Archive for the ‘In the news’ Category
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 »
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 »
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 »
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 »
In the past few weeks, I’ve found myself thinking a lot about privilege and parenthood. At the Breastfeeding and Feminism International Conference and the Kellogg #FirstFoods16 forum, I heard testimony from men and women of color who described structural barriers, indifference and outright hostility from health care providers and community members. These two meetings bracketed House Bill 2, in which the North Carolina state government legalized discrimination against trans, gay and lesbian individuals, and prohibited local municipalities from instituting a living wage.
These events and discussions drove home for me the multiple levels of sex, race, and class privilege that undermine the health and wellness of our nation’s families.
With these experiences fresh in my mind, this morning, I picked up the New York Times Sunday Review and saw Nicholas Kristof’s column, “When Whites Just Don’t Get It, Revisited.” Kristof reviews the burgeoning evidence of discrimination against people of color, from disparities in the quality of public schools serving children of color to experiments demonstrating that a job applicant named “Brendan” is 50% more likely to get a callback that an applicant with the identical resume named “Jamal.”
I was nodding in vigorous agreement, as Kristof affirmed the testimony I’d heard at Breastfeeding and Feminism and at the First Food Forum – until I hit this paragraph:
Reasons for inequality involve not just institutions but also personal behaviors. These don’t all directly involve discrimination. For instance, black babies are less likely to be breast-fed than white babies, are more likely to grow up with a single parent and may be spoken to or read to less by their parents.
In this aside about infant feeding, Kristof misses the crucial role of structural barriers that prevent women from breastfeeding – barriers that affect all families, but are especially severe for women of color. Contrary to popular belief, breastfeeding is not simply a “personal behavior” – it is constrained by the life circumstances and support (or lack thereof) that a woman receives from her family, her community, her employer, and her health care providers. Read the rest of this entry »
Dr. Jon Matthew Farber published the final installment of pearls reflecting on his practice in the January 1, 2016 edition of Contemporary Pediatrics. (Farber, Pearls from the trenches: Part 4, Contemporary Pediatrics. ) As Dr. Farber noted in the introduction, “I have heard it said that half of what we practice now will be out-of-date in 10 years, but the trick is to know which half.” Many of his clinical observations are quite valid and helpful for the practitioner. Unfortunately, one of the tips in that edition is out-of-date and could be counterproductive.
Under “Words to Live By,” item #10 addresses breastfeeding routines and states that “After 10 minutes, if not sooner, a breast is mostly empty. Having a child feed for 20 to 30 minutes at the first breast will exhaust both the mother and the child (and can lead to very sore nipples). Particularly for newborns, I recommend 10 minutes at the first breast, switching breasts for another 10, and then “topping off” for another 5 to 10 minutes at each breast if the baby is still hungry.” This statement includes the Lancet reference. ( Lancet. 1979 Jul 14;2(8133):57-8. )
Indeed, as Dr. Farber has noted, in the more than 35 years since that publication, our understanding of breast milk production and transfer, as well as the composition of milk, has improved significantly. We also know that each baby is different, as he or she masters the skills of feeding from the breast with continued practice. While some babies may indeed consume a substantial volume of milk in 10 minutes, others, and especially newborns, may take significantly longer. (Breastfeed Med. 2013 Dec;8(6):469-73. )In addition, the greatest proportion of fat is consumed towards the end of a feeding. Frequent “switching” from side to side may result in relatively higher water and sugar intake, with proportionately less fat intake, tending to make babies more fussy and gassy, with frequent frothy, green stools. In some circumstances, these babies may suffer from growth faltering. (J Am Board Fam Med. 2016 Jan-Feb;29(1):139-42. ) Therefore, it is no longer recommended that parents follow the clock when feeding, but instead observe the baby for signs of satiety, such as, relaxing of the posture or falling asleep. A full feeding (no specific time, but noted by less frequent swallowing or the baby drifting off to sleep) on the first breast offered, followed by as much feeding as desired on the second breast, if requested by a baby, works well for most babies, especially during the newborn period. (Breastfeed Med. 2010 Aug;5(4):173-7.) The breast never completely empties, because production continues throughout the feeding. Soreness of nipples does not correlate with the time spent nursing, but with the adequacy of latch.
If the mother is experiencing sore nipples (J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37), the latch should be carefully evaluated by someone skilled in breastfeeding assessment, whether that be a doctor, nurse, lactation consultant, or other helping professional. Fellows, or members, of the Academy of Breastfeeding Medicine, an organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation, are excellent resources. ( Academy of Breastfeeding Medicine) Good breastfeeding routines are especially important in the early days and weeks in order to establish and maintain a good milk supply. Timed feedings may actually increase the risk of insufficient milk supply, which can be challenging to resolve.
While the pearls gleaned from practical experience can be very useful in our clinical decision making tool kit, they must be combined with current knowledge of clinical practice. The majority of mothers initiate breastfeeding, however, 60% do not meet their own breastfeeding goals. (Pediatrics. 2012 Jul; 130(1): 54–60. )
. Evidence-based medicine combines careful review of the medical literature with clinical experience and judgment. In order to support breastfeeding families optimally and achieve the improved health outcomes for both mothers and children, it is critical that physicians and other health care providers communicate current information and recommendations to colleagues, instead of relying only on our own observations and dated references.
Joan Meek is a Associate Dean for Graduate Medical Education and Professor of Clinical Sciences
Florida State University College of Medicine. She has served as president of the Academy of Breastfeeding Medicine, Chair of the American Academy of Pediatrics Section on Breastfeeding, and Chair of the United States Breastfeeding Commitee.
Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.
This essay is reposted with permission from CHAMPSBreastfeed.org
Thirty years ago, every newborn infant born in a US hospital was separated from their parents at the time of birth. Rooming-in was not an available option. We know now that that this standard practice was not optimal for the mother or the infant. As a pediatrician, I am concerned by the implications of this article. The image used by Time Magazine depicts an “unsafe” practice: several newborns swaddled in basinets on their sides sleeping. This sleep position carries more the double the risk of SIDS compared to infants sleeping on their backs. In addition, the bassinets are positioned adjacent, in a row, which is a practice that is fraught with risk for nosocomial infections, and has implications for security, and privacy concerns, especially when viewed by the public as is often the case in US delivery hospitals.
Beyond the disturbing photo the subtitle is inaccurate. It is important to note that what is changing among maternity care hospitals is that mothers are now offered the opportunity to allow their newborn to share a room with them. This opportunity is not “forced” but protected, given that rooming-in not only does help breastfeeding, it is safer than sleeping separated from mom. In the past, mothers were forced to separate from their newborn infants and required to have their infants sleep separately in a nursery setting, where they were grouped with other infants. Rooming in is the recommended environment for all mothers regardless of chosen feeding method. The author repeatedly refers to rooming-in as unsafe but with appropriate guidance and monitoring it is not unsafe and is safer than sleeping in a nursery. Both mother and newborn continue to receive the same level of care and supervision. Rooming-in does not mean that the care of the newborn is delegated to the mother, however, rooming-in provides the mother the opportunity to participate in their own newborn’s care. This permits staff to do additional teaching and observation of parenting skills before discharge. Read the rest of this entry »