Letters to the Editor

Promoting Breastfeeding

TO THE EDITOR: We would like to commend Dr. Sinusas and Ms. Gagliardi for their excellent article on breastfeeding.¹ They describe ways for family physicians to facilitate the early initiation and long-term success of breastfeeding in their patients.

The authors suggest the use of the "Ten Steps" of the Baby-Friendly Hospital Initiative of WHO/UNICEF to promote, protect, and support breastfeeding.² A Baby-Friendly hospital should also adhere to the WHO/ UNICEF International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly (WHA) resolutions.³ The code seeks to protect breastfeeding by preventing inappropriate marketing of breast-milk substitutes, feeding bottles, soothers, and complimentary foods when used to replace breast milk.⁴ To provide an optimal environment for breastfeeding, family physicians and pediatricians should follow the recommendations of the American Academy of Pediatrics (AAP) listed in the accompanying table⁵ and ensure that their offices are breastfeeding-friendly.⁴

Role of Physicians in Promoting and Protecting Breastfeeding Promote and support breastfeeding enthusiastically. In consideration of the extensive published evidence for improved outcomes in breastfed infants and their mothers, a strong position on behalf of breastfeeding is justified. Become knowledgeable and skilled in both the physiology and the clinical management of breastfeeding. Work collaboratively with the obstetric community to ensure that women receive adequate information throughout the perinatal period to make a fully informed decision about infant feeding. Physicians should also use opportunities to provide age-appropriate breastfeeding education to children and adults. Promote hospital policies and procedures that facilitate breastfeeding. Electric breast pumps and private lactation areas should be available to all breastfeeding mothers in the hospital, both on ambulatory and inpatient services. Physicians are encouraged to work actively toward eliminating hospital practices that discourage breastfeeding. Become familiar with local breastfeeding resources so that patients can be referred appropriately. When specialized breastfeeding services are used, physicians need to clarify for patients their essential role as the infant's primary medical caretaker. Effective communication among the various counselors who advise breastfeeding is essential. Encourage routine insurance coverage for necessary breastfeeding services and supplies, including breast pump rental and the time required by physicians and other licensed health care professionals to assess and manage breastfeeding. Promote breastfeeding as a normal part of daily life, and encourage family and societal support for breastfeeding. Develop and maintain effective communications and collaboration with other health care providers to ensure optimal breastfeeding education, support, and counsel for mother and infant. Advise mothers to return to their physician for a thorough breast examination when breastfeeding is terminated. Promote breastfeeding education as a routine component of medical school and residency education. Encourage the media to portray breastfeeding as positive and the norm. Encourage employers to provide appropriate facilities and adequate time in the workplace for breast-pumping. Adapted with permission from American Academy of Pediatrics. Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100:1035-9.

ALEXANDER K. LEUNG, M.D.
University of Calgary
Alberta Children's Hospital
1820 Richmond Rd. SW
Calgary, Alberta, Canada T2T 5C7

REGINALD S. SAUVE, M.D.
University of Calgary
Calgary, Alberta, Canada T2T 5C7

REFERENCES

1. Sinusas K, Gagliardi A. Initial management of breastfeeding. Am Fam Physician 2001;64:981-8.
2. Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. Int J Gynaecol Obstet 1990;31(Suppl 1);171-83.
3. World Health Organization. International code of marketing of breast-milk substitutes. Geneva: World Health Organization, 1981.
4. Leung AK, Sauve RS. Breast is best for babies: Part 2. Can J Diagn 2001;18:65-73.
5. American Academy of Pediatrics. Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100:1035-9.

Reducing Barriers to Breastfeeding

TO THE EDITOR: I appreciate the emphasis made on the importance of initiating breastfeeding as early as possible during the neonatal period. The article "Initial Management of Breastfeeding"¹ by Dr. Sinusas and Ms. Gagliardi addressed important issues regarding this topic. However, I think more emphasis should be made on various methods of prenatal interventions to increase breastfeeding rates and issues surrounding possible social and cultural barriers to initiating breastfeeding.

Results of studies² show that women in the United States encounter a variety of barriers to breastfeeding, including lack of social support, inadequate prenatal education, and the media's portrayal of formula feeding as the norm. It is important to address these common barriers as early as possible in the prenatal period because this might positively affect a woman's decision to breastfeed.

The long-term success of breastfeeding is based on active initial postnatal interventions and active, multifaceted prenatal interventions that are started early in the prenatal period. This intervention should include ongoing one-on-one counseling by health care providers, written materials, videos on breastfeeding techniques, and support groups. These early prenatal and postnatal interventions are essential to the success of long-term breastfeeding.

OBAFEMI OKUWOBI, M.D.
505 Fairburn Rd., Ste. 100
Atlanta, GA 30331-20999

REFERENCES

1. Sinusas K, Gagliardi A. Management of breastfeeding. Am Fam Physician 2001;64:981-8.
2. Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group on Breastfeeding. Pediatrics 1997;100:1035-9.

Corrections

Question 7 of the "Clinical Quiz" (July 1, 2001, page 31), pertaining to the article "Common Anorectal Conditions: Part II. Lesions," was not clearly worded. Answer choice B should also be a correct response because topical diltiazem is helpful in the treatment of chronic fissures. The corrected question is printed below; the correct answers are B, C, and D.

Q7. Which of the following statements about the treatment of anal fissures is/are correct?

1. Lateral sphincterotomy incises fibers of the external sphincter.
2. Chronic fissures respond well to topical therapy.
3. Nitroglycerin therapy may be complicated by headache.
4. Topical nifedipine may successfully heal acute fissures.

Question 18 in "Clinical Quiz"(September 15, 2001, page 921), pertaining to the article "Guideline for the Management of Heart Failure Caused by Systolic Dysfunction: Part II. Treatment," was inaccurately worded. Answer choice C should refer to exercise-induced asthma rather than severe exercise-induced asthma--mild asthma is not a contraindication to the use of beta blockers in patients with systolic heart failure. The corrected question is printed below; the correct answers are A and C.

Q18. Beta blockers should not be used in patients with systolic heart failure and which of the following conditions?

1. Hemodynamic instability.
2. Dyspnea at rest.
3. Exercise-induced asthma.
4. History of myocardial infarction.