B REASTFEEDING AND THE U SE OF H UMAN M ILK An Update on the AAP Policy Statement A. Ildiko Martonffy, M.D. The Breastfeeding Coalition of South Central Wisconsin April 19, 2012

O BJECTIVES -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!

P REVIOUS P OLICY S TATEMENT Published in December, 1997 Pediatrics AAP’s 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

S PECIFICS OF P REVIOUS S TATEMENT 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 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” Sounds fairly decent! So what happened?

B ARRIERS Operative births Cost Of training Of not accepting formula samples Lack of “buy in” from key player And more …

F AST F ORWARD – WE ’ RE NOT THERE YET ! January, 2011 – Surgeon General’s 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

W HERE ARE WE ? CDC B REASTFEEDING R EPORT C ARD Target2020 Target Any BF Ever mos yr Exclusive BF To 3 mos To 6 mos Worksite support Formula in 1 st 48h

R OOM 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

AAP P OLICY S PECIFICS : EPIDEMIOLOGY ( NUMBER CRUNCHING ) 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

… 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 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 ! DM I: up to 30% reduction with 3 mos of EBF 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 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”

B ETTER FOR M AMA, 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 months ->reduced HTN, hyperlipidemia, CAD and DM Cumulative BF > 12 months, 28% decrease in breast cancer and ovarian cancer $: if 90% of US moms EBF x 6 mos, $13 billion/year

S O … 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.”

W HY 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.”

R ECOGNIZED C ONTRAINDICATIONS 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)

M ORE ABOUT M AMA Diet: extra kcal/day mg 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

S O, HOW DO WE GET THERE ?

H OSPITAL C ARE AAP Sample Hospital Breastfeeding Policy 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 BF in first hour, exclusive BH, rooming-in, avoiding pacifiers, getting phone number for post-discharge support  increased breastfeeding duration regardless of socioeconomic status

T HE T EN S TEPS TO S UCCESSFUL B REASTFEEDING, W ORLD H EALTH O RGANIZATION & U NITED N ATIONS C HILDREN ’ S F UND 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.

B UT … CDC National survey of > 80% of US hospitals 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) 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.”

P ACIFIER P ARTY L INE “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”

V ITAMINS & S UPPLEMENTS 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 1 st 6 months, then only if water concentration is <0.3ppm Iron and zinc containing foods at 6 months for Premies – multivitamin and iron orally

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

H ERE ’ S WHAT ’ S UP, D OC ! “ 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 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

“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

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

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 Will the policy statement change behaviors?

F ROM I NSIDE TO O UTSIDE P OEM BY R HIANNA ' S D AD ON HER B EHALF. 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

R EFERENCES Breastfeeding and the Use of Human Milk. Section on Breastfeeding. Pediatrics Vol. 129 No.3 March1, pp. e827-e841 American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100: 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: /j X 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.