Team-based primary care breastfeeding support

(left to right) Samantha Walters IBCLC , Ann Witt, MD, IBCLC, Lauren Lasko APRN, IBCLC, Kristen Auletta, RN, IBCLC, and Maya Bolman, RN, IBCLC team-up and provide breastfeeding support.

Imagine seeing a breastfeeding family two days after hospital discharge and having the time needed to correct latch, help manage engorgement, or review hand expression and supplementation for the baby with poor weight gain.  Health care provider support improves breastfeeding initiation and duration.  Yet, too often primary care providers (PCP) do not have the time or knowledge to provide breastfeeding support after hospital discharge.  These challenges can be solved with team-based lactation consultant and primary care (LC/PCP) providing breastfeeding support in the primary care office.

Per American Academy of Pediatrics and Family Physicians, a breastfeeding infant should be seen by their primary care provider (PCP) within two to three days of discharge (https://pediatrics.aappublications.org/content/125/2/405).  This visit includes evaluation of weight and jaundice.  In a breastfeeding infant, significant weight loss or jaundice is often triggered by breastfeeding difficulties including latch, pain, or delayed onset of milk production. Team-based primary care breastfeeding support combines the PCP’s initial post-discharge visit with lactation consultant support.  The team approach facilitates physician evaluation of the infant along with immediate lactation support on needed topics such as feeding patterns, output, latch, engorgement, and appropriate supplementation.

Team-based LC/PCP care acknowledges:

1. Families want to breastfeed.
2. Families experience breastfeeding challenges.
3. Feeding challenges require a plan that supports the breastfeeding dyad.
4. Education on that plan takes time and breastfeeding knowledge.

Over 80% of mothers initiate breastfeeding in the United States, yet many women do not meet their goal of continued breastfeeding beyond a year.  Given pain and low milk supply are common causes for weaning, breastfeeding support after hospital discharge is critical.

Ann Witt, MD, IBCLC, and Maya Bolman, RN, IBCLC with breastfeeding family during a clinic visit.

Having successfully provided team-based lactation care for over a decade within a suburban pediatric (https://www.ncbi.nlm.nih.gov/pubmed/21657890) practice, we look toward sharing this movement in other communities. Recently we partnered with a Federally Qualified Health Care system in Cleveland, Ohio to implement team-based lactation care.( https://www.jabfm.org/content/32/6/818)  Prior to implementation  a survey of providers at the FQHC found that 80% noted there was “not enough time” to provide lactation support during the visit  and 58% thought there was “inadequate lactation consultant staffing at the practice” with 80% of PCP’s commenting that patients were “not receiving adequate help.”  One year later, following implementation of team-based breastfeeding support, a repeat survey of PCP’s, found 100% reporting they were “providing better breastfeeding support” to their patients and liked having “breastfeeding support available for patient that NP/MD previously did not have time to provide.”  A majority of the PCP’s also liked having “a lactation consultant join an already scheduled visit so the patient does not need an extra visit,” as well as “on-site immediate lactation support.” The program has been so successful that the FQHC is expanding this service beyond their main clinic to satellite sites.

To implement team-based care, practices need to personalize it to fit their own practice needs. We determined feasibility of the team-based practice model at the FQHC by assessing breastfeeding intent and rates, health care provider knowledge, billing reimbursement, and currently available breastfeeding supports.  We used the information gathered to formulate a business plan, identify additional training needs, and facilitate communication with administration.  Other practices can build on this structure to implement team-based LC/PCP care in their own communities.

Now is the time for our health care system to help families get timely breastfeeding support after hospital discharge.  If your practice has already implemented a team-based primary and lactation care approach share your story so others know it is possible. If you are interested and trying to figure out how, gather the basic information, begin the dialogue and draw on other practice’s experience.

Together we can improve the care of our families after delivery, and better support breastfeeding duration!

References:

1. Stark et al. Committee on Fetus and Newborns 2008-09. Hospital Stay for Healthy Newborns. Pediatrics February 2010, 125 (2) 405-409;
2. Witt AM¹, Smith S, Mason MJ, Flocke SA. Integrating routine lactationconsultant support into a pediatric practice. Breastfeed Med. 2012 Feb;7(1):38-42.
3. Witt AM, Witt R, Lasko L, Flocke SA Translating Team-Based Breastfeeding Support into Primary Care Practice. JABFM Nov/Dec 2019

Blog posts reflect the opinions of individual authors, not ABM 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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Towards Improved Support for Medical Trainees Who Are Breastfeeding

Dr. Helen Johnson

Ironically, physicians have some of the lowest rates of breastfeeding in the United States. Despite acute awareness of the medical risks of not breastfeeding and deep commitment to educating their patients about the importance of breastfeeding, many physician mothers face significant challenges in their own breastfeeding efforts. Medical trainees – including medical students, resident physicians, and fellows – are among the most vulnerable. This month’s IABLE podcast focuses on how to improve support of medical trainees who are breastfeeding.

Dr. Anne Eglash recording the IABLE podcast.

Medical trainees have jam-packed schedules with little to no control over their time. It can be a small feat to find time to scarf down a snack between surgeries or surreptitiously slip away from hospital rounds to run to the bathroom. In a culture in which self-sacrifice for the greater good of one’s patients is the norm, devoting 20-30 minutes every few hours to express breastmilk can feel like an indulgence. In addition, trainees may fear being perceived as less dedicated than their peers to their education or to patient care should they attend to personal needs at work. Even in a workplace environment that strongly supports breastfeeding – such as the obstetrics/gynecology department – lack of accessible, sanitary, and private spaces can limit a trainee’s ability to breastfeed at work.

In the past several months, several steps have been taken to improve support for medical trainees who are breastfeeding. In June, the American Academy of Family Physicians (AAFP) published a statement (https://www.aafp.org/about/policies/all/breastfeeding-accommodations-trainees.html) stressing the need to better support these women through policies that address protected time, adequate facilities, and a supportive workplace environment. On July 1, new Accreditation Council for Graduate Medical Education (ACGME) regulations went into effect: residency and fellowship programs are now required to provide clean, private lactation facilities for trainees that are in close proximity to patient care and include refrigeration capabilities.

Dr. Rebecca Snyder cartoon from her days as a surgical resident.

The ACGME notes: “While space is important, the time required for lactation is also critical for the wellbeing of the resident and the resident’s family.” Last month, a departmental lactation policy implemented by the surgery departments at the University of Michigan and the University of Wisconsin was published. This policy has been circulated on social media and adapted by dozens of other departments across the nation.

Most recently, my colleagues and I issued a “call to action”, urging the creation of a universal policy to better support resident physicians and fellows who are breastfeeding. We admire the grassroots efforts to create departmental policies and respect the significance of the new ACGME regulations. However, we feel that there is an urgent need to do more to ensure that all medical trainees have the support they need to breastfeed their children. In our publication, we underscore the importance of cultivating a supportive workplace culture, promoting access to appropriate lactation spaces, and ensuring adequate time for breastfeeding, and suggest specific action steps that program directors and institutional leadership can take to achieve these goals. Our piece was highlighted by Duke Forge and is discussed in detail in this month’s IABLE podcast.

Dr. Helen Johnson and her child visiting her at work as a surgical resident.

The podcast features not only the three authors of the “call to action” but also Laurie B. Jones, the founder of Doctor Mothers Interested in Lactation Knowledge. This online peer-to-peer breastfeeding support group for physician mothers has been instrumental in helping thousands of women – including trainees – meet their breastfeeding goals. Dr. MILK members encourage each other and share their wisdom for balancing breastfeeding and a medical career. Let’s take this to the next level by joining forces with breastfeeding medicine physicians and national organizations – together, let’s advocate for a universal lactation policy for medical trainees. ABM has already confirmed their support of the AAFP’s statement. Now it is time to amplify each other’s voices and effect meaningful change.

Dr. Katrina Mitchell and Dr. Laurie Jones in Sedona, AZ where they recorded the podcast for IABLE. The doctors’ three children have been breastfed for cumulative length of 14 years!

– Helen M. Johnson, MD is a general surgery resident at East Carolina University / Vidant Medical Center in Greenville, North Carolina. She is originally from Tampa, Florida and obtained her medical degree from the Warren Alpert Medical School of Brown University. Dr. Johnson plans to pursue fellowship training in breast surgical oncology after graduation from residency. She has a special interest in the intersection of breast cancer and breastfeeding, and is working towards IBCLC certification. Dr. Johnson enjoys gardening, playing the cello, and spending time with her husband, two children, and beloved cat. Connect with Dr. Johnson on Twitter: @HelenMJohnsonMD

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

First Droplets Website: Empower Parents Enable Breastfeeding #WBW2019

By Dr. Jane Morton

“I’m going to try.” This is the tentative answer many mothers give, instead of “Yes, I’m going to breastfeed!”

Why do so many women worry that breastfeeding may be complicated, painful and probably dependent on professional help? If breastfeeding is so natural, why doesn’t it come naturally, as it seems to in all other mammals? Over the past several decades, research in human lactation steers us to the answers, pointing directly to the sensitive time in the first few hours immediately after delivery. What does or does not happen in this window may determine whether mothers give up on breastfeeding for problems related to, what could be called the ABC’s of breastfeeding. A = attachment (how a baby latches on and transfer milk from the breast), B = breastmilk production, and C = calories or what a baby consumes.

The longer the interval between birth and the first feed, the greater the likelihood a baby will have some issues with latching and comfortably removing milk, or “A = attachment”. Likewise, the longer the interval between birth and the early, (first hour) frequent and effective removal of milk, the weaker the signal to the breast to make milk (B = breastmilk production). This may compromise subsequent production potential. And finally, the more protracted the delay before the first feed, the greater the compromise of passive and active immunity, provided by the multitude of bioactive factors that enhance the functionality of the infant’s own immune system.

Weight loss differentials between infants who feed in the first hour, compared to those who do not, become evident as early as 6 hours. The “last supper” for the newborn ends after delivery with the cutting of the umbilical cord. So presumably, it’s not hunger that drives the newborn mammal to immediately seek out the breast, but a grand design, so to speak, to protect the cornerstones of breastfeeding.

Unlike other mammals, the “naturalness” of the human birth process has been challenged by surgery, drug and early gestation delivery. For example, cesarean delivery, induction and preterm births reduce the likelihood a baby will feed effectively in the first hour. That said, there are simple solutions to avoid complex problems, that become less remedial by the hour. It’s all about learning comfortable techniques and easy-to-remember facts about the ABC’s before D, delivery.

The goal of a new website, www.firstdroplets.com, is to give an expectant mother the tools she’ll need to protect her own breastfeeding experience, no matter what the delivery scenario. Counting down the days before delivery, she can anticipate the opportunities of the first hours. For breastfeeding to be fun, nursing needs to be comfortable for her and easy for her baby. And she needs to make plenty of milk. The short and simple lessons aim to prepare her to answer these questions:

1. What is a “good” latch and why is it important?
2. What do I do to help my baby with a latch, if needed?
3. How do I make more milk sooner?

Using props, animation and real mothers and babies in their 1st postpartum hours, expectant mothers learn about the magic of that first feed when things go “naturally”. To reduce her worries, she also learns that if there are any concerns, she can use the best and most “natural” tools, her hands, to help her baby and protect her production. Hand expression and feeding “dessert from a spoon” are normalized as the first hour response for the baby unable to latch. “Handling” breastfeeding includes suggestions on holding and positioning baby and breast for comfortable and effective nursing, not waiting for soreness to develop.

A separate video for a mother expecting a premature NICU baby aims to prepare her for the earliest challenges and give her a sense of control and recognition for the vital role she’ll play in continuing to protect her baby.

The website, videos, graphics, participant mothers and donations to fund this project were all inspired by the hope that new mothers and their partners come to delivery with confidence, answering “Yes, I’m going to breastfeed!” Please join our effort spreading the word.

Our thanks,
Jane Morton, MD

Website videos may be downloaded for educational non-commercial use. References to support the science behind the video are summarized in a website section and in a recent publication: Morton J. Hands-on or hands-off when first milk matters most? Breastfeeding Med. 2019;14(5):295-297.

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  Pregnant hand expression

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  Cesarean separated from baby

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

Support for Lactating Medical Trainees

Authored by: Sarah Shubeck, MD and Megan Pesch, MD, MS

The culture of medical training and demands of residency work is often regarded as not conducive to the needs of lactating physicians. The need for “breaks” or perceived lack of dedication to workplace can lead to misperception of lactating trainees and pressures to stop milk expression before reaching an individual’s goal. Additionally, recent work has demonstrated that physician mothers struggle to meet their personal breastfeeding goals at rates higher than their peers, most often attributed to the demands of their work and lack of workplace support and infrastructure.

Those successful lactating medical trainees have squeezed in quick “pump breaks” in between patients or cases, struggled with mastitis or discomfort from extending duration between milk expression, or have experienced being reprimanded for taking time to express milk. Additionally, the lack of clean and available lactation spaces result in women turning to bathroom stalls or skipping times for expression. Despite these discouraging and humiliating encounters, many lactating medical trainees have found success through pressing on individually, but often with having to sacrifice their supply and morale and compromise their personal breastfeeding goals.

The plight of the breastfeeding medical trainee has received recent well deserved attention. Several publications, including those by Livingston-Rosanoff et al., and Pesch et al, have highlighted these difficulties and proposed protections and education around the needs of lactating physicians. This recent work highlights three key components:

• First, there is a critical need for supporting trainees to be allowed time for milk expression as determined by the trainee and her healthcare providers. For example, residents are often hesitant to ask for a “pump break,” but departmental support for milk expression times allows women residents to meet their health needs without sacrificing learning opportunities.
• Second, as required by federal mandate, medical resident employees must be provided lactation spaces that are clean, private, and close to patient care settings to minimize time away from clinical and educational opportunities. Program directors and departments can work to provide convenient and private spaces through creative use of call rooms and empty patient care settings to meet the needs of their lactating trainees.
• Finally, creating an open and supportive culture around lactation within a department and institution is essential. Workplace education of faculty, staff, and trainees and the adoption of policies and guidelines can protect and support lactating trainees can function to normalize lactation in medical training. (See Livingston-Rosanoff et al., and Pesch et al, for examples of policies and guidelines).

Supporting lactation for medical trainees is not only the right thing to do for their health and wellness, but it will almost surely have a trickle-down effect to the care they provide their breastfeeding patients.

Eliminating Disparities in Breastfeeding and Infant Mortality: Conference 2018

Although breastfeeding rates are increasing in the US, significant disparities in breastfeeding and infant mortality persist.  Cincinnati Children’s Hospital Medical Center and partners were delighted to host the “Third Annual Conference to Eliminate Disparities in Breastfeeding and Infant Mortality:  Taking Action for Equity” as a pre-Conference to the Ohio Infant Mortality Summit at the Duke Energy Convention Center in Cincinnati, Ohio.  Our Keynote speaker was the inspiring Dr. Camara Jones from Morehouse School of Medicine, who helped us critically examine how racism must be acknowledged and addressed to make inroads toward health equity.

Our First Annual Conference with Keynote speaker, Dr. Michal Young, helped us to define the problem of breastfeeding disparities and infant mortality.  The Second Annual Conference featured Keynote speaker, Dr. Kimarie Bugg, who took us deeper by addressing the role of Implicit Bias.  Our participants provided feedback, requesting to leave the next conference with Action Tools to make changes in their own communities to eliminate disparities so this year we are “Taking Action for Equity”.

To that end, our Conference this year began with an inspiring opening from City of Cincinnati Health Commissioner, Melba Moore, who challenged everyone to develop novel ways to improve community health.  From there, the conference highlighted the successful efforts of 42 speakers from around the State of Ohio and beyond, representing these programs:  CenteringPregnancy, the State of Ohio efforts to improve breastfeeding (Ohio First Steps, WIC, Ohio Department of Health), Hospital Quality Improvement, the importance of Fathers, and the amazing work of Doulas.  These programs provided the first set of Key Highlights to nearly 400 health care providers, community members, and parents, who then were able to “go deeper” in workshop formats, along with an option to learn the basics of “Breastfeeding 101.”  After lunch, attendees rejoined for a second set of Key Highlights, with representatives from Home Visitation programs, Mom-to-Mom Support groups (https://www.facebook.com/Avondale-Moms-Empowered-to-Nurse-1257926900973280/), Rural and Appalachian breastfeeding groups and Breastfeeding while Going back to Work.  These presenters also provided a deeper dive with workshop sessions, and the option for a “Breastfeeding 911” course to help front-line providers and support people troubleshoot common problems.  Each workshop provided a take home “toolkit” for attendees.

In addition to many local Cincinnati area efforts to eliminate disparities in breastfeeding, we were delighted to have experts from Cleveland, Columbus and beyond share their expertise with us.  The Doula segment was especially exciting  as co-presenter, Jessica Roach from ROOTT (Restoring Our Own Through Transformation) arrived to the conference JUST as her bio was being read, (coming, of course, from a delivery, directly to the stage!), as well as Christin Farmer, at Birthing Beautiful Communities in Cleveland who brought her “Dude-la”, Neal Hodges!  We learned about ROBE (Reaching Our Brothers Everywhere) from our local Wisdom Council Member, Calvin Williams, and Founder, Wesley Bugg, Esq., the CenteringPregnancy program in Cleveland , and so many more Ohio highlights!

Dr. Lori Winter and Dr. Julia Ware

Commissioner, Melba Moore, Dr. Camille Graham, Dr. Corinn Taylor, Dr. Karen Bankston

Dr. Camara Jones and Jamaica Gilliam

Dr. Camara Jones took us through an intensive discussion of the multiple dimensions through which racism drives health disparities using her powerful 3-dimensional cliff analogy highlighting differences in: the quality of care received within the healthcare system, access to healthcare and preventive services, and life opportunities, exposures, and stresses that result in differences in underlying health conditions.

She defines racism as “a system of structuring opportunity and assigning value based upon the social interpretation of how one looks. Racism is a system that:

1. Unfairly disadvantages some individuals and communities
2. Unfairly advantages other individuals and communities
3. Saps the strength of the whole society through the waste of human resources.

Racism has created inequities in our country. Dr. Jones helped us to see that the barriers to health equity include the narrow focus on the individual (“I am not racist, so these facts don’t apply to me or how I treat my patients!”); the fact that we are an “A-historical” culture that is disconnected from and fails to acknowledge our recent past (“Slavery ended more than a hundred and fifty years ago – why can’t you get over it?”; we don’t recognize the underlying structural system of inequity and privilege that is at the foundation of health disparities (“Why is it that a mom’s zip code is more likely to predict birth outcomes, infant survival, and breastfeeding success than her access to health care?”); and that we are instead overly focused on the myth of meritocracy – an example – two babies – equal opportunity or equal potential? (“They just aren’t trying hard enough – they could breast feed if they really wanted to!”)

Some key takeaways from Dr. Jones:

1. When you feel uncomfortable, “LEAN IN”
2. To achieve health equity we need to:
   1. Value all individuals and population equally
   2. Recognize and rectify historical injustices
   3. Provide resources according to need
3. You can learn more about Dr. Jones’ Cliff Analogy in this 5 minute video by the Urban Institute.

An added treat to the Conference was an optional learning lunch with new AAP Section on Breastfeeding Chair, Dr. Lori Feldman-Winter, who was giving a talk on Safe Sleep and Breastfeeding at a Safe Sleep Summit occurring simultaneously to our Conference!  Over 130 of our participants were able to join this event, and enjoyed the review of the evidence and guidelines for safe sleep and breastfeeding from the AAP lens.

One of the most exciting aspects of the Conference is still to come.  We will harness the energy generated from the diverse Conference presenters and attendees to continue improving breastfeeding rates in marginalized populations. It is clear that we have a wealth of talent and will need to use many different strategies to achieve this goal. Our participants are filling out a “Call to Action” survey as part of their Conference evaluation, so that we can continue to connect and collaborate in areas of interest to eliminate disparities through learning communities across the state. Stay tuned for More to Come!

Pre- and post-conference video clips:

http://www.fox19.com/video/2018/12/14/breastfeeding-disparities-challenges/

http://www.fox19.com/video/2018/12/14/breaking-down-barriers-breastfeeding/

Shared Safe Sleep and Breastfeeding Posters (unbranded) from Ohio First Steps:

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Feeding-Safe-Sleep-flierUNBR.pdf

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Spanish-Feeding-Safe-Sleep-flier.pdf

Cincinnati Children’s Conference Co-Chairs:

Julie Ware, MD, MPH, FABM and ABM Board Member

Laura Ward, MD, ABM Member

Camille Graham, MD, Executive Community Leader

 

For more information, please contact Dr. Julie Ware, julie.ware@cchmc.org

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

Where will you be when (not if) you fall asleep while feeding your baby?

Healthy newborns wake easily and often to feed, and a “good sleeper” in this age group is one that lets you know when he or she is hungry, is an efficient and effective feeder, and settles after the feeding and falls back asleep.  Modern societal expectations often do not allow for or encourage new mothers to sleep during the 16-20 hours/day that a newborn sleeps.  There is often housework, family and visitors, thank you notes, older siblings, and far too often at least in the U.S., an earlier-than-it-should-be return to work.  The “village” that traditionally swooped in and surrounded the dyad with care and support is often spread across miles, even oceans, and these mothers, while still recovering from birth, are left alone as their partner returns to work.  It is not surprising that new mothers find themselves exhausted and in “survival mode” during which time the recommendations that they have heard to feed a certain way or have the baby sleep a certain way may fly out the window as they desperately try to achieve a little more sleep.  And even though they may or may not be planning to, mothers of newborns are falling asleep while feeding their babies.

In addition, depending on where they turn for information, the recommendations for infant feeding and safe sleep can be confusing and may appear to be at odds with one another.  We know that mothers who bedshare with their infant breastfeed for longer.  We also know that where babies start off the night is not always where they end up in the morning.  We know that breastfeeding is protective against Sudden Infant Death Syndrome (SIDS), but also that bedsharing may pose a risk for a sleep-related infant death, particularly in the setting of other risk factors such as prenatal smoking, formula feeding, maternal substance use, sedating medications, maternal obesity, prematurity, and the presence of soft bedding in the sleep environment.  Some organizations recommend bedsharing as a means of supporting breastfeeding and cite data about the physiologic patterns and postures of mothers and babies when they bedshare.  Other recommendations focus on safe sleep and recommend breastfeeding as a strategy to reduce the risk of SIDS but recommend against bedsharing to avoid an unintended sleep-related death.

ABM’s Model Maternity Policy Supportive of Breastfeeding: More than just a protocol revision

The new ABM Clinical Protocol #7 could have just been the revision of an outdated protocol. That was my idea when I received Wendy Brodribb’s invitation to help update the 2011 Breastfeeding Hospital Policy protocol. Being the national coordinator of the Baby-Friendly Initiative in Spain, a member of the BFHI coordinator’s network, and a practicing pediatrician, I am fully aware of the importance of a breastfeeding supportive policy in hospitals, so I was passionate about being part of the update of this specific protocol. I knew the subject, it was just an update and it was also about teamwork with great colleagues: Melissa Bartick, Paula Schreck and Cadey Harrell and the supervision of the ABM protocol committee. Before me I saw an idyllic task that seemed simple and rewarding even for a non-native English speaker. Thus I gladly accepted the challenge and was grateful to be able to contribute to ABM’s mission.

However, I had not envisioned the ambitious team we had formed! Soon it was clear that my “simply reviewing and updating” plan was to become an absorbing, demanding, and exciting piece of work to produce a completely new and comprehensive protocol. The last two months trying to meet the deadline were exhausting but really exciting with transoceanic telephone conversations and chats, and continuous emails. Working on the same document while adjusting our different timelines in mid-August (we took turns to write fervently while the others were sleeping) was really fun!

The social inequalities and structural determinants that result in health injustice are the same that interfere with a happy breastfeeding experience. These interferences and the lack of adequate protection and support for breastfeeding unjustly burdens the health of women and infants (the most vulnerable part of society) at risk, especially if they belong to disadvantaged classes or countries with the least resources. Health professionals and health care facilities can be part of the problem, or they may become part of the solution.

ABM’s First Australia/ New Zealand Regional Conference

The inaugural ABM Australia/New Zealand Regional Conference was held  at the Gold Coast, Queensland, Australia on July 20-21 2018 with over 85 registrants from Australia, New Zealand, Malaysia, Indonesia and Taiwan.

 

The conference was preceded by a one day workshop “Breastfeeding Essentials for Medical Practitioners” which is a Australian/NZ version of the ABM ‘What every physician need to know about breastfeeding’ course, modified to meet the needs of Australian and New Zealand doctors.  In Australia and New Zealand, most breastfeeding medicine is provided by general practitioners (family physicians) who care for the mother-baby dyad routinely in the postpartum period.  Australian research in 2009, indicated only 23% of general practice registrars felt confident that their breastfeeding knowledge was adequate, with common sources of information being undergraduate teaching, post graduate teaching, general practice and personal experience. (1)  Our aim was to present a breastfeeding conference organised by doctors, for doctors, with clinically relevant and evidence based presentations.

There is a disappointing lack of routine data collection around breastfeeding in Australia; however in 2010 (2) around 96% of women initiated breastfeeding, with a rapid drop in the early months with 39% of women exclusively breastfeeding at 4 months (2). Data from 2007 (3) indicated only 28% of babies continued to be breastfed at 12 months of age. The Australian government has a paid parental scheme where mothers who earn less than AU$150,000 per annum are entitled to 18 weeks paid leave at the national minimum wage. Some employers also provide additional paid parental leave. All mothers are entitled to take up to 12 months maternity leave in total (paid and unpaid) and have their jobs protected under legislation. A similar scheme operates in New Zealand, with 18 weeks government paid parental leave,  increasing to 26 weeks in 2020.

The well-being of mothers and children is not a tradeable commodity

Breastfeeding is the foundation of public health and economic development. All major medical organizations recommend 6 months of exclusive breastfeeding, followed by continued breastfeeding through the first one to two years of life and beyond.

Evidence continues to mount that disrupting optimal breastfeeding contributes to disease burden and premature death for women and children. Globally, optimal breastfeeding would prevent 823,000 child deaths each year. In the US, enabling optimal breastfeeding would prevent 721 child deaths and 2619 maternal deaths each year, as well as 600,000 ear infections, 2.6 million gastrointestinal illnesses, 5,000 cases of maternal breast cancer and more than 8,000 heart attacks.

Optimal infant feeding is also essential for economic development. Being breastfed is associated with a 3 to 4 point increase in IQ, leading to better school performance and workplace productivity. As stated by the World Bank’s Keith Hansen, “If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics.”

Breastfeeding is vital and essential to protect the world’s children, the most vulnerable who cannot speak for themselves.  Given the essential role of breastfeeding in global health and wellbeing, it is imperative that every nation supports policies and programs that enable women and children to breastfeed. It is therefore deeply troubling that the United States delegation to the World Health Assembly actively undermined efforts to enable optimal breastfeeding, as reported by the New York Times.