pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

Breastfeeding – Recent Findings and Recommendations

Trying to catch up on all the recent research findings about infant nutrition, specifically breastfeeding, we’ve already described a fair number of new findings. We’ll conclude today with a fairly comprehensive listing of new recommendations.

Mother breastfeeding her infant
More benefits, in fact, than even those of us who completed our residency training merely 10 years ago had any idea about – yes, the research is that startling and that recent.

In the previous article in the series we went through many individual research studies and their findings. I’ve placed them into a table below and there are two additional benefits that I’ll describe.

Breastfeeding Benefits

Research Proven Benefits

Dose-Response Benefits of Breastfeeding

Condition % Lower Risk Breastfeeding Comments

Otitis media

23

Any

Otitis media

50

≥3 or 6 mo

Exclusive BF

Recurrent otitis media

77

Exclusive BF ≥6 mo

Compared with BF 4 to <6 mo

Upper respiratory tract infection

63

>6 mo

Exclusive BF

Lower respiratory tract infection

72

≥4 mo

Exclusive BF

Lower respiratory tract infection

77

Exclusive BF ≥6 mo

Compared with BF 4 to <6 mo

Asthma

40

≥3 mo

Atopic family history

RSV bronchiolitis

74

>4 mo

Atopic dermatitis

27

>3 mo Exclusive BF

negative family history

Atopic dermatitis

42

>3 mo Exclusive BF

positive family history

Gastroenteritis

64

Any

Inflammatory bowel disease

31

Any

Obesity

24

Any

Celiac disease

52

>2 mo

Gluten exposure when BF

Type 1 diabetes

30

>3 mo

Exclusive BF

Type 2 diabetes

40

Any

Leukemia (ALL)

20

>6 mo

Leukemia (AML)

15

>6 mo

SIDS

36

>1 mo

All of these studies were done at different times, on different sets of babies by different sets of researchers. Taken together, they display a formidable body of evidence that “breast is best.” It’s not just a cutsey catch-phrase any more.

Notice that in some cases the length of time a baby is breastfed makes a significant difference; moreover, even certain solid foods are shown to be less problematic when instituted while on human milk rather than formula. Go figure!

Maternal Benefits

Infant breastfeedingInfant breastfeeding

Ok, now to answer the “but what’s in it for me” question lets take a look at what the recent studies show about the effects of breastfeeding on the mothers. Remember, just like the studies we’ve described previously, these studies don’t usually try to explain “WHY” but merely show whether or not there is any correlation between two events which is statistically greater than mere chance.

Here’s what the research shows:

  • Breastfeeding mothers have decreased postpartum blood loss
  • The uterus in Breastfeeding mothers involutes back to normal more rapidly
  • Continued breastfeeding leads to increased “child spacing” – due to lactational amenorrhea
  • Increased postpartum depression is noted in mothers who do not breastfeed or who wean early
  • An increased level of abuse and neglect was found by a huge study in non-breastfeeding mothers. [Most likely a “marker” rather than a causative relationship]
  • For every year of breastfeeding there is a 4 – 12% decrease in the risk of developing type 2 diabetes [in women without gestational diabetes]
  • Women breastfeeding longer than 6 months are 1.38 kg lighter than those who do not (14,000 women)
  • Cumulative lactation history of 12-23 months gives significant reduction in hypertension, hyperlipidemia, cardiovascular disease and diabetes [139,000 postmenopausal women]
  • Cumulative breastfeeding >12 mos gives less risk of rheumatoid arthritis, >24 mos even less risk
  • Each year of breastfeeding is calculated to give a 4.3% reduction in breast cancer
  • Longer than 12 months breastfeeding is correlated with 28% less breast and ovarian cancer

Economic Benefits

Looking over the lists I’ve given, you can calculate for yourselves areas of economic savings in your own family. On a national scale the savings are enormous.

And believe it or not, that is an exercise the “calculators” over at the AHRQ (Agency for Healthcare Research and Quality – US Dept of Health and Human Services) have actually done – in minute detail.

Their findings: “If 90% of US mothers would comply with the recommendation to breastfeed exclusively for 6 months, there would be a savings of $13 billion per year.”

I don’t know who is actually paying those dollars but, consulting Wolfram Alpha, that’s $3,060 for every child born in the US every year. Seems like, whoever they are, they’d be ahead if they paid women to breastfeed.

Additionally, the bean-counters are quick to disclaim: That does NOT even include “savings related to a reduction in parental absenteeism from work or adult deaths from diseases acquired in childhood, such as asthma, type 1 diabetes mellitus, or obesity-related conditions.”

Current Recommendations

So, let’s take a look at what the experts actually recommend.

Duration of Exclusive Breastfeeding

The American Academy of Pediatrics (AAP) recommends: “Exclusive breastfeeding for about 6 months, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.” [Concurred by the WHO and Institute of Medicine]

The rationale for that much of a pronouncement comes from all the things we’ve already talked about including the “protection” from the intestinal, ear, respiratory and allergic diseases. Also the benefits to the mother.

The AAP is the organization who most recognizes life’s many complications, so also extends their statement: “… for some infants, because of family and medical history, individual developmental status, and/or social and cultural dynamics, complementary feeding, including gluten-containing grains, begins earlier than 6 months of age. Because breastfeeding is immunoprotective, when such complementary foods are introduced, it is advised that this be done while the infant is feeding only breast milk. Mothers should be encouraged to continue breastfeeding through the first year and beyond as more and varied complementary foods are introduced.”

Contraindications to Breastfeeding

bottle feeding breast milk in a pinchBottle feeding breast milk in a pinch

Compared with all the diseases there are in the world, the number which prevent breastfeeding is very small. Galactosemia (inherited metabolic disease), phenylketonuria, human T-cell lymphotrophic virus type I or II84, untreated brucellosis, active HIV, active untreated tuberculosis, active H1N1 Influenza or active herpes simplex come to mind.

Even most of these have “work-arounds” like expressing milk to place in a bottle, or alternating with other modified feedings. In others, breastfeeding can resume following or within treatment or resolution of the disease.

In the industrialized world we don’t recommend HIV-positive mothers breastfeed. HOWEVER, in the developing world infant mortality is so increased in non-breastfed infants due to a combination of factors that it may make breastfeeding (even with HIV) less of a risk. Recent studies document that combining exclusive breastfeeding for 6 months with 6 months of antiretroviral therapy significantly decreases the postnatal acquisition of HIV-1.

A mother being seropositive for cytomegalovirus (CMV) may still breastfeed even a low-birthweight infant although the infant may warrant antiviral therapy. Pasteurization kills CMV virus but destroys bioactive factors so isn’t used.

Maternal substance abuse needs individual consideration based on type of drug and other maternal factors. Many street drugs (including marijuana) are detected in human milk and may harm the infants long-term neurobehavioral development.

Alcohol does not help milk production but does negatively affect infant motor development. So, while not an absolute contraindication to breastfeeding, alcohol consumption must be minimized. Nursing (or pumping) must be done at least 2 hours after alcohol ingestion.

The minimum dose of alcohol which will cause harm to the infant isn’t known for sure (it may be lower than this); but, intake cannot be regular (i.e. occasional only) and less than 0.5 gram alcohol per kilogram of mothers body weight. That amount would mean a 130 pound mother should limit to 2 oz liquor, 8 oz wine, or 2 beers in any 24 hour period.

Besides reducing a mothers milk supply and causing poor weight gain in the baby, maternal smoking is associated with increased respiratory allergy and SIDS. Smoking should not occur in the presence of the infant so as to minimize the negative effect of secondary passive smoke inhalation.

Maternal Diet

Although some clinicians recommend continuing prenatal vitamin supplements during lactation there is really no evidence that the extra 450 to 500 kcal/day required for the mother couldn’t easily be made by a modest increase in her normally balanced, varied diet.

Breastfeeding maternal diet contains fishBreastfeeding maternal diet contains fish

We know that breastfeeding does require an average daily intake of about 300mg of the ω-3 long-chain polyunsaturated fatty acids (docosahexaenoic acid [DHA]) in order for it to get into the milk. That is easily obtained by 1-2 portions of herring, tuna or salmon per week. Avoid pike, marlin, mackerel, tile fish or swordfish, you know the predatory fish, if you feel concerned about mercury.

Poorly nourished mothers or vegans should take DHA and multivitamin supplements.

Maternal Medications

I really don’t know how to write about this and still keep it under 100 pages. Suffice to say that a lot of medications cross into the breast milk but only a few of them cause any difficulty in the infant and for most that will cause problems there are alternative approaches to therapy.

Very few medications that the mother will take will completely prohibit breastfeeding. Your pediatrician is your best advocate in this. Call or visit him before taking any medication to be safe and to find alternatives.

Some x-ray diagnostic procedures may require temporary cessation of breastfeeding and some conditions of the infant may require that the mother avoid certain types of food. Another resource for information is LactMed from the National Library of Medicine and Institutes of Health.

For Preterm Infants

The benefits of human milk are so great that all preterm infants should receive human milk, fresh or frozen, even if pasteurized donor milk is necessary. It should be fortified appropriately if the infant weighs less than 1.5 kg.; if needed mother’s own milk can be stored at refrigerator temperature (4°C) in the NICU for as long as 96 hours.

There are other guidelines which concern hospitals and involve quality assurance protocols.

For Hospitals

Several sets of guidelines have been written for hospitals because studies show that a large portion of US hospitals don’t yet fully follow quality protocols. Less than 65% have implemented the WHO/UNICEF “Ten Steps” program for breastfeeding involving practices like: rooming in, breastfeeding in first hour, delaying labs and injections until breastfed, no pacifiers etc..

This is a HUGE change for some hospitals. For some, “rooming-in” was just an “advertising gimmick” not facilitated by nursing routines and hospital policies. Fifty-eight percent limited suckling time, 41% routinely used pacifiers, 30% routinely supplemented with infant formula and 66% included formulas in “discharge packs.”

Less than 25% supported breastfeeding mothers after discharge. Only 37% supported more than 5 of the 10 steps and only 3.5% nine or more.

Breastfeeding should begin within the first hour of life (including c-sections); infants should have continuous accessibility to the mother; staff training should be continuous and address unsubstantiated myths; use of formulas, other liquids and pacifiers should be medically indicated and not customary.

You should know that the “Ten Steps” program has demonstrated such clear benefit that it has been endorsed by a whole host of other organizations. The AAP endorses it fully, albeit with an asterisk by the pacifiers as explained below.

For Term Infants

We’ve talked extensively about preterm infants, here are the full guidelines for term infants:

Recommendations: Breastfeeding of Healthy Term Infants

  1. Exclusive breastfeeding for about 6 mo
    • Breastfeeding preferred; alternatively expressed mother’s milk, or donor milk
    • To continue for at least the first year and beyond for as long as mutually desired by mother and child
    • Complementary foods rich in iron and other micronutrients should be introduced at about 6 mo of age
  2. Peripartum policies and practices that optimize breastfeeding initiation and maintenance should be compatible with the AAP and Academy of Breastfeeding Medicine Model Hospital Policy and include the following:
    • Direct skin-to-skin contact with mothers immediately after delivery until the first feeding is accomplished and encouraged throughout the postpartum period
    • Delay in routine procedures (weighing, measuring, bathing, blood tests, vaccines, and eye prophylaxis) until after the first feeding is completed
    • Delay in administration of intramuscular vitamin K until after the first feeding is completed but within 6 h of birth
    • Ensure 8 to 12 feedings at the breast every 24 h
    • Ensure formal evaluation and documentation of breastfeeding by trained caregivers (including position, latch, milk transfer, examination) at least for each nursing shift
    • Give no supplements (water, glucose water, commercial infant formula, or other fluids) to breastfeeding newborn infants unless medically indicated using standard evidence-based guidelines for the management of hyperbilirubinemia and hypoglycemia
    • Avoid routine pacifier use in the postpartum period*
    • Begin daily oral vitamin D drops (400 IU) at hospital discharge
  3. All breastfeeding newborn infants should be seen by a pediatrician at 3 to 5 d of age, which is within 48 to 72 h after discharge from the hospital
    • Evaluate hydration (elimination patterns)
    • Evaluate body wt gain (body wt loss no more than 7% from birth and no further wt loss by day 5: assess feeding and consider more frequent follow-up)
    • Discuss maternal/infant issues
    • Observe feeding
  4. Mother and infant should sleep in proximity to each other to facilitate breastfeeding
  5. Pacifier should be offered, while placing infant in back-to-sleep-position, no earlier than 3 to 4 wk of age and after breastfeeding has been established

Pacifier Use

Looking at babies as a whole (and not any one in particular) pacifier use is definitely associated with less successful breastfeeding so it’s tempting to issue a blanket ban on the things.

However, they are also useful for pain relief, as a calming agent or as part of structured program for enhancing oral motor function; and they’ve been associated with a reduction of SIDS incidence to boot!

Back to sleep position with pacifier

The AAP recommends: Pacifier use in the hospital in the neonatal period should be limited to specific medical indications (such as pain reduction and calming in a drug-exposed infant.) Mothers of healthy term breastfed infants should be instructed to delay pacifier use until breastfeeding is well-established, usually about 3 to 4 wk after birth. After that, mothers of healthy term infants should be instructed to use pacifiers at infant nap or sleep time.

Vitamins and Supplements

Hemorrhagic Disease of the Newborn is still real even though our routine practice has been to prevent it on all babies by an injection of vitamin K1 (not oral) on the first day of life. This is usually done immediately after birth but can (ought to be) delayed until after the first feeding at the breast; BUT not later than 6 hours of age.

Since the original human model was designed there has been a dramatic change in lifestyle and dress and even the use of anti-sun compounds to prevent burning. What that means is an equivalent drop in Vitamin D (the sunshine vitamin). In order to maintain an adequate serum vitamin D concentration, all breastfed infants routinely should receive an oral supplement of vitamin D, 400 U per day, beginning at hospital discharge.

Fluoride, Iron and Zinc are also dietary issues for infants. To protect the developing dentition (even before eruption) an infant needs adequate fluoride. However, supplementary fluoride should not be provided during the first 6 months. From age 6 months to 3 years, fluoride supplementation should be limited to infants residing in communities where the fluoride concentration in the water is <0.3 ppm. Complementary food rich in iron and zinc should be introduced at about 6 months of age. Supplementation of oral iron drops before 6 months may be needed to support iron stores – your pediatrician will test for that at routine well child visits.

Premature infants should receive both a multivitamin preparation and an oral iron supplement until they are ingesting a completely mixed diet and their growth and hematologic status are normalized.

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