Regulatory Monitoring Is
Not an Intervention; It Is
Merely Information
The authors of “Regulatory Monitoring of Feeding During the Birth Hospitaliza-tion”1make a common error in their assumptions about the use of an indi-cator. A monitoring indicator is not a policy, an intervention, or a behavior. The usefulness of any indicator de-pends on what actions are taken on the basis of that indicator.
The authors then go on to speculate about a practice (the discouragement of formula) that they have not verified exists. Furthermore, they then go out even further on a limb to speculate that discouraging the use of formula harms breastfeeding. By logical exten-sion this means that they are claiming that the use of formula improves breastfeeding rates. This speculative link is simply not plausible.
I do not yet have a randomized clinical trial, but I do have clinical evidence from⬎5000 mothers and infants with whom I have worked in Manhattan, New York. Many hospital policies in-volve interruptions that make it diffi-cult for mothers and infants to feed optimally. More than 90% of the moth-ers with whom I have worked were told that although breastfeeding is best, their infants needed formula in the hospital. More than half of these moth-ers were not told that they could and should have expressed milk for their infants until the underlying feeding problem was identified and rectified. This, I believe is the real source of most of the problems. As a result, many of these women unnecessarily end up with engorgement, plugged ducts, and mastitis, which then compromises the milk supply. To compensate for this early mismanagement, these mothers end up needing to express milk for weeks and sometimes months. The mothers who have had the good for-tune to have appropriate assistance
end up with an adequate milk supply and are able to return to normal feed-ing much sooner.
Rather than dumping mothers’ milk out with the indicator, we actually need much more specific information about the policies, interventions, and practices that are actually occurring. Theoretical speculation is not suffi-cient to justify eliminating an indicator that might, in conjunction with a seri-ous and thoughtful examination of in-fant feeding practices, yield better pol-icies than the current “breastfeeding is best, but formula is just as good” environment. The latter patronizes mothers on many levels.
Susan E. Burger, MHS, PhD, IBCLC
President, New York Lactation Consultant Association New York, NY 10024
REFERENCE
1. Flaherman VJ, Newman TB. Regulatory mon-itoring of feeding during the birth hospital-ization.Pediatrics. 2011;127(6):1177–1179
doi:10.1542/peds.2011-2698A
In Reply
For our nation to achieve its child health goals, it is critical that health care professionals, maternity care fa-cilities, and organizations act consis-tently on the basis of the best available evidence to create environments that will promote achievement of these goals. Policy should not be aimed at exceptions; therefore, we are respond-ing to a recentPediatricscommentary, “Regulatory Monitoring of Feeding During the Birth Hospitalization.”1 Al-though they initially stated agreement on the importance of exclusive breast-feeding for health outcomes, Drs Fla-herman and Newman argue from per-sonal experience (“we have seen”)1 that an indicator to measure exclusive breastfeeding during the hospital stay might cause harm and has not been shown to increase exclusive
breast-feeding rates. To the contrary, sub-stantial published research data have shown that supplementation with for-mula on day 1 of life is predictive of shorter breastfeeding duration.2–4 A study of a national sample, along with many hospital-level studies, found that changing hospital policy in accor-dance with the “Ten Steps to Success-ful Breastfeeding,”5a set of American Academy of Pediatrics– endorsed hos-pital practices that support and allow for optimal feeding6that are used na-tionally and internana-tionally,5 is effec-tive in improving breastfeeding rates and allowing mothers to achieve their exclusive breastfeeding intentions.7 Other literature on supplement provi-sion8indicates that support for exclu-sive breastfeeding (no supplements given) during the hospital stay is asso-ciated with women achieving their early exclusive breastfeeding inten-tions during the hospital stay and thereafter.
We concur that supporting mothers who wish to exclusively breastfeed should never include, as Flaherman and Newman stated, “pressuring mothers to breastfeed exclusively in the hospital when their infants are hungry or at high risk of jaundice.” It is imperative that all hospital staff who work with pregnant and postpartum women and families be adequately trained to support breastfeeding dy-ads, recognize true medical indica-tions for supplementation, and re-spectfully educate and inform families on the risks of non–medically indi-cated formula supplementation. Rather than pressuring mothers with hungry infants, the goal should be to create a supportive environment in which “hunger” and “high risk of jaun-dice” would become rare events. In fact, jaundice is vastly decreased when mothers are enabled to breastfeed fre-quently during the hospital stay,9 be-ginning with skin-to-skin contact and
ready availability of the breast in the first hour after birth, followed by 24-hour rooming-in.10,11Hunger in the first 24 hours is a rarity, especially with proper support for breastfeeding. If mothers are taught to recognize and understand the earliest hunger cues, they will not wait to feed until their in-fant is crying and too frantic to latch. Such delay contributes to the pre-sumption of hunger by both mothers and health care providers and the con-comitant use of supplements. This pos-itive support of mothers results in in-creased exclusive breastfeeding, not diminution as implied by Flaherman and Newman. It is much more frustrat-ing to a mother, and a greater attack on her self-efficacy, when her desire to succeed in exclusive breastfeeding is undermined by hospital practices such as supplemental formula feeding, which gives her the unintended but very real message of “you are the problem in that you are not making enough milk for your infant” and un-dermines self-confidence.12
There are times when supplements are medically required.13 In such cases, the first accepted supplement is the mother’s own milk. When an infant is not latching well, a mother can still often manually express some of her own nutrient- and immune-factor–rich colostrum into a spoon or a medicine cup, when shown how, which can then be spoon-fed to her infant. If the mother is unable to express the needed colostrum, the next best sup-plement is pasteurized donor human milk, which is available from any of the Human Milk Banking Association of North America milk banks in the United States and Canada.14In both of these cases, we emphasize the importance of human milk and also the need to avoid undermining the mother’s belief in the importance of her own milk and, thus, her self-efficacy. If pasteurized donor human milk is used, it is for a
short-term and does nothing to dis-turb the careful balance of immuno-globulins and gut microbiota that are laid down when breastfeeding com-mences. When formula is used, it is not just “one little harmless bottle of for-mula.” Existing evidence indicates that as little as 1 formula supplement can adversely change intestinal flora, influencing host metabolism, and inflammatory and immunomodulatory states, increasing the possibility that anti-infective, anti-inflammatory, and proinflammatory responses will be significantly changed, potentially af-fecting function.15–17
There is an abundant literature de-scribing postdischarge breastfeeding outcomes, including the cited Gray-Donald et al18report (of a controlled trial from 1985), that notes that the playing field changes once the mother and infant return home. Lack of sup-port from the pediatricians19 and obstetricians/gynecologists20 during those first weeks, along with limited social support and lack of paid mater-nity leave, exert a heavy negative effect on exclusive breastfeeding continua-tion. The research data underscore that these other factors come into play after the maternity stay.21Lack of ma-ternity leave interferes with the contin-uation of this behavior (exclusive breastfeeding), and data presented in an article that was published more re-cently in Pediatrics (by Ogbuanu et al22) on length of maternity leave taken and predominant (nearly exclusive) breastfeeding underscore this fact.
The Joint Commission measurement of exclusive breastfeeding during the birth hospitalization is a good start to-ward raising awareness that early management practices do affect longer-term breastfeeding exclusivity and success.23To be truly effective in the long run, care after leaving the hospital must be complemented by needed changes in current practices
and supporting exclusive breastfeed-ing in the hospital environment, fol-lowed by the outpatient environment. Breastfeeding dyads must be seen by knowledgeable providers soon after hospital discharge.24,25Until all provid-ers, especially pediatricians and ob-stetricians but also any physician or other health care provider who sees the mother during the preconception and interconception periods, begin to receive adequate training in the set of skills necessary to be able to fully sup-port breastfeeding26and until our so-ciety supports exclusive breastfeeding and paid maternity leave, it is unlikely that the 6-month exclusive breastfeed-ing goal will be achieved. Unless women are enabled from the start to carry out the practices associated with physiologically appropriate initia-tion of breastfeeding, it is also unlikely that we will make progress toward these public health goals.
In sum, improvements are needed at the clinical and societal levels to affect the desired health-supportive change in maternal breastfeeding decisions and success. Commentary such as the one by Flaherman and Newman, pub-lished by the editors of Pediatrics, which reflects the thinking and biases of many clinicians in current practice rather than the available research findings, may confuse the issue and keep us from attaining increased ex-clusive breastfeeding for all the con-comitant positive health outcomes. Ex-clusive breastfeeding for the first 6 months is more than a lifestyle choice; it is an evidence-based individual and public health measure. We, the under-signed, as physicians and members of organizations that seek to improve ma-ternal and child welfare, will continue to support the American Academy of Pediatrics endorsement of the “Ten Steps to Successful Breastfeeding,”4 the Surgeon General’s call to action to support breastfeeding,27the policies of
e1312 LETTERS TO THE EDITOR
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the American Academy of Pediatrics,24 the American Academy of Family Physi-cians,28the American Public Health As-sociation,29the American College of Ob-stetricians and Gynecologists,20 the Centers for Disease Control and Pre-vention,30and the Healthy People 2020 goals, which include a goal to “reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.”31We also support the international World Health Organization’s Baby-Friendly Hospital Initiative.32All of them offer evidence-based support for the Ten Steps to Suc-cessful Breastfeeding,5 which are practices that increase exclusive breastfeeding and support the Joint Commission measure.23
ORGANIZATIONAL SIGNATORIES
Academy of Breastfeeding Medicine American Association of Birth Centers American Breastfeeding Institute American College of Nurse Midwives American Dietetic Association American Nursing Association American Public Health Association AnotherLook
Baby-Friendly USA, Inc Best for Babes
Bright Future Lactation Resource Centre Ltd Coalition for Improving Maternity Services Every Mother, Inc
Healthy Children Project
Human Milk Banking Association of North America
International Childbirth Education Association La Leche League USA
Lamaze International
National Alliance for Breastfeeding Advocacy National Native Council of Breastfeeding National Perinatal Association Tidewater Lactation Group, Inc (Military
Lactation Consultant Association) US Breastfeeding Committee US Lactation Consultant Association Wellstart International
Miriam Labbok, MD, MPH, IBCLC
Carolina Global Breastfeeding Institute Gillings School of Global Public Health University of North Carolina Chapel Hill, NC 27599
Kathleen A. Marinelli, MD, IBCLC
Neonatology and Lactation Services Connecticut Children’s Medical Center Hartford, CT 06106
Department of Pediatrics University of Connecticut School of Medicine Farmington, CT 06030 Connecticut Chapter American Academy of Pediatrics Hartford, CT 06106
Melissa Bartick, MD, MSc
Department of Medicine Cambridge Hospital and Harvard Medical School Boston, MA 02115
Gerald Calnen, MD
Academy of Breastfeeding Medicine New Rochelle, NY 10801
Lawrence M. Gartner, MD
Departments of Pediatrics and Obstetrics/Gynecology University of Chicago Chicago, IL 60637
Ruth A. Lawrence, MD
Departments of Pediatrics and Obstetrics/Gynecology University of Rochester School of Medicine Rochester, NY 14642
Joan Younger Meek, MD, MS, RD, IBCLC
Department of Pediatrics Orlando Health/Arnold Palmer Medical Center Florida State University College of Medicine Orlando, FL 32806
Jose J. Gorrin-Peralta, MD, MPH
University of Puerto Rico San Juan, PR 00936
Ana M. Parrilla-Rodriguez, MD, MPH
Maternal and Child Health Program Graduate School of Public Health-Medical Sciences Campus University of Puerto Rico San Juan, PR 00936
Nancy G. Powers, MD
University of Kansas School of Medicine–Wichita Wichita, KS 67028
REFERENCES
1. Flaherman VJ, Newman TB. Regulatory monitoring of feeding during the birth hos-pitalization. Pediatrics. 2011;127(6): 1177–1179
2. Bolton T, Chow T, Benton P, Olson B. Charac-teristics associated with longer breastfeed-ing duration: an analysis of a peer counsel-ing support program.J Hum Lact. 2009; 25(1):18 –27
3. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity care practices on breastfeeding.Pediatrics. 2008;122(suppl 2):S43–S49
4. Sheehan D, Watt S, Kruger P, Sword W. The impact of a new universal postpartum pro-gram on breastfeeding outcomes.J Hum Lact. 2006;22(4):398 – 408
5. World Health Organization/United Nations Children’s Fund.Protecting, Promoting and Supporting Breast-Feeding: The Special Role of Maternity Services. Geneva, Switzerland: World Health Organization; 1989.Available at: www.who.int/nutrition/ publications/infantfeeding/9241561300/ en/index.html. Accessed June 3, 2011 6. Tayloe DT Jr. AAP ten step endorsement.
Available at: www.aap.org/breastfeeding/ files/pdf/TenStepswosig.pdf. Accessed June 3, 2011
7. Declercq ER, Labbok M, O’Hara M, Sakala C. The relationship of hospital practices to women’s likelihood of fulfilling their inten-tion to exclusively breastfeed.Am J Public Health. 2009;99(5):929 –935
8. Cramton R, Zain-Ul-Abideen M, Whalen B. Op-timizing successful breastfeeding in the newborn. Curr Opin Pediatr. 2009;21(3): 386 –396
9. Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics. 1990;86(2):171–175
10. Kurinij N, Shiono P. Early formula supple-mentation of breast-feeding. Pediatrics. 1991;88(4):745–750
11. Ferber S, Makhoul I. The effect of skin-to-skin contact shortly after birth on the neu-robehavioral response of the newborn: a randomized control trial.Pediatrics. 2004; 113(4):858 – 865
12. Entwistle F, Kendall S, Mead M. Breastfeed-ing support: the importance of self-efficacy for low-income women.Matern Child Nutr. 2010;6(3):228 –234
13. Academy of Breastfeeding, Medicine Proto-col Committee. ABM clinical protoProto-col #3: hospital guidelines for the use of supple-mentary feedings in the healthy term breastfed neonate, revised 2009 [published correction appears in Breastfeed Med. 2011;6(3):159].BreastfeedMed. 2009;4(3): 175–182
14. Human Milk Banking Association of North America. Home page. Available at: www. hmbana.org. Accessed June 3, 2011 15. Musso G, Gambino R, Cassader M. Obesity,
diabetes and gut microbiota: the hygiene hypothesis expanded?Diabetes Care. 2010; 33(10):2277–2284
16. Walker A. Breast milk as the gold standard for protective nutrients.J Pediatr. 2010; 156(2 suppl):S3–S7
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
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DOI: 10.1542/peds.2011-2698B
2011;128;e1311
Pediatrics
Parrilla-Rodriguez and Nancy G. Powers
Gartner, Ruth A. Lawrence, Joan Younger Meek, Jose J. Gorrin-Peralta, Ana M.
Miriam Labbok, Kathleen A. Marinelli, Melissa Bartick, Gerald Calnen, Lawrence M.
In Reply
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DOI: 10.1542/peds.2011-2698B
2011;128;e1311
Pediatrics
Parrilla-Rodriguez and Nancy G. Powers
Gartner, Ruth A. Lawrence, Joan Younger Meek, Jose J. Gorrin-Peralta, Ana M.
Miriam Labbok, Kathleen A. Marinelli, Melissa Bartick, Gerald Calnen, Lawrence M.
In Reply
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