Breastfeeding

Breastfeeding has long been recognized as the gold standard for infant nutrition. Human milk provides a mix of proteins, lipids, carbohydrates, and micronutrients that is uniquely adapted to the nutritional needs of human infants, leading to optimal growth and development. Moreover, breast milk provides antibodies, immune cells, and other anti-infective components that significantly reduce the infant's risk of infections, from diarrhea and colds to meningitis and other life-threatening infections. Infants who were breastfed for 3 months or more also made fewer medical office visits, received fewer procedures, took fewer medications, and experienced fewer hospitalizations. Beyond these short-term benefits, research has demonstrated that breast milk protects the infant against a growing list of chronic diseases, including cardiovascular disease, cancer, and diabetes. Evidence is accumulating that breastfeeding also reduces the infant's risk of childhood and adult obesity.

A recent meta-analysis suggests that breastfeeding is associated with a reduced risk of obesity in childhood and adolescence, even after controlling for important factors such as socioeconomic status and parental obesity (Dewey, 2003). Exclusive breastfeeding during the first 4 to 6 months was most consistently associated with reduced risk of being overweight, while most studies found that increased duration of any breastfeeding (up to 12 months) was associated with decreasing risk of overweight as a child. Exclusive breastfeeding refers to nourishing a child only with human milk through nursing.

Health Providers
Provider guidance for breastfeeding has been shown to be positively associated with success in breastfeeding (Rosenberg KD et al., 1998), but clinician support for breastfeeding is often inadequate (Schanler RJ et al., 1999). A recent study found that a majority of pediatricians felt that formula feeding and breastfeeding were equally healthy methods for feeding infants (Schanler RJ et al., 1999). Physicians are critical members of a mother's breastfeeding support team because they are contacted frequently after birth, and can help solve common problems as well as offer words of encouragement. Mothers also receive a majority of their breastfeeding knowledge and support from hospital staff where they have their child. More hospitals need to have fully supportive breastfeeding policies to meet the World Health Organization's 10 Steps to be designated as "Baby Friendly" (Naylor, 2001) to ensure that mothers are getting appropriate support and counseling to breastfeed their infants immediately after birth.

Effective breastfeeding promotion strategies
Structured breastfeeding education and behavioral counseling programs led by specially trained nurses or lactation specialists have been shown to increase breastfeeding rates (AHRQ). The most effective interventions use brief, directive health education combined with skills training and problem-solving counseling conducted face-to-face outside the context of routine clinical care. Provision of ongoing support through visits or telephone contacts increases the number/proportion of women who continue breastfeeding for up to 6 months.

Barriers to breastfeeding
In the U.S., and in NYS, approximately 71% of mothers breastfeed their infants in the early postpartum period, which is close to the Healthy People 2010 target of 75% (Figure 14).

Figure 14:Proportion of mothers who breastfeed their babies in early postpartum (HP Objective 16-19a).

Proportion of mothers who breastfeed their babies in early postpartum
Source: 2003 National Immunization Survey, CDC, and Department of Health and Human Services

However, breastfeeding rates at 6 months (36% for the U.S. and 35% for NYS) and one year (17% for both the U.S. and NYS) are considerably lower than the Healthy People 2010 target goals of 50% and 25% respectively (Figures 15 and 16).

Figure 15:Proportion of mothers who breastfeed their babies at 6 months. (HP Objective 16-19b)

Proportion of mothers who breastfeed their babies at 6 months
Source: 2003 National Immunization Survey, CDC, and Department of Health and Human Services

Figure 16:Proportion of mothers who breastfeed their babies at one year. (HP Objective 16-19c)

Proportion of mothers who breastfeed their babies at one year
Source: 2003 National Immunization Survey, CDC, and Department of Health and Human Services

These national objectives do not specify a goal for exclusive breastfeeding, but the American Academy of Pediatrics recommends exclusive breastfeeding for 4-6 months (2004), while the World Health Organization recommends exclusive breastfeeding for the first 6 months of life. Currently only 60% of mothers are exclusively breastfeeding in postpartum and only 8% are exclusively breastfeeding by 6 months (PRAMS 1999). Breastfeeding support is a major factor in a mother's decision to initiate or to continue breastfeeding, and needs to begin before pregnancy and continue well after the child is born.

Community Health Workers (CHWs)

Community Health Workers (CHWs) provide individual outreach and support to childbearing families in high-risk regions of the state. The training that all new CHWs receive includes information about breastfeeding, and the program monitors breastfeeding rates among their clients.

Work
In the U.S., the sharpest drop in breastfeeding rates occurs between 2 and 3 months, and between 3 and 4 months for exclusive breastfeeding (Li et al., 2003). This is usually when women return to work or school and need additional supports from their environment to continue breastfeeding. Studies consistently show that full-time employment is associated with shorter periods of breastfeeding (Kurinij N et al., 1989; Gielen AC et al., 1991; Auerbach KG & Guss E, 1984; Hills-Bonczyk SG et al., 1993) and that the length of a mother's maternity leave is positively associated with the duration of breastfeeding (Visness CM, Kennedy KI, 1997). Government family policies could play an important role in enabling women to achieve improved breast-feeding rates. In Norway, women far surpass the U.S. Healthy People 2010 goals for breastfeeding (97% of women breastfeed when leaving the hospital, 80% are breastfeeding at 3 months, and 20% beyond 12 months). Success in Norway is most likely due to policies that are very supportive of the breastfeeding mother. For example, maternity leave nationwide is 42 weeks with full pay or 52 weeks with 80% of salary. Flexible part-time is available for women from 2 months after giving birth with income supplemented from maternity benefits, and after returning to work, women are entitled to 1- to 1.5-hour breaks to return home to breastfeed, or to have the child brought to work.

Policies enacted within the workplace can also help to increase breastfeeding rates among mothers. Company-sponsored lactation programs can enable employed mothers to provide human milk for their infants as long as they wish, by providing lactation rooms equipped with breast pumps and refrigerators.

Breastfeeding and Human Lactation Study Center

Dr. Ruth Lawrence, an internationally known expert on breastfeeding, and the New York State Department of Health have provided continuing educational opportunities for physicians, midwives, nurse practitioners, and other health care providers about normal lactation and the management of breastfeeding in special circumstances. Best Practices Guidelines and policies for hospitals, managed care plans, ambulatory care facilities, workplaces, and childcare centers have been developed and distributed promoting and supporting breastfeeding. The guidelines are based on the consensus of ad hoc expert panels and in the case of the hospital guidelines, on the breastfeeding-promotion section of the New York State code of hospital regulations. The Center conducts research focused on breastfeeding behaviors and breastfeeding management.