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The new ABM Clinical Protocol #7 could have just been the revision of an outdated protocol.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

Short report on the Baby-Friendly Hospital Initiative Congress

Submitted on Behalf of the World Alliance for Breastfeeding Action (WABA) and the Academy of Breastfeeding Medicine (ABM)

Dr Felicity Savage, FABM, Chair of WABA.

Dr Rukhsana Haider, FABM, Co-Chair of WABA.

Introduction

The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by WHO and UNICEF, with the aim of protecting, promoting and supporting breastfeeding in maternity facilities worldwide.  To be designated “Baby-Friendly”, facilities are required to follow the Ten Steps to Successful Breastfeeding and the Code of Marketing of Breastmilk Substitutes.

Since 1991, great progress has been made, and 20,000 maternity facilities world-wide have been designated Baby-Friendly. However, in the last decade, progress has slowed down, and the total number of designated facilities still represents less than one third of all maternities in the world. Also it has been difficult to maintain the necessary standards as the BFHI assessment procedure often lies outside normal hospital accreditation processes.

The 25^th Anniversary of the launch of the BFHI seemed an appropriate time to review progress and consider the need for the development of revised or new guidelines.

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.

Rebuttal to Dr. Amy Tuteur regarding Time editorial

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.

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.

I #March4Nutrition to make #breastfeeding a right, not a privilege

I #March4Nutrition because breastfeeding is a powerful predictor of health and wellbeing for mothers and infants — and yet, too many families face barriers that prevent them from achieving their own breastfeeding goals.

Families who want to breastfeed navigate a veritable minefield of “Booby Traps.” Many maternity providers have minimal training in lactation support, and providers may not ask about breastfeeding during prenatal care — or spend only seconds on the topic — missing the opportunity to address concerns and provide guidance.  Parents are inundated with misleading materials from infant formula manufacturers, promising that their product is “designed to be like breast milk” or will magically convince fussy babies to sleep through the night. Indeed, in a study, mothers looking at formula advertisements voiced concerns that their milk didn’t have added vitamins, so perhaps it would be healthier to formula feed.

At birth, too few families receive evidence-based maternity care that gets infant feeding off to an optimal start. For example, putting a baby skin-to-skin for the first hour of life increases breastfeeding duration by as much as 6 weeks — yet 28% of US hospitals do not provide such care to most women.  Skin-to-skin is one of the World Health Organization Ten Steps to Successful Breastfeeding. Hospitals that implement all ten can be designated as “Baby Friendly” – but currently, only 11.5% of US maternity centers meet that standard. It’s worth noting that we are making progress — just 2.9% of hospitals were Baby Friendly in 2007 — but 88% of families are still hobbled at the starting gates when they start their breastfeeding journey.

ABM Protocol and Statement Updates!

Today I wear my dual hats as ABM Protocol Chair and ABM Blogger.  It came to the attention of the Protocol Committee that there were typos/errors in a couple of our ABM protocols after publication.  Two protocols have been corrected in the on-line copies for Breastfeeding Medicine previously, and have now been updated on the ABM website as of today. 

Here are the corrections that have been made:

1.  Protocol #3—Supplementation—Volume 4, Number 3:

  Table 3, page 178  under “Time” the second line was originally printed 24-28 hours; correction is 24-48 hours.

2.  Protocol #7—Model Hospital Policy—Volume 5, Number 4:

  Page 176 and in the listing of the Ten Steps.  Step #6: only the US version require that hospitals purchase their formula.  The original published text stated: 

   6.  Give newborn infants no food or drink other than breast milk, unless medically indicated. (A hospital must pay fair market price for all formula and infant feeding supplies that it uses and cannot accept free or heavily discounted formula and supplies.)

Now it correctly and in keeping with the original, international Ten Steps says:

  6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

I will let you know if any future changes occur in published protocols or statements. 

And by the way, the just published issue of Breastfeeding Medicine contains ABM’s second Statement, Educational Objectives and Skills for the Physician with Respect to Breastfeeding.  Check it out in the latest Journal (Breastfeeding Medicine. April 2011, 6(2): 99-105).  Our first ABM Statement, Position on Breastfeeding (Breastfeeding Medicine 2008;3(4):267-270), can be found under the “About Us” tab on our web page right now.  As we now have two statements, and several more on the way, we are setting up a “Statements” section on our Protocol page to make them easy to find all in one place.  Please be a little patient with us!  Our newest statement will be on our website soon!

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

“A sucker born every minute”: pacifiers and breastfeeding

For new moms, deciding about whether to offer a pacifier to a newborn, like deciding whether to breastfeed, can be an emotionally loaded decision.  Newborns need to suck – for non-nutritive (comfort) as well as nutritive (food) reasons.  I can’t count the number of times I’ve heard “that baby is using [me/you/her mom] as a pacifier!” from parents and nursery nurses during the first hours of life.

When I hear that, I can’t help but to cringe and comment that pacifiers were invented as a substitute for moms, not vice versa.   The physiology of lactation requires frequent suckling and emptying of the breast to establish and maintain a mom’s milk supply.  So it makes sense that giving a pacifier to a newborn who wants to suckle, instead of letting him nurse, could adversely affect his mom’s milk supply as well as his own growth.  Thus physicians who want to support breastfeeding usually caution new parents about the use of pacifiers before breastfeeding is well established, usually about two weeks after birth. ( Avoidance of artificial teats or pacifiers is, in fact, one of the WHO/UNICEF Ten Steps to Successful Breastfeeding.)

However, it has been difficult to find definitive scientific evidence to support this advice.  And as a mom, I well remember the frustration of seemingly incessant newborn breastfeeding.  That’s why I was hopeful when I saw the abstract for a new Cochrane meta-analysis that suggests pacifiers need not be avoided.

WABA Global Breastfeeding Partners’ Forum

The World Alliance for Breastfeeding Action (WABA) is organizing the Global Breastfeeding Partners’ Forum (GBPF) on October 17 to 18 in Penang, Malaysia. This two-day forum will have as main theme “Enabling Mothering: Keeping mothers and babies together”, focusing on the expanded Baby Friendly Hospital Initiative (BFHI)  and maternity protection and support for working women. WABA’s Core Partners, participants and speakers from around the world will be sharing new technical knowledge and programmatic updates in the areas of the expanded BFHI maternity protection. Among the purposes of this meeting is to further collaboration with WABA’s Core Partners and other participants to plan and advance the common vision and strategic direction of the breastfeeding movement.

The Academy of Breastfeeding Medicine is a Core Partner and the physicians’ arm of WABA. ABM representatives will be actively participating in this forum looking for strategies to help promote effectively the expanded BFHI among physicians around the world. Physicians are key care providers to increase the BFHI and achieve the Innocenti Declaration goals globally. All ABM physicians should enthusiastically embrace the tenets of the Innocenti Declaration as the premium policy for infant and child health promotion and a necessary public health strategy around the world.

We invite all ABM members to sign the ABM/WABA Physician’s Pledge to Promote, Protect and Support Breastfeeding. The Physician’s Pledge is a vehicle for all physicians to declare their support for the Innocenti Declaration Goals and to “go on record” as a breastfeeding-friendly practitioner. Please fax your signed Physician’s Pledge to ABM at its USA headquarters, 914-740-2101, or mailed to: Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd floor, New Rochelle, New York 10801, USA.

Ana M. Parrilla-Rodríguez, MD, MPH, is a public health physician, breastfeeding researcher and clinician, and associate professor of the Maternal and Child Program at the University of Puerto Rico School of Public Health. She is a member and a Fellow of the Academy of Breastfeeding Medicine.
Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Why ‘Beetlejuice’ is a losing argument to bolster breastfeeding

I’ve been thinking a lot about Similac’s recent recall of 5 million cans of formula thought to contain beetle parts, and what it means for breastfeeding advocacy. At first blush, it looks like a slam dunk argument to encourage more moms to breastfeed. Faced with a decision between bug-part-tainted powder and mom’s milk, surely more moms will want to breastfeed.