Transcript Breastfeeding and the Use of Human Milk

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
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!
PREVIOUS POLICY STATEMENT
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Published in December, 1997 Pediatrics
AAP’s Work Group on Breastfeeding
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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
SPECIFICS OF PREVIOUS STATEMENT
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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
…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”
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Sounds fairly decent! So what
happened?
BARRIERS
Operative births
 Cost
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Of training
 Of not accepting formula samples
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Lack of “buy in” from key player
 And more …
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FAST FORWARD – WE’RE NOT THERE YET!
January, 2011 – Surgeon General’s Call to Action
 New AAP Policy Statement
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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
WHERE ARE WE?
CDC BREASTFEEDING REPORT CARD
2007
2010 Target
2020 Target
Ever
75.0
75
81.9
6 mos
43.8
50
60.5
1yr
22.4
25
34.1
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
Any BF
Exclusive BF
ROOM FOR IMPROVEMENT
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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
AAP POLICY SPECIFICS:
EPIDEMIOLOGY (NUMBER CRUNCHING)
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AHRQ data highlights:
Pneumonia: risk reduced 72% if exclusive BF > 4mos;
compared to EBF > 6 mos, 4 fold increase in
pneumonia if EBF 4-6 months
 OM: any BF reduces incidence by 23%, EBF > 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 …
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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 mom’s 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
IT JUST GETS BETTER, BABY!
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DM I: up to 30% reduction with 3 mos of EBF
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Theory: early cow’s milk β-lactoglobulin exposure
stimulates immune-mediated process, reaction with
pancreatic β cells
DMII: 40% reduction – self regulation, weight
 Leukemia/lymphoma – correlated with duration
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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!
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Short term:
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Decreased blood loss
Child spacing
Higher risk for post-partum depression of wean early
Long term:
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If NO gestational DM, decreased risk of DM II (412%)
NHANES – decreased RA, cumulative effect
♥
- cumulative BF 12-23 months ->reduced HTN,
hyperlipidemia, CAD and DM
 Cumulative BF > 12 months, 28% decrease in
breast cancer and ovarian cancer
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$: if 90% of US moms EBF x 6 mos, $13
billion/year
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.”
WHY THE CHANGE TO A SOLID 6?
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Outcome differences when EBF 4 vs. 6 months
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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
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No breastfeeding or expressed milk
Galactosemia
 Mom with human T-cell lymphotrophic virus I or II
 Untreated brucellosis
 HIV positive mom in “industrialized world”*
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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
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Diet: 450-500 extra kcal/day
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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?
HOSPITAL CARE
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AAP Sample Hospital Breastfeeding Policy
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Based on WHO’s “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
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BF in first hour, exclusive BH, rooming-in,
avoiding pacifiers, getting phone number for
post-discharge support  increased
breastfeeding duration regardless of
socioeconomic status
THE TEN STEPS TO SUCCESSFUL
BREASTFEEDING, WORLD HEALTH
ORGANIZATION & UNITED NATIONS
CHILDREN’S FUND
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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-in—allow 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.
BUT …
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CDC National survey of > 80% of US hospitals
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Only 37% of US birth centers practice > 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)
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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.”
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
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mom instead of babe)
Fluoride: none for 1st 6 months, then only if water
concentration is <0.3ppm
 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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HERE’S WHAT’S UP, DOC!
“PEDIATRICIAN’S 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
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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
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*applicable to any health care worker
“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”
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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
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, nonbathroom areas to express breast milk during the work day
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.”
WHAT’S OLD IS NEW AGAIN
Much of this information is not new
 AAP recognition of it and emphasis on it IS new
 Carefully chosen wording
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Will the policy statement change behaviors?
FROM INSIDE TO OUTSIDE
POEM BY RHIANNA'S DAD ON HER BEHALF. HTTP://LAITDAMOUR.EU/INDEX.PHP?MAIN_PAGE=PAGE&ID=13
before:
you were an angel not yet incarnate,
unfurling your blameless wings inside me
now:
your little body still moulds itself
to my shape, mouth an extension
of our continued oneness,
your soft head nestled in my arm
your eyelashes moving like butterflies
as you delay - your flight - a little - longer
REFERENCES
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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 1997;100:1035-39.
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: 124–131. doi: 10.1046/j.1523536X.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.