More on Breastfeeding

It’s been a big week for breastfeeding.  To start, it’s official:

I’m a Certified Lactation Counselor!I couldn’t have been more excited to get that envelope in the mail.

This week was also La Leche League meeting week on Nantucket, which is so much fun.  There’s such a great group of mamas here, and our leader, Sunny, is phenomenal.  I love going to meetings and being able to talk things through with other mamas; yes, we talk about breastfeeding (yesterday’s topic was the advantages of breastfeeding), but it’s also a forum for talking about nighttime parenting (sleeping or not), food introduction, baby’s health, gentle discipline, parenting strategies, and relationships with partners and extended families.  We have a lot of toddler (over a year) nursers here who keep coming to meetings despite having gone through the topic series already, which says a lot about what else the meetings offer.

Yesterday was also the day Surgeon General Regina M. Benjamin released The Surgeon General’s Call to Action to Support Breastfeeding at George Washington University.   There was a live webcast of the presentation and a stakeholders phone call (which I listened in on).  The call to action is an important step in helping mothers who want to breastfeed to be successful in doing so.   Three out of four mothers (75%) in the U.S. start out breastfeeding, according to the Centers for Disease Control and Prevention’s 2010 Breastfeeding Report Card, but at the end of six months, breastfeeding rates fall to 43%, and only 13% of babies are exclusively breastfed.  Among African-American babies, the rates are significantly lower, 58% start out breastfeeding, and 28% breastfeed at six months, with only 8% exclusively breastfed at six months (there’s a great blog, Blacktating, that focuses on this issue). The Healthy People 2020 objectives for breastfeeding are: 82% ever breastfed, 61% at 6 months, and 34% at 1 year.

I’m proud to say that Nora is still nursing at 16 months, and nowhere near stopping — which actually works out well for me when she wants to be held or cuddled, but I need to do something else important like make dinner:

Now that’s multitasking!

The call to action states that, “The success rate among mothers who want to breastfeed can be greatly improved through active support from their families, friends, communities, clinicians, health care leaders, employers and policymakers.  Given the importance of breastfeeding for the health and well-being of mothers and children, it is critical that we take action across the country to support breastfeeding.”  And provided 20 action steps based on the idea that everyone can help make breastfeeding easier:

Actions for Mothers and Their Families:
1. Give mothers the support they need to breastfeed their babies.
2. Develop programs to educate fathers and grandmothers about breastfeeding.

Actions for Communities:
3. Strengthen programs that provide mother-to-mother support and peer counseling.
4. Use community-based organizations to promote and support breastfeeding.
5. Create a national campaign to promote breastfeeding.
6. Ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding.

Actions for Health Care:
7. Ensure that maternity care practices around the United States are fully supportive of breastfeeding.
8. Develop systems to guarantee continuity of skilled support for lactation between hospitals and health care settings in the community.
9. Provide education and training in breastfeeding for all health professionals who care for women and children.
10. Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians.
11. Ensure access to services provided by International Board Certified Lactation Consultants.
12. Identify and address obstacles to greater availability of safe banked donor milk for fragile infants.

Actions for Employment:
13. Work toward establishing paid maternity leave for all employed mothers.
14. Ensure that employers establish and maintain comprehensive, high-quality lactation support programs for their employees.
15. Expand the use of programs in the workplace that allow lactating mothers to have direct access to their babies.
16. Ensure that all child care providers accommodate the needs of breastfeeding mothers and infants.

Actions for Research and Surveillance:
17. Increase funding of high-quality research on breastfeeding.
18. Strengthen existing capacity and develop future capacity for conducting research on breastfeeding.
19. Develop a national monitoring system to improve the tracking of breastfeeding rates as well as the policies and environmental factors that affect breastfeeding.

Action for Public Health Infrastructure:
20. Improve national leadership on the promotion and support of breastfeeding.

The full report can be found here.

And there was plenty of other news worldwide.  Positive stories like the fact that the first available photo of Miranda Kerr’s and Orlando Bloom’s baby, Flynn, was of him nursing.  He was, by the way, born naturally, too.  Ms. Kerr wrote on her blog, “He weighed 9lb 12 ounces (a very healthy and big baby boy). I gave birth to him naturally; without any pain medication and it was a long, arduous and difficult labour, but Orlando was with me the whole time supporting and guiding me through it.”

Photos of and stories about celebrities breastfeeding help in a big way to normalize it in our society.  Though I doubt Ms. Kerr reads my blog, I’d like to thank her for putting that photo out there — she’s showing the world how beautiful it is to mother naturally.

The other big news of last and this week was a British Medical Journal (BMJ) article, which calls into question the UK’s (and WHO’s) recommendation to delay introduction of solids until 6 months.  This report isn’t necessary detrimental to breastfeeding research, but the news articles that stemmed from it certainly were.  This week, I learned a big lesson in the unreliability of journalists.  Titles like Is breast milk really the best option? (on the BBC, no less!), Study Suggests Exclusive Breastfeeding Leads to Infant Health Problems, and In Breastfeeding, What’s Best? Editorial Questions Guidelines on How Long Moms Should Breastfeed (ABC),  present more misleading information than actually represent what the BMJ article is about.  This is irresponsible journalism at its worst.  Controversial headlines to attract attention and a complete misreading of the BMJ article, leaving out many pertinent facts.  This Washintong Post blog piece was a little better, but still provided a shallow read of the article.

Being the fact-oriented person that I am, I had to seek out and read the actual BMJ article.  Immediately, problems popped out at me with the article itself and the news reports that stemmed from it.  Despite what some reports may have said, the researchers did not question the benefits of breastfeeding at all.  In fact, they specifically state that breast is best.  Essentially, the article is a literature review of research (there’s no new research here) that questions whether existing guidelines to delay the introduction of solid foods until 6 months is best.  The study agrees that there are huge benefits to breastfeeding exclusively, including a significantly reduced risk of gastroenteritis.  It does call into question evidence challenging the adequacy of breast milk as a reliable sole source of nutrition to six months, suggesting that 4-6 months may be a more appropriate timing of the introduction of foods, because of concerns that exclusive breastfeeding during that two month window may lead to “higher risk of iron deficiency anaemia (identified in data from the developing and developed worlds) known to be linked to irreversible adverse mental, motor, and psychosocial outcomes. The lack of a screening programme in the United Kingdom to detect such adverse population effects is a further concern. And, concerns over a higher incidence of food allergies, including higher risk of coeliac disease, with concomitant long term complications.”

I’m not convinced after reading the article that early introduction of solids is the way to go in addressing these concerns.  In discussing the risk of anemia, the researchers stated that

Such risks might be reduced by improving iron status in pregnancy, delaying umbilical cord clamping, and supplementing infants at risk (for example, those with low birth weight). However, any residual adverse effects on suboptimal iron status of six months’ exclusive breast feeding are likely to be missed in the United Kingdom, which has no screening policy for iron deficiency.

Wouldn’t it seem better to first address the lack of screening in the UK, the iron status of pregnant women, and the propensity of doctors to quickly clamp and cut umbilical cords before stating that exclusive breastfeeding is the problem?  And, if all of that is corrected and there still seems to be a problem for some babies, why not just supplement with iron?  The WHO definition of exclusive breastfeeding allows for infants to be given medication, vitamins, and minerals and still be considered exclusive.  Why the need to introduce food?  It seems especially silly considering current recommendations to get the white (read: iron-fortified cereal) out of baby’s first foods.

Similarly, the potential risk for allergies also has several compounding factors.  Babies who are not birthed vaginally, for example, have an increased risk of developing allergies.  That’s 1/3 of the babies in the US.  I’m sure there are many other factors which could lead to food allergies and it seems inappropriate to make a policy change without further study.  Even the articles authors stated that there isn’t enough evidence that the 6 month recommendation is wrong, and suggested that further study is needed.

As a side note, the literature review mentioned “relatively unexplored concerns about the potential for prolonged exclusive breast feeding to reduce the window for introducing new tastes.”  But seeing as there is evidence that the flavor of breastmilk varies depending upon the food mom eats, I can’t see how breastmilk would be more likely to create picky eaters in comparison to formula which has a static flavor.  And, anecdotally, we waited until 6 months to introduce foodsand though she wasn’t too keen on them the first day, Nora quickly started to like all kinds of fruits and vegetables, including bitter greens (like kale) that were specifically mentioned in the the review.

With all these things popping out at me, I can’t support a change in policy.  (And neither can the WHO, who issued a statement reaffirming the importance of exclusivity until 6 months.)

In fact, the researchers themselves presented several other pieces of evidence FOR the delayed introduction of foods:

In a Danish birth cohort, earlier introduction of solids was associated with late emergence of a higher risk of overweight at 42 years.  […] Four observational studies in developed countries have provided further evidence on exclusive breast feeding and risk of infection:

• Questionnaire based data from the National Health and Nutrition Examination Survey III (NHANES III) cohort showed that US infants who were exclusively breast fed for more than six months had lower risk of pneumonia and recurrent otitis media than those breast fed for four to six months.
• A Spanish study found risk of hospital admission for all infant infections was decreased with longer exclusive breast feeding.
• A German study found infants exclusively breast fed for six months, compared with less than four months, had less gastroenteritis.
• The large representative UK Millennium cohort study suggested 53% of admissions for gastroenteritis and 27% of those for chest infection could be prevented each month by exclusive breast feeding.

The article stated in its conclusion

It can be argued that, from a biological perspective, the point when breast milk ceases to be an adequate sole source of nutrition would not be expected to be fixed, but to vary according to the infant’s size, activity, growth rate, and sex, and the quality and volume of the breast milk supply. Signalling of hunger by the infant is probably an evolved mechanism that individualises timing of weaning for a mother-infant pair.

Which I think is fair.  But, I also think that infants needing early solids are the exception, not the norm. And the other thing which cemented my skepticism of the article was buried in a footnote and not mentioned in any of the news reports:

MF, AL, and DCW [3 of the 4 authors] have performed consultancy work and/or received research funding from companies manufacturing infant formulas and baby foods within the past 3 years.

That’s a pretty big conflict of interest if you ask me.