscess for weeks. And so I'm really interested in how to avoid that this time and then pregnant again. And then someone else will be in that meeting saying, All right, well, you know, I just got support to do X Y Zed. And that is what's really challenging when that kind of when their belief system is shattered. And they realise that actually, they did have other options. And the breastfeeding was maybe sabotaged by poor health care, professional advice or wider pressure, I think to stop when actually they would have liked to have continued, 

Emma Pickett  29:04

yeah, that I got I just suddenly had a moment of recognition there. There is nothing sadder than the face of a parent who's rewriting their history in their brain as they realise that the person that told them to stop because they had thrush, the person that told them to stop because they had to take this particular medication, didn't necessarily have the right information and they'd come to peace with the end of their previous breastfeeding journey because they felt it was out of their hands. And when they realised they were given false information and that word sabotage, I think it's valid if you can just see them crumbling in that moment. That's incredibly tough for everybody. 

Emma Pickett  29:38

A little advert just to say that you can buy my four books online. You've Got It In You, a positive guide to breastfeeding is 99p as an e book, and that's aimed at expectant and new parents. The Breast Book published by Pinter Martin is a guide for nine to 14 year olds, and it's a puberty book that puts the emphasis on breasts, which I think is very much needed. And my last two books are about supporting breastfeeding beyond six months and supporting the transition from breastfeeding. For a 10% discount on the last two, go to Jessica Kingsley Press. That's uk.jkp.com and use the code MMPE10, Makes Milk Pickett Emma 10. Thanks. 

Emma Pickett  30:26

So, in terms of supporting people continuing to breastfeed beyond infancy, do you find that the parents you're talking to are under greater pressure to end lactation if they're babies are above a certain age? Are their children above a certain age? Do you have a world where people are being supported to breastfeed beyond infancy? You know, despite their medical issues? Or am I living in dreamland? Are people still very much expected to end breastfeeding once they get to 12 months? 

Dr Justice Reilly  30:50

Yeah, I'm not sure. I feel like if I'm on an internet peer support forum, I definitely get that sense that people are just starting to enjoy breastfeeding their babies six weeks old. And they're already getting asked questions about when they're being introduced solid foods or when how long they're going to do it for. But if I'm in my little pocket of Glasgow, or I'm in a La Leche League meeting, I'm actually finding that people are very confident in breastfeeding for longer, that I see it quite openly, maybe it's because I'm looking for it. But I do see, you know, toddlers and walking with being breastfed directly. And it's lovely. And I don't know if maybe it's because it's not their first child. And, you know, they're not maybe getting those questions, or they're more firm in their own in their own knowledge and convictions. I mean, we do have a slightly different landscape in Scotland and had mentioned the breastfeeding collaborative, which originally started as the Scottish Government, breastfeeding advocacy, advocacy and culture change group. And we've we've just continued on. So there are pieces of policy, like our NHS in Scotland now has returned to work for breastfeeding policy. So it outlines very clearly that, you know, breastfeeding is recommended to to these are the resources that you should be able to access. And you should be able to get a locked room and we want to support that it's good for maternal and child health. So maybe, you know, things like that are just helping shaping people's views. Yeah, it is interesting that I feel like there weren't many people breastfeeding beyond six months, let alone one year when I had my eldest, but now I'm seeing it more than norm that people will come to a peer support meeting in pregnancy with the intention of breastfeeding for at least two years.

Emma Pickett  32:47

Gosh, that is, that's not common. 

Dr Justice Reilly  32:50

It's not common for you. 

Emma Pickett  32:51

I know. I live in a little pocket London where there are really high breastfeeding rates. But for someone to come to an antenatal meet antenatal class to say, you know, for my first child, this is my aim. I wouldn't say that was a common UK experience in Scotland. You know, we could do a whole nother hour on what's happening in Scotland with government support for breastfeeding, and education in schools, which is my particular passion, having written the breast book and helped develop the module for the ATMs, education and schools resources. There's so much special stuff happening in Scotland, and we're seeing it and there was the rates, the rates are increasing, you're still doing your infant feeding surveys, we've got the evidence to show that it's having an impact. So it makes sense that that's filtering through for support for older children being breastfed as well. 

Dr Justice Reilly  33:34

That's yeah, I should mention that, actually, that the breastfeeding rates, if you're someone who starts breastfeeding in Scotland, you're 1/3 of those people are still breastfeeding, the 13 to 15 month review. So obviously, you know that that swing has happened. And that's after typically, people have gone back to work. But yeah, that swing has happened in the last sort of six to six to seven years.

Emma Pickett  33:57

That is fantastic. And in England, we don't even know that number. We have nobody asking that question. So we can't even guess whether our results or anything like that. But from what we do know, the results we do have was suggests that we're nowhere close to that. Yeah. So so let's talk about Let's Move away from abscesses and start talking about breast cancer a little bit because I think it's something that often comes up as a question. We know that breastfeeding protects against the risk of breast cancer. Tell me a little bit more about that before we go into the details of treatment and screening. 

Dr Justice Reilly  34:28

Yeah, so the most commonly cited studies, one from I think 2002. And, and it was kind of the largest study at the time, but it kind of showed that if you were to breastfeed for one year, that reduces your risk, your lifetime risk of breast cancer by about 4.3%. So, you know, obviously, if you're someone who has multiple kids, or is breastfeeding for a couple of years each kid, then that can confer quite a significant risk reduction. What we now know is that for those people who are particularly high risk, so if they have what we talked about as the cancer genes, the breast cancer genes that are mutated to those braca, one and braca, two genes, if you're a braca, one carrier, these are usually the people, you know, like Angelina Jolie who had a strong history of breast and ovarian cancer in younger women in their family, then, if you're breastfeeding for up to two years, you can reduce your risk by more than 50%, which is massive.

Emma Pickett  35:35

That is incredible. 

Dr Justice Reilly  35:37

So then what we're finding is that people who know they have this gene mutation are then being told quite early, you need to start your screening programme. And then there's a wee bit of confusion about the sensitivity of the mammogram in that age group. Because just generally, the younger you are, the denser your breast tissue, the reduced theoretical sensitivity of that screening test. So then they sometimes get this information to, you know, breastfeed, but you need to stop really early, because we need to get you back into the screening programme. So that's where I started to get interested, because working in breast screening, we know that there are ways that we can reduce density, or we know that there are other tests that we can do, we can do no kind of CT type imaging of the breast. Or we can do MRI with some contrast. But continuing to breastfeed is obviously overhaul quite beneficial. And it also comes down to that person's autonomy and their reproductive rights. So I don't feel like we should be putting in barriers to screening and actually having this huge psychological distress. When ultimately lactation is the primary normal function of the breast. Okay? We don't have people walking into any with a sprained ankle, saying, well, we can't actually image that because you're walking on it, because walking is the primary function of the fit. So why are we putting barriers in place to someone using their breast in the way that it was intended to be used? There are workarounds and there are also, you know, equality laws in place to protect people from that kind of discrimination in healthcare. So there is a wee bit of a nudge towards people understanding that I think, ultimately, it's the radiologist who is reporting that scan who has the responsibility. So I understand why they would want to get the best image possible to be able to see there's not a cancer there, or there's no microcalcifications there, because when you're looking for very early breast cancer, it is tiny. It can be microscopic, you know, it's really sensitivity is important. But what I'm trying to do is maybe shift the perspective to just lactation and breastfeeding being normal. And if we can support someone to directly feed or express their milk right before their study, and optimise those results, then actually you're getting the best of both worlds. 

Emma Pickett  38:10

Yeah. Okay. So funny, you should mention this, because I had a message from a mum on Instagram a couple of weeks ago, she said, I'm 45 years old, I want to start screening early because of family history, or I'm just a bit worried that I might be at risk. And I'd like to start breast screening early. But I don't think I'm going to be able to get one and breastfeeding. And you're saying that should be possible. So if somebody's sort of Breast Health Department at their local, your hospital is saying, No, I'm sorry, we don't screen lactating breasts. What can that patients say to that team is there? So you're saying there are different kinds of tests that are available? Yeah. Someone could ask for a CT scan. Tell me a little bit more about the language that they might want to use in that conversation.

Dr Justice Reilly  38:51

Yeah. So firstly, I would suggest speaking to the radiologist who would be reporting that scan because quite often that information is passed on from the geneticist who's doing the counselling for these high risk genes or it's passed on from the admin department or the breast care nurse or the breast surgeon, the radiologist is who will ultimately be making that decision. So if that's who you need to get in contact with myself, and one of my colleagues did write an article talking about the kind of implications of not screening and my colleagues actually breast radiologists. So she was able to get images from someone who was breastfeeding over, you know, passed the first year from one breast. So what she's done is she's able to compare the two side by side showing those images and showing actually there's not a huge difference in sensitivity when that person has been supported to express her or feed their milk right before the study. So I think helping people see that it's not maybe the problem they think it is, can be quite key. And also the Academy of breastfeeding medicine have Very good protocol and talking about the all the studies that have been done in lactating breast, because in America they have a much more. I don't I don't I don't know if I'd call it better, but that their breast feeding programme starts at age 40, for any any person who enter screening, and it's annually, whereas we in the UK, we start at age 50. And it's every three years. And so what that means is there's more of an overlap between, you know, the population of people who might be lactating and the population of people who will be going into breastfeeding, so they have a lot more evidence. And I think, in general, the radiologists are a lot more comfortable with imaging and lactation. So I think a lot of it is to do with our culture around screening. So yeah, I would I would speak to the radiologist or get an email for the radiologist or write a letter to their secretary and just kind of detailed those reports. And obviously, their concerns, if a patient is happy to accept the fact that they may have a reduced sensitivity because they are breastfeeding. And then I think that absolves the reporting radiologists from some of the responsibility where they feel like they may not have they may not be getting the correct or the best images. But having said that, the Royal College of radiologists guideline doesn't actually say that a person shouldn't be screened in lactation, it says a patient may opt to wait until we have ceased lactation for a period of over three months. So that doesn't mean that we can't screen it just means that ultimately the decision is the patient's decision. So sometimes that gets conflated. 

Emma Pickett  41:43

It sounds as though a lot of it comes down to the confidence of the actual individual radiologist and and their experience and, and feeling brave enough to have a go now it's interesting what you're saying about how the imaging that showed of breast that had been recently drained into comas. Really there wasn't significant difference. That's that's a really powerful bit of information. And, and I have sometimes work with a mom who was going in for screening and she didn't want to tell the person that was doing the screening that she was still lactating because she was worried she'd get told off that there's a couple of stories where people have been told to breastfeeding, and within two weeks, they were expected to come back for another test. And the idea was that they would have dried up in two weeks. And that, you know, she was she was worried she still had milk. She didn't know what to do about it. And so she didn't really want to express milk in the hospital because someone might find her and she getting even more trouble. I mean, they that interesting guideline of three months after lactation for screening, is it. Would we expect people to dry up in three months? What's the sort of timeframe if someone is going to need to screen on a breast that is no longer lactating? What's the sort of normal timeframe for when lactation would end because some people go on for quite a long time, don't they? Even though after three months, they may have some milk.

Dr Justice Reilly  42:56

That is the challenge as well is that you're giving people this timeline, and every body is different. And yeah, I know plenty of people who will present to breast clinic because they've got nipple discharge. And actually they've just had a grandchild in the last month. And every lactate is a little bit or I had a patient who had breastfed for a couple of years. Her daughter went in for a tonsillectomy and she started leaking milk because her body had kind of recognised her child was unwell or her child was in distress and had just you know that had kicked in. I guess it's an evolutionary hack, isn't it? But historically, people would have breastfed abandoned or orphaned babies, or their sister's baby or whoever. It's just that that is how it kicks in that prolactin pathway gets quite well primed if you've established breastfeeding. So yeah, it's really difficult to see it's not it's not a tap that you can turn off. And yeah, I think that kind of advice just shows that they don't have the first clue about like patient. 

Emma Pickett  44:01

So you ideally, you want to have radiographer who you can have an honest open conversation with describe exactly what's happening to you and express right in front of them seconds before you have the procedure done and the test done and you can continue to have that honest dialogue. So just to state the obvious people despite the reduction in risk when you are breastfeeding people can still get breast cancer while they are breastfeeding. Do you recommend that people continue to do sort of self checks on their breasts while they're lactating? talk through a little bit about that that process 

Dr Justice Reilly  44:32

I definitely do and I think no matter what age you are, that you should be familiar with your breasts and your breast tissue and what those lumps and bumps feel like and you know if if you are someone that doesn't have a lot of subcutaneous fat around your breast tissue, then you will feel those lumps and bumps and getting familiar with that. So we usually recommend that you do it intentionally. You do it once a month, and that involves inspecting the breasts So, you know, actually having a look in the mirror looking for any new asymmetry, any skin tethering, which, you know, would make once one part of the skin and be drawn in any new nipple discharge or nipple changes, and then having a feel and it can be really individual, some people like to approach it with, you know, they draw imaginary lines across the breast and will feel in different quadrants, some people will do in the bath because they feel a bit more relaxed, and they can lay back or in bed or say, for example, on a Friday night, they're always watching the same TV show, and that will remind them, you know, to examine their breasts, Copperfield in the UK, also have a text message reminder. So that's, that's a good thing as well to just, you know, especially when people then have children, and are running around, it's very easy to forget to examine your breath. But yeah, you should definitely still be examining during lactation in the same way that you should be doing it through pregnancy, before pregnancy, and beyond, I think.

Emma Pickett  46:05

So when you are lactating, and you find a lump, if it's a discernible lump, it's probably going to be lactation related, but we don't necessarily know so. So we would do the normal block duct stuff and you know, getting support with positioning attachment. And, and you know, as you say, not necessarily going at it with an electric toothbrush, but maybe some very gentle massage, varying your positions, getting some breastfeeding support. And if that blocked, doctors not going away, what happens next, they go into their GP, what's the sort of procedure? 

Dr Justice Reilly  46:36

Go to your GP, and they would examine you again. And usually you would be referred to the breast clinic, your local breast clinic, and they tend to be very efficient clinics. And usually, you know, you can bring your baby if they're feeding as well, that's, that's sometimes a concern, because sometimes the appointments can be up to two hours, because you're seeing the surgeon or clinician, then if there is a lump to examine, then you'll see the radiologist and they'll usually ultrasound that if there's something really solid on ultrasound, and they might biopsy or they might do a mammogram as well. So you might be there for a week. While that is usually what happens. I mean, sometimes people get referred by their GP, and they have that referral in place. And by the time they go to the clinic, there's no lump there anymore. And that that happens quite frequently. And that's not something to worry about. So just don't sit on it for too long, we kind of expect mumps to come and go and that's a good thing. If it's still there, you know, a week or two later, then we definitely want to definitely want to have a look. And just you know, accepting it's not actually your responsibility. It's it's the breast team's responsibility. So don't try and get too tied up in, you know, waiting or being a nuisance or going with something that's not cancer. And we're very, very used to pursuing those kinds of presentations.

Emma Pickett  47:56

And sometimes lumps can be filled with fluid that's actually milk. So galactosyl It doesn't necessarily always mean an abscess or something scary or something ominous breasts do unusual things during lactation and, and cancer in lactation is rare, but we don't want people to think it's impossible, which is why it's important to to get that support. So you and I both was talking to a mum before Christmas, who was being treated for cancer, and she's actually ended up continuing to breastfeed throughout her treatment. So for some a cancer diagnosis doesn't necessarily mean that mean an end to breastfeeding. But sometimes it can mean an intravenous feeding. What's the sort of rain range of experience for somebody who's diagnosed with cancer while they're breastfeeding? 

Dr Justice Reilly  48:38

Yeah, I think it can. It is it does vary hugely, it will depend on you know what that tumour is responsive to in terms of hormones. So if someone needs to then be on hormone treatment after their surgery, that in itself can be a contraindication to breastfeeding. Similarly, if they need some chemotherapies, then again, they're not compatible with breastfeeding. I think for the lady we're talking about, she had quite a large lump, but actually, it was a very kind of pre invasive cancer. So for her, yes, she had to have a mastectomy on one side, but didn't have to have all of the kind of adjuvant extra treatments that would prohibit breastfeeding. So that was hugely reassuring for her because it just meant that she didn't have to interrupt her child's nursing relationship. She wasn't going through that huge kind of psychological hormonal shift at the same time as also dealing with her cancer and her surgery. And that, that that separation for surgery, and I think for them, that was that was a great outcome. For some people, yes, they will have to stop. But again, it doesn't have to be you know, bad and they're in that clinic appointment, for usually is a window of time and ultimately, if both breasts are being removed that's gonna be a signal to the child to stop anyway. And we can talk about other ways we can support, you know, psychologically or with donor human milk, or, you know, just with that transition, I think for some people, it can, yeah, it's not nice to have an abrupt end to breastfeeding, it's not nice to have to stop that when you're really invested in how important it is for your child. So there is a lot of psychological support that's needed. 

Emma Pickett  50:29

And some people have chemotherapy and then resumed breastfeeding after chemotherapy, how common would you say that is?

Dr Justice Reilly  50:35

it really depends on the age of the child. And usually that would be a case of someone having treatment quite soon after birth, because a child coming back to the breast can be really dependent on they're still having that that suckling reflex. So I think the times where it's worked best has actually been if the child has been wet, nursed by someone else in the interim period, so they don't sort of forget the suckling skills. And if the chemotherapy that's been used as kind of a shorter term, I mean, there's some chemotherapeutic agents that you actually only have to stop nursing for four days at a time, it just depends on the intensity of that programme, whether it's sustainable. And obviously, for that mother for that birthing person, you know, what kind of reserves they have, what kind of advocacy they have a read them is hugely influential as well, I don't want to present this is something that is that should be done is very individual, sometimes for an older child as well, if they because we knew it was, well, if parents are separated for work or travel, you know, they can have not nursed directly for a week, and then be quite happy to resume feeding when they're reunited. So sometimes, that can actually work quite well. I think the tricky part is when they're kind of in that distractible phase anyway, you know, that kind of like six months to a year, where a lot of people might see all the they stopped themselves. And actually, they've just gone on a nursing strike, and they found it difficult to feed and take in the world around them sort of thing. I think that can be the time where actually, breastfeeding will probably end because it's that the You can't force a child to breastfeed. That's the thing. You can pump your milk and you can maintain supply, but you can't actually force a baby or a child to breastfeed us is very much on their terms. So that's when again, the decision might be taken out of their hands. 

Emma Pickett  52:37

Yeah, that age group. Yeah, the sucking reflex has faded by six months. And they haven't yet consciously realised that they're breastfeeding as it were, that's not like a two year old who like draws pictures of it and leaps on you when you walk in the door. So yeah, I can see that's challenging, but they will be there to see people there to support you if that is the situation that you're in. And talking of support. Just a quick shout out to the charity, mommies star, which is brilliant at supporting people who are diagnosed with cancer in pregnancy or in the year after birth. Are there any other resources that you would highlight for anybody who's dealing with cancer while they're breastfeeding?

Dr Justice Reilly  53:10

I mean, I think it will really depend on on your local area. I think there's no, there's not a huge network because what we call pregnancy associated with breast cancer is a very, very unusual thing. I'm not actually aware of anyone specific to them. But yeah, mommy, mommy star is a really important one. And I think throughout the UK, it's not just it's not just based in England. 

Emma Pickett  53:32

Yeah. And also getting in touch with the breastfeeding support organisations. I mean, they're going to be people that who understand how important breastfeeding is to you and will empathise and, and help you with your emotional journey as well. You very kindly helped me with a chapter of my book on transitioning from breastfeeding. And in that chapter, we talked about people having to wean quickly, perhaps for medical purposes, I always think this is the worst situation for a parent to be in because they are dealing with their own medical issues that can be really frightening and stressful. And having to end breastfeeding when you don't want to and your child doesn't want to is the kind of nightmare scenario. So I was very grateful for your help with that with that chapter. If somebody is going to win, and they're perhaps going to have to win. Let's imagine the child is 18 months old, they're going to have to wean, perhaps over a period of a couple of weeks to be able to start treatment quite quickly. It's not an easy question to answer briefly, but what are some of the things that you would want them to know if they are going to have to win quickly for medical reasons?

Dr Justice Reilly  54:30

18 months is a tricky age. I mean, it really depends on the personality of your child because for some people, you know, winning by distraction, winning by having someone else take over that care is fairly straightforward and fairly easy, and it's home was easy to throw out these suggestions, isn't it but if you have a child that's actually very breast feeding focused, very mommy focus then that just presents another barrier. I did have someone that was referred to me kind of through will actually go do some work for their professional liaison committee. So again, that's really interesting, who had to win for breast cancer. And what they did was maintain the kind of dream feats. So she felt that she wasn't kind of promoting and offering direct breastfeeding. But she was still able to get some encouragement relief, and not have that huge kind of rapid slump in mood and supply. And it just meant there was an easier transition for them. But yeah, throughout the day, it was lots of cups and beakers and straws and try all these different kinds of milks. And is this hugely stressful? And actually, I think sometimes just having someone else take, take over that, although you really want to be there for your child at that time. So it can feel quite conflicting. But sometimes having someone else take take over that role can be the most straightforward thing. But yeah, hugely dependent on the child.

Emma Pickett  56:03

I agree. I mean, I think at this age, in this situation, this is the one time where perhaps another adult taking the lead can be helpful because you're at your most vulnerable already. And, you know, that's not something I advocate normally for, for sort of gentle yearning or in you know, emotionally sensitive weaning. I think this is a time where another adult really can help you and take the lead. And I also think sometimes, even quite young children can understand concepts like you know, breasts needing a rest. And also that you might even be able to have some language around breasts not working and being broken. I mean, you know, that's not something I normally advocate for weaning. I'm not someone who's going to sit just put plasters on your nipples and talk about breasts being broken. But if we can get as close to the reality as possible, we can be as authentic as possible. And that child's going to see you coming back with dressings, they may even see coming back with a breast being removed, they're going to see your post surgery. So talking about breast being broken, even for as young as an 18 month old, they may have a sense of what it means when your saw or somewhat, something's hurt, or something's broken. Yeah. But yeah, there's not one right answer to this. Because every as you say, every situation is going to be different.

Dr Justice Reilly  57:08

And people use that language as well see if they are nursing through pregnancy, and they have this huge aversion, and it can be quite painful. When you're there driving nursing, you know, it's okay to, to voice your concerns, and to say something similar to say something that doesn't feel nice, because that is also part of your child's learning, bodily autonomy and respect for other people's spaces, and, and everything else, as long as it's not presented in a kind of way that the child feels blamed or, you know, hurt by that. I think I think that's, that's also a good lesson. 

Emma Pickett  57:45

Yeah, absolutely. And I also think it's, if you really are winning, when you don't want to win, it's also okay to say that to a child that you're sad to that you wish you didn't have to end, you know, having boobie and you're sad too. I don't think that's a problem, I don't think have to hide that from your child. If you're, you know, you're potentially going to be hit quite hard with weaning blues if you are winning abruptly. And that on top of dealing with your medical situation is going to be super stressful. So feeling like you can have some space to talk about real emotions, even with a relatively young child. I think that can be done safely if it's done if it's done carefully. Yeah, so I think if someone is going through this experience, reach out for help have a lactation consultant or a breastfeeding counsellor or supporter alongside you. You don't have to go through this go through this alone. So another area that's often a struggle is when a parent has a skin condition on the nipple or on the areola and quite often in the UK, they're going down the road of being diagnosed as having thrush. That seems to happen a lot. Lots of people I come across you've got eczema and dermatitis and their worst of it, you're just going down the Thrush Treatment road. What are some of the conditions that you see parents struggling with on the sort of nipple and areola?

Dr Justice Reilly  58:52

I think maybe because of the kind of practice I have, I do see a lot of nipple trauma. And then sometimes that that nipple trauma is kind of exacerbated by putting certain lotions or ointments and things on it, which can then cause an allergic reaction. So I think I see a lot of the bad parts of the pollutions. Obviously, because my background is breast. You want to make sure there's not something underlying because as we've said, you know, breast conditions like breast cancers can present in in pregnancy and breastfeeding. So you know, something that's always in the back of my mind is this Paget's disease of the nipple, which can look very much like a nipple eczema.

Emma Pickett  59:32

Yeah, tell us tell us that in lay language, Paget's disease or something or breastfeeding counsellors? Was there in their training, but just tell us what that looks like what that looks like, usually?

Dr Justice Reilly  59:42

because it's not due to an allergic reaction. It's usually just on the one side, and I think in about half of cases, there might be a lump behind it. So it's usually in connection with a breast cancer, and it looks flaky and red. Sometimes You know, the nipple pores can be kind of obliterated by by this kind of rash. And these plaques, and so it can cause kind of blockages to the exit of milk. And it tends to kind of grow and spread over a longer time, it doesn't tend to be receptive to things like, you know, steroids or your own milk or the things that we would normally put on it. But it is it's super rare in lactation, but I think it's always just something that I am conscious about, particularly if it's if it's just on one side. And for that, you know, if it's something that's been present for a long time, either a dermatologist or breast surgeon would do a punch biopsy of the nipple as well, just to be able to look at that skin sample under the microscope. But yeah, the much more common things are eczema or blocked ducts, nipple Blabs, which some people you know, they will have very painful feeding quite suddenly. And they really have to go looking for for what's causing the problem, because a nipple bleb is literally like a pinpoint, thickening over one four of the neck of the nipple, but actually can be very painful can cause shooting pains all the way into the breast. Yeah, it's amazing how such a small thing can cause too much trouble.

Emma Pickett  1:01:22

If someone asks you what's how nipple blebs caused, I often just talk about positioning attachment, and something's been rubbing, and there's been abrasion in that area was that sort of fit with the sort of language that you 

Dr Justice Reilly  1:01:33

Yeah, it's kind of like what we'd call granulation tissue, so that thickening because your body's trying to heal. But unfortunately, it heals over one of the usually about five to nine nipple pores and a nipple for the milk can come out. So if there's a thickening of the skin over that area, it's gonna stop the milk flowing. And yeah, usually is, you know, something to do with the friction. There's more of an interest now I think and dysbiosis. And the thickening of the milk caused by the difference in the flora, that kind of bacteria that we have in the breast. So that can be you know, one element of treatment, but usually you just treat it with a really weak steroid, to spin that skin down. What you don't want to do is start kind of prodding at it with a needle because yes, it will lift off that layer of skin. But then your body thinks, hey, I need to heal this though. So you just come back with an even thicker layer of skin. And you don't really resolve the problem, you just get rid of it for a couple of days. And then usually it's you know, just turns into the cycle. Or you know, some people will get kind of an exfoliating sponge or something like that.

Emma Pickett  1:02:46

Some quite reliable breastfeeding support resources, which are talking about rubbing with flannels on and you're saying bad idea. You're you're talking Yeah, get it your face. It was not go if it's not going by itself, talking to a doctor and maybe thinning the skin somehow or the steroid creams. direction you'd talk about going in people's about using olive oil. I don't know what warm olive oil on the nipple, is that going also good.

Dr Justice Reilly  1:03:10

So I think the theory in that is that it will kind of soften the skin and lift it a little bit. So I guess if that's all you have at home, and I don't see it maybe as as being as problematic as you know, traumatising the skin. And I would just worry that maybe that oily kind of texture might block other ducts or you know, you could be allergic to certain oils. I'm not sure there's I don't know that there's good evidence for it. But that's not to say it wouldn't work. There's lots of things in women's health that traditionally work very well but we don't have you know, randomised control trials for them. There's lots of things in labour and delivery, you know, that are actually very reliable, even

Emma Pickett  1:03:54

nipple healing amid let's let's mark Module Two for the breastfeeding counsellor course for the the IBM and one of the questions is about the evidence around nipple healing, and that is a massive difference of opinion. And we've got the sort of cultural Cochrane Review talking about sore nipples and using breast milk or nothing but when it comes down to a cracked, damaged nipple, there are super respect respected practitioners in this field who have utterly different opinions on on whether you use soap to break down a bacterial biofilm. Do you use hydrogel dressings do you use nothing? Do you use you know lanolin it's it's a minefield, you know, most wound healing or nothing at all those things are completely different. And then we've got the world of silver cups. And I actually spoke to somebody last last week who was overusing her silver cups and that was causing redness on the Napoleon. She was having all sorts of problems. And then then when she stopped using them, the redness cleared up completely and she gave me permission permission to share that. What do you say to someone who's got a cracked nipple? It was positioning attachment related the cause has been addressed. What do you advocate for healing that cracked nipple?

Dr Justice Reilly  1:04:58

and so yeah, this emotional attachment is the main thing, isn't it, because if you've got a really shallow, large where that child's palate is still rubbing against the area that's going to be repeatedly traumatised, and then it's never going to heal. I do like moist wound healing. I think that, particularly with the hydrogel dressings, I find that if people keep them in the fridge, then it can be, you know, soothing as well as quite effective. Because I used to do some burns and plastic surgery, I think I'm quite invested in the idea of you know, Jelena dressings and skin grafts and just using that, that moisture and healing environment, I've seen it work really well. So I think with nipples and equally kind of sensitive area, I think it can be really important. But yeah, I try not to overdo things and throw everything at it, if someone already has silver cuts, that's fine, but they are very expensive. And they won't work for everyone. And like you see the shape of them are, they're quite rigid. So for some people, having them on the nipple, for a lot of time can actually cause you know, moisture to build up and can make the tissue quite friable, quite, quite weak. So I don't love them. But I don't hate them either. But it's quite individual. For some people that have got very deep wounds, I think the moist wound healing is really useful, but it doesn't replace getting a deep attachment, because I've seen plenty of people with, you know, a proper ulcerated area on the nipple face. And actually, when you change position, and you get that deep latch, and it's not rubbing on the baby's palate, then it can be perfectly comfortable. But it is a bit of a pickle of time, doesn't it? 

Emma Pickett  1:06:44

Yeah. And do you have opinions on lanolin versus kind of Vaseline type products? What's your jello net? You recommended that does have sort of a Vaseline type path and stuff impregnated into it, do you do you feel we have evidence to suggest lanolin is particularly valuable, it seems to be the default for lots of people. But

Dr Justice Reilly  1:07:03

I don't I don't love it. And it's hugely expensive. And I've seen real problems with it in that it can kind of create this greasy layer. Obviously on the packaging, it says you don't need to remove it before your baby feeds. But sometimes if people are overusing it, and then you're trying to let your baby who actually cannot get a seal because this is just slathered on that can cause issues. But I have seen a couple of cases now of really bad nipple blebs and mastitis, which cleared up when we stopped using the, the lanolin. And obviously, as I mentioned, the, you know, it can exacerbate things like eczema, if someone's allergic to it, and people often don't know that they're allergic to it until they put it on very sensitive part of their body. So yeah, I think I don't recommend it any more than certainly if you're able to hand express a few drops of your own milk, we know that that's already got some anti inflammatory properties. It doesn't have any kind of foreign material. So ultimately, that is much more accessible than a 910 pounds tube. Isn't it so much prefer that? 

Emma Pickett  1:08:11

Yeah. And also not vegan? vegan friendly? Yeah, yeah. Coconut oil. That's something I've been exploring mites. And because it's got natural antibacterial and antifungal properties, there was a little bit of research around that as well. So much research not happening in areas that are really needed, because so many people are scrambling around looking for solutions here. But yeah, I like what you're saying about not throwing everything at it, sometimes you'd need to keep it simple to work out which the variable is it's making the difference. Let's talk a bit about spectrum lactation. So I'm going to put you on the spot slightly and ask you to describe what is spectrum lactation, and why is it needed.

Dr Justice Reilly  1:08:50

So Spectrum Lactation is going to be an image bank of different breast images during lactation that have different presentations in a variety of skin tones, but focusing on black and brown skin. So I think this is really important for patients themselves, for breastfeeding people themselves, because then they're able to, you know, help guide their diagnosis, if they've never, if they open up Google and they see what a condition looks like. And it's only in white skin that may not be representative of what it's going to look like on their skin. So it just creates this barrier to getting the support that they need. And it's also hugely important for healthcare professionals to be able to access that because, yeah, we know from our own textbooks that everything is very white centred, even in things like chickenpox, diagnosing chickenpox, and someone who has darker skin tones can sometimes be delayed. So, of course, if someone's already got a problem with their breast and maybe there's a barrier to them going to the doctor because they think that you know they don't want to expose their breasts in front of them. Perhaps a male doctor. And then there's a barrier of that doctor has never seen something like that before. Because I've only ever seen white breast, it's massively important just for getting people the care that they need. Especially I think, in Scotland, because over 80% of our population is white. So if you're only used to seeing certain presentations in certain skin tones, then that will then inform your practice, it's not to say that, that we as clinicians, wouldn't want to have a greater breadth of experience, but just that we don't, because we don't have a very diverse population. So I think it should be hugely helpful. It's going to be free to access, which is important. Yeah, and it's been a slow burn hasn't. It's taken a while,

Emma Pickett  1:10:50

it's been takes a long time. So we've had to learn about all these things to do with liability and data protection and all this stuff. And we've very kindly had donations from different breastfeeding organisations to help us get off the ground. And we know it's being run by busy people, but we're getting there, there was now call out for images. And I'll put those links in the show notes. So we're collecting those images together, then we're going to have a panel who look at those images and work out what the labels should be to go with each image. So it's, as the name suggests, the spectrum, it's for a spectrum of skin tones, we're gonna have, you know, be a library for everybody. And and if you think was this thrush, I'm not sure, you know, we're not saying you can diagnose yourself by looking at the spectrum length lactation image bank, but you're going to hopefully see something that you might recognise that will help you then talk to someone to get the right information. So yeah, so I'll put the links in the show notes for the Instagram on the website. And hopefully, people can go and have a look, if you're aware in the world of breastfeeding support. I'm hoping you'll find it useful in your training, if you're a parent, I hope you'll find it useful. But at this stage, we're really asking for help to get the images sent in. And there's information about how to do that on the website. Thank you very much for your time today. Justice, I'm incredibly grateful. I have one last really mean question for you. Did you watch the matrix movies? Have you seen The Matrix films, you know how they can like download the ability to fly a helicopter into their brain? I'm gonna give you a magic matrix download. And you can use this matrix download for all medical doctors in the UK on an aspect of breastfeeding and lactation? What are the sort of key highlights that you would want all medical doctors to understand about about supporting breastfeeding? 

Dr Justice Reilly  1:12:32

Gosh, I mean, I think the most key thing for me is just appreciating that lactation is normal. And it's important, and it's something worth preserving. You don't have to be an expert in it. Maybe knowing that there are experts in it, who you ought to refer to would be useful. But just not having that default position of or you're going to be on this medication. So you probably can't breastfeed or you're going to need the scan, you probably can't breastfeed actually just have coming to it from the point of view of, you know, oh, you have a one two year old, are you still breastfeeding? How can we continue to maintain and support that? You know, if I think about other paediatric conditions, if we're giving a child, an antibiotic, we'll consider it, you know, is this one that we can avoid? That's not going to affect the hearing later on? So in the same way, you know, are there are there ways of keeping that parent and or mother and baby together, and that is not going to impact their breastfeeding relationship. You know, we're just having that appreciation that it's a normal thing. And lots of people are still doing it into toddlerhood, we do have a good policy in one of the health boards in Scotland, where the infant teething team will be alerted if if a baby is breastfeeding or if a lactating mother is admitted to the hospital, so that they can then you know, be on it and support them that just is part of their normal intake form. Now, in the same way, you know, we ask, Are you diabetic? What do you have any dietary preferences? We should be asking people? Are you lactating or breastfeeding? Or do you have or is your child lactating or breastfeeding? I think that would be for me, is quite a simple thing. 

Emma Pickett  1:14:19

Yeah. I love the idea of the alert going up like the kind of breast version of economic activity as a as a part dyad in this in this hospital boob signal goes up in the sky. Just come and support them and ask them how to help them and talk to their colleagues. Yeah, okay. That sounds like a good situation. Thank you for that matrix download. Thank you very much for your time today. Justice. I really appreciate it. You've got so much expertise and obviously if somebody is in the world of having to investigate breast cancer or having treatment for breast cancer and they want to protect their lactation, you are someone to talk to, you know, your resources are not infinite, but they can find you on your website, which we'll put in the show notes as well. Well thank you so much for your time.

Dr Justice Reilly  1:15:01

It's a pleasure. 

Emma Pickett  1:15:02

Eeally appreciated.

Emma Pickett  1:15:08

Thank you for joining me today. You can find me on Instagram at Emma Pickett IBCLC and on Twitter @MakesMilk. It would be lovely if you subscribed because that helps other people to know I exist. And leaving a review would be great as well. Get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast. This podcast is produced by the lovely Emily Crosby Media.