The COVID Mothers Study: How ABM’s Worldwide Network of Physicians Collaborated on Urgent Research

By Melissa Bartick, MD, MS, FABM

This week, the results of the COVID Mothers Study were published in Breastfeeding Medicine, providing more evidence that it may be safe to keep mothers and newborns together and, importantly, that separating them causes significant harm.  Indeed, as the authors point out, the “significantly low rate of [neonatal] hospitalization in the literature indicates it may be nearly impossible to demonstrate a clinical benefit from disrupting Baby-Friendly practices.”

Like other studies involving COVID-19, coordinating and launching this study had to be done quickly, for answers were urgently needed.  As the World Health Organization declared a pandemic on March 11, news stories appeared about infected mothers being forcibly separated from their infants with the rationale of protecting infants from infection, without evidence to support this practice, which violated existing quality standards of maternity care from the World Health Organization.  By the end of March, I, together with Dr. Lori Feldman-Winter, and Dr. Verónica Valdés had planned to gather such evidence. Lori and I had known one another for many years and had collaborated before, and we both met Verónica when she volunteered to help us after I sent out an email to the ABM membership.  Lori and I are Americans; Verónica is Chilean. We met and planned out a study using a survey, initially thinking we would quickly and easily get a large number of respondents by recruiting from social media platforms. Lori was also able to recruit statistical support (Dr. John Gaughan, PhD) and medical student manpower with social media expertise (Nikhil Bhana, B.S.) from her university.

We took full advantage of ABM’s internal communications networks to help us line up people who could translate and distribute the survey. Word of the study spread around the world. Having heard of the study through an Italian ABM member, we were thrilled to be approached by Angela Giusti, PhD of the Italian National Institute of Health (ISS) and Elise Chapin, MEd of the Italian National Committee for UNICEF, and they joined our team. Not long afterward, Dr. Maite Hernández-Aguilar, an ABM member, joined us and became instrumental in getting the survey around Spain, where cases numbers were very high.  Other ABM members in Germany (Dr. Elien Rouw) and Saudi Arabia (Dr. Fouzia AlHreashy) came forward, and still other members led us to contacts that helped with translation and recruitment in Brazil and other parts of Latin America, as well as Asia. This is how we came to meet nursing professor Elysângela Dittz Duarte, RN, PhD of Brazil, an important member of the research team. 

When it became clear that there were not nearly as many birthing women with histories of active COVID as the news led us to believe, we relied on our networks of doctors and their colleagues, including midwives and other health professionals, to get the survey to patients they knew.  We engaged Lucia Jenkins, RN, IBCLC of Baby Café USA to send the survey out immediately via social media to her network of 158 breastfeeding support sites in 28 U.S. States, expanding geographical reach. We are able to engage many American ABM members, including those who worked in COVID “hot spots,” to directly reach their patients. Together, our total sample size of 357 infants is one of the largest to date for a single study, and the neonatal subset of 129 infants, with 84 SARS-CoV-2+ mothers, is among one of the larger sizes for a COVID study.

We could not have done this study without the amazing network that ABM provided, as well as many other people we knew or got to know around the world.  We are grateful to all of them, and to the mothers who took the time to answer our survey.

Academy of Breastfeeding Medicine Publishes New Bedsharing Guidelines

By Melissa Bartick, MD, MSc, FABM

The Academy of Breastfeeding Medicine has released its updated Bedsharing and Breastfeeding Protocol. The protocol presents evidence-based recommendations synthesized by an international collaboration of authorities on the topic who conducted a rigorous review of the literature.

Aimed at physicians and other health care professionals caring for families who have initiated breastfeeding, the protocol recognizes that bedsharing promotes breastfeeding.  In contrast to recommendations by some organizations, breastfeeding mothers and infants are not advised against bedsharing, as long as no hazardous circumstances exist. The protocol emphasizes that all parents should be educated on safe bedsharing, recognizing that bedsharing is very common, and when bedsharing is unplanned, it carries a higher risk of infant death than planned bedsharing.

Hazardous circumstances include sleeping with an adult on a sofa or armchair; sleeping next to an adult impaired by alcohol, medications, or illicit drugs; tobacco exposure; preterm birth; and never having initiated breastfeeding.

The ABM protocol takes a “risk minimization” approach, emphasizing a discussion of risks and benefits of bedsharing with parents. This type of approach is being increasingly adopted in countries such as the UK and Australia. “Having conversations about safe bedsharing is important for removing stigma around the topic and facilitating open and honest dialogue between parents and providers,” says Dr. Lori Feldman-Winter, Professor of Pediatrics at Cooper Medical School in Camden, New Jersey and one of protocol’s authors. Dr. Feldman-Winter serves as co-faculty chair on the National Action Partnership to Promote Safe Sleep (US), and she was also an author of the American Academy of Pediatrics’ 2016 protocol on safe sleep.

ABM was pleased and honored to collaborate with three of the world’s leading experts on this topic: anthropologists Helen Ball and James McKenna, and epidemiologist Peter Blair. Dr. Blair, Professor of Epidemiology and Biostatistics at the University of Bristol (UK) is chair of the International Society for the Study and Prevention of Perinatal and Infant Death (ISPID), and Dr. Ball, Professor of Anthropology at the University of Durham (UK), directs the Durham Infancy & Sleep Centre, as well as serving on ISPID Board. Dr. McKenna is known for his ground-breaking work from his Mother-Infant Sleep Lab at the University of Notre Dame (Indiana, USA). Dr. Kathleen Marinelli, Clinical Professor of Pediatrics at University of Connecticut Medical Center and co-author, was instrumental in arranging the participation of Drs. Blair, Ball and McKenna.

In creating the protocol, we rigorously reviewed all available evidence about risk. In addition, we put the current research and evidence into historical context, noting that solitary sleep and artificial feeding are related and were recent developments in human history. We noted that some marginalized and low-income populations have a higher rate of sudden infant death as well as a higher rate of artificial feeding, thus measures to increase breastfeeding and lower the exposure to hazardous circumstances in these populations are important.

“The welcome fall in unexpected deaths over recent decades has come about through risk reduction advice being closely aligned to the available published evidence. This protocol takes the same approach,” says Dr. Blair. 

Breastfeeding is important for safe infant sleep when bedsharing. “When bedsharing next to their mothers, breastfeeding infants sleep on their backs, and are naturally positioned away from pillows and objects that might obstruct their airways. Breastfeeding mothers form a protective position around their infant,” says Dr. Ball. Dr. Ball’s team provides detailed information for families through the Baby Sleep Information Source.

“Breastfeeding while bedsharing comprises a unique set of behaviors between mother and infant known as ‘breastsleeping,’ which also results in increased time breastfeeding compared to separate sleep,” notes Dr. McKenna.  Breastfeeding is associated with a lower risk of Sudden Infant Death Syndrome.

As the person charged with seeing the protocol through to fruition from writing to approval, I found the process of achieving consensus on the evidence and recommendations to be both challenging and rewarding. It required working closely with many people who held a variety of differing viewpoints and experiences on the topic and finding common ground. We are thus especially satisfied that this protocol represents the best evidence-based and practical recommendations for clinicians. We hope this protocol will be widely used.

Melissa Bartick, MD, MSc is an internist at Cambridge Health Alliance and Assistant Professor at Harvard Medical School. 

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

Baby Friendly Increases Breastfeeding Rates— The Problem with the Fancy Graph Study

By Melissa Bartick, MD, MSc, FABM

Did the Baby-Friendly Hospital Initiative meet its intended goal of increasing breastfeeding across the United States? A recent study claims it failed. The study, published in The Journal of Pediatrics by Bass and colleagues, is replete with fancy statistics and graphs, but the obvious answer is that Baby-Friendly is succeeding.  Anyone interested in breastfeeding knows that breastfeeding rates across the US have risen as the percentage of births in Baby-Friendly Hospitals has risen.  Study after study, including a meta-analysis, have shown the efficacy of the Baby-Friendly Hospital Initiative (BFHI) in increasing breastfeeding rates and improving health outcomes. Furthermore, other studies have shown that the Ten Steps have additive effects in increasing breastfeeding rates.

The problem with the study by Bass and colleagues is that it compared breastfeeding rates among all US states and the percentage of births in Baby-Friendly hospitals among all US states at a single recent point in time. And, not surprisingly, there was no correlation between breastfeeding rates in the different states and the percentage of Baby-Friendly births. Why? For two reasons. First, the very best way to look for the effect of an intervention is with a randomized control trial. This was done with Baby-Friendly in the PROBIT trial, which found that 3 month exclusive breastfeeding rates were 6% in the hospitals without the intervention compared to 43% with implementation of a BFHI-type intervention.  If such a trial isn’t possible, the best way to judge the efficacy of an intervention is to look at the outcomes over time as the intervention is implemented. That way, one can infer cause and effect.

The other reason why the study’s conclusions aren’t valid is that states can have markedly different baseline breastfeeding rates due to a variety of socio-demographic factors, like education, income, and culture.  For example, even before there were many Baby-Friendly Hospitals, Louisiana and Vermont had very different breastfeeding rates. So, course, if you compare their breastfeeding rates to each other as a function of Baby-Friendly, the result will look like nonsense. You can only compare a state to itself over time as Baby-Friendly is implemented. Or you can look at the entire US over time as a function of Baby-Friendly implementation. But you can’t compare Louisiana to Vermont at the same time, which is what these authors did.

As far as the Bass study goes, the authors claimed they tried to minimize a type of bias known as ecological fallacy by controlling for each state’s birth rate. But breastfeeding rates are unaffected by birth rates. It is commonly known that breastfeeding rates are highly affected by sociodemographic factors, yet the authors made no attempt to control for these factors. The CDC reports breastfeeding rates by racial and ethnic groups, and their data shows different racial and ethnic groups have markedly different breastfeeding rates, and we know the populations of different racial and ethnic groups are not evenly distributed among the states. Their study reports sophisticated statistical methods and shows complex figures, complete with mathematical formulae, which gives their study the appearance of professorial authority. Unless one has an advanced degree in biostatistics, the way their methods and findings are displayed may be difficult for most readers to understand. Readers may even fail to notice that the basic premise of their methods is so flawed that the study should have never been performed, let alone published. It is the intellectual equivalence of the “The Emperor Has No Clothes.” The efficacy of an intervention simply cannot be ascertained by looking at one point in time and across populations that are highly diverse.

Here are some statistics to dig deeper, taken from the CDC’s Breastfeeding Report Cards:

In 2007, only 1.8% of US births occurred in Baby-Friendly Hospitals and the US breastfeeding initiation rate was 75% with a 3-month exclusive breastfeeding rate of 33%.  Yet in 2016, 18.3% of US births occurred in Baby-Friendly hospitals and the 2015 initiation rate grew to 83.2% and with a 3-month exclusive rate of 46.9%.  As individual hospitals become Baby-Friendly, they see their exclusive breastfeeding rates at discharge increase markedly.  Achieving certain exclusive breastfeeding rates at discharge is even part of the criteria for becoming a Baby-Friendly hospital, so we know on a micro level that Baby-Friendly increases breastfeeding rates.

For example, in 2004, Louisiana had 0 Baby-Friendly hospitals and a 56.6% initiation rate with an exclusive breastfeeding rate 22.0% at 3 months. By 2016, 12.7% of births occurred in Baby-Friendly facilities, which would leap to 41% in 2018, related to work from the CHAMPS initiative. By 2015, Louisiana’s breastfeeding initiation rate grew to 67% and it’s 3 month exclusive rate grew to 39.6%.

Vermont, by contrast, had an 85.2% breastfeeding initiation rate and 47.3% exclusive breastfeeding at 3 months in 2004, much higher than the national average. By 2015, was at 89.3% and 62.8%.  Vermont had 3.8% of births occur in Baby-Friendly facilities in 2004, and this went up to only 10% in 2015. 

Vermont was starting the breastfeeding race way ahead of Louisiana when Baby-Friendly came in, so a recent snapshot comparing their breastfeeding rates and Baby-Friendly births is meaningless.  In Vermont, breastfeeding has been a normal part of the culture, whereas breastfeeding has historically been seen as unusual in Louisiana. Louisiana has also consistently ranked among the lowest states in household income and education, while Vermont has consistently been ranked as one of the highest.

Vermont’s relatively wealthy, well-educated population may be predisposed to breastfeed at increasing rates over time, despite not having formal Baby-Friendly designation at 90% of its hospitals.   If we only look these states from the current snapshot in time, Louisiana has higher Baby-Friendly “penetrance” with lower breastfeeding rates than Vermont, and we miss the likely impact of Baby-Friendly on that state.   In addition, research shows that Baby-Friendly is important for reducing racial disparities in breastfeeding the Southeastern US.

Multiple previous studies have demonstrated the efficacy of the Baby-Friendly Hospital Initiative and the Ten Steps. Those studies still hold more power than one poorly done study with some fancy graphs.

Blog posts reflect the opinions of individual authors, not ABM as a whole.

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Reclaiming “Breastfeeding” from “Human Milk:” Politics, Public Health, and the Power of Money

If there is one thing that formula makers and breastfeeding advocates agree on, it’s that mother’s milk is amazing stuff. Researchers have identified countless compounds in human milk such as lactoferrin, erythropoietin, docosahexaenoic acid (DHA), immunoglobulins, and human milk oligosaccharides, or HMOs. There are at least one hundred different HMOs in human milk and the infant doesn’t digest any of them—rather they seem to exist to feed the bacteria in the infant’s gut, its “microbiome,” and have some other properties, too.  Each mother secretes unique sets of HMOs for her infant. Often researchers discuss adding HMOs to formula in hopes of transforming the microbiome of a formula fed infant into one that more resembles that of a breastfed infant, as the microbiome of a breastfed infant is thought to better protect against disease.

Research into human milk composition has been exploding, funded by the federal government, private foundations, but especially by the $70 billion infant formula industry and other industries looking for commercial applications for the components of human milk. The motives for research might vary: to help understand why breastfeeding is truly superior; to help use components of human milk to fight diseases in infants, children and adults; or to synthesize components of human milk in order to add them to infant formula. The US government’s interest in human milk composition revolves around ensuring that infant formulas meet minimal nutritional requirements.

At the heart of the study of milk composition is the distinction between “human milk” and “breastfeeding.” The term “human milk” disembodies the substance from the precious act of nurturing, bonding, and intimacy between a mother and child. Language around “human milk,” as opposed to “breastfeeding,” is often used by entities concerned with breast pumps and infant formula, as well as for the necessary provision of milk for infants too tiny to suckle at the breast.

For breastfeeding advocates, the dark side of research on human milk composition is its application to the formula industry. The biggest recent application has been the synthesis of HMOs, which have been patented and added to formula, now for sale on supermarket shelves where they cost at least 30% morethan formulas without HMOs. It is unclear if these products are actually better for babies, even though they might technically resemble human milk slightly more than formula without HMOs. But given that genuine mother’s milk has unique HMOs for a unique infant, it’s unclear which HMOs a manufacturer should even be adding to a formula. So, is this product actually better, or is this just a marketing ploy and an excuse to mark up the price?

Worldwide study on sudden infant death finds factors associated with poverty and racism are more important than bedsharing

Last week, we published our novel study, “Sudden Infant Death and Social Justice: A Syndemics Approach,” showing that bedsharing – which has been the main focus of many interventions – is not the primary risk behind sudden infant death.

Instead, factors associated with poverty and racism have much more to do with Sudden Unexplained Infant Death (SUID), which includes suffocation, and its subset, SIDS (Sudden Infant Death Syndrome). Looking at populations around the world and the known risk factors for sudden infant death, we found that the vast majority of infants dying are from poor or marginalized populations, especially people who have experienced historical trauma. On the other hand, many wealthy and privileged populations have high rates to moderate rates of bedsharing,like Asian Americans and Swedes, yet have some of the lowest rates of SUID/SIDS in the world.

We used the medical anthropological theory of syndemics to help explain how social inequities that may be driven by historical forces and their legacies lead to the clustering of these risk factors, which ultimately results in higher death rates in poor and marginalized populations. It is important to view SUID/SIDS in the greater context of the growing field of social determinants of health.

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.

“Lactivism” and breastfeeding backlash: A second look

It’s become routine: a big anti-breastfeeding piece comes out in a major publication like the New York Times, or The Atlantic or Time. A mom complains how the benefits of breastfeeding are overrated, how breastfeeding is being forced on people, how moms are feeling shamed into breastfeeding or risk being bad mothers.

Let’s listen to these moms for a minute. Regardless of what we breastfeeding people are actually saying, this is what moms are hearing. We need to ask ourselves, why do they hear this message?

Here’s why: Moms experience the “lactivist.” To the uninitiated, the term “lactivist” equals zealot. Someone who believes that breastfeeding is the answer for every mom in every situation, someone who is inflexible, incapable of listening to a mom’s individual needs and desires.

Any woman who’s just had a baby would probably see a “lactivist” as The Enemy. Imaging yourself as that new mom. You are not thinking the “lactivist” is a savior in a white cape who’s going to defend you from evil hospitals who want to give your baby formula. She’s someone who’s going to push everyone out of the way and make you breastfeed, regardless of your own trials and tribulations, your pain, your exhaustion. She’d not there to help you. She’s there to advance her own agenda of world breastfeeding hegemony.

And, if a mom doesn’t actually encounter a self-described lactivist, she might see the effects. All it takes is a journalist-mom who hears one resentful nurse say “we’re not allowed to teach formula feeding,” and you’ve generated enough anger for a full page New York Times op-ed. This journalist then misrepresents the scientific evidence for the entire world to prove her point that the so-called “Breastfeeding Nazis” are out to get you, and it’s just not worth it, because breastfeeding’s not even all that good for your baby anyway.

We must be careful with our rhetoric, and treat every single mom with compassion and understanding. We must take care in how we train our staff and how that staff communicates to patients. Breastfeeding people all know that it’s required to teach moms how to formula feed, and staff must feel inside that this is valuable information for many moms.

It only takes one “lactivist” to piss off a journalist. You never know who might turn around and write that next full page op-ed for the New York Times.

So please, let’s stop using the word “lactivist.” Better yet, let’s replace zealotry with compassion and understanding, and meet every mom where she is. And if we see zealotry in our colleagues, let’s gently remind them that this may be how we got to that Time magazine cover and New York Times op-ed. That is the only way we will stop this negative press.

Melissa Bartick, MD, MSc is an internist at Cambridge Health Alliance and Assistant Professor at Harvard Medical School. 

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

Should the AAP Sleep Alone?

Some public health messages everyone can agree with: Never drink and drive. Always put your infant in a car seat. Other public health messages seem to ask us to do the impossible: Teenagers must never have sex. Mothers must never share a bed with their infants.

Advice around the US urges parents never to bed share, reinforced by the official stance of the American Academy of Pediatrics. Scary ads abound. One ad shows a queen-sized bed with a headstone in place of headboard reading “For too many babies last year, this was their final resting place.” Another shows a baby in an adult bed with a meat cleaver, stating “Your baby sleeping with you can be just as dangerous,” and another ad says “Your baby belongs in a crib, not a casket.”

The fact is, across the United States and the world, across all social strata and all ethnic groups, most mothers sleep with their infants at least some of the time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.^1-4 Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far more likely to feed their babies at night on chairs and couches in futile attempts to stay awake, which actually markedly increases their infants’ risk of suffocation.⁵ According to a 2010 study of nearly 5,000 US mothers, “in a possible attempt to avoid bed sharing, 55% of mothers feed their babies at night on chairs, recliners or sofas. Forty–four percent (25% of the sample) admit that they [are] falling asleep with their babies in these locations.”⁶ This is truly disturbing.

The advice to never sleep with your baby has backfired in the worst possible way. Rather than preventing deaths, this advice is probably even increasing deaths. In another study, parents of two SIDS infants who coslept on a sofa did so because they had been advised against bringing their infants into bed but had not realized the dangers of sleeping on a sofa.⁵ In fact, deaths from SIDS in parental beds has halved in the UK from 1984-2004, but there has been a rise of deaths from cosleeping on sofas.⁷

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.