Regulatory Monitoring of Feeding During the Birth Hospitalization

No one disputes the value of colostrum. However, it is self-evident that colostrum cannot benefit the baby while it remains in the breast. The central issue I observe is the need to recognize and manage conditions that hamper effective colostrum transfer out of the breast.

Pliability of the areola and subareolar tissues is the key that favors effective colostrum transfer. A soft areola permits the nipple- areolar complex to respond efficiently in tandem with the suckling forces applied by the baby's oral cavity. It also facilitates the removal of colostrum by hand expression or judicious use of vacuum.

Many mothers in the United States experience what I call "Pre-L-2 edema". Edema formation results from intrapartum administration of crystalloid IV fluid in amounts sufficient to reduce colloid osmotic pressure below normal for up to a week or more. (Park et al.) In addition, delays in renal elimination of excess fluid result from the antidiuretic side effects of pitocin (Chou et al.) administered for long hours of induction, augmentation, or third stage management.

Gravity attracts edema forward toward the nipple-areolar complex when the breast is in a dependent position, more so in the pendulous breast. Colostrum transfer suffers when edema crowds or buries the subareolar ducts, and causes subareolar tissue resistance that soon exceeds the baby's suckling forces.

In addition, too few health care providers realize that vacuum does not pull; other forces push. Five centuries of evidence exist for this. Since "nature abhors a vacuum", hydrostatic forces from increased interstitial fluid in the breast effectively push edema forward toward the pump flange and the nipple-areolar tissues.

Anesthesiologists and obstetricians are responsible for decisions on intrapartum fluid management and oxytocics. Part of their goal is to avoid complications inside the chest wall. However, these same decisions often produce complications on the outside of the chest wall which need further research and better understanding by all MCH professionals!

Given the potentially life-saving use of crystalloid IV fluids in emergencies, and the broader general use for prenatal complications, managed labor, epidural anesthetics and operative delivery, the easiest solutions I have found to permit better transfer of colostrum are anti- gravity positioning and the early and regular use of reverse pressure softening (RPS) to temporarily displace edema from the nipple-areolar complex before latching or hand expression and before and during pumping. (Cotterman)

This issue will not be overcome solely or primarily by debate over hospital routines, mPINC scores, or even maternal dedication unless the problem of ineffective colostrum transfer can be more fully and widely understood and managed.

K. Jean Cotterman

References

Park GE, Hauch MA, Curlin F, Datta S, Bader AM, The effects of varying volumes of crystalloid administration before Cesarean delivery on maternal hemodynamics and colloid osmotic pressure, Anesth Analg 1996; 83:299-303.

Chou CL, DiGiovanni SR, Mejia R, Neilsen S, Knepper MA, Oxtocin as an antidiuretic hormone I. Concentration dependence of action, Am J Physiol (United States), Jul 1995, 269(1 Pt 2) p F78-85.

Cotterman KJ, Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement, Journal of Human Lactation, May 2004, vol. 20, iss. 2, pp. 227-237.

http://www.kellymom.com/bf/concerns/mom/rev_pressure_soft_cotterman.html Accessed 7/24/11

Conflict of Interest:

None declared

To the editor:

We appreciate the responses by Burger, Marinelli et al., Feldman- Winter et al. and Perrine et al. to our commentary.

We have several areas of agreement with the writers:

1. Breastfeeding offers important health benefits to babies and their mothers and exclusive breastfeeding through 3 and 6 months offers optimal nutrition. We share with the writers the goal of advocating for effective policies to improve U.S. breastfeeding rates, especially at 3, 6 and 12 months of age.

2. We support CDC Healthy People 2020 breastfeeding goals and the 10 Steps to Successful Breastfeeding recommended by the World Health Organization (except for the prohibition against pacifier use). (1-5)

3. There is a strong association between formula supplementation and decreased duration and exclusivity of breastfeeding in observational studies. (6-10)

4. Breastfed babies should not be routinely supplemented with formula or other fluids. The Joint Commission quality measure may improve breastfeeding rates in some hospitals by discouraging such inappropriate routine supplementation.

While we agree with the writers above that the new Joint Commission quality measure may improve breastfeeding rates at hospitals where formula supplementation is routine, we are concerned that the proposed quality measure could negatively impact breastfeeding and mother and infant well- being at the many U.S. hospitals where formula supplementation is already used judiciously. For example, at the hospital where we practice, 89% of mothers breastfed exclusively through discharge in 2009. (11) While we appreciate the value of exclusive breastfeeding, we believe that sometimes excessive enthusiasm for exclusive breastfeeding leads to counterproductive reluctance to give formula when it could be helpful. The proposed Joint Commission quality measure seems to fit this mindset and could do mothers, infants and breastfeeding advocates a disservice at hospitals such as ours, where unnecessary formula use is rare.

Association is not the same as causation

Mothers who are more dedicated to breastfeeding, have a more rapid onset of lactogenesis II and receive stronger breastfeeding education and clinical support for breastfeeding are less likely both to supplement with early formula and to discontinue breastfeeding. Therefore, observational studies showing a strong association between supplementation and later breastfeeding rates cannot show whether hospital policy restricting supplementation improves long-term breastfeeding duration. Using a quasi-randomized trial design that randomly distributed maternal and infant confounders related to breastfeeding duration, Gray-Donald et al. found that hospital policy restricting formula use was not effective in improving rates of breastfeeding and exclusive breastfeeding at 4 or 9 weeks. (12) Perrine et al erroneously characterize the study by Nylander et al. (13) as a randomized clinical trial; in fact it was a before/after longitudinal study in which many simultaneous changes were occurring to support breastfeeding.

Our concern is how best to support mothers in the hospital so that they continue to breastfeed long-term. Excessive reluctance to supplement with formula can lead to frantic, hungry infants and demoralized, discouraged, exhausted parents who are so upset by their inpatient experience that they give up breastfeeding entirely. A little formula administered in a guilt-free, supportive way can transform the postpartum experience of these families in a way that supports, rather than undermines breastfeeding.

Baby Friendly Ten Steps Are Effective. (14)

Step 6 of the Baby Friendly Hospital Initiative is "Give newborn infants no food or drink other than breastmilk, unless medically indicated." (3) Unfortunately, the current Joint Commission quality measure currently excludes only death, galactosemia, parenteral infusion, admission to the neonatal intensive care unit, length of stay >120 days, enrolled in clinical trials, HIV infection, HTLV infection, active tuberculosis, cancer chemotherapy, radiation therapy, active varicella and herpetic breast lesions. (15, 16) Common medical indications for supplementation, such as adoption and delayed or deficient lactogenesis II with associated excessive weight loss and dehydration, are not included. In many such clinically common situations, we have seen temporary formula supplementation, in small, controlled volumes, result in an immediate improvement in maternal and infant well-being and continued breastfeeding through 3, 6 and 12 months.

CDC Healthy People 2020 goals are valuable

The Healthy People 2020 goal MICH-23 aims "to reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life." (2) The Joint Commission quality measure differs from MICH-23 in four important ways. First, reducing length of hospital stay would increase compliance with the Joint Commission measure, because the longer an infant stays in the hospital, the more likely the infant will receive formula before discharge. However, reduced length of stay results in increased readmission, (17) and therefore might reduce longer- term breastfeeding outcomes even while improving compliance with the new Joint Commission measure. Second, Healthy People 2020 targets 14.2% of breastfed newborns receiving formula in the first two days. In contrast, the Joint Commission measure states that an improvement is noted as an increase in the rate of this measure, and does not make an exception for hospitals with rates that are already high. (15) Third, the Healthy People 2020 goal MICH-23 includes only breastfed newborns and does not include newborns whose mothers have chosen not to breastfeed. In contrast, the Joint Commission quality measure instructions state (somewhat absurdly): "The mother's refusal to feed the newborn breast milk does not constitute a reason for not exclusively feeding breast milk." Fourth, Healthy People 2020 represents targets for breastfeeding rates throughout infancy; the Joint Commission provides certification for individual hospitals and is more likely to focus provider behavior on the specific goal of reducing formula use during the birth hospitalization, rather than increasing overall breastfeeding rates.

Definitions of exclusive breastfeeding

Feldman-Winter et al. write "Flaherman and Newman misinterpret the comprehensive meta-analysis by Ip, Chung and colleagues ...by assuming that the health outcomes associated with breastfeeding are not dependent upon the exclusivity of breastfeeding ." We do not make that assumption. Definitions of exclusive breast feeding vary. For example, regarding severe lower respiratory tract infections, Ip et al. state "Exclusive breastfeeding was defined as little or no formula feeding" (page 40) (18) and rely on a previous systematic review by Bachrach et al., in which it is stated "Additionally, we looked for studies that characterized breastfeeding as exclusive (meaning little or no formula offered)." (19) In any case, we do believe that there are health benefits of exclusive breastfeeding, and this is always our first choice.

Improving national breastfeeding rates at 3, 6 and 12 months

As described by Marinelli et al., there is a wealth of literature describing the many factors influencing our nation's breastfeeding rates throughout infancy, including lack of physician support, lack of social support and inadequate maternity leave. Addressing these issues is important to improving U.S. breastfeeding rates and infant health outcomes. The Joint Commission quality measure may improve breastfeeding rates in some hospitals, especially those that previously practiced routine supplementation of breastfed newborns. However, this well-intentioned measure may have the opposite effect in other hospitals. We suggest the Joint Commission defer implementation of this quality measure until its full effects on breastfeeding have been determined.

References

1. Jaafar SH, Jahanfar S, Angolkar M, Ho JJ. Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev.3:CD007202.

2. Centers for Disease Control. Maternal, Infant and Child Health. 2011; http://healthypeople.gov/2020/ topicsobjectives2020/objectiveslist.aspx?topicid=26. Accessed March 14, 2011.

3. UNICEF/WHO. Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, Section 1, Background and Implementation, Preliminary version. 2006; http://www.who.int/nutrition/topics/BFHI_Revised_Section1.pdf. Accessed January 17, 2008.

4. O'Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and breastfeeding: a systematic review. Arch Pediatr Adolesc Med. Apr 2009;163(4):378-382.

5. Li DK, Willinger M, Petitti DB, Odouli R, Liu L, Hoffman HJ. Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome (SIDS): population based case-control study. BMJ. Jan 7 2006;332(7532):18- 22.

6. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2002(1):CD003517.

7. Petrova A, Hegyi T, Mehta R. Maternal race/ethnicity and one-month exclusive breastfeeding in association with the in-hospital feeding modality. Breastfeed Med. Jun 2007;2(2):92-98.

8. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity- care practices on breastfeeding. Pediatrics. Oct 2008;122 Suppl 2:S43-49.

9. Bolton TA, Chow T, Benton PA, Olson BH. Characteristics associated with longer breastfeeding duration: an analysis of a peer counseling support program. J Hum Lact. Feb 2009;25(1):18-27.

10. Sheehan D, Watt S, Krueger P, Sword W. The impact of a new universal postpartum program on breastfeeding outcomes. J Hum Lact. Nov 2006;22(4):398-408.

11. California Department of Public Health. California In-Hospital Breastfeeding as Indicated on the Newborn Screening Test Form. 2011; http://www.cdph.ca.gov/data/statistics/Documents/MOBFPHospitalTotalsReport2009.pdf. Accessed June 23, 2011.

12. 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. Mar 1985;75(3):514-518.

13. Nylander G, Lindemann R, Helsing E, Bendvold E. Unsupplemented breastfeeding in the maternity ward. Positive long-term effects. Acta Obstet Gynecol Scand. 1991;70(3):205-209.

14. Kramer MS, Guo T, Platt RW, et al. Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding. Am J Clin Nutr. Aug 2003;78(2):291-295.

15. Joint Commission. Specifications Manual for Joint Commission National Quality Measures (v2011a), Measure Information Form. 2011; http://manual.jointcommission.org/releases/TJC2011A/MIF0170.html. Accessed June 17, 2011.

16. Joint Commission. Specifications Manual for Joint Commission National Quality Measures (v2011A), Reason for Not Exclusively Feeding Breast Milk. 2011; http://manual.jointcommission.org/releases/TJC2011A/ DataElem0274.html. Accessed June 17, 2011.

17. Datar A, Sood N. Impact of postpartum hospital-stay legislation on newborn length of stay, readmission, and mortality in California. Pediatrics. Jul 2006;118(1):63-72.

18. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Outcomes in Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality;2007.

19. Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Arch Pediatr Adolesc Med. Mar 2003;157(3):237-243.

Conflict of Interest:

Authors of previous commentary.

Although we agree with the authors of the commentary "Regulatory Monitoring of Feeding During the Birth Hospitalization"1 on the benefits of breastfeeding, we disagree with their synthesis and interpretation of the existing literature. They suggest that the new Joint Commission measure for tracking exclusive breastfeeding during the hospital stay may inadvertently have a negative impact on breastfeeding, whereas we believe that it has the potential to substantially improve hospital maternity care practices and subsequent breastfeeding rates.

First, the authors argue there is a lack of data examining the effects of formula supplementation in the hospital. In fact, numerous studies have demonstrated a strong association of hospital supplementation with reductions in breastfeeding duration and exclusivity.2-4 Both suboptimal breastfeeding behaviors and delayed onset of lactation are evident among infants who receive non-breast milk supplements in the hospital, as early as the first few days after birth.5 Additionally, a randomized controlled trial has demonstrated increased duration and exclusivity of breastfeeding after hospital implementation of policies that limit hospital 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 breastfeeding completely. On the contrary, women whose infants are not supplemented in the hospital are more likely to achieve their breastfeeding intentions.7 Difficulties establishing lactation and lack of comprehensive hospital support pose a threat to the continuation of successful breastfeeding. Achieving high rates of exclusive breastfeeding will require not just limiting supplementation, but overall improved maternity care, including prenatal breastfeeding education, early skin-to-skin contact, continuous rooming-in of mother and infant, teaching signs of infant hunger, and professional support in addressing breastfeeding challenges.8

Finally, the authors suggest that hospital policies and practices that support exclusive breastfeeding are "attempting to control maternal decision-making regarding infant feeding." However, about 80% of pregnant women in the U.S. intend to breastfeed, and approximately 70% of these 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. While there are infants for whom supplementation is medically indicated, these instances are extremely uncommon.11 Currently 24% of U.S. hospitals routinely provide non-breast milk feedings to over half of healthy full-term breastfed infants, a rate that is excessive.12 Even infants of mothers who plan to feed their infants both breast milk and formula should not be given formula in the hospital unless medically indicated, as this interferes with establishing breastfeeding 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 reduce the proportion of breastfed newborns who receive formula supplementation within the first two days of life.14 The new Joint Commission measure will likely bring more attention to hospital maternity care practices and has the potential to improve hospital practices and breastfeeding outcomes in the U.S.

Cria G. Perrine, PhD Epidemiologist Centers for Disease Control and Prevention

Ruowei Li, MD, PhD Epidemiologist Centers for Disease Control and Prevention

Laurence M. Grummer-Strawn, PhD Chief, Nutrition Branch Centers for Disease Control and Prevention

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.

References 1. Flaherman VJ, Newman TB. Regulatory monitoring of feeding during the birth hospitalization. Pediatrics. 2011;127(6):1177-1179. 2. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122 Suppl 2:S43-49. 3. Ekstrom A, Widstrom AM, Nissen E. Duration of breastfeeding in Swedish primiparous and multiparous women. J Hum Lact. 2003;19(2):172-178. 4. Petrova A, Hegyi T, Mehta R. Maternal race/ethnicity and one-month exclusive breastfeeding in association with the in-hospital feeding modality. Breastfeed Med. 2007;2(2):92-98. 5. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics. 2003;112(3 Pt 1):607-619. 6. Nylander G, Lindemann R, Helsing E, Bendvold E. Unsupplemented breastfeeding in the maternity ward. Positive long-term effects. Acta Obstet Gynecol Scand. 1991;70(3):205-209. 7. Declercq E, Labbok MH, Sakala C, O'Hara M. Hospital practices and women's likelihood of fulfilling their intention to exclusively breastfeed. Am J Public Health. 2009;99(5):929-935. 8. Kurinij N, Shiono PH. Early formula supplementation of breast-feeding. Pediatrics. 1991;88(4):745-750. 9. Declercq ER, Sakala C, Corry M, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences. New York: Childbirth Connection; 2006. 10. Centers for Disease Control and Prevention. Infant Feeding Practices Study II: Results. http://www.cdc.gov/ifps/results/index.htm. Accessed June 5, 2011. 11. World Health Organization and UNICEF. Acceptable medical reasons for use of breast-milk substitutes. Geneva: World Health Organization; 2009. 12. Centers for Disease Control and Prevention. Maternity Practices in Infant Nutrition and Care Survey: Results. http://www.cdc.gov/breastfeeding/data/mpinc/results.htm. Accessed June 6, 2011. 13. World Health Organization. Evidence for the Ten Steps to Successful Breastfeeding. Geneva: World Health Organization; 1998. 14. U.S. Department of Health and Human Services. Healthy People 2020: Maternal Infant Child Health Objectives. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26. Accessed June 6, 2011.

Conflict of Interest:

None declared

To the Editors:

We, the members of the Executive Committee of the American Academy of Pediatrics Section on Breastfeeding, strongly applaud The Joint Commission for setting a new requirement under the Perinatal Care Core Measure Set that hospitals track and record "exclusive breastmilk feedings" among term newborns beginning April 2010 and strongly disagree with the comments by Flaherman and Newman (1).

Because of poor hospital performance the CDC launched the maternity care practices survey (mPINC) which indicated that many birth centers are in need of quality improvements necessary to facilitate breastfeeding. Surprisingly, 25% of hospitals reported that they routinely provided formula to breastfeeding infants. We believe that having exclusive breastmilk feeding data available to birth hospitals will be a driver of quality and may indicate populations more or less likely to suffer adverse health outcomes because of early exposure to infant formula. Flaherman and Newman misinterpret the comprehensive meta-analysis by Ip, Chung and colleagues, sponsored by the Agency for Healthcare Research and Quality, by assuming that the health outcomes associated with breastfeeding are not dependent upon the exclusivity of breastfeeding (2). In contrast, multiple health outcomes are dependent on exclusive breastfeeding, but not apparent with mixed feeding, such as acute otitis media, atopic disorders, juvenile diabetes and hospitalization for severe lower respiratory tract infections. There is evidence that any supplementation will alter the immune system, change the intestinal flora, and increase the risk of imbalance between anti-infective, anti-inflammatory, tolerance inducing, and pro-inflammatory responses during the ontogeny of a fragile and immature immune system (3-5). Therefore, tracking exclusive breastfeeding in hospitals will permit hospitals to re-examine their policies and practices and implement quality improvement activities that increase rates of exclusive breastfeeding.

The Joint Commission, along with the CDC, the US Surgeon General, in her Call to Action to Support Breastfeeding, and numerous organizations have been calling for environment and policy changes within hospital settings to improve the support for breastfeeding. The American Academy of Pediatrics endorsed Ten Steps to Successful Breastfeeding which includes a specific emphasis on exclusive breastfeeding to provide the best framework for how hospitals can support a mother's decision to breastfeed. With over three-fourths of American mothers initiating breastfeeding, but merely 13% exclusively to 6 months, it is vital we find ways to eliminate the barriers mothers face once they have decided to breastfeed. Thus, one of the Healthy People 2020 goals (6) is to increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies (have adopted the Ten Steps). In addition, the Surgeon General outlined in Action 7 of her Call to Action (7): Ensure that maternity care practices throughout the US are fully supportive of breastfeeding by 1) accelerating implementation of the Baby Friendly Hospital Initiative. 2) establishing transparent, accountable, public reporting of maternity care practices in the US, 3) establishing a new advanced certification program from perinatal patient care (The Joint Commission), and 4) establishing systems to control the distribution of infant formula in hospitals and ambulatory facilities.

Despite strong evidence behind each of the Ten Steps, Flaherman and Newman have failed to acknowledge that routine supplementation of infant formula has been documented to undermine breastfeeding intensity and duration. They demonstrate the typical confusion 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 alienation. In contrast, it has been documented that infants are more likely to breastfeed exclusively and continue breastfeeding after discharge from hospitals adopting standards consistent with the Baby Friendly Hospital Initiative, including restricting formula use for medical indication or when specifically requested by mothers after appropriate education (8-11). Whether the supplement is a "small amount" as the authors indicate, or multiple bottles, any supplementation undermines 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 to breastfeed.

We believe the evidence, even in developed countries, is more than sufficient to support hospital policies that are consistent with the Ten Steps to Successful Breastfeeding and adoption of the Baby-Friendly Hospital Initiative, including restricted use of infant formula. The American Academy of Pediatrics endorses hospital implementation of the Ten Steps to Successful Breastfeeding, and reaffirms its commitment to support exclusive breastfeeding for 6 months as the best way to optimize the health and well-being of children and families (12, 13).

In conclusion, we applaud The Joint Commission for including measurement of the rate of exclusive breastmilk feeding as a Core Quality Measure of a hospital's performance. Such an action acknowledges that feeding of breastmilk 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.

References 1. Flahermann VJ, Newman TB. Pediatrics. 2011;127(6):1177-1179 2. Ip S, Chung M, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007 Apr;(153):1-186. 3. Newburg DS, Walker WA. Protection of the neonate by the innate immune system of developing gut and of human milk. Pediatric Res. 2007 Jan;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;606:455-65. 5. LeBouder E, Rey-Nores JE, Raby AC, et al. Modulation of neonatal microbial recognition: TLR-mediated innate immune responses are specifically and differentially modulated by human milk. J Immunol. 2006 Mar 15;176(6):3742-52. 6. U.S. Department of Health and Human Services. Healthy People 2020 summary Recommendations. http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/MaternalChildHealth.pdf (accessed June 1, 2011) 7. U.S. Department of Health and Human Services. Executive Summary: The Surgeon General's Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; January 20, 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):157-64 9. Merewood A, Mehta SD, Chamberlain LB, et al. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005;116(3):628-34 10. World Health Organization, UNICEF. 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. 1998. 12. AAP Ten Step endorsement, August 25, 2009. 13. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics 2005; 115:496-506.

Conflict of Interest:

None declared

To the Editors of Pediatrics:

For our nation to achieve its child health goals, it is critical that healthcare professionals, maternity care facilities and organizations act consistently based on best available evidence to create environments that will promote achievement of these goals. Policy should not be aimed at exceptions; therefore, we are responding to the commentary, "Regulatory Monitoring of Feeding During the Birth Hospitalization." [1] While initially stating agreement as to the importance of exclusive breastfeeding for health outcomes, Drs. Flaherman and Newman argue from personal experience ("we have seen") [1] that an indicator to measure exclusive breastfeeding during the hospital stay may cause harm and has not been shown to increase exclusive breastfeeding rates. To the contrary, substantial published research has shown that supplementation with formula on day one of life is predictive of shorter breastfeeding duration. [2,3,4] A study of a national sample, along with many hospital level studies, demonstrate that changing hospital policy in accordance with the Ten Steps to Successful Breastfeeding, [5] a set of American Academy of Pediatrics-endorsed hospital practices that support and allow for optimal feeding [6] that are employed nationally and internationally, [5] is effective in improving breastfeeding rates and allowing mothers to achieve their exclusive breastfeeding intentions. [7] Other literature on supplement provision [8] demonstrates that support for exclusive breastfeeding (no supplements given) during the hospital stay is associated with women achieving their early exclusive breastfeeding intentions during the hospital stay and thereafter.

We concur that supporting mothers who wish to exclusively breastfeed should never include, as Flaherman and Newman state, "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 post-partum women and families be adequately trained to support breastfeeding dyads, recognize true medical indications for supplementation and respectfully educate and inform families on the risks of non-medically indicated formula supplementation. Rather than pressuring mothers with hungry babies, the goal is to create a supportive environment where "hunger" and "high risk of jaundice" would become rare events. In fact, jaundice is vastly decreased when mothers are enabled to breastfeed frequently during the hospital stay, [9] beginning with skin-to -skin contact and ready availability of the breast in the first hour after birth, followed by 24 hour rooming in. [10,11] Hunger 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 babies are crying and too frantic to latch. Such delay contributes to the presumption of hunger by both mothers and health care providers and the concomitant use of supplements. This positive support of mothers results in increased exclusive breastfeeding, not diminution as implied by the authors. It is much more frustrating 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: "you are the problem in that you are not making enough milk for your baby" which undermines self-confidence. [12]

There are times when supplements are medically required. [13] In such cases, the first accepted supplement is mother's own milk. When a baby 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 baby. If the mother is unable to express the needed colostrum, the next best supplement is pasteurized donor human milk, available from any of the Human Milk Banking Association of North America milk banks in the United States and Canada. [14] In both of these cases, we emphasize the importance of human milk and also, the need to avoid undermining mother's belief in the importance of her own milk, and thus her self-efficacy. If pasteurized donor human milk is used, it is a short-term need, and does nothing to disturb the careful balance of immunoglobulins and gut microbiota that are laid down when breastfeeding commences. When formula is used, it is not just "one little harmless bottle of formula". Existing evidence demonstrates that as little as one formula supplement can adversely change intestinal flora, influencing host metabolism, and inflammatory and immunomodulatory states, increasing the possibility that anti-infective, anti-inflammatory, and pro-inflammatory responses will be significantly changed, potentially affecting function. [15,16,17]

There is an abundant literature describing post-discharge breastfeeding outcomes, including the cited Gray-Donald et al paper (a controlled trial from 1985), that note that the playing field changes once the mother and baby return home. [18] Lack of support from the pediatricians [19] and obstetricians/ gynecologists [20] during those first weeks, along with limited social support and lack of paid maternity leave, exert a heavy negative impact on exclusive breastfeeding continuation. The research underscores that these other factors come into play after the maternity stay. [21] Lack of maternity leave interferes with the continuation of this behavior (exclusive breastfeeding) and the article that was published this week in Pediatrics (Ogbuana C et al) [22] on length of maternity leave taken and predominant (nearly-exclusive) breastfeeding underscores this fact.

The Joint Commission measurement of exclusive breastfeeding during the birth hospitalization is a good start toward raising awareness that early management practices do affect longer term breastfeeding exclusivity and success. [23] To be truly effective in the long run, care after leaving the hospital must be complemented by needed changes in current practices and supporting exclusive breastfeeding in the hospital environment, followed by the outpatient environment. Breastfeeding dyads must be seen by knowledgeable providers soon after hospital discharge. [24,25] Until all providers, especially pediatricians and obstetricians, as well as any physician or other health care provider who sees the mother during the pre- and inter-conception periods, begin to receive adequate training in the set of skills necessary to be able to fully support breastfeeding, [26] and until our society supports exclusive breastfeeding and paid maternity leave, it is unlikely that the 6 months exclusive breastfeeding goal will be achieved. Unless women are enabled from the start to carry out the practices associated with physiologically appropriate initiation 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 Drs. Flaherman and Newman, published 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 further from attaining increased exclusive breastfeeding for all the concomitant positive health outcomes. Exclusive breastfeeding for the first 6 months is more than a lifestyle choice--it is an evidence-based individual and public health measure. We, the undersigned, as physicians and as members of organizations seeking to improve maternal and child welfare, will continue to support the AAP Endorsement of the Ten Steps, [4] the Surgeon General's Call to Action to Support Breastfeeding, [27] and the policies of the American Academy of Pediatrics, [24] American Academy of Family Physicians, [28] American Public Health Association, [29] ,the American College of Obstetricians and Gynecologists, [20] the Centers for Disease Control and Prevention, [30] the Healthy People 2020 goals which include to "reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life" [31] as well as the international World Health Organization's Baby-friendly Hospital Initiative, [32] all of which offer evidence-based support for the Ten Steps, [5] practices that increase exclusive breastfeeding, and support the Joint Commission measure. [23]

Sincerely,

Miriam Labbok, MD, MPH, IBCLC, FACPM, FABM; Professor of Maternal and Child Health; Director, Carolina Global Breastfeeding Institute; Gillings School of Global Public Health; University of North Carolina

Kathleen A. Marinelli MD, IBCLC, FABM, FAAP; Neonatology and Lactation Services, Connecticut Children's Medical Center; Associate Professor of Pediatrics, University of CT School of Medicine; Connecticut Chapter Breastfeeding Coordinator, American Academy of Pediatrics

Additional Signatories:

Melissa Bartick, MD, MSc; Dept of Medicine, Cambridge Hospital and Harvard Medical School

Gerald Calnen MD, FAAP, FABM; President, Academy of Breastfeeding Medicine

Lawrence M. Gartner, M.D., FAAP; Professor Emeritus, Departments of Pediatrics and OB/GYN, The University of Chicago

Ruth A Lawrence MD, FABM, FAAP, FAACT; Professor Pediatrics and Obstetrics/Gynecology, University of Rochester School of Medicine

Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC; Academic Chair and Residency Director, Pediatrics Orlando Health/Arnold Palmer Medical, Center Clinical Associate Professor, The Florida State University College of Medicine

Jose J. Gorrin-Peralta, MD, MPH, FACOG, FABM; Professor, Maternal and Child Health Program, Graduate School of Public Health - Medical Sciences Campus, University of Puerto Rico

Ana M. Parrilla-Rodriguez, MD, MPH, FABM, EEMCP; Associate Professor, Maternal and Child Health Program, Graduate School of Public Health - Medical Sciences Campus, University of Puerto Rico

Nancy G. Powers, MD, FAAP, FABM

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

United States Breastfeeding Committee

United States Lactation Consultant Association

Wellstart International

References:

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

2. Bolton T, Chow T, Benton P, Olson B. Characteristics associated with longer breastfeeding duration: an analysis of a peer counseling 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:S43-S49.

4. Sheehan D, Watt S, Kruger P, Sword W. The impact of a new universal postpartum program on breastfeeding outcomes. J Hum Lact 2006;22(4):398-408.

5. WHO/UNICEF. Protecting, promoting and supporting breast-feeding: The special role of maternity services, WHO, Geneva, 1989. http://www.who.int/nutrition/publications/infantfeeding/9241561300/en/index.html (Last accessed June 3, 2011)

6. AAP Ten Step endorsement, August 2009. www.aap.org/breastfeeding/files/pdf/TenStepswosig.pdf (Last 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 intention to exclusively breastfeed. Am J Public Health 2009;99(5):929-935.

8. Cramton R, Zain-Ul-Abideen M, Whalen B. Optimizing 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 supplementation of breast- feeding. Pediatrics 1991; 88:745-750.

11. Ferber S, Makhoul I. The effect of skin-to-skin contact shortly after birth on the neurobehavioral response of the newborn: a randomized control trial. Pediatrics 2004;113:858-865.

12. Entwistle F, Kendall S, Mead M. Breastfeeding support - the importance of self-efficacy for low-income women. Matern Child Nutr 2010;6(3):228-234.

13. Academy of Breastfeeding Medicine Protocol Committee. ABM Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2009. Breastfeeding Medicine 2009;4(3):175-182.

14. Human Milk Banking Association of North America. http://www.hmbana.org/ (Last 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:S3-S7.

17. Brandtzaeg P. The mucosalommune system and its integration with the mammary glands. J Pediatr 2010;156: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. Laberere J, Gelbert-Baudino N, Avral A et al. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics 2005;115(2):e139-146.

20. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. 2007 Feb;109(2 Pt 1):479-480. http://www.acog.org/departments/underserved/clinicalReviewv12i1s.pdf (Last accessed June 3, 2011)

21. Labbok M, Taylor E. Achieving Exclusive Breastfeeding in the United States: Findings and Recommendations. Washington, DC: United States Breastfeeding Committee; 2008. http://www.usbreastfeeding.org/AboutUs/PublicationsPositionStatements/tabid/70/Default.aspx (Last accessed 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. Pediatrics 2011;127:e1414-e1427.

23. The Joint Commission: Perinatal Care. http://www.jointcommission.org/perinatal_care/ (Last 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 Protocol Committee. ABM Clinical Protocol #2 (2007 Revision): Guidelines for the hospital discharge of the breastfeeding term newborn and mother: The "going home" protocol. Breastfeeding Medicine 2007;2(3):158-165.

26. The Academy of Breastfeeding Medicine. Educational objectives and skills for the physician with respect to breastfeeding. Breastfeeding Medicine 2001;6(2):99-105.

27. The Surgeon General's Call to Action to Support Breastfeeding 2011. http://www.surgeongeneral.gov/ (Last accessed June 3, 2011)

28. American Academy of Family Practice. Family Physicians Supporting Breastfeeding, (Position Paper) 2011. http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html (Last accessed June 3, 2011)

29. American Public Health Association. A Call to Action on Breastfeeding: A Fundamental Public Health Issue. 2007. http://www.apha.org/advocacy/policy/policysearch/default.htm?NRMODE=Published&NRNODEGUID=%7b40FCA601 -747E-4190-936B- BBB2DB8CDD36%7d&NRORIGINALURL=%2fadvocacy%2fpolicy%2fpolicysearch%2fdefault.htm%3fid%3d1360&NRCACHEHINT=NoModifyGuest&id=1360&PF=true (Last accessed June 3, 2011)

30. The Centers for Disease Control and Prevention. The CDC Guide to Breastfeeding Interventions. 2009. http://www.cdc.gov/breastfeeding/resources/guide.htm (Last accessed June 3, 2011)

31. Healthy People 2020 Objectives. http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf (Last accessed June 3 2011)

32. WHO/UNICEF. Baby-friendly Hospital Initiative. 2009 http://www.who.int/nutrition/publications/infantfeeding/bfhi_trainingcourse/en/index.html (Last accessed June 3, 2011)

Conflict of Interest:

None declared

The authors of Regulatory Monitoring of Feeding During the Birth Hospitalization make a common error in their assumptions about the use of an indicator. A monitoring indicator is not a policy, an intervention, or a behavior. The usefulness of any indicator depends 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, the authors then go even further out on a limb to speculate that discouraging the use of formula harms breastfeeding. By logical extension 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 over 5,000 mothers and babies that I have worked with in Manhattan. Many hospital policies involve interruptions that make it difficult for mothers and babies to feed optimally. Over 90% of the mothers I have worked with were told that while breastfeeding is best, but that their babies needed formula in the hospital. More than half of these mothers were not told that they could and should express milk for their babies 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, mastitis which then compromises the milk supply. In order 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 fortune to have appropriate assistance end up with an adequate milk supply and are able to return to normal feeding 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 sufficient to justify eliminating an indicator that may, in conjunction with a serious and thoughtful look at infant feeding practices, yield better policies than the current "breastfeeding is best, but formula is just as good" environment. The latter patronizes mothers on many levels.

Conflict of Interest:

None declared