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

2. 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.

3. 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.

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

5. 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

7. 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

8. Breastfeeding is the physiologic norm for mammalian mothers and babies

9. 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

10. FREE!

11. …and is composed entirely of

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

14. 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!

15. 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.

16. 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

17. 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

18. Exclusive Breastfeeding at 6 months
CDC, 2008

19. Breastfeeding Rates (any) in US
                                                                                                                   
CDC, 2008

20. Exclusive Breastfeeding Rates in US
                                                                                                                
CDC, 2008

21. 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

22. 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

23. Obstacles to Breastfeeding Initiation and Continuation
                                                            

24. 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

25. 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

26. 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

27. 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
                    

28. 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

29. The first 24hrs
Mothers produce 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

30. 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

32. 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

33. 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 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

34. 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

35. 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

37. 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

38. 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

39. 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?

40. 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,

41. 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,

42. 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,

43. 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,

44. 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

46. 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,

47. 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%.

48. 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*
*Phillip et al, 2001

49. 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.

50. 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.

51. Breastfeeding Helplines
US Dept of Health and Human Services in English and Spanish
La Leche League, present in every state and worldwide

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

53. 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.

54. 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.

55. References
Anderson GC et al, Early Skin-skin Contact for Mothers and their Healthy New-born Infants. Cochrane Database Syst Rev. 2:CD003519
Baby 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 9/21/08
Ertem 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):70-78
Hill 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):

56. References
Merewood 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:CD003519
Phillipp 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 9/21/08
Wolfberg AJ et al, Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention. Am J Obstet Gynecol 191(3):