Breastfeeding and the Use of Human Milk

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Breastfeeding and the Use of Human Milk

• An Update on the AAP Policy Statement
• A. Ildiko Martonffy, M.D.
• The Breastfeeding Coalition of South Central
  Wisconsin
• April 19, 2012

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Objectives

• Discuss recent AAP Policy Statement on
  Breastfeeding and the Use of Human Milk
• Explain differences between recent and past
  policy statements
• Discuss ways in which we can work together to
  make recommended breastfeeding goals a reality
  in our communities
• Have fun in the company of other lactivists!

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Previous Policy Statement

• Published in December, 1997 Pediatrics
• AAPs Work Group on Breastfeeding
• chaired by Lawrence Gartner, M.D.
• AAP position human milk is uniquely superior
  for infant feeding and all substitute feeding
  options differ markedly from it
• Interesting initial backlash (but ultimate
  support)
• National Organization for Women working moms
• Misinterpreted as being told we should feed 12
  times a day for 30 minutes each feed for 1 full
  year

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Specifics of Previous Statement

• Initiate within first hour of life
• Feed 8-12 times a day, at earliest signs of
  hunger
• Continuous rooming-in
• Formal lactation support
• Hospital follow up 48-72 hours after discharge
• Avoid supplementation and pacifiers until
  breastfeeding is well established
• Assess for adequacy of intake by 5-7 days of age,
  6 wets/day
• Exclusive for approximately the first 6 months
  and continue for at least 12 months and
  thereafter for as long as mutually desired
• Only selective iron and vitamin D supplementation

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and

• Improved education of medical students and
  residents
• Promotion of hospital policies that facilitate
  breastfeeding and work toward eliminating
  infant formula discharge packs
• Encouraging media to portray breastfeeding as
  positive and the norm
• Sounds fairly decent! So what happened?

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Barriers

• Operative births
• Cost
• Of training
• Of not accepting formula samples
• Lack of buy in from key player
• And more

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Fast Forward were not there yet!

• January, 2011 Surgeon Generals Call to Action
• New AAP Policy Statement
• Released on-line February 27, 2012
• Both recognize infant nutrition as a Public
  Health issue and not just a lifestyle choice and
  recognize health risks of NOT breastfeeding
• New AAP statement more in keeping with WHO
  guidelines and Call to Action recommendations

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Where are we?CDC Breastfeeding Report Card
2007 2010 Target 2020 Target
Any BF
Ever 75.0 75 81.9
6 mos 43.8 50 60.5
1yr 22.4 25 34.1
Exclusive BF
To 3 mos 33.5 40 44.3
To 6 mos 13.8 17 23.7
Worksite support 25 --- 38
Formula in 1st 48h 25.6 --- 15.6
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Room for improvement

• Past decade modest increase in rate of any
  breastfeeding at 3 months and 6 months but
  Healthy People 2010 targets still not met
• 24 of maternity services provide supplements of
  formula as a general practice in the first 48
  hours
• Must work on improving hospital practices to meet
  2020 targets

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AAP Policy Specificsepidemiology (number
crunching)

• AHRQ data highlights
• Pneumonia risk reduced 72 if exclusive BF gt
  4mos compared to EBF gt 6 mos, 4 fold increase in
  pneumonia if EBF 4-6 months
• OM any BF reduces incidence by 23, EBF gt 3 mos
  reduces by 50 serious colds, ear and throat
  infection reduced 63 if EBF 6 mos or more
• GI Any BF 64 reduction in GI infection effect
  lasts for 2 mos after cessation of BF
• NEC NNT 8 with exclusive breast milk diet to
  prevent 1 case of NEC requiring surgery or
  resulting in death

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and more

• SIDS 36 reduced risk of SIDS (OR 0.55 for any
  BF and 0.27 for exclusive BF). 21 of US infant
  mortality attributed in part to increased SIDS in
  infants who were never breastfed. 900 lives/yr
  in USA could be saved if 90 of moms EBF x 6 mos
• Atopic disease EBF 3-4 mos 27 risk reduction in
  low-risk, 42 in babe with family history
• Celiac 52 reduction if breastfed at time of
  gluten exposure
• Obesity 4 risk reduction per month of
  breastfeeding

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it just gets better, baby!

• DM I up to 30 reduction with 3 mos of EBF
• Theory early cows milk ß-lactoglobulin exposure
  stimulates immune-mediated process, reaction with
  pancreatic ß cells
• DMII 40 reduction self regulation, weight
• Leukemia/lymphoma correlated with duration
• How? Reduction of infections vs. direct mechanism
• NICU NEC, neurodevelopment, retinopathy
• all preterm infants should receive human milk
• pasteurized donor human milk, appropriately
  fortified, should be used if mother's own milk is
  unavailable or its use in contraindicated

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Better for Mama, too!

• Short term
• Decreased blood loss
• Child spacing
• Higher risk for post-partum depression of wean
  early
• Long term
• If NO gestational DM, decreased risk of DM II
  (4-12)
• NHANES decreased RA, cumulative effect
• ? - cumulative BF 12-23 months -gtreduced HTN,
  hyperlipidemia, CAD and DM
• Cumulative BF gt 12 months, 28 decrease in breast
  cancer and ovarian cancer
• if 90 of US moms EBF x 6 mos, 13 billion/year

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So AAP now says

• The AAP recommends exclusive breastfeeding for
  about 6 months, with continuation of
  breastfeeding for 1 year or longer as mutually
  desired by mother and infant, a recommendation
  concurred to by the WHO and the Institute of
  Medicine.

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Why the change to a solid 6?

• Outcome differences when EBF 4 vs. 6 months
• GI disease, otitis media, respiratory illnesses,
  topic disease and maternal benefits
• Culturally sensitive aware that some will
  introduce complementary foods sooner than 6
  months, stress that this be done while the
  infant is feeding only breast milk
• Mothers should be encouraged to continue
  breastfeeding through the first year and beyond
  as more and varied complementary foods are
  introduced.

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Recognized Contraindications

• No breastfeeding or expressed milk
• Galactosemia
• Mom with human T-cell lymphotrophic virus I or II
• Untreated brucellosis
• HIV positive mom in industrialized world
• No breastfeeding but okay to use expressed milk
• Active, untreated tuberculosis
• Active herpes simplex lesion on the breast
• Mom with varicella (chicken pox) 5 days before
  through 2 days after delivery
• H1N1 (from 2009)

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More about Mama

• Diet 450-500 extra kcal/day
• 200-300mg of DHA fatty acids
• 1-2 portions of fish/week (herring, tuna,
  salmon), minimizing predatory fish (pike, marlin,
  swordfish)
• If vegan, consider DHA supplement, MVI (B12)
• Medications
• AAP recommends LactMed as most comprehensive,
  up-to-date source of information
• AAP is working on a policy statement for
  medications
• Insufficient data on may psychiatric medications
• Least problematic amitriptyline, clomipramine,
  paroxetine, sertraline

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So, how do we get there?
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Hospital Care

• AAP Sample Hospital Breastfeeding Policy
• Based on WHOs Ten Steps to Successful
  Breastfeeding
• Emphasizes need
• To NOT interfere with early skin-to-skin contact
• To NOT provide glucose water or formula without
  medical indication
• To NOT restrict time baby spends with mom
• To NOT limit feeding duration
• For NO unlimited pacifier use
• BF in first hour, exclusive BH, rooming-in,
  avoiding pacifiers, getting phone number for
  post-discharge support ? increased breastfeeding
  duration regardless of socioeconomic status

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The Ten Steps to Successful Breastfeeding, World
Health Organization United Nations Childrens
Fund

• Have a written breastfeeding policy that is
  routinely communicated to all health care staff.
• Train all health care staff in skills necessary
  to implement this policy.
• Inform all pregnant women about the benefits and
  management of breastfeeding
• Help mothers initiate breastfeeding within a
  half-hour of birth.
• Show mothers how to breastfeed, and how to
  maintain lactation even if they should be
  separated from their infants.
• Give newborn infants no food or drink other than
  breast milk, unless medically indicated.
• Practice rooming-inallow mothers and infants to
  remain together 24 hours a day.
• Encourage breastfeeding on demand.
• Give no artificial teats or pacifiers to
  breastfeeding infants.
• Foster the establishment of breastfeeding support
  groups and refer mothers to them on discharge
  from the hospital or clinic.

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But

• CDC National survey of gt 80 of US hospitals
• Only 37 of US birth centers practice gt 5/10
  steps and only 3.5 practice 9 to 10 steps
• 58 advised moms to limit sucking at the breast
  to a specific length of time (lower BF rates and
  duration)
• 41 gave pacifiers to more than some newborns
  (lower BF rates and duration)
• In 30 of hospitals, more than half received
  supplementation with formula (shorter duration of
  BF, less exclusivity)
• change attitudes and eradicate unsubstantiated
  beliefs about the supposed equivalency of
  breastfeeding and commercial infant formula
  feeding.

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Pacifier Party Line

• limited to specific medical situations like
  for pain relief or as part of a program to
  enhance oral motor function
• Yes, they are associated with reduction in SIDS
  incidence.
• So use pacifiers at infant nap or sleep time
  after breastfeeding is well established, at
  approximately 3 to 4 weeks of age

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Vitamins Supplements

• Vitamin K 0.5 to 1mg IM x once to reduce risk of
  hemorrhagic disease of the newborn. A delay
  until after the first feeding at the breast but
  not later than 6 hours of age is recommended.
• Vitamin D 400 IU orally each day, beginning at
  hospital discharge (AAP does not mention
  supplementing mom instead of babe)
• Fluoride none for 1st 6 months, then only if
  water concentration is lt0.3ppm
• Iron and zinc containing foods at 6 months for
• Premies multivitamin and iron orally

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WHO and how to grow

• As of 9/2010, CDC and AAP recommend use of the
  WHO growth curves for all children younger than
  24 months
• CDC charts are based on data from mostly
  formula-fed Caucasian infants
• WHO curves reflect optimal growth of the
  breastfed infant and include data from Brazil,
  Ghana, India, Norway, Oman and USA

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Heres whats up, Doc!pediatricians role (aap
wording)

• Promote BF as the norm for infant feeding
• Learn about principles and management of
  lactation and breastfeeding
• Learn to assess adequacy of breastfeeding
• Support training and education in BF and lactation

• Promote hospital policies that follow WHO/UNICEF
  Ten Steps
• Collaborate with OB community to develop optimal
  BF support programs
• Coordinate with other care providers to ensure
  uniform, comprehensive BF support

applicable to any health care worker
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• communicating with families that breastfeeding
  is a medical priority that is enthusiastically
  recommended by their personal pediatrician will
  build support for mothers in the early weeks
  postpartum
• Attention called to Academy of Breastfeeding
  Medicine protocols, especially unrestricted time
  for BF to minimize hyperbilirubinemia and
  hypoglycemia
• Importance of close outpatient follow up stressed
• Encourage physicians to be breastfeeding advocates

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what about business?
Mother-baby friendly worksite ? reduction in
health care costs, lower absenteeism, reduction
in turnover, improved morale and
productivity For every 1 invested in lactation
support, there is a 2-3 return The Business
Case for Breastfeeding Provides details of
economic benefits to the employer and toolkits
for creation of lactation support
programs Patient Protection and Affordable Care
Act of 2010 mandates reasonable break time for
nursing mothers and private, non-bathroom areas
to express breast milk during the work day
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in conclusion

• Breastfeeding and the use of human milk confer
  unique nutritional and non-nutritional benefits
  to the infant and the mother and, in turn,
  optimize infant, child, and adult health as well
  as child growth and development. Recently,
  published evidence-based studies have confirmed
  and quantitated the risks of not breastfeeding.
  Thus, infant feeding should not be considered as
  a lifestyle choice but rather as a basic health
  issue.

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whats old is new again

• Much of this information is not new
• AAP recognition of it and emphasis on it IS new
• Carefully chosen wording
• Will the policy statement change behaviors?

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From Inside to OutsidePoem by Rhianna's Dad on
her Behalf. http//laitdamour.eu/index.php?main_pa
gepageid13

• beforeyou were an angel not yet
  incarnate,unfurling your blameless wings inside
  menowyour little body still moulds itselfto
  my shape, mouth an extensionof our continued
  oneness,your soft head nestled in my arm your
  eyelashes moving like butterfliesas you delay -
  your flight - a little - longer

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References

• Breastfeeding and the Use of Human Milk. Section
  on Breastfeeding. Pediatrics Vol. 129 No.3
  March1, 2012. pp. e827-e841
• American Academy of Pediatrics Work Group on
  Breastfeeding. Breastfeeding and the use of human
  milk. Pediatrics 19971001035-39.
• Rowe-Murray, H. J. and Fisher, J. R. (2002), Baby
  Friendly Hospital Practices Cesarean Section is
  a Persistent Barrier to Early Initiation of
  Breastfeeding. Birth, 29 124131.
  doi 10.1046/j.1523-536X.2002.00172.x
• Ip S, Chung M, Raman G, et al Tufts-New England
  Medical Center Evidence-based Practice Center.
  Breastfeeding and maternal and infant health
  outcomes in developed countries. Evid Rep
  Technol Assess (Full Rep). 2007 153(153)1-186.