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The new ABM Clinical Protocol #7 could have just been the revision of an outdated protocol.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.

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?

Marijuana and Breastfeeding

Ryan, Ammerman, and O’Connor’s Clinical Report on “Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes” was published recently in Pediatrics.  The report, co-authored by the American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention and the AAP Section on Breastfeeding, summarizes data on the prevalence of marijuana use in women of childbearing age.  Overall, rates of marijuana use have increased in recent years, according to the National Survey on Drug Use and Health.  Pregnant women use marijuana less frequently than do nonpregnant women in the same age range.

Legalization of marijuana has made both inhaled and edible forms of marijuana more widely available and have decriminalized its use in certain US states.  Medical marijuana is available in an even larger number of states. Some women report using marijuana during pregnancy to combat nausea and vomiting, and this has been advocated in certain social media postings. Federal laws in the US still prohibit the use of marijuana. 

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.

Every time a baby goes to breast, the $70 billion baby food industry loses a sale

On Sunday, the most shared story in the New York Times was about breastfeeding – specifically, about how the US government threatened multiple countries with trade sanctions and withdrawal of military support if they backed a resolution calling for more support for breastfeeding mothers and their babies.

According to the Times:

American officials sought to water down the resolution by removing language that called on governments to “protect, promote and support breast-feeding” and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children.

Why would the US government stand in the way of global breastfeeding advocacy? There are a number of theories – but my money is on the $70 billion baby food industry – upon whom the US dairy industry relies to convert massive milk surpluses into profitable products. In a face-off between a powerful industry lobby and global maternal and child health, the powerful industry carried the day.

This is the critical take-home message for anyone who cares about the health of moms and babies: When it comes to global infant and young child feeding, industry profits take precedence over public health.

Postpartum Mood & Anxiety Disorders in Breastfeeding Mothers: To Treat or Not To Treat

May 2^nd is World Maternal Mental Health Day.  Here in my home state, The Governor and General Assembly, back in 2015, declared May as Maternal Mental Health Month in the Commonwealth of Virginia.  The Blue Dot Project has defined this year’s Maternal Mental Health Week (#MMHweek) by removing the stigma of perinatal mood and anxiety disorders. Women (and men) all across the world are posting their stories (with a pastel blue dot) about the trials and tribulations of parenting, while showing the face of postpartum anxiety and depression.  #noshame #realparenting

On my iPhone early this morning, I saw a #MMHW post where a women posted a picture of her feeding her child with a bottle. She told her story about the guilt she felt (and still feels) about not being able to breastfeed her child and how that exacerbated her depression.  What followed were comments by so many other moms, how they also felt that guilt when their ‘body didn’t work’ making them unable to breastfeed their child.  Many of these women commented on how they felt shame when giving their child a bottle in public.

The Academy of Breastfeeding Medicine Issues Guidance on Informal Milk Sharing for Healthy Term Infants

New Rochelle, NY, January 8, 2018—In response to the increasing informal sharing of human milk, the Academy of Breastfeeding Medicine (ABM) has published guidelines to minimize the risk of this practice while enhancing the health benefits. The position statement is published in Breastfeeding Medicine, the official journal of the Academy of Breastfeeding Medicine published by Mary Ann Liebert, Inc., publishers. The article is available free on the Breastfeeding Medicine website until February 8, 2018.

“Academy of Breastfeeding Medicine’s 2017 Position Statement on Informal Breast Milk Sharing for the Term Healthy Infant ” discusses strategies to maximize the safety of community-based breast milk sharing, including 1) medical screening of the donor and 2) safe milk handling practices. Donors should have no medical illness where breastfeeding is contraindicated nor on any medication that is incompatible with breastfeeding. Mothers can further reduce the risk of infections by performing home pasteurization of donated milk prior to giving it to her infant; however, pasteurization can decrease some of the beneficial components of human milk. ABM also emphasizes that while informal milk sharing has potential health benefit, “internet-based milk sharing is not recommended under any circumstances.”

“Informal breast milk sharing is becoming increasingly common for healthy term infants as 21^st century families desire to feed their infants human milk,” says Dr. Timothy Tobolic, president of ABM. “Physicians and other health care providers can help mothers and families evaluate the risks and benefits of informal milk sharing.”

Surgeons who pump: #ILookLikeASurgeon

If you follow trends on social media, you have seen the viral tweets and pics from women surgeons who have copied the New Yorker magazine cover showing three women leaning over an operating table.   These posts share two common hashtags:  #ILookLikeASurgeon and #NYerORCoverChallenge.  As an admin for the 7,000+ member Dr. MILK online physician mother breastfeeding support group, I wanted to see this picture taken from the perspective of a multi-tasking surgeon mother who fits in pumping her milk between cases and a very hectic schedule.  I asked our members to try and coordinate OR schedules and pumping schedules to make this happen.  Three superstar OB GYNs from Baylor College of Medicine created this pic while at Texas Children’s Pavilion for Women in Houston, TX.  They don’t literally pump their milk while leaning over an operating table, but this picture represents the duality of surgeon moms who balance patient care needs with meeting the nutritional needs of their infants.  Their stories of breastfeeding/pumping challenges and successes will hopefully encourage mothers of all walks of life to confront and remove barriers to maintaining a milk supply while at work and #normalizePumping.

Here’s what their workday looked like when they managed to take this picture:  One doctor had a delivery and then a c-section while the second had a fetal surgery.  The third surgeon was performing a robotic hysterectomy.  They tried to coordinate the photo between the delivery and c-section but timing wasn’t right, and then just before the fetal surgery the three women rushed into an empty OR to make it happen. 

The Burden of Proof

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 1^st 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!

Trust and test weights

“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.