Obstacles to Breastfeeding in the US and Strategies for Success Asiya S. Tschannerl, PGY-1

Case Presentation 19yo 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.

Case Presentation Mother 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.

Guidelines are to Breastfeed WHO, UNICEF, AAFP, AAP and ACOG have all composed policy statements strongly supporting breastfeeding Why?                            

Benefits 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 SIDS Immunological- decreases bacterial meningitis, bacteremia, diarrhea, late-onset sepsis, necrotizing enterocolitis, otitis media, respiratory tract infections, urinary tract infections Developmental- improved developmental outcomes in premature infants, increased IQ 6-7points Keister et al, 2008

                           

Benefits of Breastfeeding Maternal Health- decreased risk of breast and ovarian cancers, decreased post-partum bleeding, earlier return to prepregnancy weight, lactation amenorrhea Psychological- analgesic effects during painful procedures Nutritional- species specific, superior to substitutes Keister et al, 2008

Breastfeeding is the physiologic norm for mammalian mothers and babies

Benefits of Breastfeeding Environmental- Decreased disposal of formula cans and bottles Economical- decreases annual health care costs by $3.6billion, decreases cost for public supplementation programs (WIC), decreases sick care visits, decreases maternal work absenteeism And best of all, it is entirely… Keister et al, 2008

FREE!

…and is composed entirely of

…which has led to promotion of breastfeeding worldwide by healthcare agencies

Healthy People 2010 Launched in 2000 by the Department of Health and Human Services Builds on similar initiatives pursued over the preceding two decades A comprehensive, nationwide health promotion and disease prevention agenda Contains 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!

Healthy People 2010 Initiative- Aims for Breastfeeding in the US Aims are for at least 75% of all mothers to attempt breastfeeding 50% to continue any breastfeeding for 6mo 25% to continue any breastfeeding for 1yr 60% exclusive breastfeeding through 3mo 25% exclusive breastfeeding through 6mo WHO, AAFP and AAP support continued breastfeeding up to 2yrs or beyond.

Healthy 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

EXCLUSIVE BREASTFEEDING Health People 2010 Objectives National 2005 Rates in US INITIATION AND DURATION OF BREASTFEEDING 75% of mothers initiating breastfeeding 74.2% +/- 1.2 50% of mothers continuing any breastfeeding of their infant at 6 months of age 43.1% +/- 1.3 25% of mothers continuing any breastfeeding of their infant at 12 months of age 21.4% +/- 1.1 EXCLUSIVE BREASTFEEDING 60% of mothers exclusively breastfeeding their infant through 3 months of age 31.5% +/- 1.3 25% of mothers exclusively breastfeeding their infant through 6 months of age 11.9% +/- 0.9 CDC, 2008

Exclusive Breastfeeding at 6 months 2000 2005 CDC, 2008

Breastfeeding Rates (any) in US                                                                                                                     CDC, 2008

Exclusive Breastfeeding Rates in US                                                                                                                  CDC, 2008

Disparities in Breastfeeding The following groups have the lowest breastfeeding rates: Non-Hispanic blacks Low maternal education Poverty income ratio <100% Receiving WIC Age <20yrs Unmarried CDC, 2008

Discontinuation 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

Obstacles to Breastfeeding Initiation and Continuation                                                             

Lack of confidence in breastfeeding Lack of prenatal breastfeeding education Nipple pain and ineffective latch Perceived insufficient milk supply Early formula supplementation Lack of early skin-skin contact and early breastfeeding Lack of support from hospital staff Lack of social support Not recognizing early hunger cues Engorgement or mastitis Returning to work Concerns about public breastfeeding Media portrayal of bottle feeding as the norm

Lack 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

Lack of Prenatal Breastfeeding Education A prenatal educational program is the most effective intervention to promote initiation of breastfeeding is A 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

Nipple Pain and Ineffective Latch Breastfeeding should not be painful Pain is often result of ineffective positioning and latch, which can damage the nipple Correct positioning will have infant well supported at level of the breast, nose to nipple Correct latch will be asymmetric with more areola visible above infant’s mouth Nipple must reach until infant’s junction of hard and soft palate Infant’s chin should touch the breast                      http://www.ameda.com/breastfeeding

Perceived Insufficient Milk Supply Occurs in 50% of mothers and is a frequent cause of early discontinuation of breastfeeding This perception may be real to many mothers but often is not valid Patients may think milk supply is inadequate because of soft breasts after birth Normal physiology is for breast milk to increase over first several days, usually accompanied by breast fullness Breast fullness then lessens after the 2nd week but does not indicate decrease in milk supply International Lactation Consultant Association, 2005

The first 24hrs Mothers produce 30-100 ml of colostrum in the first 24 hours, with only 2-10 ml per feeding on day 1 So how will that fill the infant? International Lactation Consultant Association, 2005

Infant Stomachs are Very Small! Day 1 Size of marble Capacity 5-7ml Day 3 Size of ping pong ball Capacity 22-27ml Day 10 Size of extra large chicken egg Capacity 22-27ml http://www.ameda.com/breastfeeding/started/stomach.aspx

                            

Perceived Insufficient Milk Supply Mothers should feed infants on demand, at least every 3hrs, with each feeding lasting 20-30mins, this will help produce more milk The first few weeks are critical to establishing the milk supply International Lactation Consultant Association, 2005

Signs 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 10 At least 3 bowel movements per 24hrs after day 1 Bowel movements that go from black meconium on day 1 to seedy yellow by day 5 At least 6 clear urinations per day by day 4 Satisfied and content after feedings Audible swallowing during feedings International Lactation Consultant Association, 2005

Signs 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 5 Nipples show no evidence of damage Breast fullness relieved by breastfeeding International Lactation Consultant Association, 2005

Lack 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

                                       

Lack 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

Early 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 demand Plastic 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

Lack 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?

The 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, http://www.babyfriendlyusa.org/eng/03.html

The 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, http://www.babyfriendlyusa.org/eng/03.html

The 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 clinic Baby Friendly USA, http://www.babyfriendlyusa.org/eng/03.html

Designation as a Baby-Friendly Institution Designation as ‘Baby-Friendly’ can only occur with Implementation of the 10 steps to support successful breastfeeding and Commitment to not use free or low-cost breastmilk substitutes, feeding bottles or teats Baby Friendly USA, http://www.babyfriendlyusa.org/eng/03.html

No Free Formula Samples or Coupons! Convincing hospital administrators to pay for something they can get for free may be difficult But has potential for maintaining breastfeeding initiation rates above 80%* *Merewood et al, 2005

                                 

Prevalence 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, http://www.babyfriendlyusa.org/eng/03.html

Successes of BFHI In 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%. http://www.unicef.org/programme/breastfeeding/baby.htm

Successes of BFHI In 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* http://www.unicef.org/programme/breastfeeding/baby.htm; *Phillip et al, 2001

What 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.

Unique 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.

Breastfeeding Helplines US Dept of Health and Human Services 1-800-994-9662 in English and Spanish La Leche League, present in every state and worldwide http://www.lllusa.org

What did you learn today? Can you identify all the risk factors for breastfeeding discontinuation in the case presented earlier?

Case revisited 19yo 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.

Case revisited Mother 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.

References Anderson GC et al, 2003. Early Skin-skin Contact for Mothers and their Healthy New-born Infants. Cochrane Database Syst Rev. 2:CD003519 Baby Friendly USA. http://www.babyfriendlyusa.org/eng/03.html, last accessed on 9/22/08. Center for Disease Control and Prevention, 2008. Breastfeeding Among U.S. Children Born 1999—2005, CDC National Immunization Survey. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm last accessed 9/21/08 Ertem IO et al, 2001. The timing and predictors of the early termination of breastfeeding. 107(3):543-548 Gagnon AJ et al, 2005. In-hospital formula supplementation of healthy breastfeeding newborns. J Hum Lact 21(4):397-405 Gartner LM et al. American Academy of Pediatrics: Breastfeeding and the use of Human Milk. Pediatrics. 115(2):496-506 Guise JM et al, 2003. 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):70-78 Hill PD et al, 1997. Does early supplementation affect long-term breastfeeding? Clin Pediatr 36(6):345-350 Keister D et al, 2008. Strategies for Breastfeeding Success. Am Fam Phys 78(2):225-232

References Merewood A et al, 2005. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics 116(3):628-634 Meyers D, Turner-Maffel C, 2008. Improved Breastfeeding Success through the Baby-Friendly Hospital Initiative. Am Fam Phys 78(2):180-181 Moore ER et al, 2007. Early Skin-skin Contact for Mothers and their Healthy Newborn Infants. Cochrane Database Syst Rev. 3:CD003519 Phillipp BL et al, 2001. Baby-friendly Hospital Initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics 108(3):677-681 Phillipp BL, Merewood A, 2004. The Baby-Friendly Way: the best breastfeeding start. Pediatr Clin North Am. 51(3):761-783 Pisacane A et al, 2005. A Controlled Trial of the Father’s Role in Breastfeeding Promotion. Pediatrics 116(4):494-498 Sinusas K, 2008. Why can’t I get my patients to exclusively breastfeed their babies? Am Fam Phys 78(2):265-268 United Nations Children Fund. The Baby Friendly Hospital Initiative. http://www.unicef.org/programme/breastfeeding/baby.htm last accessed 9/21/08 Wolfberg AJ et al, 2004. Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention. Am J Obstet Gynecol 191(3):708-712