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Baby-Friendly Provider Presentation

An introduction and skills building presentation for providers about the Baby-Friendly Hospital Initiative

Lissa Knudsen

on 17 October 2013

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Transcript of Baby-Friendly Provider Presentation

What Does That Mean To Me?

1. Understand the relationship between infant feeding and infant and maternal health outcomes.

2. Become familiar with the Baby Friendly Hospital Initiative (BFHI).

3. Become familiar with the evidence behind the Ten Steps to Successful Breastfeeding.

4. Appreciate the importance of the practitioner/hospital role in breastfeeding success.
Questions to Keep In Mind
What are some strengths I see in my hospital or clinic that will aid in implementing Baby Friendly or supporting breastfeeding?

What are some barriers I see in my hospital or clinic that might hinder implementation of Baby Friendly?

How can our clinic/unit help to send a positive message about breastfeeding?

What are some of my concerns, or concerns I have heard or imagine others might have, about Baby Friendly or breastfeeding in general?

Which barriers/concerns should I or my work place address first and how?
Emilie Sebesta, MD,
Associate Professor, Pediatrics, UNM
Provider & Staff Presentation
First Step Center, Las Cruces, NM
July 31, 2013

If every baby were exclusively breastfed for 6 months, an estimated 1.5 million lives world-wide would be saved each year.
In the U.S. alone if 90% of babies were exclusively breastfed for 6 months, an estimated 911 lives and
$13 billion
would be saved each year.
Additional Risks Associated with
Formula Feeding
The Surgeon General's Call to Action to Support Breastfeeding, 2011 US Department of Health and Human Services, pg 2, Table 1
Recent Evidence
Meta-Analysis reviewing formula feeding & risk of SIDS (18 studies meeting strict eligibility criteria)

Any formula feeding: Risk of SIDS increased
Exclusive formula feeding resulted in largest increase in risk
Exploring Perinatal Outcomes among Children

Retrospective cohort study of 6-13 yo exposed to diabetes in utero (89) and unexposed (379) who were adequately breastfed or not.

Exposed & unexposed children BF >/= 6 months had
waist circumference, and
subcutaneous adipose tissue
Hauck, et al, “Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis,” Pediatrics 2011;128;103; http://pediatrics.aappublications.org/content/128/1/103.full.html.
Crume, TL, et al, “Long-Term Impact of Neonatal Breastfeeding in Childhood Adiposity and Fat Distribution Among Children Exposed to Diabetes in Utero,” Diabetes Care March 2011;34:3;641-645.
Western Australian Pregnancy
Cohort Study

Compared academic scores of 1038 ten year olds who were “predominantly” breastfed for 6 months vs. those who were breastfed for a shorter period or not at all.
Breastfed boys scored significantly higher in mathematics, reading, and spelling.
No significant effect seen in girls.
Oddy, et al, “Breastfeeding Duration and Academic Achievement at 10 Years,” Pediatrics 2011;127;127;e137; http://pediatrics.aappublications.org/content/127/1/e137.full.html
More Intelligence Effects
Promotion of Breastfeeding Intervention Trial (PROBIT)

Randomized 31 maternity hospitals/prenatal clinics to Baby Friendly intervention vs. usual care.

F/U of 13,889 children at age 6.5 years

Those born at Baby Friendly hospitals had significantly
higher verbal IQ
scores and significantly
higher reading and writing abilities.
Kramer, M.S., “’Breast is Best’: The Evidence,” Early Human Development 86 (2010) 729-732
U.S. case-control study compared 828 parous women with ovarian cancer to 1006 parous controls.

Women who breastfed all their children or their last born child had a significantly reduced risk of ovarian cancer.
0.58 (95% CI 0.37-0.91) breastfed some of children, including last born child
0.72 (95% CI 0.58-0.91) breastfed all children
0.91 (95% CI 0.66-1.26) breastfed some of children, but not last born child
Ovarian Cancer
Titus-Ernstoff, et al, “Breast-feeding the Last Born Child and Risk of Ovarian Cancer,” Cancer Causes Control (2010) 21:201-207.
Breast Cancer
Oddy, et al, “Breastfeeding Duration and Academic Achievement at 10 Years,” Pediatrics 2011;127;127;e137; http://pediatrics.aappublications.org/content/127/1/e137.full.html
Indian multicenter case-control study, 1866 cases and 1873 controls (pre- and postmenopausal)

Risk of breast cancer decreased with duration of BF
2 yrs OR 0.65 (0.41-0.95)
3 yrs OR 0.62 (0.41-0.95)
4 yrs OR 0.53 (0.35-0.80)
5 yrs OR 0.56 (0.37-0.87)
6 yrs OR 0.40 (0.25-0.64)
7+ yrs OR 0.37 (0.24-0.58)

Risk of breast cancer decreased with number of children BF
2 OR 0.74 (0.55-0.99)
3 OR 0.56 (0.40-0.78)
4 OR 0.46 (0.29-0.73)
5+ OR 0.31 (0.16-0.59)
Maternal Depression
2011 study of 6410 women via an online survey found breastfeeding mothers reported:
more sleep (6.6 hours vs. 6.4 (mixed) and 6.3 (formula)
more daily energy
better overall physical health
less depressed mood
less anhedonia

Researchers “concluded that supplementing or weaning actually decreases women’s total sleep time, lowers their sense of well-being, and increases their risk of depression.”
Kendall-Tackett, K., Cong, Z., Hale, T.W., “The Effect of Feeding Method on Sleep Duration, Maternal Well-Being, and Postpartum Depression,” Clinical Lactation, Vol. 2-2, 2011.
Maternal CVD
2009 study using data from 139,681 postmenopausal women (median age 63 years) enrolled in the Women's Health Initiative found that:

Women who breastfed for more than 12 months, versus parous women who never breastfed, were less likely to have
hypertension (OR=0.88, p<0.001),
diabetes (OR= 0.80, p<0.001),
hyperlipidemia (OR=0.81, p<0.001)
cardiovascular disease (OR= 0.91, p=0.008)

Breastfeeding did not reduce a woman’s risk of becoming obese
Schwarz, E.B., et al., Duration of Lactation and Risk Factors for Maternal Cardiovascular Disease, Obstet Gynecol. 2009 May; 113(5): 974–982.
What is the Baby-Friendly™ Hospital Initiative?
The Baby-Friendly Hospital Initiative (BFHI) is a global program sponsored by the WHO and UNICEF to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding.
Step One: Have a written breastfeeding policy that is
routinely communicated
to all health care staff.
Step Two: Train all health care staff in skills necessary to implement the policy.
Training Requirements:
20 hours initially
2 hours every 2 years thereafter

3 hours initially
2 hours every 2 years thereafter
Step Three: Inform all pregnant women about the benefits and management of breastfeeding.
"You can do it."
"This is normal."
"We can help."
Anticipatory guidance
Involve partners
Early emphasis and support
Lay the ground work
Open-ended inquiry targeted teaching
Promote Early and Often
Prenatal Questions Strategy
Patients should receive at least three contacts about breastfeeding throughout gestation

1st trimester - provide written materials, ask open ended questions and affirm answers
2nd trimester - follow up on previous conversation
3rd trimester - what to expect the first few days and work toward verbal commitment
Step Four: Help mothers initiate breastfeeding within one hour of birth.
Step Five: Show mothers how to breastfeed and maintain lactation, even if they are separated from their infants.
Step Six: Give newborn infants no food or drink other than breastmilk, unless medically indicated
Hospitals must adhere to the
WHO International Code of Marketing of Breast-milk Substitutes
, which prohibits advertising or promoting formula, including accepting free or discounted formula.
Provider order
for supplementation with formula for medical reason

If a breastfeeding mother requests formula,
nurse or provider inquires about the reason and educates her regarding this concern and effect supplementation may have on breastfeeding

Reason and education documented in chart
Step Seven: Practice "rooming in" - allow mothers and infants to remain together 24 hours a day.
Effort to limit mother-baby separation to no more than 1 hour every 24 hours
“Formula feeding not only failed to improve parent sleep, but actually resulted in parents getting less sleep, even when fathers helped during the night with supplementation feedings.”

“[M]aintenance of breast-feeding as well as deep restorative sleep stages may be greatly compromised for new mothers who cope with infant feedings by supplementing in an effort to get more sleep time.”
Prolactin is secreted at night and is associated with promoting deep sleep stages. This may explain ability of breastfeeding moms to return to sleep more quickly and obtain more sleep time.
133 couples with 3 month old babies
89 exclusively breastfed
44 formula supplementation

Exclusive breastfeeders slept 40 minutes longer

Mothers who shared responsibility for nighttime feeding slept 54 minutes less than mothers who had sole responsibility for nighttime feeding
2002 study compared breastfeeding women (10), controls without young children, (10), and bottle feeding women (7).

Total sleep time and rapid eye movement (REM) sleep time were similar in all 3 groups

Breastfeeding women demonstrated a marked increase in slow wave (deep) sleep
slow-wave sleep (SWS) is deep, restorative sleep and also plays a significant role in declarative memory by processing and consolidating newly acquired information. http://healthysleep.med.harvard.edu/healthy/matters/benefits-of-sleep/learning-memory

Breastfeeding women: 182 ± 41 min
Controls: 86 ± 22 min ( P < 0.001 compared with B/F)
Bottle feeding women: 63 ± 29 min (P < 0.001 compared with B/F)
More Maternal Sleep Research
Blyton, D.M., Sullivan, C.E., Edwards, N, Lactation is associated with an increase in slow-wave sleep in women, Journal of Sleep Research, Vol. 11:4, pp 297-303, December 2002.
1988 study compared mothers who roomed in with their newborns and mothers who did not room in with their newborns

Mothers did not sleep longer or better when their infants were returned to the nursery during the night.
Keefe, M.R., The Impact of Infant Rooming-In on Maternal Sleep at Night, J Obstet Gynecol Neonatal Nurs., 1988 Mar-Apr;17(2):122-6.
Step Eight: Encourage breastfeeding on demand.
Step Nine: Give no pacifiers or artificial nipples until breastfeeding is securely established.
Step Ten: Foster the establishment of breastfeeding support groups [and other community based breastfeeding resources] and refer mothers to them on discharge from the hospital or clinic.
Breastfeeding on demand taught to all breastfeeding mothers (and formula on demand to formula feeding mothers)
No set schedules for feeding!
Pacifiers only for
preterm infants
infants undergoing painful procedure such as circumcision
infants under phototherapy
infants with neonatal abstinence syndrome

Supplementation via finger feeding
Why Baby-Friendly™ Hospital Initiative
in New Mexico?
In 2010 The Joint Commission revised its Perinatal Core measure set to include
exclusive breastfeeding
Infants discharged from the NBICU and infants with true contraindications to breastfeeding will be excluded.

All others are expected to NOT receive

ANY supplementation
Infants born to mothers who do not wish to breastfeed are NOT excluded.
Hospitals with more than 1100 births -

Core Measure as of Jan 2014 (smaller hospitals are expected to follow)
Improve Health
2011 Surgeon General’s Call to Action to Support Breastfeeding
Healthy People 2020 Objectives for Breastfeeding
Cost Containment
Quality Improvement
CDC mPINC scores based on BFHI’s Ten Steps
Why now? Why here?
Impact of hospital and birth center practices on breastfeeding
Hospital maternity practices interfere with breastfeeding

States with low % of maternity practices promoting breastfeeding had low % of children breastfed for 6 months
National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2007
65% facilities advised women to limit duration of suckling (Step 8)
45% gave pacifiers to more than half of all healthy term BF infants (Step 9)
24% gave supplements as a general practice to more than half of all healthy term BF infants (Step 6)
National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2007
Typical Problem Areas
Researchers examined the exposure of 1,000+ women to six of the “Ten Steps” and found

Mothers who experienced
of the steps were nearly
more likely to
discontinue breastfeeding
before 6 weeks
The more steps that mothers experienced, the greater the likelihood of continuation of breastfeeding at and beyond 6 weeks
strongest risk factors
for early breastfeeding termination were
late breastfeeding initiation
In China, after two years of BFHI implementation, exclusive breastfeeding rates doubled in rural areas and increased from 10% to 47% in urban areas.
The Ten Steps
Make a Difference!
Prenatal Education
New Mexico 2012 Data
New Mexico mPINC Scores
Baby-Friendly 4D Pathway
Bacterial Colonization & Immune Development
Breast milk contains over 700 species of bacteria.

Early colonization of the gut is critical.

Differences in bacterial colonization of formula-fed and breast-fed babies lead to changes in the infant’s expression of genes involved in the immune system, and in defense against pathogens.

Human milk oligosaccharides (HMO) both directly and indirectly influence intestinal development by regulating cell proliferation, acting as prebiotics for beneficial bacteria, and modulating immune development.
Cabrera-Rubio, R, et al, "The Human Milk Microbiome Changes Over Lactation and is Shaped by Maternal Weight and Mode of Delivery," Am J Clin Nutr. 2012 Sep;96(3):544-51.

Donovan, et al, (2012). Host-Microbe Interactions in the Neonatal Intestine: Role of Human Milk Oligosaccharides. Advances in Nutrition, Vol 3. p 4505-4555
2007 UCSF study on
Maternal Sleep and Breastfeeding
including a phone call to the patient's home,
opportunity for follow up visit, and
referral to community breastfeeding support
Discharge Care
Contact Us!
Talk with a WIC Breastfeeding Peer Counselor (English or Spanish 1-800-994-9662)
Talk to a La Leche League Leader
Call the Local Breastfeeding Task Force
NEC (Necrotizing Enterocolitis)
Exclusive Human Milk-Based Diet Reduces NEC in ELBW newborns

RCT of extremely low birth weight (500-1250g) premature infants in 11 centers fed exclusively with EBM, donor milk, and human milk-based fortifier vs. infants fed EBM, donor milk, and bovine milk-based fortifier.
Sullivan, S, et al. "An Exclusively Human Milk-Based Diet is Assoicated with a Lower Rate of Necrotizing Enterocolitis than a Diet of Human and Bovine Milk-Based Products," J Pediatr 2010;156:562-7.
NEC by 50% (NNT to prevent 1 case NEC = 10)
Surgical NEC by 90% (NNT to prevent 1 case surgical NEC or death = 8)
Effect thought secondary to avoidance of bovine protein in addition to protective effect of species-specific milk
Hospitals must follow the Ten Steps to Successful Breastfeeding.
Baseline data from CDC National Immunization Survey, 2012 Breastfeeding Report Card, www.cdc.gov/breastfeeding/data/reportcard2.htm.
The Revised 3rd Edition of Wellstart’s Lactation Management Self-Study Modules, Level 1.
Improved maternal “affectionate love/touch” during observed breastfeeding and maternal attachment behavior

Skin-to-Skin infants cried for a shorter length of time

Late preterm infants had better cardio-respiratory stability with early Skin-to-Skin

No adverse effects were found
Skin to Skin
Written material given alone is not effective!
NO commercial discharge bags that contain artificial formula or promotional material should be distributed!
Mothers who receive free formula discharge bags are 39% more likely to supplement within 10 weeks (mPINC, CDC, 2008).

The Center for Disease Control (CDC), The American Academy of Pediatrics (AAP), and The World Health Organization (WHO) all recommend that hospitals discontinue the use of free formula discharge bags.

Distributing free infant formula contradicts American Medical Association (AMA ) policy, yet 48% (15/31) of New Mexico facilities continue to distribute them.
The Surgeon General’s Call to Action to
Support Breastfeeding 2011
Identified barriers to breastfeeding:
Lack of knowledge
Information regarding breastfeeding and formula rarely provided by obstetricians during prenatal visits
Women uncertain what to expect or how to breastfeed
Poor social support (eg hospital/provider, childcare-provider, employer, and family)
Lactation problems, including
Concern insufficient milk supply
Not understanding normal physiology of lactation
Lack of confidence
Return to employment
Action1. Give mothers the support they need to breastfeed their babies.

Action7. Ensure that maternity care practices throughout the U.S. are fully supportive of breastfeeding.
Implement BFHI.

Action 9. Provide education and training in breastfeeding for all health professionals who care for women and children.

Action 10. Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians.
The Surgeon General’s Call to Action
At Boston Medical Center, the nation’s 22nd Baby Friendly hospital, breastfeeding rates rose from 58% to 87%, including an increase among US-born African-American mothers from 34% to 74%.
[Philipp BL et al. 2001. Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US Hospital Setting. Pediatrics 108(3):677-681.]
Largest RCT on effect of Baby Friendly
(17,046 term breastfed infants)
Rates of exclusive breastfeeding at 3 months:

43.3% in Baby Friendly hospitals/clinics

6.4% in control hospitals/clinics
Kramer, M.S., “Breast is Best”: The Evidence, Early Human Development 86 (2010) 729-732.
In Nicaragua, breastfeeding rates have increased from 47% prior to implementation of the BFHI to nearly 100% in 1999
Baby-Friendly In the Clinic Setting
Counsel mothers on breastfeeding during prenatal and postnatal visits.
Provide information about Baby-Friendly hospital practices.
Provide information and support about the laws protecting mothers' rights to breastfeed and pump in public at the workplace.
NM Breastfeeding Task Force has a template letter to employers available.

Have signs posted that state that breastfeeding is welcome anywhere in the clinic and that private space is available should a mother prefer to feed or pump in a quiet, clean space.

Have a trained lactation specialist on site.
In the event that they are not on site, ensure that you have a way to easily and quickly refer a mother to a lactation specialist (eg at the local WIC office, hospital, or in the community).

Be familiar with the International Code of Marketing Breastmilk Substitutes.
Do not have magazines nor other literature that market formula.
Do not handout free formula as gifts or use as incentives.
Advocate to the AAP to stop accepting sponsorships from formula manufacturers.

Become a Provider Champion and encourage local hospitals to become Baby-Friendly.
Write letters to the editor, testify to elected leaders, advocate for hospital association support, and provide trainings to other providers statewide*. (*funding available)
Other Ways to support breastfeeding
in an outpatient clinic
BREASTFEEDING IN PUBLIC PLACES: NMSA 1978, Section 28-20-1 (1999) makes it legal for a mother to "breastfeed her child in any location, public or private, where the mother is otherwise authorized to be present."

USE OF A BREAST PUMP IN THE WORKPLACE: NMSA 1978, Section 28-20-2 (amended 2007) requires employers to provide flexible break time, and a clean, private space, not a bathroom, in order to foster the ability of a nursing mother who is an employee to use a breast pump in the workplace
NM Breastfeeding Laws
©2013 by American Academy of Pediatrics
Corriveau S K, et al. Pediatrics 2013;131:942-950
Rates of exclusive breastfeeding in clinics implementing ABM Clinical Protocol #14:Breastfeeding-Friendly Physician’s Office
The Academy of Breastfeeding Medicine (ABM) has developed a protocol entitled “The Breastfeeding-Friendly Physician's Office, Part 1: Optimizing Care for Infants and Children” based on BFHI.

Clinics following the protocol support breastfeeding in many ways, including

Establishing a written breastfeeding policy
Encouraging exclusive breastfeeding for 6 months
Offering a prenatal visit
Scheduling Newborn FU visits within 48-72 hours and with lactation support included
Discouraging formula marketing

Results from a study in 2 clinics in Northern Virginia “suggest that the use of a breastfeeding-friendly clinical protocol . . . may help increase exclusive (no formula) breastfeeding rates up to 6 months of age.”
Breastfeeding Friendly Physician’s Office
Momentum in New Mexico:
WK Kellogg Foundation & the New Mexico Breastfeeding Task Force
The New Mexico Breastfeeding Task Force received $1.5M in grants to improve breastfeeding exclusivity & duration rates in NM.
Grant time period 2012-2015

$750,000 dedicated to a NM Baby-Friendly Hospital Initiative.
April 2013 - First Annual NM Maternity Care & Infant Feeding Summit held in Albuquerque.
131 total attendees
26/31 (84%) Perinatal Hospitals sent representatives
~85% of NM births covered
8/31 (26%) of NM Hospitals are on the Baby-Friendly Pathway
16/31 (52%) of NM have stopped providing formula discharge bags
Breastfeeding is consistently associated with a lower risk of type 2 diabetes in later life compared with those initially formula fed

Native American and Hispanic/Latino populations have higher rates of diabetes than white Americans.

Native Americans make up 10.1% of the New Mexican population (vs. 1.2% U.S.)

Hispanics or Latinos make up 46.7% of the New Mexican population (vs. 16.7% U.S.)
Diabetes Reduction
Owen, CG, et al., “Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence,” Am J Clin Nutr November 2006 vol. 84 no. 5 1043-1054.
Reduction in Diabetes Especially Pronounced
in Native Americans
Young, T.K., et al., “Type 2 Diabetes Mellitus in Children: Prenatal and Early Infancy Risk Factors Among Native Canadians,” Arch Pediatr Adolesc Med. 2002;156(7):651-655. doi:10.1001/archpedi.156.7.651
The Case For Breastfeeding
Cochrane Database of Systematic Reviews 2007; 30 studies involving 1925 participants (mother-infant dyads)
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