The Promotion of Breast-Feeding

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American Academy of Pediatrics.

654 PEDIATRICS Vol. 69 No. 5 May 1982

AMERICAN

ACADEMY

OF

PEDIATRICS

Policy Statement Based on Task Force Report

The

Promotion

of Breast-Feeding

From its inception, the American Adademy of Pediatrics has been a staunch advocate of breast-feeding as the optimal form of nutrition for infants. One of the earliest Academy publications was a 1948 manual, Standards and Recommendations

for the Hospital Care of Newborn Infants. This manual included the statement, “It is recommended that efforts be made to have every mother of a fuilterm infant nurse him.” A major concern of the Academy has been the development of standards of proper nutrition for infants and children. The activ-ities, statements, and recommendations of the Academy have continuously promoted breast-feed-ing of infants as the foundation of good feeding practices.

In the past decade the Academy has continued

to explore avenues for increasing the practice of breast-feeding. The following statement is from a 1976 commentary that outlined specific steps for encouraging breast-feeding.

Important steps which will encourage breast feeding in-dude more educational programs for adolescents and pregnant women and reinforcement by obstetricians, pe-diatricians and nurses attending pregnant women. Changes in employment policies and working conditions and provision of day care centers at or near places of employment to make breast feeding practical for working mothers will increase the frequency of breast feeding. Such changes are urgently needed where rural poor have migrated to urban areas in the United States and

else-This commentary also stated that the issues af-fecting the decision to breast-feed are multiple, complex, and changing. Although some important factors influencing breast-feeding may be unknown, research attempting to identify all influential fac-tors and determine their relative significance is important but difficult. Controlled prospective studies involving the use of mothers and their

in-fants, although the most definitive approach, may not be possible because true randomization would

be unethical.

In celebration of the International Year of the Child, the Academy and the Canadian Paediatric Society jointly published a commentary, “Breast Feeding,” with current information on the benefits of breast :ii In a follow-up statement,

“Encouraging Breast Feeding,” intended to imple-ment some of the recommendations in the 1978 statement, the Academy stated:

Physicians, nurses, nursing personnel and hospitals need to examine their practices and procedures that encourage or discourage breast feeding. The cultural attitudes and life styles of today’s world tend to militate against breast feeding. Yet the benefits of breast feeding to the neonate and the mother are so numerous that pediatricians must strongly encourage the practice.3

Concern about massive malnutrition in Third World countries has recently stimulated new inter-est in promoting breast-feeding as the single most important immediate remedy for high infant mor-tality. Extensive marketing, coinciding with wide-spread use of infant formulas in developing coun-tries, was perceived as a major influence in the declining practice of breast-feeding. These concerns culminated in the development of the World Health Organization (WHO) Code of Marketing of Breast-milk Substitutes. The Academy endorses the stated aim of this Code which is:

... to contribute to the provision of safe and adequate nutrition for infants by the protection and promotior of breast feeding and by ensuring the proper use of breast-milk substitutes when these are necessary on the basin of adequate information and through appropriate marketing and distribution.

However, the body of the WHO Code focuses

narrowly on almost a single aspect of the infant feeding problem, marketing practices of formula manufacturers. The narrow focus and the essen-tially negative regulatory proposals of the Code represent a limited approach to an issue that is

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AMERICAN ACADEMY OF PEDIATRICS 655

complex and involves extensive social, economic, and motivational factors. This limitation seems par-ticularly evident for the situation in the United States.

0 In 1981, the Academy formed a Task Force on the Promotion of Breast Feeding (Alvin M. Mauer, MD, Chairman, Lewis A. Barness, MD, L. J. Filer,

MD,

Frederick C. Holmes,

MD,

and William B. Weil, MD) to explore how mothers’ choices of infant feeding practices are influenced by: “physicians and others providing health care and counsel, hospital and workplace ambience, formula manufacturers and their marketing practices,” and to make rec-ommendations for the effective promotion of breast-feeding. The present policy statement is based on the report of the Task Force.

MATERNAL CHOICE OF HOW TO FEED THE INFANT: A CRUCIAL DECISION

Any discussion of the incentives or deterrents to breast-feeding must focus on the factors surround-ing the decision about how the infant is to be fed. This issue is so complex that it is difficult to study in a controlled fashion; but the greater potential for harm comes from ignoring the complexity and fo-cusing on a single variable as the all important determinant.

The complexity of the problem4 can be appreci-0 ated when one realizes that the composite profile of

the American woman of the 1970s who is most likely to choose breast-feeding and to lactate for a prolonged period of time is one who was breast-fed

as an infant, has successfully breast-fed an infant before, has friends who breast-feed their infants, receives support from health care personnel, re-ceives support from her husband, strongly believes breast-feeding is “healthy,” believes her infants

en-joy breast-feeding more than bottle feeding, has an educational level beyond high school, does not work out of the home, lives in a cultural environment that is supportive of breast-feeding, is socioecon-omically advantaged, and does not belong to a racial minority. In contrast, the proffle ofthe mother most likely to bottle feed is one who belongs to a lower

socioeconomic group, has a lower educational level, is more likely to be receiving governmental support, and is younger, single, and a smoker. She is also

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more likely to be gainfully employed outside the home and to have physical or emotional prenatal or postnatal illness; she also has a greater propen-sity to deliver a low-birth-weight infant. As is evi-dent from these profiles, many factors correlate with one or the other mode of feeding, but it would

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be naive to assume that, because a given variable 0 correlates with breast- or bottle feeding, it plays a

primary, causal role.

Bentovim5 has developed a flow chart (Fig 1) which traces the decision-making process for

breast-feeding and attempts to take account of the causality, or at least the chronology, of the many variables that are likely to enter into the decision to breast-feed and to reinforce this decision once it is made. All positive feedback processes in Fig 1 are shown as solid lines; these processes promote the

system in establishing, maintaining, and stabilizing breast-feeding. The negative feedback factors are indicated by dashed lines. These factors reduce the likelihood of the success of breast-feeding and thus increase the chances of substitution of alternative feeding practices.

Studies designed to isolate and determine the effect of any given variable on the success of breast-feeding or, for that matter, the superiority of human milk over modern formulas are admittedly difficult to design, and these difficulties should be recognized in evaluating any study of the problem. The basic difficulty is that there is a subtle, built-in difference between groups of mot1iers and their infants who are breast-fed and mothers and infants who are bottle fed. These differences are partly due to the

inherent difference in maternal makeup (as dis-cussed above), which makes interpretation of cause and effect of the variable under study extremely difficult. The two most important problems in the design studies concern:

1. The impossibility of random assignment of infants to breast-feeding or to bottle feeding; this is due to the fact that mothers make this decision and hence the choices are not subject to random assign-ment by an impartial investigator. This is a self-selected population. Because maternal choice in turn reflects an inherent set of differences between mothers who breast-feed and those who do not, the two study groups will never meet the criterion of being evenly matched.

2.

Any change in the method of feeding will almost always occur in the direction away from

breast-feeding, ie, infants who begin breast-feeding will change to bottle feeding at a subsequent period, whereas the reverse is extremely rare. This one-way

flow effectively nullifies the ideal of obtaining two groups of infants who are exclusively breast-fed or exclusively bottle fed from birth and remain in their

respective feeding groups for prospectively deter-mined intervals regardless ofwhether their progress is good or bad. This is so because, if breast-fed infant is not doing well, the infant is likely to be switched to partial or complete bottle feeding. This factor is of great importance in assessing the supe-riority of breast-feeding over bottle feeding in such matters as infectious morbidity because it has the effects of keeping the breast-fed group healthy and adding “nonhealthy” infants to the bottle-fed

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0 Fig 1. Flow chart tracing decision-making process for breast-feeding (Reproduced with permission from Bentovim’).

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group. Even if the infants lost from breast-feeding were not added to the bottle-fed group, the selective removal of nonthriving infants from the breast-fed group would tend to maintain the selectivity for healthy infants.

The variables that may enhance or deter the decision to breast-feed by relatively easy interven-tion are: (1) maternal and family attitudes toward breast-feeding, and (2) the attitudes and activities of the health care professionals who care for mother and infant prenatally and postnatally.

These variables include several subfactors. It has been argued that maternal and family attitudes may be adversely influenced by commercial influ-ences and by the failure of adequate support by health care professionals during pregnancy. Simi-larly the attitudes and activities of health profes-sionals may affect not only maternal attitudes but also the medical management of delivery (the use of analgesics, for example), of the postpartum

pe-riod (the practice of early skin-to-skin contact and early suckling of the infant), and hospital policy with respect to the housing of mothers and infants, feeding routines, and dispensing of discharge packs of infant formula. The factors that influence the

656 PROMOTION OF BREAST-FEEDING

behavior of health professionals are undoubtedly complex, but they may include personal feelings and prior experiences, professional education or lack thereof in the art of breast-feeding, the practice and attitudes of peer groups and role models, the activities of the infant formula manufacturers, and the current medical literature.

ALTERNATIVES TO BREAST-FEEDING

Efforts to devise alternative methods for feeding infants date back to antiquity. In a 1954 lecture to the British Pediatric Society, Goldbloom6 described the evolution of concepts of infant feeding within North America. A review of the history of American pediatrics by Cone7 devotes three of ten chapters to delightful descriptions of infant feeding during

the 18th, 19th, and 20th centuries.

The technology and nutritional science underly-ing alternative methods of infant feeding have

evolved over centuries. Major advances, however, have occurred in the past four decades with formula products the nitrogen sources of which are based upon cow’s milk, soy protein, or meat, as well as protein hydrolysate and crystalline amino acids. As

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AMERICAN ACADEMY OF PEDIATRICS 657

the nutritional requirements ofinfants have become

better understood, it has been possible for the Com-mittee on Nutrition of the Academy to set stand-O ards for such products.’ In the United States,

cm-ical experience with such products has repeatedly demonstrated that they can be used safely as alter-natives to breast-feeding. In circumstances in which

the formula must be diluted or stored prior to use, care must be taken to ensure a safe water supply, proper understanding of formula preparation, and adequate means for refrigeration. Obviously, if cost were not a factor, a ready-to-feed unit would best meet the nutritional and food safety needs of infants being reared in less than ideal environments. Such considerations add dimensions of public assistance, and public health and education to the health care delivery process.

Trends in infant-feeding practices within the

United States since 1900 are shown graphically in Figs 2 and 3. The relative percentage of breast- and bottle-fed infants prior to 1940 are estimates. Re-ports by Bain,8 Martinez and Nalezienski,9”#{176} Mar-tinez et al,” and Meyer’2 on infant-feeding practices over the past four decades provide documentation for the changes that have occurred in alternative

feeding. Breast-feeding within the hospital setting reached a minimal value in 1970 when only one in four mothers elected to breast-feed. However, within the past decade the percentage of infants 0 being breast-fed in hospitals has increased

dramat-ically to the point at which 60% of infants now are

so fed. This change is true for feeding of infants from all socioeconomic strata.

Abandonment ofbreast-feeding in the earlier part of this century started first within the upper socio-economic levels and spread downward on the soci-oeconomic scale. This began to occur before the

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Fig 2. Feeding practices in hospital, 1900 to 1980: solid

line, breast-feeding; dotted line, combined feeding of

for-0 mulas prepared from evaporated milk or whole cow’s

milk; dashed line, commercially prepared formulas.

Fig 3. Feeding practices of infants, aged 5 to 6 months, 1900 to 1980: solid line, breast-feeding; dotted line, com-bined feeding of formulas prepared from evaporated milk or whole cow’s milk; dashed line, commercially prepared formulas.

present infant formula industry was well developed. Similarly, the recent resurgence of interest in, and

the practice of, breast-feeding began at the upper socioeconomic levels and is progressing along class lines in much the same manner as the abandonment

of breast-feeding occurred. The renewal of breast-feeding has taken place at a time when the formula industry is highly developed and its promotion is active. From the changing prevalence of breast-feeding and the changes that are taking place in the character of industry advertising-emphasizing

breast-feeding as the first choice in infant feeding-it appears that promotion by formula companies is more likely to follow social change than to lead it.

Commercial formulas were not fed to large

num-bers of infants until after World War II. As shown in Fig 2, commercially prepared formulas replaced formulas prepared from evaporated milk or whole

cow’s milk rather than human milk as a mode of infant feeding. When, as the result of a series of highly complex societal events, the number of breast-feeding mothers increased, the percent of infants fed commercially prepared formulas de-creased for a time.

Mothers who elected to breast-feed their infants make long-term commitments to this practice, as shown in Fig 3. Approximately half of the women who initiated breast-feeding continued to nurse their infants until 5 to 6 months of age. When these mothers weaned their infants, they gave them corn-mercial formula, as recommended by the Academy.

Use of cow’s milk as an alternative showed further decline. Increase in the number of older infants fed commercial formula resulted in a dramatic increase in sales. Thus, a return to breast-feeding has been associated with an increased use of commercially prepared formulas.

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658 PROMOTION OF BREAST-FEEDING

The use of soy-based formulas, now so prevalent, deserves separate comment.

In 1909 John Ruhrah’3 published the first paper in the United States on the use of soybean milk in infant feeding. He suggested its use “as a substitute for milk in diarrhea, in intestinal and stomach dis-orders, and in diabetes meffitus.”4 The technology ofproducing a soy-based formula ofhigh nutritional quality has advanced rapidly in the last two dec-ades. With availability of these improved products, formulas prepared from soy protein surprisingly are now fed to approximately 20% of infants. Clinical indications for their use stifi carry the overtones of early pioneers who regarded soy-based formulas as efficacious in the management of diarrhea, other gastrointestinal disorders, and eczema.

The importance of other, more specialized,

for-mulas for infant feeding also deserves comment. A variety of formula products is now available for the

management of infants with inborn errors of metab-olism.’5 Although they are regulated by the Food and Drug Administration as food, each of these formulas has specific medical indications for use.

Their development and manufacture represent ma-jor advances in infant nutrition.

From a historic and scientific perspective much

effort has gone into the development of breast milk substitutes. Pediatricians and the Academy have played a key role in ensuring the safety and

nutri-tive quality ofalternative methods ofinfant feeding. Given this history, it is entirely appropriate and significant now that we reemphasize the superiority of breast-feeding.

INFLUENCING THE CHOICE

Before the advent of safe alternatives, it was necessary for every mother to nurse or employ a wetnurse. Fathers, mothers, children, and grand-parents knew no other technique and no special encouragement was considered necessary to pro-mote breast-feeding. It is neither possible nor prob-ably desirable to return to the infant-feeding status of the past. However, there is a need to recreate the social support and public acceptance of breast-feed-ing as standard practice. Some of the social changes

necessary to promote breast-feeding are already in progress. To extend this progress will require some fundamental changes in motivational and educa-tional systems, for both the general public and health professionals.

The Committee on Nutrition has delineated some of the ways to encourage breast-feeding.3 It is gen-erally agreed that there is a need for education about breast-feeding in school for boys as well as girls because later support by .the father helps

breast-feeding succeed. More pediatricians should

participate as school physicians and assure that students are taught the fundamentals of infant nu-trition. Public education through television, news-papers, magazines, and radio could be expected to enhance the acceptability of breast-feeding. Edu-cational materials should be factual and designed to present the advantages of breast-feeding but should not promote guilt among non-breast-feeding families.

There should also be improved education about

breast-feeding techniques in medical schools, nurs-ing schools, and in residency programs of obstetrics, pediatrics, and family practice. Health professionals who are not knowledgeable about breast-feeding

obviously will be ineffective at promoting the prac-tice.

In prenatal classes, or in any prenatal contact, appropriate education provided to the prospective mother should include the father. All federal or state-supported prenatal programs should encom-pass nutrition education and support breast-feed-ing.

Obstetricians and family physicians should be encouraged to promote breast-feeding during their prenatal care contacts. They also may wish to refer the pregnant mother and the father to the pediatri-cian or family physician who is going to care for the infant for

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discussion of infant nutrition and pro-motion of breast-feeding. The role and responsibil-ity of the obstetrician or physician providing

pre-natal care cannot be overemphasized with respect to the subsequent decision of the mother regarding breast-feeding. In most situations, the mother has already come to a decision about breast-feeding prior to the delivery of the child. Therefore, for these women, the important period for providing information and supporting their decision is before the delivery takes place. Furthermore, the current tendency for ever shorter durations of postnatal hospitalization for mothers and infants reduces the potential influence that can be exerted by health professional personnel in the immediate postnatal period. The time immediately surrounding the de-livery is also important, and there is some indication that the presence of a “doula” or other supportive personnel’6”7 for the mother is helpful at, and im-mediately after, delivery. It should also be deter-mined whether the mother would benefit from fur-ther support after discharge from the hospital and prior to the initial routine checkup. The hospital experience of the mother and infant could be im-proved in several ways. The degree of sedation should be decreased if possible. Rooming-in should be encouraged, except when it is specifically con-traindicated or inappropriate. The extended pres-ence of the infant with the mother during the first

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AMERICAN ACADEMY OF PEDIATRICS 659

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hours after delivery is particularly desirable.

Routine supplemental feeding should be avoided.

Lactation suppressants should not be given unless 0 requested by the mother.

Definitive evidence indicating that routine din-pensing of discharge packs of infant formula deters breast-feeding is not available. However, discharge

packs should be given only at the discretion of the attending physician or at the request of the mother. It should not be a routine hospital practice.

The development of day nurseries adjacent to

school or work places should be encouraged and supported to enable students and working women to feed their infants. Whenever possible, nursing areas in school for school-aged mothers should be made available.

Mothers should be encouraged not to utilize a!-ternatives for breast-feeding with respect to vaca-tion, night feeding, relief, and so forth until after nursing is well established.

Mothers should be counseled concerning their

own nutritional needs, and when necessary, ade-quate nutrition for lactating mothers should be provided.

It should be a routine practice to schedule a supportive infant checkup by the pediatrician or family physician two weeks after discharge from the hospital.

The support and resources of lay groups such as 0 a LaLeche League should be used when appropriate

for providing counsel and information.

If it is necessary to admit the breast-feeding

infant to the hospital, the mother should be en-couraged to come in and nurse or to pump her breast and bring in milk for feeding. The mother should also be taught relactation if necessary.

ADVERTISING OF INFANT FORMULA

The practice of medicine in the United States has traditionally been assumed to be a private,

privileged interaction between the patient, or child’s family, and the physician. The decisions regarding an individual’s health have been reached by discussion between the physician and the patient

(family) using the former’s medical knowledge and the latter’s values and assessments of risks and benefits in terms of these values. There has been a general acceptance of the concept that the medical care provider’s information and recommendations should be based on the best scientific information

available and not be biased by elements of personal gain or prejudice. In addition, there has always been a strong opposition to interference by other parties

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in the doctor-patient (family) relationship, unless a recognized and accepted social value is involved, eg,

legally required immunization, phenylketonuria (PKU) screening, etc.

The sources of the patient’s (family’s) informa-tion and values, as noted, are multiple and difficult to identify. One of the more influential sources is the media and its reporting of “medical” stories, features, and research. Although industry advertis-ing of various types may well be another source of information and value structure, it would be impos-sible to separate this source and assign a value to it in most circumstances. In terms of the infant for-mula industry, the problem of public advertising has begun to resurface, with the resumption of some direct lay advertising in the United States. The

Academy strongly recommends that all advertising of infant formula preparations be directed to health care professionals and not to the lay public.

The sources of the physician’s medical knowledge

are known to be diverse and include formal medical education, scientific publications, medical confer-ences, discussion with peers, and personal

experi-ence.

Around the turn of the century, many physicians caring for infants seemed to be negative about commercially prepared infant feedings advertised to the public because they enabled the mother to feed the infant without medical supervision, which posed potentially serious problems to the physician. Acting to some extent on this premise, manufac-turers began voluntarily to limit their advertising to the medical profession and to forego advertisements to the public. When the manufacturers of

DextriMaltose adopted this practice in 1912, they also began to distribute reminder items such as prescription pads with the product’s name on them

and “calculators” to simplify formula use.’8

As the practice of breast-feeding decreased in the

early 20th century, physicians became more

de-pendent on the embryonic formula industry for a relatively safe and dependable source of infant food. This industry, in turn, began to orient its advertis-ing practices toward the “share of the market”

concept. The advertising did not suggest that any formula was better than breast milk; instead the choice was identified as between

“physician-di-rected” alterations in cow’s milk-a potentially in-dividualized, but complex process-and the use of a standardized, commercial modification of cow’s milk.

By the 1920s, the medical profession’s concern about the ethics of advertising infant formulas led to the formation of a committee on infant feeding and infant foods by the American Medical Associ-ation’s Section on Diseases of Children. In 1925 under Isaac Abt, the committee offered a resolution regarding their “investigation of the sale,

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660 PROMOTION OF BREAST-FEEDING

ing methods and indications and contraindications for the use of proprietary infant food.” It stated: “This problem is best attacked at its source, which consists of the education of the medical student in simplified methods of infant feeding.” It also stated that “there should be increased propaganda among physicians and in layjournals to increase knowledge about breast feeding. Such propaganda will include the dangers of artificial feeding of infants, particu-larly when carried on without the supervision of medical men.” The resolution concluded, “There is a disposition on the part of many manufacturers of proprietary foods to cooperate with the medical profession and its medical journals. The committee believes that much good may be accomplished by a better understanding and cooperation between these manufacturers and representatives of the American Medical Association.”9

In the 1930s, the AMA’s Committee on Foods published advertising guidelines which stated that it was not permissible to advertise infant formulas to the laity, and labels were not to contain any instructions or directions if the product was to receive the AMA Seal of Acceptance)’#{176} This at-tempt to keep the physician “in charge” was almost universally accepted by the manufacturers. Even though the “Seal” idea was abandoned about 30 years ago, the manufacturers of infant formula have continued the policy of advertising only to profes-sionals, with only a few exceptions until recently.

If any promotion to physicians leads to inappro-priate or unbalanced medical advice or

recommen-dations to patients, a serious ethical problem exists. The public holds physicians to a high standard of medical advice, and the advice must be more than just accurate. With regard to infant feeding, the physician should point out the advantages of breast milk and breast-feeding as well as give accurate

information about formulas.

Another distinction concerning advertising prac-tices needs to be emphasized. Promotion of individ-ual company products to the medical profession can have two goals. One can be to compete for breast-fed infants. The other can be to enlarge a company’s share of the non-breast-feeding market. Activities that tend to encourage the first goal should be opposed, whereas activities oriented to the second goal represent a legitimate business practice.

It is inappropriate to characterize an entire

in-dustry by the actions of individual firms. This is particularly important when some firms have been exemplary in their support of the best traditions of the medical profession and of their educational

efforts, as was noted by Dr Abt in 1925. Neverthe-less, any practices by industry, government, or other groups that can be identified as prejudicial to

opti-mal medical care should be opposed by physicians and the Academy. When specific activities might

unduly influence physicians, they should be countered with improved educational efforts by the Academy and its members. By contrast, activities of the Academy, industry, or government that en-hance the best of scientific medicine, such as pro-motion of breast-feeding in WIC (Special Supple-mental Program for Women, Infants and Children) and other health care and food assistance programs for mothers and children, should be encouraged and supported.

The American Academy of Pediatrics believes: 1. Advertising of specific infant nutritional prod-ucts to health professionals is legitimate business practice that can serve the public interest if its goal

is to compare one product with another, if the products are not depicted as a better source of nutrition than human milk, and if the data provided are the best scientific information available.

2. Support of educational programs and the awarding of development contracts and research grants represent laudatory uses of corporate funds and should be accepted by the Academy and its members if they meet the following criteria: (a)

awards are based on merit (educational or scien-tific) and are granted on a competitive basis; and

(b) no sense of obligation, expressed or unexpressed, is reflected in the experimental design, methodology or the results of grant-supported programs, and no topic or speaker restrictions are placed on educa-tional programs.

3. Because of the nebulous nature of “intent” and the difficulty of applying terms such as undue influence, new issues may arise to create uncer-tainty in industry-physician relationships. As such issues are recognized or identified, they will be referred to the Committee on Bioethics for evalua-tion and recommendations to the Executive Corn-mittee of the Academy.

CONCLUSIONS

A

primary goal of the American Academy of Pediatrics is to encourage optimal infant nutrition through the promotion of breast-feeding, stressing

the superiority of human milk and the proper use of nutritionally appropriate breast milk substitutes for infants who cannot be breast-fed. To reach this goal, there are four major objectives of perinatal care: (1) A woman should have the opportunity prior to the time of delivery to make a fully

in-formed decision to breast-feed or not to breast-feed her infant. (2) Health care providers should be knowledgeable about breast-feeding and work to provide surroundings, personnel, and information

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AMERICAN ACADEMY OF PEDIATRICS 661 that encourage mothers to breast-feed. (3) The

breast-feeding mother should be supported by her physician, by hospital personnel and practices, and 0 by work-place practices. (4) Any routine

profes-sional, institutional, or commercial practices that tend to discourage breast-feeding should be op-posed.

RECOMMENDATIONS

1. Pediatricians should work to improve the knowledge of health care providers about optimal

infant nutrition, stressing the nutritional, immuno-logic, and other advantages of breast milk, and the appropriate use of breast milk substitutes. Such education should become a routine component of the curriculum for medical, nursing, and nutrition personnel, and a routine component of pediatric and family practice, and ofobstetric residency train-ing programs. It should receive major emphasis in pediatric and family practice and in obstetric con-tinuing medical education programs. Pediatricians should work with obstetricians and family physi-cians to foster these educational programs.

2. Pediatricians should work to improve the knowledge of all potential expectant and current parents on optimal infant nutrition, emphasizing the positive aspects ofbreast-feeding and the proper choice and utilization of breast milk substitutes. 0 Within hospitals, both the administrative and

the professional staff should examine in detail their procedures for perinatal care. Emphasis should be placed on encouraging those practices that are sup-portive of breast-feeding and discouraging those that are not.

4. Pediatricians and all those with concern for healthy infants should work to improve the envi-ronmental support system for mothers after the method of feeding their infants has been chosen.

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REFERENCES

1. American Academy of Pediatrics, Committee on Nutrition: Commentary on breast-feeding and infant formulas, includ-ing proposed standards for formulas. Pediatrics 57:278, 1976

2. Nutrition Committee of the Canadian Paediatric Society and the Committee on Nutrition: Breast feeding. Pediatrics

62:591, 1978

3. American Academy of Pediatrics, Committee on Nutrition: Encouraging breast-feeding. Pediatrics 65:657, 1980

4. Sauls HS: Potential effect of demographic and other van-ables in studies comparing morbidity of breast-fed and bot-tie-fed infants. Pediatrics 64:528, 1979

5. Bentovim A: Shame and other anxieties associated with breast-feeding: A systems theory and psychodynamic ap-proach. Ciba Found Symp 45:159, 1976

6. Goldbloom A: The evolution of the concepts of infant feed-ing. Arch Dis Child 29:385,1954

7. Cone, TB Jr. History ofAmerican Pediatrics. Boston, Little, Brown and Co, 1979

8. Bain K: The incidence of breast feeding in hospitals in the United States. Pediatrics 2:313, 1948

9. Martinez GA, Nalezienski JP: The recent trend in breast-feeding. Pediatrics 64:686, 1979

10. Martinez GA, Nalezienski JP: 1980 update: The recent trend

in breast-feeding. Pediatrics 67:260,1981

11. Martinez GA, Dodd DA, Samartgedes JA: Milk feeding patterns in the United States during the first 12 months of life. Pediatrics 68:863, 1981

12. Meyer HF: Infant feeding practices in hospital maternity nurseries. Pediatrics 21:288, 1958

13. RUhrah J: The soy bean in infant feeding. Arch Pediatr 26:496, 1909

14. RUhrah J: Further observations on the soy bean. Trans Am

Pediatr Soc 23:386, 1911

15. American Academy of Pediatrics, Committee on Nutrition: Special diets for infants with inborn errors of amino acid metabolism. Pediatrics 57:783, 1976

16. Raphael D: The Tender Gift: Breastfeeding. New York, Schocken Books, 1973

17. Sosa R, Kennell J, Klaus M, et a!: The effect of a supportive companion on perinatal problems. N Engl J Med 303:597, 1980

18. Apple RD: “To be used only under the direction of a physi-cian”: Commercial infant feeding and medical practice 1870-1940. Bull Hist Med 54:402, 1980

19. Committee on Infant Feeding and Infant Foods. JAMA

84:1744, 1925

20. Committee on Foods. JAMA 99:391, 1932

BIBLIOGRAPHY

Baer EC, Winikoff B (eds): Breastfeeding: Program, policy and research issuee. Stud Fam Plann, vol 12, no. 4, 1981

Lawrence HA: Breast-feeding: A Guide for the Medical

Profes-sion. St Louis, CB Mosby Co, 1980

National Academy of Sciences: A Selected Annotated

Bibliog-raphy on Breast Feeding 1970-1977. Washington, DC, 1978 Raphael D: The .Tender Gift: Breastfeeding. New York,

Schocken Books, 1973

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