Before the advent of the 20th century, breastfeeding didn't need promotion to educate new mothers about its benefits or remind health care professionals that their recommendation to breastfeed improves breastfeeding rates. But that's not the case now.
The United States continues to fall short of the breastfeeding goals set by the HHS' Healthy People 2020(www.healthypeople.gov) initiative, which call for
- 81.9 percent of infants to be breastfeeding at birth,
- 60.6 percent of infants to be breastfeeding at age 6 months and
- 34.1 percent of infants to be breastfeeding at 1 year.
According to the CDC's 2014 Breastfeeding Report Card,(www.cdc.gov) breastfeeding rates recorded in 2011 show
- 79.2 percent of infants were breastfeeding at birth,
- 49.4 percent of infants were breastfeeding at age 6 months and
- 26.7 percent of infants were breastfeeding at 1 year.
- The AAFP recently released a set of breastfeeding resources, including an updated version of its position paper on the topic, to help physicians support expectant and new mothers.
- The position paper includes new scientific research that has been distilled into a condensed core paper with supporting appendices.
- The AAFP has endorsed the 10 Steps to Successful Breastfeeding, which were developed by the World Health Organization and UNICEF in 1989 to boost breastfeeding initiation and duration.
To bridge this gap, it's important for family physicians to continue to educate and support pregnant women, new mothers and their families and work to remove barriers to breastfeeding in their practices and communities. In support of this effort, the AAFP recently released a set of resources for FPs, including an updated version of its breastfeeding position paper.
Position Paper Bolstered by New Evidence
Since the release of the previous AAFP breastfeeding position paper in 2008, a significant amount of new scientific research has been published that warranted inclusion in the update on this topic, said AAFP member Anne Montgomery, M.D., M.B.A., of La Quinta, Calif., who chaired the working group that oversaw development of the paper.
Montgomery, who is associate program director of the family medicine residency at Eisenhower Medical Center in La Quinta, told AAFP News that the format of the paper has also changed substantially.
Before the update, she said, "It was a 42-page document that wasn't incredibly easy to navigate. This version has been restructured to have a shorter core paper that includes recommendations. Then all other supporting materials are in appendices. This way, the core paper could be handed out at a conference or referenced more easily."
AAFP Endorses 10 Steps to Successful Breastfeeding
The 10 Steps to Successful Breastfeeding, which were developed by the World Health Organization and UNICEF in 1989 to boost breastfeeding initiation and duration, have been endorsed by the AAFP. According to Montgomery, they are just as important today as when they were first issued because they are evidence-based and have proven helpful in improving breastfeeding rates.
"We have pretty good evidence that the more of the 10 steps that a facility follows, the higher its breastfeeding rates are," she said. "The 'Baby-Friendly' hospitals that have committed to following all 10 steps have the highest rates, as well."
Hospitals that have been certified by the Baby-Friendly Hospital Initiative(www.babyfriendlyusa.org) also do not accept free formula from manufacturers because that practice has been identified as one of the barriers to breastfeeding in the United States, Montgomery added.
"People who aren't breastfeeding advocates think we are trying to not support formula-feeding mothers and that's not really true," she said. "What we are trying to do is provide evidence-based care for optimal health outcomes, which means we want babies to breastfeed and we want to support mothers who choose to breastfeed in meeting their breastfeeding goals."
Also with regard to formula use, Montgomery said she has struggled with some hospital staff regarding one of the 10 steps, which says to "give newborn infants no food or drink other than breast milk, unless medically indicated."
"You can usually troubleshoot and not need the formula," she said. "A lot of moms think that babies have to eat more but newborns don't have to take much volume the first two days. Putting the baby skin-to-skin is going to calm the baby down quite a bit. There are actually studies that show that moms sleep better if they're near their babies than if the baby isn't in their room. A mom and a baby are like one unit biologically."
Montgomery said one of the most important of the 10 steps is facilitating breastfeeding within an hour of birth. Data released after the 10 steps were published indicate that maintaining skin-to-skin contact between mother and infant at least until the first successful breastfeeding attempt helps the baby learn to feed better, she noted.
She said the final of the 10 steps, which calls for Baby-Friendly facilities to "foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic" is also critical for mothers to succeed in their breastfeeding efforts.
"Make sure they don't go out into the world and you don't see them for three weeks," Montgomery said. "It's important to do a follow-up visit within two days -- at the most -- to make sure breastfeeding is going OK, checking for jaundice, etc."
Make Your Office Breastfeeding-friendly
According to the position paper, family physicians have the unique opportunity to emphasize breastfeeding education beginning with preconception visits and continuing through prenatal care, delivery and postpartum care, as well as during ongoing care of the family.
AAFP member Michelle Quiogue, M.D., of Bakersfield, Calif., who also served on the working group overseeing the paper's update, has had success making her office at Kaiser Permanente's East Hills Medical facility breastfeeding-friendly. She said family physicians as community leaders, business owners, supervisors and/or employees should advocate the same for other workplaces.
"For physicians and residents who are currently breastfeeding, it is important to recognize how we can lead by example," Quiogue said. "As hospital staff administrators, we can set the goal of achieving Baby-Friendly designation for our hospital. As managers, we can work to create flexible solutions to accommodate breaks and a location for pumping and storage."
As national and community leaders in population health, family physicians can promote resources such as those offered by the CDC's Division of Nutrition, Physical Activity and Obesity(www.cdc.gov) to other businesses and organizations, she said. As legislative advocates, family physicians should also weigh in about the importance of paid family leave in the promotion of exclusive breastfeeding, she added.
Quiogue said her Kaiser Permanente office strives to use a team-based care model that includes certified lactation consultants to support breastfeeding moms. To better serve new mothers, the office refers them to external peer support groups and uses other internal support systems.
"In my EHR (electronic health records system), I saved templates for common breastfeeding-related problem diagnoses including assessment, treatment plan and patient education," she said. "Sometimes I use a simple application on my smartphone called Breastfeeding Solutions.(www.nancymohrbacher.com) Our medical group can track rates of exclusive breastfeeding by coding at every well-child visit, as well."
Quiogue said because she and her husband struggled to initiate breastfeeding with their first daughter, her empathy as a physician caring for breastfeeding moms and infants has increased tremendously.
"Like everything else in our daily work, inspiring sustainable change toward wellness starts with a personal connection with our work-based teams and our patients," she said. "That is why I believe that the family doctor-patient relationship is our superpower."