Breastfeeding Support and Promotion Joan Younger Meek, MD, FAAP AAP Section on Breastfeeding The American Academy of Pediatrics strongly supports breastfeeding for virtually all mothers and infants. This presentation is designed to explain  Why breastfeeding is important for babies and their mothers and families and results in optimal health outcomes  How breastfeeding can be best be initiated and supported  The role every health care professional can play in promoting breastfeeding in hospitals, clinics, offices, and the community The author would like to acknowledge members of the Section on Breastfeeding Executive Committee and Rachel Meek for their review of the material in this slide set. The slides may be used for educational purposes with credit to the original source. 1

AAP Policy Statement Role of Pediatricians and Other Health Care Professionals in Protecting, Promoting, and Supporting Breastfeeding Strong position of support based on published evidence of improved outcomes Knowledgeable and skilled in physiology and management of breastfeeding Collaboration with the obstetric community Age-appropriate breastfeeding education in the office and in the school system Because of the well-documented advantages of breastfeeding, the health care professional can take a strong position of advocacy. Pediatric practitioners must be knowledgeable about basic breastfeeding management and should work closely with obstetric professionals to encourage optimal breastfeeding education and practices in their communities. Breastfeeding education should be incorporated into the clinical office setting and the school curriculum so that children learn from an early age that breastfeeding is the normal method of infant feeding.

AAP Policy Statement Role of Pediatricians and Other Health Care Professionals in Protecting, Promoting, and Supporting Breastfeeding Promote hospital policies that facilitate breastfeeding Eliminate mother- infant separation Eliminate formula discharge packs Continuous rooming-in from the time of delivery until hospital discharge encourages optimal breastfeeding. Infant formula should not be offered to breastfed infants in the hospital, unless there is a clear medical indication, nor should breastfeeding mothers be given infant formula or formula coupons to take home from the hospital. Photo © La Leche League International

AAP Policy Statement Role of Pediatricians and Other Health Care Professionals in Protecting, Promoting, and Supporting Breastfeeding Promote community resources Communicate with lactation support personnel Encourage third-party payer coverage for breastfeeding services and supplies Encourage child care providers to support breastfeeding and feeding expressed breast milk Support breastfeeding in the workplace Advocate for supportive legislation Health care practitioners for infants and children should promote the establishment of breastfeeding support groups in the community and work closely with lactation support personnel in the hospital and community settings. Physicians need to advocate for third-party and government payers to cover lactation consultations or breast pump rental when indicated because breastfeeding decreases health care costs. In addition, physicians can work with employers to assist employed mothers in continuing to breastfeed after returning to work.

AAP Policy Statement Role of Pediatricians and Other Health Care Professionals in Protecting, Promoting, and Supporting Breastfeeding Positive media image of breastfeeding Breastfeeding education during medical training Family and societal support for breastfeeding Breastfeeding as cultural norm The pediatric professional should encourage a positive image of breastfeeding in the media. Breastfeeding education should be incorporated into medical education, residency training, and postgraduate continuing medical education. Photo © La Leche League International

Opportunities to Promote Breastfeeding Preconception Education in school systems Pediatric and adolescent visits Gynecologic visits Breast examinations Health care professionals should take advantage of every opportunity to educate patients about breastfeeding and that the breasts are designed to produce milk to nourish the young. Encourage parents to talk with young children about the importance of breastfeeding and good nutrition. This education should occur in the school setting, during routine pediatric and adolescent visits, and during routine gynecologic evaluations of young women. During the breast examination, the health care professional can discuss the role of the breast in milk production and provide reassurance that the young woman appears to have normal anatomy and should be able to breastfeed.

Opportunities to Promote Breastfeeding Early pregnancy Perform breast examination. Discuss normal anatomy and physiology. Assess previous surgeries, scars, biopsies. Talk about previous breastfeeding experiences. Provide positive support for benefits of breastfeeding. The first prenatal visit should include a thorough breast examination and a history of previous breast surgery, as well as previous breastfeeding experiences. The breast examination should include evaluation of nipple configuration, especially inverted nipples, and presence of breast scars. Benefits of breastfeeding should be discussed, with appropriate noncommercial literature provided and referral to breastfeeding classes in the community or at the delivery hospital.

Opportunities to Promote Breastfeeding Prenatal visits Provide appropriate literature, resources. Refer for prenatal and breastfeeding classes. Refer to pediatrician for prenatal visit. Avoid formula coupons or products. During the pregnancy, all mothers should be assisted in making an informed decision about infant feeding. Mothers should be referred for breastfeeding classes to obtain additional education. Mothers with previous breastfeeding problems, anatomic abnormalities, or history of breast surgery may benefit from consultation with a lactation specialist prior to delivery. Mothers should not be given free formula or coupons to obtain formula during pregnancy. Physicians and their office staff should avoid giving patient names and addresses to formula manufacturers or signing pregnant patients up for the formula company clubs.

Opportunities to Promote Breastfeeding Peripartum/postpartum Provide supportive delivery environment. Facilitate early skin-to-skin contact. Place on mother’s abdomen and dry. Have trained professionals to assist mother if needed. Initiate breastfeeding within the first hour after delivery. The majority of mothers have made the decision about how they will feed their infants prior to delivery. But some mothers are undecided. A supportive delivery environment with avoidance of unnecessary medications and early skin-to-skin contact will help to encourage successful initiation of breastfeeding. The baby should be placed on the mother’s abdomen and thoroughly dried while being assessed for stability of the respiratory and cardiac systems. Newborns who have not been sedated by maternal medications during delivery are active and alert during this period. They are capable of locating and self-attaching to the nipple and areola for the first feeding of colostrum. Optimally, breastfeeding should be initiated within the first hour after delivery. Delivery nurses should be knowledgeable about breastfeeding and assist mothers in offering the breast or positioning the baby, especially if the mother has had a difficult or cesarean delivery. This early skin-to-skin contact helps to maintain the baby’s temperature; stabilize the heart rate, respirations, and oxygenation of the baby; and colonize the baby’s skin with maternal skin flora, helping to protect against pathogenic bacteria. The swallowed colostrum colonizes the newborn’s gastrointestinal (GI) tract with beneficial flora, produces an optimal pH in the newborn’s intestine, and protects the lining of the GI tract with secretory IgA. Vitamin K administration, eye prophylaxis, and bathing can be delayed until after this critical first feeding.

Baby Friendly Hospital Initiative Ten Steps to Successful Breastfeeding Hospital Policies to Support Breastfeeding Have 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. Help mothers initiate breastfeeding within the first hour of birth. Show mothers how to breastfeed and maintain lactation, even if separated from infants. Hospital policies have been shown to affect the initiation and continuation of breastfeeding. The “Ten Steps to Successful Breastfeeding” of the Baby Friendly Hospital Initiative, originally developed and supported by the United Nations Children’s Fund (UNICEF), the World Health Organization, Wellstart International, and many other organizations, provide a summary of those policies. The Ten Steps are evidence-based practices which have been shown to increase rates of breastfeeding, and they have been endorsed by the American Academy of Pediatrics http://www.babyfriendlyusa.org/eng/10steps.html

Hospital Policies to Support Breastfeeding Baby Friendly Hospital Initiative Ten Steps to Successful Breastfeeding Hospital Policies to Support Breastfeeding Give newborn infants nothing other than breast milk, unless medically indicated. Practice rooming-in 24 hours a day. Encourage breastfeeding on demand. Give no artificial nipples or pacifiers. Foster the establishment of breastfeeding support groups. Hospital policies that support breastfeeding have been demonstrated to have a significant effect on breastfeeding initiation and continuation rates. Baby Friendly USA has developed a pathway for becoming certified as a Baby Friendly Hospital in the US. The National Initiative for Children’s Health Quality is providing technical support for hospital who wish to become certified through the Best Fed Beginnings: http://www.nichq.org/our_projects/cdcbreastfeeding.html http://www.babyfriendlyusa.org/eng/10steps.html

Percentage of US hospitals with Recommended Policies and Practices to Support Breastfeeding, 2007 and 2009 The CDC provides feedback for maternity hospitals on their compliance with evidence-based maternity care policies. This survey, collected by self-assessment, is conducted every other year. The 2011 survey will be released in 2012. The previous studies have indicated that many hospitals do not have the policies in place to provide optimal breastfeeding support. SOURCE: CDC National Survey of Maternity Practices in Infant Nutrition and Care (mPINC)

Percentage of hospitals by number of recommended policies and practices to support breastfeeding in 2009

Less than 5% of all babies are currently born in a Baby Friendly designated facility.

The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding The Joint commission defines exclusive breast milk feeding as: “a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines” includes expressed mother’s milk as well as donor human milk, both of which may be fed to the infant by means other than suckling at the breast The Joint Commission has included exclusive breast milk feeding in the hospital as a perinatal core measure. The Joint Commission launched a public service campaign, one of their highly successful “Speak Up” Campaigns, aimed at consumers to educate consumers about the maternity care policies they should expect for optimal breastfeeding support. Hospitals should be measuring their rates of breastfeeding as part of their ongoing maternity care quality improvement processes. Guidance on breastfeeding data collection is available from the United States Breastfeeding Committee: http://www.usbreastfeeding.org/HealthCare/HospitalMaternityCenterPractices/ToolkitImplementingTJCCoreMeasure/tabid/184/Default.aspx http://www.jointcommission.org/perinatal_care/

The Joint Commission assesses how many non-NICU babies without a contraindication to breastfeeding were exclusively breast milk fed. Exceptions: Discharged from the NICU ICD-9 code for Galactosemia ICD-9 code for Parenteral infusion Experienced Death Length of stay > 120 days Enrolled in clinical trials Documented Reasons for not exclusively feeding breast milk (See next slide) http://www.jointcommission.org/perinatal_care/

The only acceptable maternal reasons for which “breast milk should be avoided” are as follows: HIV infection Human t-Lymphotrophic virus type I or II Substance abuse and/or alcohol abuse Active, untreated tuberculosis Taking certain meds: chemotherapy, radioactive isotopes, antimetabolites, antiretroviral meds, and other medications where the risk of morbidity outweighs the benefits of breast milk feeding. Undergoing radiation therapy Active, untreated varicella Active herpes simplex virus breast lesions ** In some of these cases the infant can and should be exclusively breast milk fed Hospitals should examine how well they are complying The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding.

The Breastfeeding Friendly Doctor’s Office Encourage women/staff to breastfeed in the office. Display pictures of breastfeeding infants. Avoid distributing infant formula or coupons. Physicians who provide care for young women, pregnant or lactating women, and infants and children should survey their own attitudes and practices concerning lactation. Breastfeeding should be welcomed and encouraged in the office. Women should feel comfortable to breastfeed in the waiting room, but be offered a private room, if desired. Physicians should encourage their staff and associates to breastfeed. Infant formula and coupons should not be distributed in the office. Photo © Joan Meek, MD, FAAP

Community Support Knowledgeable physicians Lactation specialists Hospital support groups WIC programs La Leche League International All health care professionals should become familiar with the sources of support in the local community and refer mothers and families to them as appropriate. Many communities have physicians with special expertise or interest in breastfeeding support who can serve as resources or assist in clinical problem solving when breastfeeding problems arise. Develop partnerships or coalitions with providers of pediatric and obstetric care to ensure complementary breastfeeding policies. The local Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) also can be a valuable source of breastfeeding education and support, as can La Leche League International.

Breastfeeding can be lifesaving for infants during times of disaster, and pediatricians can play a major role in advocating for legislation, community support, and also in increasing initiation and duration of breastfeeding in their local communities. The AAP developed this guidance on “Infant Nutrition During a Disaster.”

This algorithm included in the Infant Feeding During Disaster guideline highlights the feeding decisions available. Clearly, for the mothers already breastfeeding during the time of a natural disaster, infant outcomes are best.

How Long to Breastfeed? Exclusively for the first 6 months of life Continuing for at least the first year of life, with addition of solids Thereafter, for as long as mutually desired by mother and child Many mothers ask how long they should continue to breastfeed their infants. For optimal nutrition, growth, and development, the American Academy of Pediatrics recommends exclusive breastfeeding for about the first 6 months of life; continued breastfeeding for at least the first year of life, with introduction of solids at about 6 months of life; and thereafter, continued breastfeeding for as long as mutually desired. This child, being seen for his 1-year well-child check with his pediatrician, continued to breastfeed and also is taking complementary solids. Breastfeeding into the toddler years and beyond is perfectly normal and acceptable in most cultures and continues to provide benefits to the breastfed child. Photo © Mary Boyd, MD, FAAP AAP Pediatrics 2012;129;e827-41

Summary Breastfeeding is the preferred feeding for almost all infants. Mothers should be informed of the benefits of breastfeeding. Supplementation is rarely indicated and interferes with successful lactation. Breastfeeding should be actively supported and promoted in the medical community and society. Women should feel comfortable continuing to breastfeed for as long as desired. Breastfeeding is preferred feeding for almost all infants. Supplementation is rarely indicated and interferes with successful lactation. Breastfeeding should be actively supported and promoted in the medical community and society. Women should feel comfortable continuing to breastfeed for as long as desired. Breastfeeding is a gift that only a mother can give to her infant. Many mothers who have been successful at breastfeeding report that breastfeeding was an extremely rewarding and meaningful experience to them. Many mothers who did not breastfeed express feelings of regret and even grief that they did not receive the education or support to be successful in meeting their breastfeeding goals. Pediatricians and other health care professionals need to provide education about breastfeeding in their offices and community, empower women to make an informed decision about feeding their infants, and support women during the course of breastfeeding, so that all women desiring to breastfeed can meet their breastfeeding goals and they and their babies can reap the benefits.