- Email: [email protected]
Promote Breastfeeding in the Outpatient Setting: It’s Easy!
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Promote Breastfeeding in the Outpatient Setting: It’s Easy! Natasha K. Sriraman, MD, MPH, FAAP, FABM
The numerous benefits for both mother and baby of breastfeeding are evidence-based and well-defined. Breastmilk is the physiologic norm for infant nutrition, offering multiple health benefits and protections for mothers and babies. Although major medical and health organizations, which represent the health of women and children, such as the American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecology (ACOG), American Academy of Family Practice (AAFP), Centers for Disease Control (CDC), UNICEF, the World Health Organization (WHO) and the National Public Health Service (NPHS), all recommend exclusive breastfeeding, few
women meet the recommended goals for duration and exclusivity, despite high initiation rates. This article will discuss the barriers women face when breastfeeding. Strategies will be discussed on how physicians and health care providers can assist and advocate for their mothers while helping to improve the health of women and children. Physicians/pediatricians can support women and design interventions that can help patients’ mothers overcome these challenges. Curr Probl Pediatr Adolesc Health Care 2017;47:311-317
Physicians/pediatricians can better support women and he numerous benefits for both mother and baby design interventions that can help mothers overcome of breastfeeding are evidence-based and wellthese challenges. defined. Breastmilk is the physiologic norm for infant nutrition, offering multiple health benefits and protections for mothers and babies.1 Although major medical and health organizations, which represent the Provider Knowledge, Attitudes, and health of women and children, such as the American Beliefs Academy of Pediatrics (AAP), American College of Despite the evidence, many providers still feel Obstetrics and Gynecology (ACOG), American Acaduncomfortable “telling a mother how to feed a baby.”9 emy of Family Practice (AAFP), Centers for Disease Even though physicians discuss eating habits, smoking Control (CDC), UNICEF, the World Health Organizacessation and immunizations, tion (WHO), and the National many providers fear they will Public Health Service (NPHS), Breastmilk is the physiologic make mothers feel guilty recomall recommend exclusive norm for infant nutrition, offermending breastfeeding especially breastfeeding, few women choose not to breastmeet the recommended goals ing multiple health benefits and if they 10,11 feed. However, the manner for duration and exclusivity, protections for mothers and 2–8 in which physicians address infant despite high initiation rates. babies. feeding can determine how a What are the barriers mother will feel about the recomwomen face when breas12 mendation. Physicians can use techniques to give tfeeding? What can physicians and health care probreastfeeding advice while empowering the mother to viders do to assist and advocate for their mothers while breastfeed.13 helping to improve the health of women and children? Currently practicing physicians were trained when less than 25% of mothers initiated breastfeeding. While From the Division of General Academic Pediatrics, Children’s Hospital of The King’s Daughters/Eastern Virginia Medical School, Norfolk, VA. many pediatricians feel that they are confident with Curr Probl Pediatr Adolesc Health Care 2017;47:311-317 breastfeeding counseling, this does not always corre1538-5442/$ - see front matter late with their knowledge of breastfeeding. In fact, & 2017 Elsevier Inc. All rights reserved. pediatricians still recommend mothers to discontinue http://dx.doi.org/10.1016/j.cppeds.2017.10.002
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TABLE 1.
Resources
Website
Breastfeeeding Friendly Consortium AAP Breastfeeding Residency Curriculum
www.bfconsortium.org www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Breastfeeding/Pages/ Residency-Curriculum.aspx Wellstart International www.wellstart.org Academy of Breastfeeding Medicine Protocols www.bfmed.org/resources/protocols.aspx United States Breastfeeding Coalition Core www.usbreastfeeding.org/core-competencies Competencies Health e-Learning Modules www.health-e-learning.com Breastfeeding Matters: The Pediatrician’s Role www.shop.aap.org/breastfeeding-matters-the-pediatricians-role/ Breastfeeding and the Law www.llli.org/law/lawus.html Breastfeeding and the Use of Human Milk www.pediatrics.aappublications.org/content/129/3/e827 Organizations AAP Section on Breastfeeding Academy of Breastfeeding Medicine United States Breastfeeding Coalition La Leche League The American Congress of Obstetricians and Gynecologists American Academy of Family Physicians
www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Breastfeeding/Pages/ Section-on-Breastfeeding.aspx www.bfmed.org www.usbreastfeeding.org www.llli.org/ www.acog.org/About-ACOG/ACOG-Departments/Breastfeeding www.aafp.org/patient-care/public-health/breastfeeding.html
dump” advice given to many mothers who are takbreastfeeding for conditions that are compatible with ing/placed on medication while nursing. breastfeeding.14 Most commonly, this occurs when In many instances, myths about breastfeeding perbabies present with jaundice or slow weight gain. Also, petuate misinformation regarding sleep, diet, and mothers are told to discontinue breastfeeding when they medications. These myths are taking medication and/or told to can undermine a woman’s “pump and dump” when given decision to breastcontrast for a radiological exam. Linking with a lactation consul- informed 16 feed. In addition to comPersonal experiences of the provider or provider’s family member tant and/or having accessibility mon misconceptions about with breastfeeding can play a big to a nurse with lactation skills is the negative effects on sleep, role in a provider’s attitude. One helpful, as many pediatricians restrictions on diet, or medistudy found that over 90% of may not have the time to trou- cation use, many women are pediatricians felt their breastfeednervous about what breastble-shoot a lactation issue. ing experiences affected their clinfeeding will physically feel ical advice to mothers.15 This like. Physicians can help dispel these myths by asking open-ended questions about study highlights the impact of personal experiences what the patients and families have heard about on recommending what’s best for our patients. breastfeeding and then giving them factual, evidenceWhat can be done? Pediatricians can become more based information. knowledgeable about breastfeeding via numerous resources/CME/training (Table 1). Linking with a lactation consultant and/or having accessibility to a Supplementation nurse with lactation skills can be helpful as many pediatricians may not have the time to trouble-shoot a Commonly in the outpatient setting, during the early lactation issue in a busy office setting. Using evidencenewborn period, formula supplementation is recombased resources is essential. LACTMED (https://www. mended by the provider for various infant conditions, nlm.nih.gov/news/lactmed_announce_06.html) is a such as jaundice or slow weight gain in the baby. free online resource and APP that provides information Many times, this recommendation is made erroneon the compatability of medication with breastfeeding. ously which, unfortunately, can have negative effects This accessibility to information for physicians, on the breastfeeding relationship within the dyad regardless of specialty, can avoid the “pump and (Table 2). 312
Curr Probl Pediatr Adolesc Health Care, December 2017
TABLE 2.
Problem
Solution
Lack of provider knowledge/confidence
Breastfeeding CME/courses/online training
Recommendations regarding medications
LACTMED (website/free app)
Lack of time to do lactation management in outpatient setting
Referral network to lactation consultants (community) Pediatric nurse trained to be LC (onsite)
Supplementation
Observe a feed Use of objective screening tool to assess milk transfer
Jaundice/hyperbilirubinemia
ABM protocol # Supplementation with: 1) Expressed mother’s milk 2) Pasteurized donor milk 3) Hydrolyzed infant formula Maintain S2S if patient required phototherapy
Infant weight gain
Use of CDC/WHO growth charts
Milk supply
Assess maternal factors (fluids, c-section, maternal obesity)
Formula Marketing Breastfeeding-friendly office
ABM protocol Remove any materials that inadvertently advertise formula (posters/magazines/lanyards/ID badge holders/formula samples)
Hospital setting/nursery
Work with hospital to eliminate formula discharge packs/bags from nursery www.banthebags.org
Professional organizations
Conflict of interest corporate sponsorship agreements
Workplace issues Inform mom about options
FMLA paperwork if prolonged work absence
Maintaining milk supply after return to work
Guidance about pumping at work ACA guidelines for protected time and space “Prescription” given to mom to be given to employer stating to allow mother to pump every 2–3 hours
Electric breast pump
IRS benefit Insurance coverage (Medicaid, Private, TRICARE)
Jaundice The fear of jaundice in newborns often leads to increased formula use. While it is true that poor breastfeeding is associated with increased jaundice risk, frequent and effective breastfeeding can be protective against the development of non-physiologic jaundice.17 Breastfed babies usually have a prolonged physiologic jaundice (unconjugated) that can extend into the second week of life. Breastfed babies should nurse 8–12 times within a 24-hour period for adequate nutrition and hydration, thereby preventing non-physiologic jaundice. An objective screening tool can be used to check for optimal milk transfer.18 If supplementation is needed beyond mother’s own milk, the baby should receive (in this order) (1) expressed mother’s milk, (2) pasteurized donor milk, and (3) infant formula. Hydrolyzed/elemental protein
Curr Probl PediatrAdolesc Health Care, December 2017
formulas has been shown to be more effective than standard formula to inhibit the intestinal absorption of bilirubin.19 If a baby requires phototherapy, it can be provided with minimal breastfeeding interruption by keeping the infant in the mother’s room for frequent feeding and providing phototherapy while the infant is held skin-to-skin.20
Supply/Weight Gain Many times, mothers have the perception that the amount of colostrum is not sufficient for their baby’s needs in those first few days of life. These mothers may be told to supplement thereby undermining her confidence to feed her baby. Instead, physicians can reassure the mother by reviewing newborn anatomy and physiology and the actual amount of colostrum a newborn needs based on the size of his stomach. This is
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and rather, suggests that also an opportunity to watch and assess a breastfeeding session. Recommending infant formula signs, brochures, and photos feature positive images of Recommending infant formula supplementation in the early breastfeeding and encourage supplementation, especially in this newborn period, whie under- mothers to breastfeed.26,27 early newborn period, while undermining a mother’s confidence, Providers that examine their mining a mother’s confidence, will actually reduce the amount of will actually reduce the amount practice environments and breast stimulation, which results of breast stimulation, thereby implement changes that are in a reduction of milk supply— of breastfeeding reducing the milk supply-affect- supportive thereby affecting the chain of supmay also see a rise in the rates ing the chain of supply and ply and demand. of exclusive breastfeeding in demand. Providers must look at the baby, their patient population.28 mother, appropriate growth chart What can be done? Check and assess prenatal factors that may cause an error in for inadvertent formula advertising within the office weight gain (such as excessive IVF in a mother), and/or setting (pens/notepads/mugs/posters). Discard parentmaternal factors that may cause delayed lactogenesis ing/baby magazines that advertise formula, since many (caesearean section, maternal obesity, and fertility of these include mail-in postcards asking for mom’s history). information. Double-check that the growth charts While there are some maternal and infant factors that being used are from the WHO/CDC as these account deem formula supplementation necessary, these are for breastfed children, while in the past, the growth very few in a term, healthy newborn.21 charts which were sponsored by formula companies generally skewed the weight curves to formula-fed babies, causing pediatricians to recommend Maternal Factors supplementation. Obesity continues to be an epidemic in this country, Infant formula, or commercial, artificial breastmilk and unfortunately women and new mothers are equally substitute is a heavily marketed product—both in the affected. BMI rates continue to increase. In 2012, 36% United States and internationally. This occurs in the of women were obese, with 32% of these women being free market, as well as through the Women, Infants & of child-bearing age.22 While there are multiple health Children Program (WIC), a federally funded program risks for an obese mother and her baby, maternal BMI that serves a vulnerable population. Although breastalso negatively affects breastfeeding rates. Women feeding rates are rising, WIC recipients characteristiwith a BMI ≥ 30 are less likely to initiate breastfeedcally have lower breastfeeding rates compared to those ing, breastfeed for a shorter duration and are at risk for not receiving WIC.29 WIC purchases over 50% of the 23–25 delayed onset of lactation. Addressing breastfeedformula in the US, which translates into $850 million ing may be more challenging due to maternal anatomy, of a $7.3 billion budget. Over $90 million is spent on physical mobility issues, including issues related to formulas with additives (DHA/ARA) that have not modesty and the stigma associated with being obese. been shown to have any benefit to the baby’s developWomen with higher BMIs can be referred for expert ment.30 The World Health Organization’s International breastfeeding education prenatally and provided Code of Marketing Breastmilk Substitutes clearly opportunities for breastfeeding support and managestates that formula samples should not be given to ment postnatally to help them meet their goals. pregnant women and new mothers; and feeding with infant formula should only be done so with a medical indication and demonstrated by health care workers.31 In the Office Setting Pregnant women are commonly exposed to formula advertising in their OB’s office, parenting magazines, Marketing is very powerful in the messages it sends to our patients/families—this can occur anywhere in and are sometimes offered free formula. Receiving the office: waiting room, exam room, or triage area. formula, whether in maternity discharge packs or at home through the mail, may prevent women from The American Academy of Pediatrics (AAP) and the Academy of Breastfeeding Medicine (ABM) discourreaching their breastfeeding goals. Peripartum breastages displaying any images of bottle-feeding babies, feeding cessation was significantly higher in women
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exposed to commercial formula packs in a physician’s Pediatricians can start the discussion about returning office.32 Physician professional organizations should to the workplace and how to maintain breastfeeding at the 1-month well child check. We can give guidance strive to follow the Conflict of Interest statement on how often to pump/express milk during the workregarding corporate sponsorship and work as individday, and storage guidelines can be discussed.38 In uals to limit the amount of corporate-sponsored education material and advertising in their environments. many instances, mothers may not feel supported nor These sponsorships may unduly influence professional empowered to approach their employer about taking judgments involving the primary interests and goals of the time to pump breastmilk. While we can liken it to medicine while ignoring evidence-based practices.33 the employees taking a break to smoke outside, a strong approach is to write a note/prescription Finally, regarding hospital discharge, women who addressed to the employer clarreceived free formula samples ifying that the mother has the at discharge were less likely to be breastfeeding at 1 month and Evaluate for inadvertent formula right to a clean place and protected time to pump while in more likely to introduce solids at advertising with in the office the workplace.37 2 months. In addition, the rates setting. of initiation, exclusivity, and The ACA now requires most duration were decreased.34 Medhealth insurance plans to cover the cost of a breast pump as part of women’s ical providers are in a role to educate, encourage, and preventive health services. The Internal Revenue support mothers to breastfeed in the hospital and Service (IRS) considers breast pumps and other refrain from giving formula discharge packs. The lactation supplies as medical supplies, which allows provision of commercial hospital discharge packs these items to be eligible for tax breaks and/or flexible (with or without formula) reduces the number of 35 spending accounts.37 Women who have Medicaid are women exclusively breastfeeding at all times. Movements to ban the bags have been successful in getting eligible for WIC that also provides breast pumps under rid of formula samples within the hospital setting while certain circumstances. Many WIC programs also improving breastfeeding success. provide breastfeeding peer counselors, as well. Health care providers can ensure that pregnant women and breastfeeding mothers are aware of the provisions within their insurance plans and suggest that they call Workplace Issues the number on their insurance card to determine what is covered under their specific health insurance plan. The United States is “the only economically Breast pumps and breast pump supplies are covered advanced country”… “where employers are not at no cost for new mothers, including mothers who required to provide any paid maternity leave after a adopt an infant and plan to breastfeed. woman gives birth.” The United States is ranked at the For military mothers/families, the mother must have bottom out of 36 countries on the Breastfeeding Policy a prescription from a TRICARE-authorized physician scorecard. Ninety-eight countries give new mothers 14 or health care provider that states which type of breast weeks or more of paid maternity leave. In this country, pump is needed: hospital-grade, manual, or standardexpectant mothers in the United States can apply for electric breast pump. If the mother has leave under the Family and Medical Leave Act paid out-of-pocket for a pump, a claim can be (FMLA), which provides the mother with 12 weeks submitted for reimbursement. Breastfeeding supplies, of unpaid maternity leave; however, companies are not including two breast pump kits (per birth) for up to 36 required to provide FMLA. Also, economically, months after the birth event, also are covered by unpaid leave is not a feasible choice for many TRICARE.39 families.36 As a result, many women are forced to return to work within 6 weeks, thereby making it very difficult for mothers to continue to breastfeed. The Patient ProDiscussion tection and Affordable Care Act (ACA) states that businesses must provide reasonable break time and Pediatricians/physicians have an important role in adequate space for nursing mother to express milk.37 affecting the health and well-being of newborn babies
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and their mothers. There are numerous influences, many which are erroneous, that can adversely affect a mother’s decision and duration to breastfeeding her infant. When mothers make the important decision about infant feeding, they should be given evidence-based information to make a truly informed choice, just like any other health care decision. By presenting infant feeding as a health decision impacting the health of mother and baby, the physician/nurse health care team can tailor the information given based on the mother’s knowledge, goals, and concerns. Pediatricians who take care of these newborns, especially in the outpatient setting, can educate themselves about what changes can be made to help mothers feel prepared and supported in order to reach their breastfeeding goals. Whether it is working with a lactation consultant, receiving more education to increase our confidence with evaluating a breastfeeding dyad, or simply removing items that advertise formula within the medical care setting, we can have a significant impact in breastfeeding rates, which will positively affect the health of mothers and babies in our practice.
References 1. Agency for Healthcare Research and Quality; U.S. Department of Health and Human Services. Publication No. 07-E007; April. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries 2007:Publication No. 07-E007; April. 2. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. 3. United States Breastfeeding Committee. Implementing The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding. Washington, DC, 2010. 4. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012;129 (3):e827–41. 5. Academy of Breastfeeding Medicine. Position on breastfeeding. Breastfeed Med 2008;3(4):267–70. 6. Fifty-fourth World Health Assembly. Global Strategy for Infant and Young Child Feeding: The Optimal Duration of Exclusive Breastfeeding. Geneva, Switzerland: World Health Organization, 2001. 7. Healthy People 2020. Maternal, Infant, and Child Health 2012. http://www.healthypeople.gov/2020/topicsobjec tives2020/overview.aspx?topicId=26. Accessed September 15, 2014. 8. Centers for Disease Control and Prevention. Breastfeeding Report Card—United States 2012. http://www.cdc.gov/breast feeding/data/reportcard.htm. Accessed September 15, 2014.
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9. Colen CG, Ramey DM. Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons Soc Sci Med 2014;109:55–65. 10. Shah D. Is breast always best? A personal reflection on the challenges of breastfeeding? Obstet Gyn 2013;121(4):869–71. 11. Labbok M. Exploration of guilt among mothers who do not breastfeed: the physician’s role. J Hum Lact 2008;24(1):80–4. 12. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider–parent vaccines discussions in helath supervision visits. Pediatrics 2013;132(6):1037–46. 13. Elliott-Rudder M, Pilotto L, McIntyre E, Ramanathan S. Motivational interviewing improves exclusive breastfeeding in an Australian randomised controlled trial. Acta Paediatr 2014;103(1):e11–6. 14. Pound CM, Williams K, Grenon R, Aglipay M, Plint AC. Breastfeeding knowledge, confidence, beliefs, and attitudes of Canadian physicians. J Hum Lact 2014;30(3):298–309. 15. Dixit A, Feldman-Winter L, Szucs KA. “Frustrated,” “depressed,” and “devastated” pediatric trainees: US academic medical centers fail to provide adequate workplace breastfeeding support. J Hum Lact 2015;31(2):240–8. 16. Doan T, Gardiner A, Gay CL, Lee KA. Breast-feeding increases sleep duration of new parents. J Perinat Neonatal Nurs 2007;21(3):200–6. 17. Maisel MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant ≥35 weeks’ gestation: an update with clarifications. Pediatrics 2009;124:1193. 18. LATCH Breastfeeding assessement tool. https://www.cdph.ca. gov/programs/breastfeeding/Documents/MO-LatchBreastfee dingAssessment.pdf. Accessed October 4, 2015. 19. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #22: guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks’ gestation. Breastfeed Med 2010;5(2):87–93. 20. Szucs KA, Rosenman MB. Family-centered, evidencebased phototherapy delivery. Pediatrics 2013;131(6):e1982–5. 21. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeed Med 2009;4(3): 175–82. 22. NCHS Data Brief, Number 131, Prevalence of Obesity Among Adults: United States, 2011–2012. October 2013. http://www. cdc.gov/nchs/data/databriefs/db131.htm. Accessed January 21, 2015. 23. Amir LH, Donath S. A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth 2007;7:9. 24. Hauff LE, Leonard SA, Rasmussen KM. Associations of maternal obesity and psychosocial factors with breastfeeding intention, initiation, and duration. Am J Clin Nutr 2014;99(3):524–34. 25. Nommsen-Rivers LA, Chantry CJ, Peerson JM, Cohen RJ, Dewey KG. Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr 2010;92(3):574–84.
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26. Grawey AE, Marinelli KA, Holmes AV. Academy of Breastfeeding Medicine. ABM Clinical Protocol #14: Breastfeedingfriendly physician’s office: optimizing care for infants and chidren, revised 2013. Breastfeed Med 2013;8(2):237–42. 27. American Academy of Pediatrics. How to have a breastfeeding friendly practice. https://www2.aap.org/breastfeeding/files/pdf/ AAP%20FindFriendlyPractice.pdf. Accessed October 4, 2015. 28. Corriveau SK, Drake EE, Kellams AL, Rovnyak VG. Evaluation of an office protocol to increase exclusivity of breastfeeding. Pediatrics 2013;131(5):942–50. 29. CDC National Immunization Survey. Rates of any and exclusive breastfeeding by socio-demographics among children born in 2011. http://www.cdc.gov/breastfeeding/data/ nis_data/rates-any-exclusive-bf-socio-dem-2011.htm. Accessed January 21, 2015. 30. Oliveira V, Frazao E, Smallwood D. Rising infant formula costs to the WIC program: recent trends in rebates and wholesale prices. ERR-93, USDA, Economic Research Service, Feb 2010:3-4. http://www.cbpp.org/cms/?fa=view&id= 3201#_ftn2. Accessed September 17, 2014. 31. International Code of Marketing of Breast-Milk Substitutes. Geneva: World Health Organization, 1981. http://www.who. int/nutrition/publications/code_english.pdf. Accessed January 21, 2015. 32. Howard C, Howard F, Lawrence R, Andresen E, DeBlieck E, Weitzman M. Office prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol 2000;95(2): 296–303. 33. Conflict of Interest in Medical Research, Education, and Practice. Institute of Medicine (US) Committee on Conflict
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of Interest in Medical Research, Education, and Practice. In: Lo B, Field MJ, (eds). The National Academies Collection: Reports funded by National Institutes of Health. Washington (DC): National Academies Press (US), 2009. Rosenberg KD, Eastham CA, Kasehagen LJ, Sandoval AP. Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on breastfeeding. Am J Public Health 2008;98(2):290–5. Donnelly A, Snowden HM, Renfrew MJ, Woolridge MW Commercial hospital discharge packs for breastfeeding women. Cochrane Database Syst Rev. 2000;(2):CD002075. U.S. Department of Labor. Family Medical Leave Act of 1993. http://www.dol.gov/compliance/guide/fmla.htm. Washington DC: U.S. Department of Labor; Office of the Assistant Secretary for Policy. Updated September 2009. Accessed September 21, 2014. Garvin CC, Sriraman NK, Paulson A, Wallace E, Martin CE, Marshall L. The business case for breastfeeding: a successful regional implementation, evaluation, and follow-up. Breastfeed Med 2013;8(4):413–7. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #8: human milk storage information for home use for full-term infants (original protocol March 2004; revision #1 March 2010). Breastfeed Med 2010;5 (3):127–30. Sriraman NK. Insurance coverage of breastfeeding counseling, supplies aids military mothers. Oct. AAP News 2016;17 Oct www.aappublications.org/news/2016/10/17/Breastfeed ing101716. Oct 17, 2016.
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Promote Breastfeeding in the Outpatient Setting: It’s Easy! Natasha K. Sriraman, MD, MPH, FAAP, FABM
The numerous benefits for both mother and baby of breastfeeding are evidence-based and well-defined. Breastmilk is the physiologic norm for infant nutrition, offering multiple health benefits and protections for mothers and babies. Although major medical and health organizations, which represent the health of women and children, such as the American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecology (ACOG), American Academy of Family Practice (AAFP), Centers for Disease Control (CDC), UNICEF, the World Health Organization (WHO) and the National Public Health Service (NPHS), all recommend exclusive breastfeeding, few
women meet the recommended goals for duration and exclusivity, despite high initiation rates. This article will discuss the barriers women face when breastfeeding. Strategies will be discussed on how physicians and health care providers can assist and advocate for their mothers while helping to improve the health of women and children. Physicians/pediatricians can support women and design interventions that can help patients’ mothers overcome these challenges. Curr Probl Pediatr Adolesc Health Care 2017;47:311-317
Physicians/pediatricians can better support women and he numerous benefits for both mother and baby design interventions that can help mothers overcome of breastfeeding are evidence-based and wellthese challenges. defined. Breastmilk is the physiologic norm for infant nutrition, offering multiple health benefits and protections for mothers and babies.1 Although major medical and health organizations, which represent the Provider Knowledge, Attitudes, and health of women and children, such as the American Beliefs Academy of Pediatrics (AAP), American College of Despite the evidence, many providers still feel Obstetrics and Gynecology (ACOG), American Acaduncomfortable “telling a mother how to feed a baby.”9 emy of Family Practice (AAFP), Centers for Disease Even though physicians discuss eating habits, smoking Control (CDC), UNICEF, the World Health Organizacessation and immunizations, tion (WHO), and the National many providers fear they will Public Health Service (NPHS), Breastmilk is the physiologic make mothers feel guilty recomall recommend exclusive norm for infant nutrition, offermending breastfeeding especially breastfeeding, few women choose not to breastmeet the recommended goals ing multiple health benefits and if they 10,11 feed. However, the manner for duration and exclusivity, protections for mothers and 2–8 in which physicians address infant despite high initiation rates. babies. feeding can determine how a What are the barriers mother will feel about the recomwomen face when breas12 mendation. Physicians can use techniques to give tfeeding? What can physicians and health care probreastfeeding advice while empowering the mother to viders do to assist and advocate for their mothers while breastfeed.13 helping to improve the health of women and children? Currently practicing physicians were trained when less than 25% of mothers initiated breastfeeding. While From the Division of General Academic Pediatrics, Children’s Hospital of The King’s Daughters/Eastern Virginia Medical School, Norfolk, VA. many pediatricians feel that they are confident with Curr Probl Pediatr Adolesc Health Care 2017;47:311-317 breastfeeding counseling, this does not always corre1538-5442/$ - see front matter late with their knowledge of breastfeeding. In fact, & 2017 Elsevier Inc. All rights reserved. pediatricians still recommend mothers to discontinue http://dx.doi.org/10.1016/j.cppeds.2017.10.002
T
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311
TABLE 1.
Resources
Website
Breastfeeeding Friendly Consortium AAP Breastfeeding Residency Curriculum
www.bfconsortium.org www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Breastfeeding/Pages/ Residency-Curriculum.aspx Wellstart International www.wellstart.org Academy of Breastfeeding Medicine Protocols www.bfmed.org/resources/protocols.aspx United States Breastfeeding Coalition Core www.usbreastfeeding.org/core-competencies Competencies Health e-Learning Modules www.health-e-learning.com Breastfeeding Matters: The Pediatrician’s Role www.shop.aap.org/breastfeeding-matters-the-pediatricians-role/ Breastfeeding and the Law www.llli.org/law/lawus.html Breastfeeding and the Use of Human Milk www.pediatrics.aappublications.org/content/129/3/e827 Organizations AAP Section on Breastfeeding Academy of Breastfeeding Medicine United States Breastfeeding Coalition La Leche League The American Congress of Obstetricians and Gynecologists American Academy of Family Physicians
www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Breastfeeding/Pages/ Section-on-Breastfeeding.aspx www.bfmed.org www.usbreastfeeding.org www.llli.org/ www.acog.org/About-ACOG/ACOG-Departments/Breastfeeding www.aafp.org/patient-care/public-health/breastfeeding.html
dump” advice given to many mothers who are takbreastfeeding for conditions that are compatible with ing/placed on medication while nursing. breastfeeding.14 Most commonly, this occurs when In many instances, myths about breastfeeding perbabies present with jaundice or slow weight gain. Also, petuate misinformation regarding sleep, diet, and mothers are told to discontinue breastfeeding when they medications. These myths are taking medication and/or told to can undermine a woman’s “pump and dump” when given decision to breastcontrast for a radiological exam. Linking with a lactation consul- informed 16 feed. In addition to comPersonal experiences of the provider or provider’s family member tant and/or having accessibility mon misconceptions about with breastfeeding can play a big to a nurse with lactation skills is the negative effects on sleep, role in a provider’s attitude. One helpful, as many pediatricians restrictions on diet, or medistudy found that over 90% of may not have the time to trou- cation use, many women are pediatricians felt their breastfeednervous about what breastble-shoot a lactation issue. ing experiences affected their clinfeeding will physically feel ical advice to mothers.15 This like. Physicians can help dispel these myths by asking open-ended questions about study highlights the impact of personal experiences what the patients and families have heard about on recommending what’s best for our patients. breastfeeding and then giving them factual, evidenceWhat can be done? Pediatricians can become more based information. knowledgeable about breastfeeding via numerous resources/CME/training (Table 1). Linking with a lactation consultant and/or having accessibility to a Supplementation nurse with lactation skills can be helpful as many pediatricians may not have the time to trouble-shoot a Commonly in the outpatient setting, during the early lactation issue in a busy office setting. Using evidencenewborn period, formula supplementation is recombased resources is essential. LACTMED (https://www. mended by the provider for various infant conditions, nlm.nih.gov/news/lactmed_announce_06.html) is a such as jaundice or slow weight gain in the baby. free online resource and APP that provides information Many times, this recommendation is made erroneon the compatability of medication with breastfeeding. ously which, unfortunately, can have negative effects This accessibility to information for physicians, on the breastfeeding relationship within the dyad regardless of specialty, can avoid the “pump and (Table 2). 312
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TABLE 2.
Problem
Solution
Lack of provider knowledge/confidence
Breastfeeding CME/courses/online training
Recommendations regarding medications
LACTMED (website/free app)
Lack of time to do lactation management in outpatient setting
Referral network to lactation consultants (community) Pediatric nurse trained to be LC (onsite)
Supplementation
Observe a feed Use of objective screening tool to assess milk transfer
Jaundice/hyperbilirubinemia
ABM protocol # Supplementation with: 1) Expressed mother’s milk 2) Pasteurized donor milk 3) Hydrolyzed infant formula Maintain S2S if patient required phototherapy
Infant weight gain
Use of CDC/WHO growth charts
Milk supply
Assess maternal factors (fluids, c-section, maternal obesity)
Formula Marketing Breastfeeding-friendly office
ABM protocol Remove any materials that inadvertently advertise formula (posters/magazines/lanyards/ID badge holders/formula samples)
Hospital setting/nursery
Work with hospital to eliminate formula discharge packs/bags from nursery www.banthebags.org
Professional organizations
Conflict of interest corporate sponsorship agreements
Workplace issues Inform mom about options
FMLA paperwork if prolonged work absence
Maintaining milk supply after return to work
Guidance about pumping at work ACA guidelines for protected time and space “Prescription” given to mom to be given to employer stating to allow mother to pump every 2–3 hours
Electric breast pump
IRS benefit Insurance coverage (Medicaid, Private, TRICARE)
Jaundice The fear of jaundice in newborns often leads to increased formula use. While it is true that poor breastfeeding is associated with increased jaundice risk, frequent and effective breastfeeding can be protective against the development of non-physiologic jaundice.17 Breastfed babies usually have a prolonged physiologic jaundice (unconjugated) that can extend into the second week of life. Breastfed babies should nurse 8–12 times within a 24-hour period for adequate nutrition and hydration, thereby preventing non-physiologic jaundice. An objective screening tool can be used to check for optimal milk transfer.18 If supplementation is needed beyond mother’s own milk, the baby should receive (in this order) (1) expressed mother’s milk, (2) pasteurized donor milk, and (3) infant formula. Hydrolyzed/elemental protein
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formulas has been shown to be more effective than standard formula to inhibit the intestinal absorption of bilirubin.19 If a baby requires phototherapy, it can be provided with minimal breastfeeding interruption by keeping the infant in the mother’s room for frequent feeding and providing phototherapy while the infant is held skin-to-skin.20
Supply/Weight Gain Many times, mothers have the perception that the amount of colostrum is not sufficient for their baby’s needs in those first few days of life. These mothers may be told to supplement thereby undermining her confidence to feed her baby. Instead, physicians can reassure the mother by reviewing newborn anatomy and physiology and the actual amount of colostrum a newborn needs based on the size of his stomach. This is
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and rather, suggests that also an opportunity to watch and assess a breastfeeding session. Recommending infant formula signs, brochures, and photos feature positive images of Recommending infant formula supplementation in the early breastfeeding and encourage supplementation, especially in this newborn period, whie under- mothers to breastfeed.26,27 early newborn period, while undermining a mother’s confidence, Providers that examine their mining a mother’s confidence, will actually reduce the amount of will actually reduce the amount practice environments and breast stimulation, which results of breast stimulation, thereby implement changes that are in a reduction of milk supply— of breastfeeding reducing the milk supply-affect- supportive thereby affecting the chain of supmay also see a rise in the rates ing the chain of supply and ply and demand. of exclusive breastfeeding in demand. Providers must look at the baby, their patient population.28 mother, appropriate growth chart What can be done? Check and assess prenatal factors that may cause an error in for inadvertent formula advertising within the office weight gain (such as excessive IVF in a mother), and/or setting (pens/notepads/mugs/posters). Discard parentmaternal factors that may cause delayed lactogenesis ing/baby magazines that advertise formula, since many (caesearean section, maternal obesity, and fertility of these include mail-in postcards asking for mom’s history). information. Double-check that the growth charts While there are some maternal and infant factors that being used are from the WHO/CDC as these account deem formula supplementation necessary, these are for breastfed children, while in the past, the growth very few in a term, healthy newborn.21 charts which were sponsored by formula companies generally skewed the weight curves to formula-fed babies, causing pediatricians to recommend Maternal Factors supplementation. Obesity continues to be an epidemic in this country, Infant formula, or commercial, artificial breastmilk and unfortunately women and new mothers are equally substitute is a heavily marketed product—both in the affected. BMI rates continue to increase. In 2012, 36% United States and internationally. This occurs in the of women were obese, with 32% of these women being free market, as well as through the Women, Infants & of child-bearing age.22 While there are multiple health Children Program (WIC), a federally funded program risks for an obese mother and her baby, maternal BMI that serves a vulnerable population. Although breastalso negatively affects breastfeeding rates. Women feeding rates are rising, WIC recipients characteristiwith a BMI ≥ 30 are less likely to initiate breastfeedcally have lower breastfeeding rates compared to those ing, breastfeed for a shorter duration and are at risk for not receiving WIC.29 WIC purchases over 50% of the 23–25 delayed onset of lactation. Addressing breastfeedformula in the US, which translates into $850 million ing may be more challenging due to maternal anatomy, of a $7.3 billion budget. Over $90 million is spent on physical mobility issues, including issues related to formulas with additives (DHA/ARA) that have not modesty and the stigma associated with being obese. been shown to have any benefit to the baby’s developWomen with higher BMIs can be referred for expert ment.30 The World Health Organization’s International breastfeeding education prenatally and provided Code of Marketing Breastmilk Substitutes clearly opportunities for breastfeeding support and managestates that formula samples should not be given to ment postnatally to help them meet their goals. pregnant women and new mothers; and feeding with infant formula should only be done so with a medical indication and demonstrated by health care workers.31 In the Office Setting Pregnant women are commonly exposed to formula advertising in their OB’s office, parenting magazines, Marketing is very powerful in the messages it sends to our patients/families—this can occur anywhere in and are sometimes offered free formula. Receiving the office: waiting room, exam room, or triage area. formula, whether in maternity discharge packs or at home through the mail, may prevent women from The American Academy of Pediatrics (AAP) and the Academy of Breastfeeding Medicine (ABM) discourreaching their breastfeeding goals. Peripartum breastages displaying any images of bottle-feeding babies, feeding cessation was significantly higher in women
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exposed to commercial formula packs in a physician’s Pediatricians can start the discussion about returning office.32 Physician professional organizations should to the workplace and how to maintain breastfeeding at the 1-month well child check. We can give guidance strive to follow the Conflict of Interest statement on how often to pump/express milk during the workregarding corporate sponsorship and work as individday, and storage guidelines can be discussed.38 In uals to limit the amount of corporate-sponsored education material and advertising in their environments. many instances, mothers may not feel supported nor These sponsorships may unduly influence professional empowered to approach their employer about taking judgments involving the primary interests and goals of the time to pump breastmilk. While we can liken it to medicine while ignoring evidence-based practices.33 the employees taking a break to smoke outside, a strong approach is to write a note/prescription Finally, regarding hospital discharge, women who addressed to the employer clarreceived free formula samples ifying that the mother has the at discharge were less likely to be breastfeeding at 1 month and Evaluate for inadvertent formula right to a clean place and protected time to pump while in more likely to introduce solids at advertising with in the office the workplace.37 2 months. In addition, the rates setting. of initiation, exclusivity, and The ACA now requires most duration were decreased.34 Medhealth insurance plans to cover the cost of a breast pump as part of women’s ical providers are in a role to educate, encourage, and preventive health services. The Internal Revenue support mothers to breastfeed in the hospital and Service (IRS) considers breast pumps and other refrain from giving formula discharge packs. The lactation supplies as medical supplies, which allows provision of commercial hospital discharge packs these items to be eligible for tax breaks and/or flexible (with or without formula) reduces the number of 35 spending accounts.37 Women who have Medicaid are women exclusively breastfeeding at all times. Movements to ban the bags have been successful in getting eligible for WIC that also provides breast pumps under rid of formula samples within the hospital setting while certain circumstances. Many WIC programs also improving breastfeeding success. provide breastfeeding peer counselors, as well. Health care providers can ensure that pregnant women and breastfeeding mothers are aware of the provisions within their insurance plans and suggest that they call Workplace Issues the number on their insurance card to determine what is covered under their specific health insurance plan. The United States is “the only economically Breast pumps and breast pump supplies are covered advanced country”… “where employers are not at no cost for new mothers, including mothers who required to provide any paid maternity leave after a adopt an infant and plan to breastfeed. woman gives birth.” The United States is ranked at the For military mothers/families, the mother must have bottom out of 36 countries on the Breastfeeding Policy a prescription from a TRICARE-authorized physician scorecard. Ninety-eight countries give new mothers 14 or health care provider that states which type of breast weeks or more of paid maternity leave. In this country, pump is needed: hospital-grade, manual, or standardexpectant mothers in the United States can apply for electric breast pump. If the mother has leave under the Family and Medical Leave Act paid out-of-pocket for a pump, a claim can be (FMLA), which provides the mother with 12 weeks submitted for reimbursement. Breastfeeding supplies, of unpaid maternity leave; however, companies are not including two breast pump kits (per birth) for up to 36 required to provide FMLA. Also, economically, months after the birth event, also are covered by unpaid leave is not a feasible choice for many TRICARE.39 families.36 As a result, many women are forced to return to work within 6 weeks, thereby making it very difficult for mothers to continue to breastfeed. The Patient ProDiscussion tection and Affordable Care Act (ACA) states that businesses must provide reasonable break time and Pediatricians/physicians have an important role in adequate space for nursing mother to express milk.37 affecting the health and well-being of newborn babies
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and their mothers. There are numerous influences, many which are erroneous, that can adversely affect a mother’s decision and duration to breastfeeding her infant. When mothers make the important decision about infant feeding, they should be given evidence-based information to make a truly informed choice, just like any other health care decision. By presenting infant feeding as a health decision impacting the health of mother and baby, the physician/nurse health care team can tailor the information given based on the mother’s knowledge, goals, and concerns. Pediatricians who take care of these newborns, especially in the outpatient setting, can educate themselves about what changes can be made to help mothers feel prepared and supported in order to reach their breastfeeding goals. Whether it is working with a lactation consultant, receiving more education to increase our confidence with evaluating a breastfeeding dyad, or simply removing items that advertise formula within the medical care setting, we can have a significant impact in breastfeeding rates, which will positively affect the health of mothers and babies in our practice.
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