In Reply

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and its integration with the mammary glands.J Pediatr. 2010;156(2 suppl):S8 –S15 18. Gray-Donald K, Kramer MS, Munday S, Leduc DG. Effect of formula supplementation in the hospital on the duration of breast-feeding: a controlled clinical trial.Pediatrics. 1985; 75(3):514 –518

19. Labarere J, Gelbert-Baudino N, Avral A, et al. Efﬁcacy of breastfeeding support provided by trained clinicians during an early, rou-tine, preventive visit: a prospective, ran-domized, open trial of 226 mother-infant pairs. Pediatrics. 2005;115(2). Available at: www.pediatrics.org/cgi/content/full/ 115/2/e139

20. American College of Obstetricians and Gynecolo-gists, Committee on Health Care for Under-served Women. ACOG committee opinion No. 361: breastfeeding—maternal and infant aspects.

Obstet Gynecol. 2007;109(2 pt 1):479–480. Avail-able at: www.acog.org/departments/ underserved/clinicalReviewv12i1s.pdf. Ac-cessed June 3, 2011

21. Labbok M, Taylor E. Achieving Exclusive Breastfeeding in the United States: Findings and Recommendations. Washington, DC: US Breastfeeding Committee; 2008.Available at: www.usbreastfeeding.org/LinkClick. aspx?link⫽ Publications%2fBarriers-EBF-2008-USBC.pdf&tabid⫽70&mid⫽388. Ac-cessed June 3, 2011

22. Ogbuanu C, Glover S, Probst J, Liu J, Hussey J. The effect of maternity leave length and time of return to work on breastfeeding. Pe-d i a t r i c s. 2 0 1 1 ; 1 2 7 ( 6 ) . A v a i l a b l e at: www.pediatrics.org/cgi/content/full/ 127/6/e1414

23. Joint Commission: Perinatal care. Available at: www.jointcommission.org/perinatal_ care. Accessed June 3, 2011

24. Gartner LM, Morton J, Lawrence RA, et al; American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2): 496 –506

25. Academy of Breastfeeding, Medicine Proto-col Committee. ABM clinical protoProto-col #2 (2007 revision): guidelines for the hospital discharge of the breastfeeding term new-born and mother—the “going home” proto-col.Breastfeed Med. 2007;2(3):158 –165 26. Academy of Breastfeeding Medicine.

Educa-tional objectives and skills for the physician with respect to breastfeeding.Breastfeed Med. 2011;6(2):99 –105

27. The Surgeon General’s call to action to sup-port breastfeeding. Available at: www. surgeongeneral.gov/topics/breastfeeding/ calltoactiontosupportbreastfeeding.pdf. Accessed June 3, 2011

28. American Academy of Family Practice. Fam-ily physicians supporting breastfeeding, (Position Paper). Available at: www.aafp. org/online/en/home/policy/policies/b/ breastfeedingpositionpaper.html. Ac-cessed June 3, 2011

29. American Public Health Association. A call to action on breastfeeding: a fundamental public health issue. Available at: www.apha.org/ advocacy/policy/policysearch/default.htm? NRMODE⫽Published&NRNODEGUID⫽%7b40F CA601-747E-4190-936B-BBB2DB8CDD36%7d&N RORIGINALURL⫽%2fadvocacy%2fpolicy%2f policysearch%2fdefault.htm%3ﬁd%3d1360 &NRCACHEHINT⫽NoModifyGuest&id⫽ 1360&PF⫽true. Accessed June 3, 2011 30. Centers for Disease Control and Prevention.

The CDC guide to breastfeeding interven-t i o n s . A v a i l a b l e a interven-t : w w w . c d c . g o v / breastfeeding/resources/guide.htm. Ac-cessed June 3, 2011

31. Healthy People 2020 objectives. Available at: w w w . h e a l t h y p e o p l e . g o v / 2 0 2 0 / t o p i c s objectives2020/pdfs/HP2020objectives.pdf. Accessed June 3 2011

32. World Health Organization/United Nations Chil-dren’s Fund. Baby-Friendly Hospital Initiative. Available at: www.who.int/nutrition/ publications/infantfeeding/bfhi_training course/en/index.html. Accessed June 3, 2011

doi:10.1542/peds.2011-2698B

In Reply

We, the members of the Executive Committee of the American Academy of Pediatrics Section on Breastfeeding, strongly applaud the Joint Commis-sion for setting a new requirement un-der the perinatal care core measure set that hospitals track and record ex-clusive breast milk feedings among term newborns beginning April 2010, and we strongly disagree with the comments by Flaherman and Newman.1

Because of poor hospital perfor-mance, the Centers for Disease Control and Prevention launched the maternity care practices survey (mPINC), the re-sults of which indicated that many birth centers are in need of quality im-provements to facilitate breastfeed-ing. It was surprising that 25% of the hospitals reported that they routinely

provided formula to breastfeeding in-fants. We believe that having exclusive breast milk feeding data available to birth hospitals will be a driver of qual-ity and might indicate populations more or less likely to suffer adverse health outcomes because of early ex-posure to infant formula. Flaherman and Newman misinterpreted results of the comprehensive meta-analysis by Ip et al,2 _{sponsored by the Agency for}

Healthcare Research and Quality, by assuming that the health outcomes associated with breastfeeding do not depend on the exclusivity of breast-feeding. In contrast, multiple health outcomes depend on exclusive breast-feeding but are not apparent with mixed feeding, such as acute otitis me-dia, atopic disorders, juvenile diabe-tes, and hospitalization for severe lower respiratory tract infections. There is evidence that any supplemen-tation will alter the immune system, change the intestinal flora, and in-crease the risk of imbalance between anti-infective, anti-inflammatory, toler-ance inducing, and proinflammatory responses during the ontogeny of a fragile and immature immune sys-tem.3–5 _{Therefore, tracking exclusive}

breastfeeding in hospitals will permit hospitals to reexamine their policies and practices and implement quality improvement activities that increase rates of exclusive breastfeeding.

The Joint Commission, along with the Centers for Disease Control and Pre-vention, the US Surgeon General (in her call to action to support breast-feeding), and numerous other organi-zations, have been calling for environ-ment and policy changes within hospital settings to improve support for breastfeeding. The American Acad-emy of Pediatrics endorsed “Ten Steps to Successful Breastfeeding,” which in-cludes a speciﬁc emphasis on exclu-sive breastfeeding to provide the best framework for how hospitals can

sup-e1314 LETTERS TO THE EDITOR

at Viet Nam:AAP Sponsored on August 28, 2020

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port a mother’s decision to breastfeed. With more than three-fourths of Amer-ican mothers initiating breastfeeding but merely 13% breastfeeding exclu-sively to 6 months, it is vital that we ﬁnd ways to eliminate the barriers mothers face once they have decided to breastfeed. Thus, one of the Healthy People 20206_{goals is to increase the}

proportion of live births that occur in facilities that provide recommended care for lactating mothers and their infants (ie, have adopted the “Ten Steps to Successful Breastfeeding”). In addition, the Surgeon General outlined the following in action 7 of her call to action7_{: ensure that maternity care}

practices throughout the US are fully supportive of breastfeeding by (1) ac-celerating implementation of the Baby-Friendly Hospital Initiative, (2) es-tablishing transparent, accountable, public reporting of maternity care practices in the United States, (3) es-tablishing a new advanced certiﬁca-tion program from perinatal patient care (the Joint Commission), and (4) establishing systems to control the distribution of infant formula in hospi-tals and ambulatory facilities.

Despite strong evidence behind each of the 10 steps, Flaherman and New-man failed to acknowledge that rou-tine supplementation of infant formula has been documented to undermine breastfeeding intensity and duration. They demonstrate the typical confu-sion between individual counseling and environmental and policy changes that would support quality of care. Their concerns are based on anecdotal personal experience (“we have seen”) and unsubstantiated speculations as to what constitutes the development of maternal self-efﬁcacy and risk of alien-ation. In contrast, it has been docu-mented that infants are more likely to breastfeed exclusively and continue breastfeeding after discharge from hospitals that have adopted standards

consistent with the Baby-Friendly Hos-pital Initiative, including restricting formula use for medical indication or to when speciﬁcally requested by mothers after appropriate educa-tion.8–11 _{Regardless of whether the}

supplement is a “small amount,” as the authors indicated, or multiple bottles’ worth, any supplementation under-mines exclusive breastfeeding and will decrease the likelihood of continued breastfeeding. Mothers who deliver in facilities that support breastfeeding are empowered to breastfeed and have the greatest chance of optimizing their self-efﬁcacy to continue breastfeeding.

We believe that the evidence, even from developed countries, is more than sufﬁcient to support hospital pol-icies that are consistent with the “Ten Steps to Successful Breastfeeding” and adoption of the Baby-Friendly Hos-pital Initiative, including restricted use of infant formula. The American Acad-emy of Pediatrics endorses hospital implementation of the “Ten Steps to Successful Breastfeeding” and reaf-ﬁrms its commitment to support exclu-sive breastfeeding for 6 months as the best way to optimize the health and well-being of children and families.12,13

We applaud the Joint Commission for including measurement of the rate of exclusive breast milk feeding as a core quality measure of a hospital’s perfor-mance. Such an action acknowledges that feeding of breast milk is a critical health issue for the maternal-infant dyad and not simply a lifestyle choice. In turn, this core measure will serve as a stimulus for the hospital to provide comprehensive and quality care and conﬁrm its commitment to public health and welfare.

Lori Feldman-Winter, MD, MPH

Department of Pediatrics Children’s Regional Hospital-Cooper University Hospital Camden, NJ 08103-1505

Richard J. Schanler, MD

Department of Pediatrics Neonatal-Perinatal Medicine Cohen Children’s Medical Center of New York at North Shore Manhasset, NY 11030-3816

Arthur Eidelman, MD

Department of Pediatrics Hebrew University School of Medicine Shaare Zedek Medical Center Jerusalem, CD 91031

Susan Landers, MD

Pediatrix Medical Group Austin, TX 78746-1910 Department of Neonatology Seton Medical Center Austin, TX 78746-1910

Lawrence Noble, MD

Department of Pediatrics Mount Sinai School of Medicine Elmhurst, NY 11373-1124 Department of Pediatrics Elmhurst Hospital Center Elmhurst, NY 11373-1124

Kinga Szucs, MD

Clinical Pediatrics Indiana University School of Medicine Pediatric Primary Care Center Indianapolis, IN 46202-2859

Laura Viehmann, MD

Department of Pediatrics Warren Alpert Medical School of Brown University Cumberland, RI 02864-3201

REFERENCES

1. Flaherman VJ, Newman TB. Regulatory monitoring of feeding during the birth hos-pitalization. Pediatrics. 2011;127(6):1177– 1179

2. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries.Evid Rep Technol As-sess (Full Rep). 2007;(153):1–186 3. Newburg DS, Walker WA. Protection of the

neonate by the innate immune system of developing gut and of human milk.Pediatr Res. 2007;61(1):2– 8

4. Kunz C, Rudloff S. Potential anti-inﬂammatory and anti-infectious effects of human milk oligosaccharides.Adv Exp Med Biol. 2008;606:455– 465

5. LeBouder E, Rey-Nores JE, Raby AC, et al. Modulation of neonatal microbial rec-ognition: TLR-mediated innate immune re-sponses are speciﬁcally and differentially modulated by human milk.J Immunol. 2006; 176(6):3742–3752

LETTERS TO THE EDITORS

PEDIATRICS Volume 128, Number 5, November 2011 e1315

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6. US Department of Health and Human Ser-vices. Healthy People 2020 summary of ob-jectives. Available at: www.healthypeople. gov/2020/topicsobjectives2020/pdfs/ MaternalChildHealth.pdf. Accessed June 1, 2011

7. US Department of Health and Human Ser-vices.Executive Summary: The Surgeon General’s Call to Action to Support Breast-feeding. Washington, DC: US Department of Health and Human Services, Ofﬁce of the Surgeon General; 2011

8. Merewood A, Patel B, Newton KN, et al. Breastfeeding duration rates and factors affecting continued breastfeeding among infants born at an inner- city US Baby-Friendly hospital.J Hum Lact. 2007;23(2): 157–164

9. Merewood A, Mehta SD, Chamberlain LB, et al. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pedi-atrics. 2005;116(3):628 – 634

10. World Health Organization/United Nations Children’s Fund.Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. Geneva, Switzerland: World Health Organization; 1989

11. World Health Organization.Evidence for the Ten Steps to Successful Breastfeeding. G e n e v a , S w i t z e r l a n d : W o r l d H e a l t h Organization; 1998

12. Tayloe DT Jr. AAP ten step endorsement. Available at: www.aap.org/breastfeeding/ ﬁles/pdf/TenStepswosig.pdf. Accessed June 3, 2011

13. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2): 496 –506

doi:10.1542/peds.2011-2698C

In Reply

Although we agree with the authors of the commentary “Regulatory Monitor-ing of FeedMonitor-ing DurMonitor-ing the Birth Hospi-talization”1 _{on the beneﬁts of}

breast-feeding, we disagree with their synthesis and interpretation of the ex-isting literature. They have suggested that the new Joint Commission mea-sure for tracking exclusive breastfeed-ing durbreastfeed-ing the hospital stay might in-advertently have a negative effect on breastfeeding, whereas we believe that it has the potential to substantially improve hospital maternity care

prac-tices and subsequent breastfeeding rates.

First, the authors argued that there is a lack of data from studies that have examined the effects of formula sup-plementation in the hospital. In fact, numerous studies have found a strong association of hospital supplementa-tion with reducsupplementa-tions in breastfeeding duration and exclusivity.2–4 _Both

sub-optimal breastfeeding behaviors and delayed onset of lactation are evident among infants who receive non– breast milk supplements in the hos-pital as early as the ﬁrst few days after birth.5 _{In addition, a}

random-ized controlled trial resulted in in-creased duration and exclusivity of breastfeeding after hospital imple-mentation of policies that limit hos-pital supplementation.6

Second, there are no data to support the authors’ anecdotal observation that some mothers feel so frustrated with hospital pressure to exclusively breastfeed that they stop breastfeed-ing completely. On the contrary, women whose infants are not supple-mented in the hospital are more likely to achieve their breastfeeding inten-tions.7 _{Difﬁculties establishing}

lacta-tion and lack of comprehensive hospi-tal support pose a threat to the continuation of successful breastfeed-ing. Achieving high rates of exclusive breastfeeding will require not just lim-iting supplementation but also overall improved maternity care, including prenatal breastfeeding education, early skin-to-skin contact, continuous rooming-in of mother and infant, edu-cation on signs of infant hunger, and professional support in addressing breastfeeding challenges.8

Finally, the authors suggested that hospital policies and practices that support exclusive breastfeeding are “attempting to control maternal decision-making regarding infant feeding.” However, ⬃80% of

preg-nant women in the United States in-tend to breastfeed, and ⬃70% of these women intend to breastfeed exclusively.9,10 _{Thus, contrary to the}

authors’ assertions, supplementing infants with formula, water, or sugar water in the hospital is the practice that interferes with maternal decision-making. Although there are infants for whom supplementation is medically indicated, these instances are extremely uncommon.11

Cur-rently, 24% of US hospitals routinely provide non– breast milk feedings to more than half of their healthy term breastfed infants, a rate that is ex-cessive.12 _{Even infants of mothers}

who plan to feed their infants both breast milk and formula should not be given formula in the hospital un-less medically indicated, because it interferes with establishing breast-feeding and is associated with early discontinuation of breastfeeding.13

The Joint Commission’s perinatal care core measure on exclusive breast milk feeding has a substantial evidence base and is consistent with the new Healthy People 2020 objective to re-duce the proportion of breastfed new-borns who receive formula supple-mentation within the ﬁrst 2 days of life.14_{The new Joint Commission}

mea-sure will likely bring more attention to hospital maternity care practices and has the potential to improve hospital practices and breastfeeding outcomes in the United States.

The ﬁndings and conclusions of this letter are those of the authors and do not necessarily represent the ofﬁcial position of the Centers for Disease Control and Prevention.

Cria G. Perrine, PhD Ruowei Li, MD, PhD Laurence M. Grummer-Strawn, PhD

Nutrition Branch Centers for Disease Control and Prevention Atlanta, GA 30333

e1316 LETTERS TO THE EDITOR

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DOI: 10.1542/peds.2011-2698C

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