Archive for the ‘policy’ Category
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. Read the rest of this entry »
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 »
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. Read the rest of this entry »
The Lancet has boldly stepped onto center stage to launch its new publication, Breastfeeding in the 21st Century. They state that “every mother and child no matter their location or circumstance, benefits from optimal breastfeeding practices.” They hosted the launch on January 29, 2016 in the Barbara Jordan Conference Center in the Kaiser Family Foundation building in Washington, D.C. The Conference Center symbolically honors Barbara Jordan, first African-American woman member of the Texas State Senate and then congresswoman from Texas starting in 1972. She was committed to fairness and to legislation that protects the underserved and the underrepresented.
The Academy of Breastfeeding Medicine was invited, and Karla Shepard Rubinger was named. I, too, received an invitation to attend. Imagine going to Washington, staying overnight at a hotel to attend a two hour meeting! But I had to be there. I had to hear the discussion with my own ears and see the members of the program from the Bill and Melinda Gates Foundation, the World Health Organization, UNICEF, USAID, the Chicago Council on Global Affairs, to mention a few. Read the rest of this entry »
A guy friend once informed me that breastfeeding breasts aren’t sexy. Sure, there might be the odd dreamboat (thank you, Brad Pitt) who will publicly announce his preference for the breeding female form, but my friend explains: “Breastfeeding breasts aren’t sexy. No one thinks they are sexy! They are generally overfirm, or oblong, with a giant nipple and a BABY attached to the end!” (He also has lots of very warm and supportive opinions of breastfeeding women) Let’s repeat that: “A baby is attached to it;” and that baby probably just pooped itself.
This struck me as essentially true, so it got me thinking: what’s the deal with the worry that this cultural myth of “breasts are for sex, not feeding” undermines women’s ability to feel comfortable with breastfeeding in public? What’s up with the leagues of women telling us they feel over-sexualized while breastfeeding? Or, at least, the leagues of lactation consultants and breastfeeding advocates worrying about it? In fact, it seems important to point out that breastfeeding women aren’t walking around complaining that they feel too sexy. In fact, one of the main reasons teen moms will give for not breastfeeding is that it isn’t sexy. Not to mention the common misconception that breastfeeding causes one’s breasts to become prematurely saggy. Saggy…real sexy. So, if we, as breastfeeding advocates, are not getting this directly from moms, where does it come from? Read the rest of this entry »