Guest Editorial

Supporting Breastfeeding Makes a Difference for Moms, Babies

August 22, 2013 02:22 pm Anne Montgomery, M.D.

The CDC recently released some good news for American mothers and their babies. The agency said in its annual breastfeeding report card(www.cdc.gov) that the percentage of newborns who initiated breastfeeding increased from 71 percent in 2000 to 77 percent in 2010. During the same period, there were double-digit increases in the percentage of babies who were breastfeeding at age 6 months (35 percent to 49 percent) and at age 12 months (16 percent to 27 percent).

Anne Montgomery, M.D.

Although we're doing a good job of getting moms and babies started -- closing in on the Healthy People 2020 goal of 82 percent -- we should be doing more to keep them on track.

The AAFP and the American Academy of Pediatrics recommend that babies, with rare exceptions, be exclusively breastfed for the first 6 months of life. Both organizations also recommend that babies continue to breastfeed -- while also receiving appropriate complementary foods -- through at least the remainder of their first year, and longer if mutually desired by mother and baby.

The corresponding Healthy People goals are for 60 percent of babies to be breastfeeding at age 6 months (as well as a goal for 25 percent of those 6 months old to be exclusively breastfed) and for 34 percent of 1-year-olds to receive some breast milk.

Unfortunately, we're nowhere near goal in any of those categories. The reality is that less than half of 6-month-olds receive any breast milk, and only 16 percent are breastfed exclusively. Only 27 percent of U.S. children still are receiving breast milk by the time they celebrate their first birthday. Disparities also exist, with some groups of mothers and babies having even more difficulty reaching these goals.

AAFP Policy Supports FP Trainees Who Breastfeed

The AAFP recommends that all babies, with rare exceptions, should be breastfed exclusively for the first 6 months of life. Now the Academy has adopted policy to support breastfeeding mothers who are training to become family physicians.

The policy, developed by the AAFP Commission on Education based on resolutions adopted by both the National Congress of Family Medicine Residents and the National Congress of Student Members in 2012, states that family medicine training programs should "promote and support institutional policies to provide appropriate accommodations to allow trainees to securely breastfeed and/or express breast milk as needed during designated duty hours."

So why is there such a steep drop-off from initiation rates that are near goal and long-term targets that are still far from ideal?

The CDC credited the improvements in initiation, in part, to hospitals doing a better job of supporting breastfeeding. The agency said the percentage of facilities that place babies skin-to-skin with their mothers within an hour after birth and that encourage "rooming in" increased significantly between 2007 and 2011.

I tracked the mothers and newborns in my maternity care practice and found that I could convince all moms (roughly 60 out of 60 in two years) to breastfeed at least once in the hospital -- even if they weren't planning to breastfeed -- so their babies could get some colostrum.

But what happens after moms and their newborns go home?

Well, some moms go back to work. Some get sore nipples. Some think -- often incorrectly -- that they aren't making enough milk and turn to formula. Some face a combination or all of these challenges.

Several years ago, I asked more than 100 moms how long they planned to breastfeed, and then I followed their progress. What I found was that there was a dramatic decline in breastfeeding between babies' first 2 weeks and 2 months of life. But for the women who could make it to age 2 months, the majority reached their goals, regardless of what those goals were.

Babies typically are seen in our offices at their 1- or 2-week appointments and again at age 2 months. That leaves moms lacking support during a vulnerable time. In my practice, we instituted 1-month appointments that are a combination of well-baby visit and breastfeeding check, and we also asked moms to call us if they were considering stopping breastfeeding. That allows us to troubleshoot whatever problems mom and baby might have and provide guidance about how to handle returning to work or school.

What else can family physicians do to help? For one thing, make sure moms know that federal law requires most employers (generally, those with 50 or more employees) to provide employees with time and an appropriate place(www.cdc.gov) to express milk for as long as one year after giving birth.

Moms with professional jobs often can use a breast pump in an office or lactation room. For hourly paid workers, it can be much more challenging, especially those who work for small employers unaffected by the aforementioned federal law.

We also can educate moms about supply and demand and the fact that babies grow in spurts. Many moms worry that they don't have enough milk and supplement with formula. That leads to babies who sleep longer and nurse less frequently. Ironically, the mother worried about her milk supply ends up making less milk.

Unfortunately, some moms see breastfeeding as an all-or-nothing proposition. The truth is that some breast milk -- whether from the source or a bottle -- is better than none at all. Moms who need to use some formula can be encouraged to continue to also breastfeed.

Another thing we can do to reassure mothers is use the right growth charts(www.cdc.gov). The World Health Organization released growth charts in 2006 that are based on growth patterns among children who were predominantly breastfed for at least their first 4 months of life and who still were breastfeeding at age 1 year. Breastfed babies grow faster than formula-fed babies during the first 2 months of life, and then they slow down around age 4 months. Thus, the growth curve in older charts -- based on formula-fed babies -- makes breastfed babies look as if they are falling behind.

We also can make our offices breastfeeding-friendly. Staff should be helpful and encouraging. Nursing in the waiting room is fine, but women who want privacy should be given that option, if possible.

So, what does the mom want, and what is she able to do? We want babies to breastfeed, but moms need to make choices that work for them, and we need to support those choices. We just need to make it as easy as possible to choose breastfeeding.

Historically, mothers got breastfeeding support from their own mothers, sisters and grandmothers. In our fragmented society, that's not necessarily true anymore. Sometimes, women have to build their own support systems, so it's important to know where to send patients who want more help. La Leche League offers support for women(www.llli.org) in communities across the country and also through its 24-hour helpline(www.llli.org). Many other sources offer online support and resources for moms, including the U.S. surgeon general's website(www.surgeongeneral.gov) and HHS' Office on Women's Health(www.womenshealth.gov).

Primary care physicians should have a good, basic understanding of breastfeeding. If you aren't there yet, there are numerous free or cheap resources that can help. Wellstart International offers a self-study module that meets physician education requirements(www.wellstart.org) for baby-friendly hospitals. Breastfeeding Basics offers a free online breastfeeding course appropriate for physicians(www.breastfeedingbasics.org).

The Drugs and Lactation Database(toxnet.nlm.nih.gov) (LactMed) is a peer-reviewed resource that covers possible effects of a wide array of drugs on mothers who are breastfeeding and on breastfed infants and offers alternative drug suggestions. The LactMed Web page also offers a free mobile app(toxnet.nlm.nih.gov).

The Health Care Provider's Guide to Breastfeeding(itunes.apple.com) and Breastfeeding Management 2(itunes.apple.com) are two other free or low-cost evidence-based apps designed to help physicians help moms.

In addition, the Academy of Breastfeeding Medicine publishes evidence-based protocols for clinical management of breastfeeding(www.bfmed.org).

Finally, family physicians can find a wealth of information about breastfeeding in the Academy's official position paper on the topic. The paper, which currently is being revised, covers a wide range of issues, including health benefits, medications, supplementation, education of medical students and residents, relevant CME, and more.

Family physicians can help with most breastfeeding concerns. For issues that exceed your expertise, be sure you know where moms can go in your area to get additional help. International Board Certified Lactation Consultants(www.americas.iblce.org) can assist with most breastfeeding challenges. More and more physicians are increasing their expertise in breastfeeding medicine to help with the more difficult or medical issues.

But why should we -- and moms -- go to all this effort when formula manufacturers are willing and eager to give moms free product now and coupons for the powdery stuff later?

Well, we already have strong evidence that breastfeeding reduces a child's risk of gastroenteritis, otitis media and atopic eczema in his or her first year of life and reduces the risk for obesity and diabetes later. Breastfeeding also reduces mothers' risks for certain types of cancer, cardiovascular disease, and type 2 diabetes.

Now, a recent study in JAMA Pediatrics(archpedi.jamanetwork.com) tells us that breastfeeding an infant during the first year of life can increase his or her IQ by about 4 points.

So, simply put, supporting our breastfeeding patients is the smart thing to do.

Anne Montgomery, M.D, is a Fellow of the Academy of Breastfeeding Medicine, an International Board Certified Lactation Consultant and a member of the AAFP Breastfeeding Advisory Committee.


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