Early, limited data for early, limited formula use

A small study published in Pediatrics suggests that supplementing newborns with small quantities of formula may improve long-term breastfeeding rates. The results challenge both dogma and data linking supplementation with early weaning, call into question the Joint Commission’s exclusive breastfeeding quality metric, and will no doubt inspire intimations of a formula-industry conspiracy. Before we use this study to transform clinical practice, I think it’s worth taking a careful look at what the authors actually found.

First, I think it’s very important to be clear about what the authors meant by “early limited formula.” The authors used 2 teaspoons of hypo-allergenic formula, given via a syringe, as a bridge for mothers whose infants had lost > 5% of their birthweight and mom’s milk had not yet come in. At UNC, we use donor milk in a similar way, offering supplemental breast milk via a syringe as a bridge until mom’s milk production increases.

The President’s Corner

It Takes a Village and Beyond to Support Breastfeeding

To cite this article:
Arthur I. Eidelman. Breastfeeding Medicine. April 2013, 8(2): 243-244. doi:10.1089/bfm.2013.9993.

Published in Volume: 8 Issue 2: April 10, 2013

Arthur I. Eidelman

—Arthur I. Eidelman, MD, FABM, FAAP

President, Academy of Breastfeeding Medicine

If there is anything that is a measure of the Academy of Breastfeeding Medicine’s (ABM’s) relevance and importance, it is its series of Clinical Protocols in general and the publication in this issue of Breastfeeding Medicine of its latest protocol,¹ entitled “Breastfeeding-Friendly Physician’s Office,” in particular. To remind those who have forgotten and to inform those not in the know, these protocols have been formally accepted for distribution by the National Guideline Clearinghouse (www.guideline.gov) of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services under its mandate to provide a “public resource for evidence based clinical practice guidelines.” No less a testimony to the quality of these protocols and their acceptance as a standard has been the pronouncement in the most recent Policy Statement on “Breastfeeding and the Use of Human Milk”² by the Section of Breastfeeding of the American Academy of Pediatrics that “evidence-based protocols from organizations such as the Academy of Breastfeeding Medicine provide detailed clinical guidance for management of specific issues,” and thus there is no need for the American Academy of Pediatrics to duplicate clinical management protocols.

So what is so special regarding the latest ABM protocol, which on the surface seems to discuss a relatively mundane issue of creating a practice environment that is supportive of breastfeeding, but does not address a clinical issue that might help the physician in the management of a specific maternal–infant dyad? From my perspective it is just this focus that makes this a most important and, I would venture to say, almost revolutionary document.

For one, it acknowledges that from a public health point of view the major problem in our breastfeeding programs is not the breastfeeding initiation rate but rather the precipitous drop in the breastfeeding rates after discharge from the hospital, the all too short duration of any breastfeeding, let alone the rate of exclusively feeding human milk. (As a reminder, in the United States the averaged initiation rates are over 75%, whereas the “any” breastfeeding rate at 6 months is 44%, and the rate for exclusivity of breastfeeding is 33% at 3 months and only 14% at 6 months, with even lower rates for minority mothers, particularly those of color.)

The “success” of the initiation rates reflects hospital-based public health policies that are best exemplified by the incorporation of the World Health Organization/UNICEF 10 Steps into hospital routines, the Baby-Friendly Initiative, and the decision of the Joint Commission to include the exclusive breastfeeding rate as a Perinatal Core Measure in their assessment of hospital performance and quality. As such, it has become increasingly clear that it is just such successful public health population-based, system-oriented approaches that need to be formulated and standardized for the post-hospital period if we wish to extend the success on initiation beyond the immediate postpartum period into the critical months of early infancy and beyond.

Thus, the evidence-based recommendations that are detailed in this latest ABM protocol are not just welcome but are a major conceptual contribution that will, it is hoped, facilitate the refocusing our efforts and the direction for the investment of resources that will result in maximum public health benefit. As I have mentioned previously, we need to go beyond the management of the individual maternal–infant dyad and create supportive, culturally sensitive, total environments for the support of breastfeeding. That this environment must be “total” and not just a reflection of the individual caretaker’s knowledge or skills is emphasized by the detailed outline in the Protocol of what is necessary to truly become a Breastfeeding-Friendly office.

Most important is the need for the office environment to implement the World Health Organization’s International Code for Marketing of Breast-milk Substitutes regarding use of noncommercial educational material and limiting the visibility of human milk substitutes so as to demonstrate breastfeeding support. In addition, the entire medical, nursing, technical, and administrative staff of the office need be properly trained in their appropriate roles so as to provide a uniform supportive environment. Furthermore, the physician and his or her team must link with other community-based programs while serving as a public advocate for breastfeeding. To paraphrase the well-used dictum “it takes a village to raise a child,”³ and, no less so, it has become increasingly clear that it takes more than the individual health practitioner working in a vacuum to succeed in increasing our breastfeeding rates.

No less important is the fact that this protocol truly reflects the international mission of the ABM. Not only do the recommendations avoid the trap of being too United States–centric, on the contrary, they reflect the reality of the varied healthcare systems and practices that exist worldwide, be it in the length of the postpartum stay in the hospital, the roles of the non-physician provider, patterns of financial compensation and insurance payments for breastfeeding support services, role of family physician versus pediatrician, etc. One need just peruse the reference list to note that this document¹ will truly serve the international audience of ABM.

Thus, the ABM Protocol Committee should be thanked and congratulated for producing this vitally needed document and refocusing our energies for the greater good.

References

1. Grawey AE, Marinelli KA, Holmes AV, Academy of Breastfeeding Medicine. ABM clinical protocol #14: Breastfeeding-friendly physician’s office: Optimizing care for infants and children, revised 2013. Breastfeed Med 2013;8:237–242.

2. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012;129:e827–e841.

3. Lawrence RA. Breastfeeding: It takes a village. Breastfeed Med 2013;8:1–2.

18th Annual International Meeting of the Academy of Breastfeeding Medicine

 

Although the 18th Annual International Meeting of the Academy of Breastfeeding Medicine seems far away, it is approaching quickly. Scheduled for November 21-24, 2013 in Philadelphia at the Sheraton Philadelphia Downtown Hotel, this is a must-do event for providers in maternal and child health. Check back soon for our conference brochure and online registration! The agenda will include world-class speakers who will present up-to-date clinical information on breastfeeding, covering both maternal and child health issues. This is a significant educational opportunity with continuing education credits.

 

Register today.

If you haven’t joined ABM for 2013, now’s a good time to do so. Don’t forget – members are eligible for a discounted registration for the annual meeting.

 

Conference Chairs:

Gail Herrine, MD, FABM

Michelle Brenner, MD

 

 

Re-visiting pacifiers and breastfeeding

A newly published study in Pediatrics  is receiving media attention due to its finding that “restricting pacifier distribution during the newborn hospitalization without also restricting access to formula was associated with decreased exclusive breastfeeding, increased supplemental formula feeding, and increased exclusive formula feeding.”

The study took place in a US hospital’s mother-baby-unit (MBU) before and after implementation of a new institutional policy restricting routine pacifier distribution as part of a breastfeeding support initiative.  (The four other breastfeeding support measures adopted by the MBU included breastfeeding in the first hour after birth, feeding only breast milk in the hospital, keeping infant in same room with mother in the hospital, and giving mother a telephone number to call for help with breastfeeding after discharge.)  Of note, pacifiers were stored in a locked supply management system as part of the new policy, but formula access was not limited in the same way.

The researchers retrospectively examined exclusive breastfeeding rates (as compared to breastfeeding plus supplemental formula, and exclusive formula feeding) before and after the change.   They saw a significant decrease in exclusive breastfeeding (from 79% to 68%) paralleled by significant increases in both formula-supplemented breastfeeding (18% to 28%) and exclusive formula feeding (1.8% to 3.4%).

While it is tempting to conclude “thus pacifier use is necessary in supporting exclusive breastfeeding”, it’s also important to note that the study in question states that “no specific script was instituted to verbally instruct parents on infant soothing techniques” either before or after restricting pacifier use.  Thus it is equally tempting  to conclude that desperate parents will resort to culturally familiar ways to soothe crying newborns — and in US culture, those include bottles and pacifiers.

It would be interesting to see a similar study conducted in a setting that emphasizes supporting parents in learning alternative ways to comfort their babies, such as skin-to-skin care and cue-based breastfeeding.  It might also be interesting to see weight loss at discharge,  and/or jaundice requiring phototherapy, as an outcome measure.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine. She has previously written about pacifiers and breastfeeding in her blog post, “A sucker born every minute:” Pacifiers and breastfeeding.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

The Breastfeeding and Obesity Controversy

Fact or fiction: Is breastfeeding actually linked with a lower risk of childhood obesity? The common thinking for the past several years has been “yes,” based on comprehensive analyses from the US Agency for Healthcare Research and Quality and the World Health Organization. However, two recent articles have disputed these conclusions. Considerable media attention has surrounded new data from the Promotion of Breastfeeding Intervention Trial (PROBIT), published in the Journal of the American Medical Association (JAMA) on March 13, and in a January 31 article in the New England Journal of Medicine (NEJM) on obesity myths by Casazza et al. We discuss both articles’ conclusions, as the public tries to make sense of all the conflicting information.

Establishing the Fourth Trimester

Lisa Selvin’s provocative article, “Is the Medical Community Failing Breastfeeding Moms?” has elicited a wide range of reactions from the breastfeeding community. Some have argued that the piece, which focuses on unmet needs of mothers who encounter physiologic problems with breastfeeding, “sensationalizes” breastfeeding, making it sound so treacherous and difficult that mothers should avoid it altogether.

I would argue that there’s a very fine line between “sensationalizing” and “truth in advertising.” Reproductive biology is imperfect — some couples can’t conceive, and some pregnancies end in miscarriage or stillbirth. The silence around these losses and the isolation that women have historically experienced has probably worsened the suffering for many women. On the other hand, emphasizing these risks and creating a culture of fear harms the majority of mothers who will have successful pregnancies and births.

Building a breastfeeding culture

Breastfeeding take a village. For me, the star of the team is my husband, who stayed at home with our baby and brought him to visit on long weekend shifts.

I started my internship in Ob/Gyn the day my first child turned three months old, walking down Brookline Avenue to Brigham and Women’s Hospital with a Pump-in-Style slung on my back and a vague determination to breastfeed. The first day of orientation, I went hunting for the lactation room I’d been told was on the 15^th floor of the hospital, only to learn that it had been closed months ago. Some merciful nurses let me into their break room, and I pumped hunched in a corner, contemplating this inauspicious beginning to working motherhood.

After a few days, I found the actual lactation room (on the 9^th floor of a different building), and I settled into a routine of blending clinical work with every-three-hour breaks. This was before hands-free pumping bras, and I gradually mastered the art of balancing bottles on my knees while answering pages and reviewing patient charts. By the time I had my first overnight call, I’d learned to pre-assemble my pump parts, screwing the flanges onto the bottles at home and covering them with sandwich bags so I could save a few precious seconds.  That first night, I forgot to pack tops for the bottles, and found myself in the newborn nursery and Mass General, where more merciful nurses borrowed tops from sterile water bottles so I could take my milk home.

Another call shift, after an increasingly excruciating six hours of catching babies and writing progress notes, I staggered into the storage closet / pumping room to discover that I had the wrong pump attachment. The midwife on call came to my rescue, tracking down the right tubing and bringing me a tangy cranberry-juice-and-Shasta-ginger-ale cocktail.

Like every mother who juggles pumping and working, I could go on and on– the pumping in airplane bathrooms on long haul flights, the Fed Ex’ing of 100 ounces of pumped milk on dry ice to my in laws when my husband took our son to visit them, and the sweet, sweet comfort of putting my baby to breast after a 36-hour shift.

Most of all, I am grateful – grateful to a confluence of people and circumstances that made it possible for me to continue breastfeeding through my child’s first year and beyond. Eleven years later, I realize that there was not “one thing” that made it possible – in fact, there were multiple factors that helped me succeed. And if we want to build a breastfeeding culture, we need to build multiple influences into every mother’s experience so that she has the best chance of succeeding.