I’m grateful for a community of physicians who care deeply about breastfeeding

Last week, more than 400 health professionals gathered in San Francisco for the Academy of Breastfeeding Medicine’s 23^rdInternational Conference. The conference drew participants from 25 counties and 41 US states, including 259 physicians from medical specialties ranging from neonatology to breast surgery.

Members of Dr. Milk at ABM 2018

We kicked off with two pre-conference courses, “What every physician needs to know about breastfeeding (WEPNTK)” and “What every physician needs to know about breastfeeding II.” WEPNTK covers the anatomy and physiology of breastfeeding that many of us missed in medical school. WEPNTK II covered more advanced clinical issues, like maternal risk factors for low milk supply, management of tongue tie, therapeutic ultrasound for mastitis, and postpartum depression.

ABM is unlike any other medical conference that I attend because the audience spans multiple medical specialties and brings together clinicians from around the world. The conference committee faces the daunting task of selecting speakers that address the interests of both subspecialists and general practitioners across the translational continuum from basic science to public policy. And as an international conference, our speakers are selected to include perspectives on breastfeeding policy and public health from around the globe.

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.

AAP New Policy Statement on Donor Human Milk for the High Risk Infant

While the birth of neonatology was in the late 1800s with the development of the incubator, it was only in the 1970’s when the modern NICU was established with the neonatal respirator. More advanced respirators and other technologic developments, including important medications such as surfactant and nitric oxide, have dramatically improved the outcome of preterm infants. Yet, one of the most important “new developments” to improve the care of these infants, is feeding an exclusive human milk diet. It is now clear that exclusive breastmilk decreases preterm mortality and the incidence of necrotizing enterocolitis, sepsis, BPD and ROP, while increasing infant brain volume and neurodevelopment in infancy, childhood and adolescence. 

Therefore, it is noteworthy that three AAP committees, the Committee on Nutrition, the Section on Breastfeeding and the Committee on Fetus and Newborn, the committee that writes policies for neonatologists, combined to write a policy statement supporting the use of pasteurized donor human milk in high risk preterm infants, with priority for those less than 1500 grams, when mother’s milk is not available. It states that the use of donor human milk in preterm infants is consistent with good health care. It recognizes that the use of donor milk is limited by its availability and affordability. It asserts boldly that the use of donor human milk should not be limited by an individual’s ability to pay. It urges health care providers to advocate for policies that assure reimbursement for its cost, while expanding the growth of milk banks by improving governmental and private financial support.

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.

It’s time to disarm the formula industry

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.

US Public Health guildelines should reflect evidence, not anecdote

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.”

How rooming in helps moms and babies

Fifteen years ago, a friend of mine had her first baby at a prestigious Boston hospital. She was a resident in Ob/Gyn at the time, and a long labor ultimately ended with a c-section, and a healthy newborn boy. That evening, when she, her baby, and her husband were in their postpartum room, the nurse entered.

“It’s time to take the baby to the nursery!” she said.

My friend looked confused. “We’re planning to keep him in the room with us tonight.”

The nurse frowned. “Well, who’s going to take care of him? You just had a c-section.”

My friend gestured to her husband, who was sitting on the couch.

The nurse frowned again. “Well, you know these c-section babies can get a little junky,” she said, alluding to the mucous that babies not born vaginally sometimes cough up.

My friend replied, with emphasis, “We are going to keep our baby in our room tonight.”

The nurse shrugged. “Well, you’re a doctor. I guess if he aspirates, you can resuscitate him.” And she walked out of the room, shaking her head.

My friend used to tell this story, laughing darkly, as she recalled how she thought perhaps she should ask for the code cart to be wheeled into the room, just in case.

For the record, baby spent an uneventful night in mom’s room. But the routine separation of moms and babies – as well as other practices that have been shown to make it harder for families to get started breastfeeding – remains the default in many maternity centers in the US. Less than half of US hospitals provide routine rooming in for healthy moms and babies.

That’s bad news for babies, and it’s bad news for mothers, because these out-of-date practices make it harder for women to achieve their own breastfeeding goals. A study of nearly 2000 US mothers found that among mothers who received six of six best practices for maternity care, 97% achieved their personal goal to breastfeeding for at least 6 weeks. Among mothers who received zero of six, nearly 30% failed to achieve their personal goals.

These practices – the World Health Organization Ten Steps to Successful Breastfeeding – have been shown to be effective in a randomized controlled trial, which is the gold standard for medical evidence. In the PROBIT study, researchers randomized 31 hospitals to the Ten Steps or to continuing usual care. The study enrolled 17,046 mother-infant pairs, all of whom intended to breastfeed. Dyads who received care in a Ten Steps hospital were more likely to be exclusively breastfeeding at 3 months (43.3 vs. 6.4%) and to be breastfeeding at 12 months (19.7 vs. 11.4%). Ten Steps care has a lasting impact on breastfeeding success.