Breastfeeding Medicine

Physicians blogging about breastfeeding

Evidence is Clear: Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in the US and Closes Breastfeeding Disparities

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By Melissa Bartick, MD, MSc and Nathan Nickel, MPH, PhD

The US Preventative Services Task Force (USPSTF) published its recommendations regarding breastfeeding promotion in the October 25, 2016 issue of JAMA, recommending individual efforts at breastfeeding promotion, but pointedly noting that systemic promotion efforts, such as the Baby-Friendly Hospital Initiative (BFHI), were outside its scope. The accompanying literature review, performed by the USPSTF team, purposely looked only at two trials of BFHI and a few randomized trials of its component Ten Steps, and concluded there was mixed evidence to support BFHI. The two trials they reviewed on BFHI both supported its efficacy, at least in less educated mothers (here and here).  One of the BFHI trials they reviewed was an observational trial, and the other was a before-and-after trial, yet several other US trials with similar methodologies exist which showed positive outcomes, but these were not even mentioned in the  literature review. For example, the literature review did not include this national trial showing a correlation of BFHI with increased breastfeeding rates and excluded national data from the CDC showing rising breastfeeding rates as percentage of live births in Baby-Friendly hospitals rose. The literature review acknowledged that other studies supported the effectiveness of BFHI. However, an accompanying editorial by Flaherman and von Kohorn concluded that interventions such as BFHI “should be reconsidered until good-quality evidence that these interventions are safe and effective.”

Despite the weak literature review, the editorial’s surprising conclusion can in no way be drawn from the evidence presented by the USPSTF, let alone the evidence as a whole. Yet this editorial is what is garnering the most media attention. Interestingly, the editorial does support previous research by one of its authors, Valerie Flaherman, who found that small amounts of formula help women breastfeed longer. This finding, which contradicts previous evidence (here and here) that non-indicated supplemental formula is a strongly associated with breastfeeding failure, would negate Step 6 of the Baby-Friendly Hospital Initiative, “to give no other food or drink besides breast milk without a medical indication.” One of the co-authors of Flaherman’s study disclosed that he worked for several formula companies. Because Flaherman is still conducting similar government-funded research on formula supplementation of breastfed infants, which is incompatible with Baby-Friendly, JAMA should have chosen an editorialist who could be objective about the weight of the evidence on Baby-Friendly as well as include an editorial with an opposing viewpoint in the same publication– especially given the widespread endorsement of the Ten Steps among major US and world medical organizations. Read the rest of this entry »

Written by Melissa Bartick, MD, MSc

November 7, 2016 at 7:38 am

A tribute to Miriam H. Labbok

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Dr. Miriam Harriet Labbok (1949-2016)

On behalf of ABM founders and as their representative on the ABM Board of Governors, I wish to celebrate the life and vitality of Miriam Harriet Labbok, MD, MPH, IBCLC and a co-founder of the ABM. On August 13, 2016 she lost a sudden and rapid battle, all the while showing great tenacity, fortitude, and sense of humor. These inspiring traits are reflected in her 40 years of supporting the mother-infant dyad as an internationally respected and influential expert on breastfeeding and maternal and child health.

Miriam Labbok’s personality was reflective of her New Jersey roots: outspoken, forthright and passionate. Her academic training reflected her integrative strengths and passion for preventive healthcare with a worldwide vision. She graduated from the University of Pennsylvania and received her M.D. and M.P.H. degrees from Tulane University. Her medical training continued in Occupational Health and Preventive Health. Her initial academic focus was on international application of contraception technology as a process to improve the health of women and their families. Her mentorship with John Queenan, MD, a distinguished Chair of Obstetrics and Gynecology at Georgetown University, rapidly clarified her life passion and focus on breastfeeding as the best primary preventive care intervention and the most important role in child spacing/contraception, especially in countries with fewer resources.

Miriam’s intellect, academic productivity (many chapters in textbooks on maternal and child health and an author of more than one hundred fifty scholarly articles), as well as, her persistent and firm advocacy for her beliefs, lead to her leadership positions supporting breastfeeding at UNICEF and USAID. Early in her career, she recognized the dangers and conflict of interest presented by makers of artificial milk, aka “formula”. One of her greatest successes was her role in galvanizing an international agreement for the Ten Steps to support breastfeeding and reduce the negative influences of the artificial milk manufacturers. Given her international successes and her outspoken beliefs, it is no surprise that Miriam was a co-Founder of the Academy of Breastfeeding Medicine. In her subsequent leadership roles in the ABM and its Board, she always reminded us of WHO Code violations and conflicts of interest and the need for the ABM to be an international organization that compliments and networks with other organizations with similar support for breastfeeding. Until her retirement this spring, Miriam was a Professor of Maternal and Child Health at the University of North Carolina Gillings School of Global Public Health and Director of the School’s Carolina Global Breastfeeding Institute. These titles and positions reflect Miriam’s vision and successes in supporting the breastfeeding mother and her family regardless of geography, culture, religion, or available resources.

As ABM members, we need to emulate her willingness to confront international challenges, collaborate with other supporting organizations, and scrutinize our behaviors and connections for potential “WHO Code” violations. Miriam, thank you for helping us grow.

Edward Newton, MD

Ed Newton, MD, FABM is a maternal-fetal medicine sub specialist and a founder of the Academy of Breastfeeding Medicine.

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

Written by newtoned

September 2, 2016 at 7:05 pm

A tribute to Audrey Naylor

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As the ABM Founders Representative to the ABM Board, I wish to reflect on the personal and professional impact of one of our ABM Founders, Audrey Naylor, DrPH, MPH, MD, who recently passed away (6/23/2016).  Her personality and actions provided an example for all of us to be successful contributors to lactation management and the future success of the ABM. Audrey, as early as the late ‘70’s, recognized the “cascade” effect of training and teaching the teachers, i.e. she was a cofounder and CEO of Wellstart International. An example of her success with Wellstart is the internet breastfeeding training modules which are free online at www.wellstart.org . She focused, as each of us must do now, on educating learners to pass their knowledge on to the next generation of providers. Her model for education recognized that optimal breastfeeding management requires a coordinated multidisciplinary team; physicians practicing alone cannot be successful. This passion was brought to focus in her role as an early and prominent proponent of the Baby Friendly initiative. Audrey believed passionately in the world community. Her voice and passion about breastfeeding has been heard and recognized at UNICEF and the WHO. As a Founder of the ABM, Audrey was a very active proponent for the ABM to be an international organization. While her advocacy has been largely successful, we must continue to act as an international organization and create better ways for us to utilize the unique strengths of every culture/country.

Lastly, Audrey Naylor had the courage, strength of personality, academic credibility, and national/international reputation to be a vocal and active “Champion” of breastfeeding on the national and international stage. While few of us will attain her stellar level of recognition and achievement, each member of the ABM needs to be a vocal and active “Champion” for breastfeeding within our smaller communities. We need to be agents for constructive and positive change, as Audrey always was.

Audrey, thank you for your example and your friendship. We will always remember your professional training and performances as “The Red Nosed Clown” at our annual meetings.

Edward Newton, MD

Ed Newton, MD, FABM is a maternal-fetal medicine sub specialist and a founder of the Academy of Breastfeeding Medicine.

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

Written by newtoned

August 7, 2016 at 10:30 am

Posted in Uncategorized

The Sixth European ABM Conference in Lisbon Portugal—A Win for Organizers and Attendees Alike!

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I returned from a trip to Europe over a week ago tonight, my first stop Lisbon Portugal. I celebrated one of those “big” birthdays in Lisbon, you know, the ones that end in a “0” or a “5” with 230 of my closest friends and colleagues in Breastfeeding Medicine from 23 nations around the globe.  Honestly!!  Well, they were not all there just to celebrate my birthday, although some did stay an extra day just to celebrate the day with us!!

What began this marvelous journey was an invitation from conference organizers Elien Rouw, MD, FABM (Germany), Monica Pina MD, ABM (Portugal), and Reet Raukas MD, ABM (Estonia) to speak at the 6th European Academy of Breastfeeding Medicine Conference, held on June 17-18, 2016 in Lisbon, Portugal.  Dr. Rouw has been behind these regional international conferences from the start, and is the mastermind in organizing them, along with local physicians and other like-minded organizations at various times in the countries in which they have been held.  The success she and her co-coordinators have had is a tribute to their hard work, their desire to bring quality physician education in breastfeeding medicine and related subjects to Academy of Breastfeeding Medicine (ABM) members and other physicians and health care members outside the United States, and their tireless efforts to make these conferences affordable, with little support outside their own “blood, sweat and tears”.  This is in actuality a matter of equity and disparities in our field.  Many US physicians cannot afford to travel to Europe or Asia or Australia yet we expect our non-US colleagues to travel to the US yearly to the Annual conference, which is expensive for many of us even if we live in the US.  So do Dr. Rouw and her European colleagues accomplish their goals?  They most certainly do!!!  If one watches and grabs an airfare when they are at their lowest, even from the US this conference is very affordable, and the bonus is, no matter where you come from, you are treated to a beautiful European city, its gracious hospitality and phenomenal cuisine!

This success has built over the past 10 years. Former conferences have been organized in Germany (2007), Austria (2008), Poland (2010), Italy (2012) and Romania (2013).  The 6th Conference in Lisbon was organized in collaboration with SOS Amamentação Portugal and with support of the city council of Lisbon —the largest thus far, and buzzing with activity!!

The speakers and some attendees from outside Portugal stayed in a wonderful hotel that was noted as not far from the site of the conference. The morning of the 17th a bus was arranged to pick all of us up who were staying at the hotel an hour before the conference started to transport us the short distance to the conference venue, Auditório Polo ArturRavara ESEL, a relatively new site of the nursing school in Lisbon.  After a late arrival, we drove around for quite a while.  Turns out our (native Portuguese) bus driver was lost, because he got the wrong address!  So, we started the first day a bit late. Was this a problem?  Not at all!  Everyone rose to the occasion and soon the conference had begun in a beautiful and comfortable venue and we were all immersed in breastfeeding medicine! Read the rest of this entry »

Written by kmarinellimd

July 28, 2016 at 6:44 am

It’s time to disarm the formula industry

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The WHO Code is turning 35, and this vital public health policy is more critical than ever. The World Health Organization Code of Marketing of Breast Milk Substitutes was passed in 1981 to regulate predatory marketing tactics by infant formula companies. After World War II, formula sales boomed in the US, reaching their apex in the 1970s – the year I was born, just 22 percent of babies were ever breastfed. As they saturated the US market, formula companies looked overseas to expand markets for their products. They promoted formula as a modern, advanced approach to infant feeding, and dressed up sales representatives as nurses in clinics, pushing their product in communities where breastfeeding had been the norm for generations, and where clean water was in short supply.

Companies raked in profits, and babies died in droves. International outrage led the World Health Organization to adapt the Code, which banned marketing of artificial breast milk substitutes to consumers.

The US has never adapted the code, but formula companies did not market directly to consumers until the late 1980s  – when, coincidentally, breastfeeding rates were rising in the US, cutting into formula profits. Today, families are inundated with formula marketing and free samples, and the formula market is big business in the US. Formula sales totaled US$4.8 billion in 2013 – that’s  $1220.69 in sales for each of the 3,932,181 babies born in the United States in 2013. Read the rest of this entry »

Written by astuebe

May 20, 2016 at 4:01 pm

US Public Health guildelines should reflect evidence, not anecdote

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In 2008, the United States Preventive Services Task Force issued the following recommendation with Grade B Evidence: “The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.” Since that time, breastfeeding initiation, continuation, and exclusivity rates have continued to rise, and the number of hospitals designated as Baby Friendly has increased by almost 5-fold.  The ABM Position on Breastfeeding–Revised 2015 indicates that “breastfeeding is, and should be considered, normative infant and young child feeding” and “a human rights issue for both mother and child.”  ABM further states that “children have the right to the highest attainable standard of health,” and “as breastfeeding is both a woman’s and a child’s right, it is therefore the responsibility of the healthcare system . . . to inspire, prepare, and empower as well as support and enable each woman to fulfill her breastfeeding goals and to eliminate obstacles and constraints to initiating and sustaining optimal breastfeeding practices.” ABM calls for an improvement in breastfeeding promotion, protection and support and states that medical professionals have a responsibility to promote, protect, and support breastfeeding as a basic ethical principle.

The American Academy of Pediatrics, in its 2012 Policy Statement on Breastfeeding and the Use of Human Milk concludes that, “research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional 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. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.”

Recently, the USPSTF proposed a new recommendation: “The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding.”  Note that this statement does not state “promote and support,” but just “support.” The task force made a deliberate decision to delete the “promote” from the previous “promote and support.” The evidence review, however, does not support the proposed change. In explanations about this change, a member of the Task Force, Dr. Alex Kemper, as quoted in MedPage Today, stated that “the reason the Task Force made this slight word change is to recognize the importance of a mother doing what she feels is best for her and her baby and not wanting to, for example, make mothers feel guilty or bad if they decide not to breastfeed,” he said. “It’s really a personal choice that needs to be made based on her own personal situation.” Read the rest of this entry »

Written by jymeek

May 11, 2016 at 8:21 am

Should You Sleep Train Your Baby at 2 Months?

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A Wall Street Journal article from May 2, 2016, “Can You Sleep Train Your Baby at 2 Months?, by Sumathi Reddi, a weekly consumer health column writer, quotes a pediatrician who routinely teaches parents to train babies to sleep through the night beginning at age 2 months. Dr. Michel Cohen bases his advice on the experience of training his own children a decade ago.  He encourages other pediatricians in his practice to follow the same advice. Dr. Cohen states that, “It actually works better at 2 months than at 4 months.”

Can you sleep train your baby at 2 months?  Perhaps.  Should you sleep train your baby at 2 months might be the better question.  Evidence on infant sleep and development does not support the practice.  A systematic review conducted in the UK showed that sleep training in the first 6 months of life did not prevent sleep or behavioral problems later on, nor did it protect against postnatal depression. It may even worsen maternal anxiety and lead to further problem crying after 6 months of age. J Dev Behav Pediatr. 2013 Sep;34(7):497-507  Sleep training at 2 months involves a significant increase in infant crying, which is stressful not only for babies, but for the whole family. Middlemiss and colleagues showed that when babies were allowed to “cry it out” at night, this resulted in babies having very high levels of stress hormones, such as cortisol, increasing heart rate and blood pressure. Early Hum Dev. 2012 Apr;88(4):227-32.  Alternatively, babies who learn early on that a caring adult will respond to their crying by feeding and holding are less likely to experience stress and isolation, especially during those early months of life, when brain development and connections between brain cells are occurring in rapid fashion.  Young babies and mothers are hard wired to be together frequently. Read the rest of this entry »

Written by jymeek

May 6, 2016 at 3:00 pm