Presentation on theme: "Obstacles to Breastfeeding in the US and Strategies for Success"— Presentation transcript:
1Obstacles to Breastfeeding in the US and Strategies for Success Asiya S. Tschannerl, PGY-1
2Case Presentation19yo African American female P1 s/p uncomplicated spontaneous vaginal delivery of healthy baby girl at Weiler hospital in NYC.Mother did not have skin-skin contact or attempt breastfeeding until 4hrs post partum.It is now post-partum day 1, and mother is having difficulty breastfeeding. She does not feel that she has enough milk, baby is not latching on properly, and baby is being fed formula to supplement.
3Case PresentationMother is frustrated with breastfeeding, and has only been advised by nurses and physicians to keep trying. She has not met with a lactation consultant.Mother and boyfriend did not attend prenatal breastfeeding classes. She knows that breastfeeding is better for her baby but does not know why. Her boyfriend and family are ambivalent about breastfeeding.Mother did not finish high school, has WIC. Plans to use both breastfeeding and formula feeding at home.
4Guidelines are to Breastfeed WHO, UNICEF, AAFP, AAP and ACOG have all composed policy statements strongly supporting breastfeedingWhy?
5Benefits of Breastfeeding Disease prevention- reduces risk of asthma, Hodgkin’s disease, hypercholesterolemia, leukemia, obesity, types 1&2 diabetes, reduces hospitalizations for lower respiratory illnesses and SIDSImmunological- decreases bacterial meningitis, bacteremia, diarrhea, late-onset sepsis, necrotizing enterocolitis, otitis media, respiratory tract infections, urinary tract infectionsDevelopmental- improved developmental outcomes in premature infants, increased IQ 6-7pointsKeister et al, 2008
7Benefits of Breastfeeding Maternal Health- decreased risk of breast and ovarian cancers, decreased post-partum bleeding, earlier return to prepregnancy weight, lactation amenorrheaPsychological- analgesic effects during painful proceduresNutritional- species specific, superior to substitutesKeister et al, 2008
8Breastfeeding is the physiologic norm for mammalian mothers and babies
9Benefits of Breastfeeding Environmental- Decreased disposal of formula cans and bottlesEconomical- decreases annual health care costs by $3.6billion, decreases cost for public supplementation programs (WIC), decreases sick care visits, decreases maternal work absenteeismAnd best of all, it is entirely…Keister et al, 2008
14Healthy People 2010Launched in 2000 by the Department of Health and Human ServicesBuilds on similar initiatives pursued over the preceding two decadesA comprehensive, nationwide health promotion and disease prevention agendaContains 467 objectives designed to serve as a framework for improving the health of all people in the United States during the first decade of the 21st century, and breastfeeding is one of them!
15Healthy People 2010 Initiative- Aims for Breastfeeding in the US Aims are for at least75% of all mothers to attempt breastfeeding50% to continue any breastfeeding for 6mo25% to continue any breastfeeding for 1yr60% exclusive breastfeeding through 3mo25% exclusive breastfeeding through 6moWHO, AAFP and AAP support continued breastfeeding up to 2yrs or beyond.
16Healthy People 2010 Initiative- Aims for Breastfeeding in the US Data from 2005 show that we are close to achieving the initiation and continuation rates, but are well short of the exclusive breastfeeding rates
17EXCLUSIVE BREASTFEEDING Health People 2010 ObjectivesNational 2005 Rates in USINITIATION AND DURATION OF BREASTFEEDING75% of mothers initiating breastfeeding74.2% +/- 1.250% of mothers continuing any breastfeeding of their infant at 6 months of age43.1% +/- 1.325% of mothers continuing any breastfeeding of their infant at 12 months of age21.4% +/- 1.1EXCLUSIVE BREASTFEEDING60% of mothers exclusively breastfeeding their infant through 3 months of age31.5% +/- 1.325% of mothers exclusively breastfeeding their infant through 6 months of age11.9% +/- 0.9CDC, 2008
21Disparities in Breastfeeding The following groups have the lowest breastfeeding rates:Non-Hispanic blacksLow maternal educationPoverty income ratio <100%Receiving WICAge <20yrsUnmarriedCDC, 2008
22Discontinuation Rates In the 1st week after birth - 25%Between 1st and 2nd week - 10%Between 2nd week and 2mo - 40%Why?Ertem et al, 2001
23Obstacles to Breastfeeding Initiation and Continuation
24Lack of confidence in breastfeeding Lack of prenatal breastfeeding educationNipple pain and ineffective latchPerceived insufficient milk supplyEarly formula supplementationLack of early skin-skin contact and early breastfeedingLack of support from hospital staffLack of social supportNot recognizing early hunger cuesEngorgement or mastitisReturning to workConcerns about public breastfeedingMedia portrayal of bottle feeding as the norm
25Lack of Confidence in Breastfeeding This is the cause of most early discontinuations*Earlier postpartum follow-up visits, at 3-5 days and at 7-14 days, can provide an opportunity for the physician to intervene, help with any issues and reinforce the importance of continued breastfeeding***Ertem et al, 2001; **Guise et al, 2003
26Lack of Prenatal Breastfeeding Education A prenatal educational program is the most effective intervention to promote initiation of breastfeeding isA systematic review and meta-analysis found that for every 3-5 women attending a program, one additional mother would initiate and continue breastfeeding for up to 3 months*.*Guise et al, 2003
27Nipple Pain and Ineffective Latch Breastfeeding should not be painfulPain is often result of ineffective positioning and latch, which can damage the nippleCorrect positioning will have infant well supported at level of the breast, nose to nippleCorrect latch will be asymmetric with more areola visible above infant’s mouthNipple must reach until infant’s junction of hard and soft palateInfant’s chin should touch the breast
28Perceived Insufficient Milk Supply Occurs in 50% of mothers and is a frequent cause of early discontinuation of breastfeedingThis perception may be real to many mothers but often is not validPatients may think milk supply is inadequate because of soft breasts after birthNormal physiology is for breast milk to increase over first several days, usually accompanied by breast fullnessBreast fullness then lessens after the 2nd week but does not indicate decrease in milk supplyInternational Lactation Consultant Association, 2005
29The first 24hrsMothers produce ml of colostrum in the first 24 hours, with only 2-10 ml per feeding on day 1So how will that fill the infant?International Lactation Consultant Association, 2005
30Infant Stomachs are Very Small! Day 1Size of marbleCapacity 5-7mlDay 3Size of ping pong ballCapacity 22-27mlDay 10Size of extra large chicken eggCapacity 22-27ml
32Perceived Insufficient Milk Supply Mothers should feed infants on demand, at least every 3hrs, with each feeding lasting 20-30mins, this will help produce more milkThe first few weeks are critical to establishing the milk supplyInternational Lactation Consultant Association, 2005
33Signs of Effective Breastfeeding in the Infant Wt loss <7% with no wt loss after day 3, wt gain by day 5, and back to birth wt by day 10At least 3 bowel movements per 24hrs after day 1Bowel movements that go from black meconium on day to seedy yellow by day 5At least 6 clear urinations per day by day 4Satisfied and content after feedingsAudible swallowing during feedingsInternational Lactation Consultant Association, 2005
34Signs of Effective Breastfeeding in the Mother Noticeable increase in firmness, weight and size of breasts and noticeable increase in milk volume and composition by day 5Nipples show no evidence of damageBreast fullness relieved by breastfeedingInternational Lactation Consultant Association, 2005
35Lack of Social Support for Breastfeeding RCTs have showed partner education resulted in an 33% increase of breastfeeding initiation*One RCT showed that partner support resulted in a 10% increase of exclusive breastfeeding at 6mo***Wolfberg et al, 2004, **Pisacane et al, 2005
37Lack of Skin-skin Contact and Early Breastfeeding A 2003 Cochrane Review found that immediate skin-to-skin contact between mother and newborn improves breastfeeding outcomes.* Other benefits include improved maternal affectionate behavior, attachment and shorter infant crying times.**The AAP recommends that postpartum breastfeeding occur within the first hour of life, even if weighing, bathing, or administering medications are delayed.^*Anderson et al, 2003; **Moore et al, 2007;^Gartner et al, 2005
38Early Formula Supplementation One study showed highest rates of formula supplementation occurring between 7pm-9am, regardless of the time of birth, to allow the mother to “get some rest”.*Another study showed that one or more formula feedings can adversely affect breastfeeding duration.**Formula feedings decrease breastmilk supply because of reduced demandPlastic nipples provide instant gratification of milk, may accustomize infants to its texture and to suckle softer, making it difficult to go back to the breast*Gagnon et al, 2005; **Hill et al, 1997
39Lack of Support from Hospital Staff Facilities that adopt the Baby Friendly Hospital Initiative (BFHI) have shown higher rates of breastfeeding initiation.What is the BFHI?
40The Baby Friendly Hospital Initiative Global program launched by WHO and UNICEF in 1991 to encourage and recognize hospitals and birthing centers that offer an optimal level of care for lactation.The BFHI assists hospitals in giving breastfeeding mothers the information, confidence, and skills needed to successfully initiate and continue breastfeeding their babies and gives special recognition to hospitals that have done so.Baby Friendly USA,
41The Baby Friendly Health Initiative Promotes the Ten Steps to Successful Breastfeeding for Hospitals, as outlined by UNICEF/WHO:1 - Maintain a written breastfeeding policy that is routinely communicated to all health care staff.2 - Train all health care staff in skills necessary to implement this policy.3 - Inform all pregnant women about the benefits and management of breastfeeding.4 - Help mothers initiate breastfeeding within one hour of birth.Baby Friendly USA,
42The Baby Friendly Health Initiative 5 - Show mothers how to breastfeed and maintain lactation, even if separated from their infants.6 - Give infants no food or drink other than breastmilk, unless medically indicated.7 - Practice “rooming in” together 24 hours a day.8 - Encourage unrestricted breastfeeding.9 - Give no pacifiers or artificial nipples to breastfeeding infants.10 - Foster establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicBaby Friendly USA,
43Designation as a Baby-Friendly Institution Designation as ‘Baby-Friendly’ can only occur withImplementation of the 10 steps to support successful breastfeedingandCommitment to not use free or low-cost breastmilk substitutes, feeding bottles or teatsBaby Friendly USA,
44No Free Formula Samples or Coupons! Convincing hospital administrators to pay for something they can get for free may be difficultBut has potential for maintaining breastfeeding initiation rates above 80%**Merewood et al, 2005
46Prevalence of Baby-Friendly Facilities Since the BFHI began, more than 15,000 facilities in 134 countries have been awarded Baby-Friendly status. In many areas where hospitals have been designated Baby-Friendly, more mothers are breastfeeding their infants, and child health has improved.As of 9/08, there are 67 baby friendly hospitals in the US. New York City’s Harlem Hospital was recently awarded baby friendly status, and is the only such hospital in NYC.**Baby Friendly USA,
47Successes of BFHIIn Cuba, 49 of the country's 56 hospitals and maternity facilities are Baby-Friendly, and rates of exclusive breastfeeding at 4 months tripled in 6 years - from 25% in 1990 to 72% in 1996.In the first 2 years of BFHI implementation at Central Hospital in Gabon, cases of neonatal diarrhea fell by 15%, diarrheal dehydration declined by 14% and infant mortality fell by 8%.
48Successes of BFHIIn China, which now has more than 6,000 Baby-Friendly Hospitals, exclusive breastfeeding in rural areas rose from 29% in 1992 to 68% in 1994; in urban areas, the increase was from 10% to 48%.In the US, Boston Medical Center increased breastfeeding initiation rates in black women from 34% in 1995 to 74% in 1999 after implementing BFHI**Phillip et al, 2001
49What can we do if we’re not in a Baby-Friendly facility? Physicians can write orders specifying immediate skin-skin contact, initiation of breastfeeding in 1st hr of life, no formula supplementation or pacifier use.*Twice daily evaluations of breastfeeding by skilled health professionals also improves breastfeeding initiation.***Keister et al, 2008; **Phillipp, Merewood, 2004.
50Unique Role as Family Physicians Opportunity to emphasize breastfeeding education beginning with preconception visits and continuing throughout prenatal care, delivery, postpartum care, and during ongoing care of the family.In caring for a mother's immediate and extended family, a family physician should encourage her social support system to support breastfeeding.
51Breastfeeding Helplines US Dept of Health and Human Services in English and SpanishLa Leche League, present in every state and worldwide
52What did you learn today? Can you identify all the risk factors for breastfeeding discontinuation in the case presented earlier?
53Case revisited19yo African American female P1 s/p uncomplicated spontaneous vaginal delivery of healthy baby girl at Weiler hospital in NYC.Mother did not have skin-skin contact or attempt breastfeeding until 4hrs post partum.It is now post-partum day 1, and mother is having difficulty breastfeeding. She does not feel that she has enough milk, baby is not latching on properly, and baby is being fed formula to supplement.
54Case revisitedMother is frustrated with breastfeeding, and has only been advised by nurses and physicians to keep trying. She has not met with a lactation consultant.Mother and boyfriend did not attend prenatal breastfeeding classes. She knows that breastfeeding is better for her baby but does not know why. Her boyfriend and family are ambivalent about breastfeeding.Mother did not finish high school, has WIC. Plans to use both breastfeeding and formula feeding at home.
55ReferencesAnderson GC et al, Early Skin-skin Contact for Mothers and their Healthy New-born Infants. Cochrane Database Syst Rev. 2:CD003519Baby Friendly USA. last accessed on 9/22/08.Center for Disease Control and Prevention, Breastfeeding Among U.S. Children Born 1999—2005, CDC National Immunization Survey. last accessed 9/21/08Ertem IO et al, The timing and predictors of the early termination of breastfeeding. 107(3):Gagnon AJ et al, In-hospital formula supplementation of healthy breastfeeding newborns. J Hum Lact 21(4):Gartner LM et al. American Academy of Pediatrics: Breastfeeding and the use of Human Milk. Pediatrics. 115(2):Guise JM et al, The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Preventive Services Task Force. Ann Fam Med 1(2):70-78Hill PD et al, Does early supplementation affect long-term breastfeeding? Clin Pediatr 36(6):Keister D et al, Strategies for Breastfeeding Success. Am Fam Phys 78(2):
56ReferencesMerewood A et al, Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics 116(3):Meyers D, Turner-Maffel C, Improved Breastfeeding Success through the Baby-Friendly Hospital Initiative. Am Fam Phys 78(2):Moore ER et al, Early Skin-skin Contact for Mothers and their Healthy Newborn Infants. Cochrane Database Syst Rev. 3:CD003519Phillipp BL et al, Baby-friendly Hospital Initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics 108(3):Phillipp BL, Merewood A, The Baby-Friendly Way: the best breastfeeding start. Pediatr Clin North Am. 51(3):Pisacane A et al, A Controlled Trial of the Father’s Role in Breastfeeding Promotion. Pediatrics 116(4):Sinusas K, Why can’t I get my patients to exclusively breastfeed their babies? Am Fam Phys 78(2):United Nations Children Fund. The Baby Friendly Hospital Initiative. last accessed 9/21/08Wolfberg AJ et al, Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention. Am J Obstet Gynecol 191(3):