During a time of abundant research surrounding the long term implications of feeding practices in the neonatal period on maternal and child health, it is of utmost importance that healthcare professionals are guided by the best available evidence regarding infant feeding while caring for breastfeeding dyads. We know that despite the recommendations against routine formula supplementation, this practice is commonplace in hospitals worldwide for a myriad of reasons. In developing ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate (Read the protocol here) newborn physiology and management of breastfeeding mothers were highlighted to impress upon healthcare professionals the delicate balance involved in helping mothers establish exclusive breastfeeding in the early postpartum days. Many mothers set out with the goal of exclusive breastfeeding, but still in many countries, few reach their feeding goals. Studies clearly demonstrate that when healthcare teams have a clear understanding of these topics, provide antenatal education, and implement supportive hospital practices, the need for supplementary feedings in term neonates is rare.
Preventing the need for supplementation altogether should be a common goal for all members of the healthcare team. It has been well established in the literature that exclusive breastfeeding protects mothers and infants from various poor health outcomes, is cost effective, and is the physiologic norm. Thus, the authors of this protocol dedicated substantial time and focus on practices that have been shown to reduce this need, which include many of the ten steps required by the Baby Friendly Hospital Initiative. The revised protocol contains an algorithm for caring for the breastfeeding dyad before and during the birth hospital stay and responding to common concerns.
It is important to recognize true medical indications of supplementary feedings as well as the preferred choice and volumes of supplement, which are appropriately outlined in this protocol, re-emphasizing that, while there is a time and place for formula use, a mother’s own expressed milk or donated human milk in volumes that mimic normal breastfeeding physiology are preferable to breast milk substitutes. The preference for donor human milk over formula use has been suggested by the Academy of Breastfeeding Medicine for years, and is further supported by emerging research on the long term health consequences of the infant microbiome and the role that breast milk substitutes may have on individual health outcomes years down the road.
Educating ourselves as healthcare providers about how best to support mothers in their breastfeeding journey is crucial to their success in meeting their personal feeding goals. This revised clinical protocol highlights supporting evidence and contains information and strategies needed to provide state-of-the-art care and support.
October is a busy month for me. I usually travel twice that month, once for the American Academy of Pediatrics Section on Breastfeeding Medicine meeting, and then again for the annual Academy of Breastfeeding Medicine meeting. One of my partners (who doesn’t have children) comes up to me and says: “Why are there so many meetings about breastfeeding? I mean we all know that’s the best thing for babies and we all should recommend it. How many meetings, research studies do you really need?” At first, I was stunned…not bad, not good, just surprised, I guess.
This reminds me of when I had invited Dr. Christina Smillie to Children’s Hospital of the King’s Daughters (CHKD)/Eastern Virginia Medical School (EVMS) to speak at our 1st Virginia AAP Breastfeeding conference in 2009. The first night I had her speak to the MPH school at EVMS. As Dr. Smillie always does, she gave a wonderful talk on the public health reasons, risks of death with sub-optimal breastfeeding, how breastfeeding is natural, etc. After 60 minutes of slides, statistics and videos, a male public health researcher raised his hand and asked: “So why isn’t everyone doing this…why aren’t BF rates at a 100%?” Dr. Smillie and I just smiled knowingly at each other.
After I thought about it, I explained to my partner that while there is so much new research/things discovered about breastmilk and its properties, I told her, that as a field, Breastfeeding Medicine is constantly battling critics and having to ‘prove’ our medicine. Whether it’s against the various industries, hospital systems, colleagues, or even other physicians, Breastfeeding medicine has to prove its worth. I was telling another ABM member about this conversation and I remarked at how I had attended an acne lecture at the AAP conference. As a general academic pediatrician, I wanted to get some new information, learn the research on various conditions that I commonly see in my practice. And it hit me like a ton of bricks. The dermatologist, while very knowledgeable and a good speaker, was quoting statistics from the 70’s and 80’s…that would be 1970/1980. Of course she spoke about the newer drugs being used, but the pathophysiology and meds/ointments used to treat this condition, well that data was over 25 years old! Read the rest of this entry »
“Nobody seems to trust test weights in our unit. What are we doing wrong?”
To “test weigh” a baby means to measure how much milk she has transferred by simply weighing her — clothing, diaper and all — before and after breastfeeding. Test weights are often used in term infants using precise scales such as the Medela BabyWeigh. A few studies have supported the utility of test weights in preterm infants: these include a Swedish study favorably comparing babies cared for in NICUs using test weights vs NICUs that did not (earlier attainment of exclusive breastfeeding and earlier discharge) as well as a small study from the illustrious LCs at my own institution describing the development of a technique for accurately performing test weights.
It still seems, though, that NICU providers and even parents have a tendency to distrust test weights in premies learning to breastfeed. Some of this distrust, especially for the providers, is probably a residuum of earlier studies using less precise scales and/or less consistent, accurate weighing techniques. (It is true that we NICU folks tend to love our numbers, and we prefer that they have as many significant digits as possible.) I suspect another large part of the distrust has to do with the fact that premies who are learning to feed don’t consistently transfer the same volume of milk even when their feeding quality seems to be subjectively “good.” As with learning to walk or talk, learning to feed is an incremental and not a linear process… but when numbers-focused, pattern-seeking people see “inconsistency” in the amount transferred, we think “that can’t be right.” Finally — just perhaps — part of the distrust might be with breastfeeding itself. If we can’t measure it or control it, we can’t trust it. And if parents hear us expressing distrust of breastfeeding, they are probably more likely to distrust it as well. Read the rest of this entry »
Submitted on Behalf of the World Alliance for Breastfeeding Action (WABA) and the Academy of Breastfeeding Medicine (ABM)
Dr Felicity Savage, FABM, Chair of WABA.
Dr Rukhsana Haider, FABM, Co-Chair of WABA.
The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by WHO and UNICEF, with the aim of protecting, promoting and supporting breastfeeding in maternity facilities worldwide. To be designated “Baby-Friendly”, facilities are required to follow the Ten Steps to Successful Breastfeeding and the Code of Marketing of Breastmilk Substitutes.
Since 1991, great progress has been made, and 20,000 maternity facilities world-wide have been designated Baby-Friendly. However, in the last decade, progress has slowed down, and the total number of designated facilities still represents less than one third of all maternities in the world. Also it has been difficult to maintain the necessary standards as the BFHI assessment procedure often lies outside normal hospital accreditation processes.
The 25th Anniversary of the launch of the BFHI seemed an appropriate time to review progress and consider the need for the development of revised or new guidelines. Read the rest of this entry »
While the birth of neonatology was in the late 1800s with the development of the incubator, it was only in the 1970’s when the modern NICU was established with the neonatal respirator. More advanced respirators and other technologic developments, including important medications such as surfactant and nitric oxide, have dramatically improved the outcome of preterm infants. Yet, one of the most important “new developments” to improve the care of these infants, is feeding an exclusive human milk diet. It is now clear that exclusive breastmilk decreases preterm mortality and the incidence of necrotizing enterocolitis, sepsis, BPD and ROP, while increasing infant brain volume and neurodevelopment in infancy, childhood and adolescence.
Therefore, it is noteworthy that three AAP committees, the Committee on Nutrition, the Section on Breastfeeding and the Committee on Fetus and Newborn, the committee that writes policies for neonatologists, combined to write a policy statement supporting the use of pasteurized donor human milk in high risk preterm infants, with priority for those less than 1500 grams, when mother’s milk is not available. It states that the use of donor human milk in preterm infants is consistent with good health care. It recognizes that the use of donor milk is limited by its availability and affordability. It asserts boldly that the use of donor human milk should not be limited by an individual’s ability to pay. It urges health care providers to advocate for policies that assure reimbursement for its cost, while expanding the growth of milk banks by improving governmental and private financial support. Read the rest of this entry »
Every day since 2010, I spend a couple of hours reading and responding to posts in a Facebook group of physician women who are breastfeeding/pumping/advocating called Dr. MILK (www.drmilk.org). And in the last 72 hours our group’s feed of 5200+ international physician mothers has exploded with dozens of deliciously gorgeous #brelfie pics of themselves nursing or pumping for their kids using the concept of the #treeOfLife breastfeeding selfie.
I completely derailed my entire Sunday evening of finishing newborn nursery charts and billing to create my own “Tree of Life” photo with dazzling filters, and I wanted to give credit to the person who came up with the idea. So I did some serious journalistic Googling and found Cassie @keeponboobin (Instagram, Twitter) and tagged her in a series of posts of my own kids from 2012. She wrote back in admiration of my edits (feigned blushing) and reposted my pics to her own account (as is customary in social media etiquette). I asked her to be interviewed for this blog to explain how this viral campaign came to be and how it has changed the landscape of women fearlessly posting bare-breasted nursing photos.
The following are excerpts from our dialogue of her inadvertent campaign to #naturalizeBreastfeeding and give women confidence to share with the world their pride in making milk for their children.
How did this Tree of Life concept unfold?
“After celebrating my 12 month anniversary of nursing my daughter, I wanted to commemorate with a nursing photo that I could hang on the wall. I had recently learned about how breast milk was considered a living organism and that having fascinated me, I chose to try and incorporate that into our photo. We had a rough beginning when we started nursing, so this was something that was truly special to me. I came up with the idea to use Photoshop and create a flower, with the vines going from my breast to her brain. A metaphor for her ‘blossoming’ into this beautiful child. While nursing her one day, I took a photo of her on my cell phone and decided to play around with it, kinda work out the idea I had come up. “
“I was able to add a flower to the photo but didn’t really like the way it looked. That is when I decided to try a tree instead. I gave it a kind of artsy look through the app’s many filters they offer and just fell in love with it. I had originally intended to take a professional photo with my camera and do this all on the computer but I really loved what I had created.” Read the rest of this entry »
Evidence is Clear: Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in the US and Closes Breastfeeding Disparities
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 »