Evidence-based support for breastfeeding

Although nearly 80% of mothers initiate breastfeeding, only 50% of mothers are still breastfeeding at 6 weeks, and less than 15% are exclusively breastfeeding at 6 months. The United States lags significantly behind Healthy People 2020 goals despite the health risks of not breastfeeding.¹

The American Academy of Pediatrics (AAP) and other organizations support breastfeeding policies and practices. In a 2012 policy statement “Breastfeeding and the use of human milk,”² the AAP supports exclusive breastfeeding for 6 months and continued breastfeeding for a year or longer as foods are introduced. The statement emphasizes that pediatricians should advocate for breastfeeding as well as be knowledgeable and skillful in its management.

More: Combating the threat of lead poisoning

Lack of knowledge, skills, and time all have been cited as barriers to breastfeeding care by pediatricians.^3-5 Given an ever-changing practice environment, time pressures, and the societal/patient benefit of breastfeeding, pediatricians need to be knowledgeable in evidence-based practices that may impact breastfeeding in their patients. Physicians are less likely to educate, promote, and encourage activities in which they do not believe themselves knowledgeable or skilled. Physician education programs, however, can increase exclusivity and duration of breastfeeding and decrease problems associated with the practice.⁶

Decision to breastfeed

Recommendation: Education and guidance for new parents should occur before and during pregnancy.

The decision to breastfeed is often made before encountering the pediatrician-often before becoming pregnant or early in the first trimester. Prenatal education is one of the most successful interventions for increasing both the initiation and duration of breastfeeding.⁷ For every 3 to 5 women participating in prenatal education, 1 woman will initiate and continue breastfeeding for up to 3 months.⁸

The prenatal visit is an excellent opportunity for the pediatrician to provide anticipatory guidance about breastfeeding. Although these visits often focus on practice philosophy-the workings of a particular practice-and have not been studied extensively as a tool to promote breastfeeding, primary care counseling has been noted to be a successful promotion intervention in very similar practice settings,^9-11 and there is no reason to suspect breastfeeding cannot be similarly promoted.

Hospital and office breastfeeding policies

Recommendation: Advocate for baby-friendly hospital policies and practices where you practice.

The Baby-Friendly Hospital Initiative (BFHI) promotes the Ten Steps to Successful Breastfeeding-evidence-based hospital practices that promote breastfeeding. The BFHI program leads to increased breastfeeding initiation, continued breastfeeding, and higher exclusivity rates.^12-15 Hospitals implementing more of the Ten Steps seem to have greater success in a dose dependent manner, achieving better results in breastfeeding initiation, continuation, and exclusivity.¹⁶ For example, implementation of BFHI leads to more breastfeeding at night, decreased nighttime supplementation with formula, and more comprehensive breastfeeding assessments.¹⁷ Mothers delivering at a hospital that implements 5 or more of the 10 steps are 8 times more likely to be breastfeeding at 6 weeks compared with mothers delivering at a hospital implementing none of the 10 steps.¹⁸

Read more: Can food labels induce parents to order fewer calories?

See "Baby-Friendly Hospital Initiative's 10 Steps to Successful Breastfeeding", page 28.¹⁹

Creating an office-friendly breastfeeding practice additionally demonstrates the pediatrician’s support for breastfeeding. This could include designing space for moms to breastfeed outside the waiting room if desired and encouraging breastfeeding in waiting areas. Additional breastfeeding-friendly office practices include displaying posters, pictures, and photographs of breastfeeding mothers in the office as well as not dispensing formula company literature or promoting formula to parents.²⁰ Pediatricians can track breastfeeding rates to evaluate how effective promotion and support activities are compared with national goals and benchmark data.²¹ Finally, development of telephone triage protocols can address a number of different breastfeeding concerns and problems that may decrease duration or exclusivity of breastfeeding.²⁰

Prevention of premature discontinuation

Recommendation: Become aware and refer to breastfeeding resources in your community.

New mothers most commonly seek out other new mothers with concerns related to decisions about child rearing, and friends are commonly cited as influential when making decisions about infant feeding.^22,23 Further, perceived social support is predictive of successful breastfeeding.²⁴  Identifying and referring mothers in the pediatrician’s practice to resources in the community may significantly improve a woman’s success rate with breastfeeding. This may be especially important if professional breastfeeding services are not available in the community.

Recommended: Pearls from the trenches

Requesting support from and receiving education from a peer counselor is associated with increased rates of initiation and duration of breastfeeding.²⁵ Although peer support is effective in all socioeconomic classes, it may be more important in groups at higher risk of not breastfeeding or early discontinuation. A study from Cook County Hospital in Chicago in the 1980s reported participation in a peer-group discussion was associated with longer duration of breastfeeding compared with those who did not participate.²⁶ Another study among low-income Latina women found individual peer counseling increased likelihood of breastfeeding rates at 1 and 3 months.²⁷

Professional support is also key to increased duration of breastfeeding. Support is more effective when given face-to-face compared with phone interventions and less effective if only delivered on patient request.²⁸ Many pediatricians rely on an International Board Certified Lactation Consultant that can assist a mother and baby with:

•           Latching on,

•           Positioning,

•           Managing lactation problems, and

•           Advising on return to work and school.

Many third-party payers from Medicaid to private insurance will not reimburse for services rendered by lactation consultants unless the practitioner is otherwise eligible for reimbursement of professional services. In this scenario, mothers most often pay for these services out-of-pocket if they are going to receive them. A pediatrician, however, that is able to provide breastfeeding support can be reimbursed for many components of the care, including billing based on time or billing for the mother as a patient.²⁹ Not only is the pediatrician providing a valued service, but he or she may be able to increase practice income and differentiate from other practices at the same time.

Common problems encountered by the pediatrician

Recommendation: Increase knowledge and skill related to common breastfeeding problems.

A comprehensive review of breastfeeding problems impacting term newborns is beyond the scope of this article. However, the following will help pediatricians begin to improve their knowledge and skills related to breastfeeding support.

Ineffective breastfeeding may present to the pediatrician as³⁰:

•           Jaundice;

•           Excessive weight loss;

•           Poor weight gain;

•           Long feeds;

•           Irritable baby after feeds; and/or

•           Feeding that is uncomfortable for the mother.

Many times breastfeeding is stopped or altered because of problems an infant develops in the nursery or shortly after going home. However, many times breastfeeding can be continued during treatment, and there are interventions to help the mother and infant. The common problems include:

Insufficient milk

Inadequate intake or the perception of inadequate milk production is the most common reason for early discontinuation of breastfeeding. There are several maternal and infant issues that can lead to insufficient milk production or the inability to extract milk. Although the pediatrician knows that newborns will feed 8 to 12 times per day, many mothers do not and may interpret this as a sign of insufficient production. If a mother then chooses to supplement, this “perceived insufficiency” can become a true milk insufficiency because less milk will be removed and less milk production will ensue.³⁰ Mothers simply may not know that they need to feed so frequently.

Another common problem is ineffective feeding as a result of poor attachment. This highlights the need for an assessment that includes observation of mother and baby breastfeeding to assess positioning, latch on, and milk transfer. Skin-to-skin contact increases hormonal responses and can increase milk supply. In some cases, galactagogue such as domperidone may be needed, but the drug should not be used in women with a prolonged QT interval.³⁰

Recommended: Online breast milk poses a risk

Maternal risk factors for a delayed lactogenesis and a temporary milk insufficiency include:

•           Type 1 diabetes;

•           Stress/ exhaustion in labor;

•           Cesarean delivery;

•           Obesity; or

•           Retained placenta.

The late-preterm infant (34 to 37 weeks’ gestation) is at higher risk for an ineffective latch and suckle. This may necessitate that the mother express milk and deliver it via an alternative method. The also late-preterm infant is at greater risk of hyperbilirubinemia, hypoglycemia, and hypothermia.⁷

Jaundice

The goal of the pediatrician should be to manage hyperbilirubinemia while preserving exclusive breastfeeding. Although the National Institute for Health and Care Excellence (NICE) cited breastfeeding as a risk factor for jaundice, hyperbilirubinemia may be a result of inadequate breastfeeding and more appropriately called “breast-non-feeding jaundice.”³⁰

The AAP recommends management of bilirubin levels per standard nomograms,³¹ and it is important to identify other causes such as an isoimmune reaction. The first step for the pediatrician is to understand the infant’s cause and not recommend supplementation if intake, output, and weight gain/loss are consistent with normal newborn patterns. If poor intake is thought to be contributing to hyperbilirubinemia, the mother’s own breast milk would be the first choice of supplementation. Often the mother can feed the infant more frequently, but expressed breast milk can be given via other methods if additional fluids are indicated.

Hypoglycemia

As with hyperbilirubinemia, standards are available for the treatment of neonatal hypoglycemia.³² For moderate hypoglycemia, direct breastfeeding is a possible treatment. If the baby does not latch effectively or repeat blood sugars are low, supplementation with expressed breast milk is another possible treatment. If these interventions are not successful, feeding a commercial formula is indicated. If the glucose is less than 28 mg/dl, then treatment with 10% intravenous dextrose should be administered immediately with continuation of unrestricted breastfeeding.⁷

Ankyloglossia

If the infant’s tongue movement is restricted, attachment and suckling may be affected. Symptoms include persistent short feeds; consistent long feeds; inability to get comfortable during feeding; excessive weight loss in the first 2 weeks of life; jaundice; and poor weight gain. If expert breastfeeding support is unsuccessful, frenulotomy may be required.

Conclusion

Pediatricians need to understand evidence-based policies that both promote initiation of breastfeeding and increase the duration of breastfeeding in their patients, as well as develop their knowledge and skills in the promotion, support, and management of the breastfeeding mother and infant.

REFERENCES

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2. Eidelman AI. Breastfeeding and the use of human milk: an analysis of the American Academy of Pediatrics 2012 Breastfeeding Policy Statement. Breastfeed Med. 2012;7(5):323-324.

3. Noble LM, Noble A, Hand IL. Cultural competence of healthcare professionals caring for breastfeeding mothers in urban areas. Breastfeed Med. 2009;4(4):221-224.

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7. Holmes AV. Establishing successful breastfeeding in the newborn period. Pediatr Clin North Am. 2013;60(1):147-168.

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16. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122(suppl 2):S43-S49.

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19. Baby-Friendly USA. Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation. Sandwhich, MA: Baby-Friendly USA; 2010. Available at: https://www.babyfriendlyusa.org/get-started/the-guidelines-evaluation-criteria. Published June 10, 2010. Updated November 28, 2011. Accessed March 10, 2015.   

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31. Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or =35 weeks' gestation: an update with clarifications. Pediatrics. 2009;124(4):1193-1198.

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PHYSICIANS' RESOURCES FOR BREASTFEEDING

American Academy of Pediatrics (AAP): Breastfeeding initiatives

www2.aap.org/breastfeeding/

La Leche League International

www.llli.org

Text4Baby

www.text4baby.org/

Wellstart International: Lactation management education program

www.wellstart.org/resources.html

Breastfeeding Basics: Fundamentals of breastfeeding

www.breastfeedingbasics.org

Academy of Breastfeeding Medicine: Clinical protocols

www.bfmed.org/Resources/Protocols.aspx

AAP: Breastfeeding residency curriculum

www2.aap.org/breastfeeding/curriculum/index.html

AAP: Sample hospital breastfeeding policy for newborns

www2.aap.org/breastfeeding/curriculum/documents/pdf/Hospital Breastfeeding Policy_FINAL.pdf

Dr Bass is chief medical information officer and associate professor of medicine and pediatrics, Louisiana State University Health Science Center–Shreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.