| | Position of The American Dietetic Association: Promotion of Breast-Feeding
Position Statement  It is the position of The American Dietetic Association (ADA) that public health and clinical efforts to promote breast-feeding should be sustained and strengthened. ADA strongly encourages the promotion and advocacy of activities that support longer duration of successful breast-feeding, in order to optimize the indisputable nutritional, immunological, psychological, and economic benefits. Breast-Feeding Trends in the United States National efforts to promote breast-feeding have been successful at increasing rates of breast-feeding initiation. Nonetheless, few infants are being breast-fed beyond 1 to 2 months of age and many of the potential benefits are being forfeited. The next challenge to ADA and other organizations is to communicate the importance of sustained exclusive breast-feeding for 4 to 6 months and, optimally, breast-feeding with weaning foods for at least 12 months. Since the first edition in 1979 of Healthy People, in which the US Surgeon General's Report stated that breast-feeding is to be encouraged (1) and the follow-up editions in which specific goals for initiation and duration rates have been identified (2), the United States has seen a resurgence in breast-feeding rates. This trend in increasing initiation rates has been fostered by a stunning accumulation of literature documenting the advantages of breast-feeding (3), (4), (5); by recognition from numerous professional societies, including ADA, of breast-feeding as the preferred form of infant nutrition (6), (7), (8), (9); and by federally supported breast-feeding promotion efforts (10). These forces have likely contributed to the increase in breast-feeding initiation from a low of about 20% in the early 1970s to a high of 60% in 1984 (11). Although the late 1980s saw a decline in breast-feeding rates, the most recent data indicate that overall initiation rates are again increasing, with the figure at 59.7% in 1995 (12). Although the highest incidence of breast-feeding continues to be among women who are college educated, older than 30 years, and in higher income groups, some of the greatest recent increases have been seen in those groups with the lowest breast-feeding rates who might also benefit most. This includes women who are lower educated, employed full-time, age less than 20 years, primiparous, ethnic minorities, have incomes less than $10,000, and those participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIG). Despite these encouraging trends, the most recent data indicate that only about 20% of all infants are still being breast-fed at 5 to 6 months of age (12). In some high-risk groups of infants, only 1 in 10 are being breast-fed. The importance of promotion efforts cannot be overstated, but it is equally true that initiation must be followed by encouragement of sustained breast-feeding and by good clinical management. Many of the well-recognized benefits of breast-feeding are substantially greater with exclusive breast-feeding for at least 4 months. The current dramatic decline in breast-feeding rates after the first 1 to 2 months indicates a forfeiture of many of the potential benefits. Barriers to Extended Breast-Feeding Because so many people look to health care professionals for advice, it is critical for them to be knowledgeable about breast-feeding. However, many health care professionals have inadequate training about lactation. Physicians, for instance, have reported attitudes supportive of breast-feeding but are frequently inadequately trained to recognize problems and to offer interventions that support breast-feeding (13). Traditional dietetics and nursing training programs have not incorporated extensive training in lactation support either (14). The unfortunate consequence of inadequate training of health care professionals is inappropriate management of lactation and a clinical bias toward use of human milk substitutes when problems with breast-feeding arise (5), (13). The recent rapid changes in health care (including shorter postpartum hospital stays) further limit the professional support and education about lactation available to new mothers. The Baby Friendly Hospitals initiative (15) has notable potential to enhance successful initiation of breast-feeding, but full implementation has yet to be realized in US hospitals. Although the practice of providing home visits during the newborn period can be helpful to compensate for short hospital stays, these may be performed by personnel without particular training in assessment and management of lactation. Unfortunately, once a mother-infant pair has experienced problems, it may be very difficult to reestablish adequate breast-feeding without lactation consultation, rental of an electric pump, or purchase of other equipment, all of which are frequently not reimbursed by third-party payers. In the extreme, substantial morbidity, as well as excessive costs, can result from belated identification and treatment of lactation problems (16). Numerous sociocultural factors also contribute to relatively short-term breast-feeding. First, breast-feeding is simply not accepted as the cultural norm, particularly within some demographic groups. The effect of sociocultural attitudes on infant-feeding decisions has been thoroughly reviewed (17) and should be considered in efforts to promote breast-feeding. The decline in breast-feeding 20 to 30 years ago has resulted in a loss of traditional knowledge and support; today's grand-mothers often have no firsthand breast-feeding experience. Demographic changes in childbirth and child rearing, such as the increasing numbers of teenaged and single mothers and more reliance on child care outside the home, are also associated with challenges to successful sustained breast-feeding. Another powerful force mitigating against sustained breast-feeding is women's relatively short-term maternity leave and the difficulty of maintaining a good milk supply with prolonged separation from the infant (18). Supportive work environments, where mothers can either have the infant present, have access to on-site or nearby child care, or at least have time and facilities for pumping and storing milk, are, as yet, relatively uncommon. Finally, a discussion of sociocultural factors cannot overlook the effect of the commercial sector on breast-feeding. Aggressive marketing practices (19) or use of products associated with shorter duration of breast-feeding (20) promote the use of human milk substitutes. Marketing or providing these products in discharge packages (19), subtly promotes maternal-infant separation and/or undermines maternal confidence. Thus, a true paradigm shift is needed to make meaningful progress toward substantially longer breast-feeding for the majority of US infants. The new paradigm will need to include more than statements from agencies, institutions, and individuals that breast-feeding is to be encouraged, with the unspoken message that human milk substitutes represent an acceptable alternative. Rather, it must entail a true expectation, which is reflected in health care and sociocultural practices, that breast-feeding an infant for at least 6 months, and preferably longer, is not only optimal but is the norm, and that use of human milk substitutes should be reserved only for a minority of infants and with specific indications. Rationale: Benefits of Breast-Feeding The advantages of extended breast-feeding are indeed indisputable and include nutritional, immunological, and psychological benefits to both infant and mother, as well as economic benefits. Breast-feeding education efforts and clinical management must highlight the importance of nursing for a longer duration to fully achieve the potential benefits for both mother and infant. Psychological Benefits That there are psychological benefits of breast-feeding for both the mother and the infant is generally assumed but has been particularly difficult to characterize and quantify. Studies relating to psychological benefits of breast-feeding have been criticized for methodological flaws such as evaluation tool limitations and a narrow focus on developmental outcomes, which exclude the processes underlying development (21). Acknowledging the challenges of such investigations, several reports have linked breast-feeding, and especially duration of breast-feeding, with cognitive and emotional psychological benefits. Mothers with early infant contact breast-fed longer (22), (23) and showed more attachment behavior than women without early contact (24) and infants who were not breast-fed. The unique composition of human milk, such as the fatty acid composition discussed later, almost certainly plays an important role in neuropsychological development. Low-birth-weight infants fed mother's milk scored better on developmental tests at age 18 months and intelligence tests at age 7 or 8 years than infants who received human milk substitutes (25). Similarly, significant increases in cognitive development test scores were identified in school-aged children (26). More importantly, the increases in cognitive development were related to the duration of breast-feeding during infancy. Nutritional Benefits Human milk provides optimal nutrition to infants with its dynamic composition and the appropriate balance of nutrients provided in easily digestible and bioavailable forms (5), (27). The relatively low protein content of breast milk is adequate, but not excessive, so that it presents a relatively modest nitrogen load to the immature kidney. The form of protein in human milk, mainly whey, forms a soft, easily digestible curd. Human milk provides generous amounts of essential fatty acids, saturated fatty acids, medium-chain triglycerides, and cholesterol. Long-chain polyunsaturated fatty acids, especially docosa-hexaenoic acid, promote optimal development of the central nervous system. Human milk has a relatively low sodium content, allowing the fluid requirements of the exclusively breast-fed infant to be met while keeping the renal solute load low. Minerals in breast milk are largely protein bound and balanced to enhance bioavailability. This mineral composition allows provision of iron, zinc, and calcium to meet infant needs with minimal demand on maternal supply. Immunological Benefits Human milk contains many components that contribute to its protective properties (5), (27). Cellular components, including specific T- and B-lymphocytes, and nonspecific macrophages and neutrophils, are especially high in colostrum but persist in milk in lower concentrations but in activated forms for months. Humoral factors include immunoglobulins, with secretory im-munoglobulin A being predominant and likely playing a critical role in the provision of local protection to the gastrointestinal tract. Other soluble factors include lactoferrin and vitamin B-12–binding proteins, that bind iron and vitamin B-12, respectively, making them unavailable to pathogens that require these nutrients to prosper in the infant's gastrointestinal tract. Such factors are critical to maintaining a striking difference in the intestinal flora of breast-fed vs formula-fed infants. Hormones and hormonelike substances, including insulin and epidermal growth factor, enhance maturation of the infant gastrointestinal tract. These and numerous other factors in human milk directly and indirectly provide critical active and passive protection to infants, especially neonates, against viral and bacterial pathogens. Because of the delicate balance between nutritional and immunological factors, maximal protection is offered by exclusive rather than partial breast-feeding. Reduced Infant Morbidity In studies performed in both developing and industrial countries, breast-fed infants have been reported to have fivefold fewer gastrointestinal illnesses, threefold fewer respiratory illnesses, and at least half the episodes of otitis media (3), (28), (29), (30). Given the challenges of studying effects of feeding method in countries with relatively low morbidity and mixed feeding patterns, it is remarkable that carefully designed and controlled studies have established reduced morbidity among breast-fed infants even in industrial countries (28), (29), (30), (31). Importantly, substantial evidence indicates that breast-feeding duration is important to realizing the reductions in infant morbidity and allergy even in affluent populations. These reductions possibly extend for periods beyond weaning. For instance, the risk of otitis media is reduced for the duration of breast-feeding and for months after weaning (29); the protection against atopic disease may extend for years (31). Maternal Health Benefits Extension of lactation duration is also integral to receiving full maternal benefits from breast-feeding. Health gains for breast-feeding women include lactation amenorrhea, maternal weight or fat loss, protection against premenopausal breast cancer, and more optimal blood glucose profiles in women with gestational diabetes (4), (32), (33), (34). Exclusive and more frequent nursing (especially at night) increases the duration of amenorrhea (32). Lactation amenorrhea accompanied with exclusive breast-feeding reduces the risk of pregnancy for at least 6 months (35). Lactation-related reductions in risk for premenopausal breast cancer are related to younger age at first lactation and lactation duration of 6 months (34). The relationship between lactation and obesity is presently unclear but may be important in the face of the increasing prevalence of obesity among women. Although the hormonal milieu favors fat mobilization from the lower body, the net effect is variable due to the interrelationship of prepregnancy nutritional status, maternal dietary intake, and activity. Economic Benefits A common perception has been that true economic benefit of breast-feeding could only be realized in developing countries where the risks of artificial feeding were substantially greater due to more marginalized conditions. However, several studies (28), (29), (30), (31) have convincingly demonstrated benefits on infant morbidity even in industrial countries. Cost projections from the differences in morbidity, even allowing for expenditures to support breast-feeding, are likely to translate to savings of millions of dollars in medical costs for physician visits, antibiotics, and hospitalizations. Perhaps the strongest evidence to date is available from a WIG and Medicaid program (36) where statistically significant savings were realized in lower cost of the food package for lactating women compared with the cost of formula (even after adjusting for the substantial manufacturers’ rebate) and from lower Medicaid pharmacy costs during the first 6 months in breast-fed compared with formula-fed infants. In addition to the medical costs, data are emerging that document the costs of not breast-feeding to employers, including higher maternal absenteeism due to infant illness (37). There are few parallels for such underuse of a recognized cost-effective and socially beneficial health practice. Clinical Considerations Lactation Management Many postpartum lactation problems are iatrogenic and are thus responsive to changes in routine care of mothers and newborns, such as those outlined in the Baby Friendly Hospital initiative (15). Early mother–infant contact increases the duration of breast-feeding by as much as 50%, and nursing should be allowed immediately after delivery when possible. The early postpartum period is a critical time for education and assistance, to ensure appropriate positioning and latch-on to avoid breast soreness and/or engorgement. Although primary lactation failure is exceedingly rare, insufficient milk secondary to either maternal or infant problems is a frequent cause of early lactation cessation. It is critical that health care professionals recognize signs and symptoms of insufficient milk, such as infant lethargy and/or irritability, jaundice, infrequent defecating or urinating, and/or failure to gain weight or excessive weight loss (greater than 7% of birth weight). Early recognition and intervention can help to prevent lactation difficulties that lead to insufficient milk supply and early lactation cessation (5), (38). During the first 2 to 3 months of life, breast-fed infants typically gain weight more rapidly than the median on standard growth charts. Thus, poor weight gain during this period should be interpreted as evidence of potential lactation problems and appropriate assessment and intervention should be undertaken. For reasons that are presently not clear, weight gain of breast-fed infants after 4 months is generally slower than indicated in standard growth charts, and the assessment of breast-feeding adequacy is more difficult at this age. Growth deviation during this time should not be misinterpreted as an indication for weaning, but requires assessment for potential problems such as adequacy of the lactation process, and appropriate use of weaning foods. New reference data are needed, but interim growth charts specific to breast-fed infants are available and may be helpful in the assessment (39). Lactation in Women with Special Needs Medical advances have made pregnancy and positive fetal outcome possible for women with many chronic diseases, including insulin-dependent diabetes mellitus, systemic lupis erythematosus, and hypothyroidism. Increasingly, women with chronic disease wish to nurse their infants, but few data exist to provide guidance (5). Guidelines are available regarding the advisability of breast-feeding in women with infectious diseases (5). Breast-feeding by women with hepatitis C remains controversial but the risk of viral transmission through breast milk is likely to be quite low. Nursing is not recommended for infants of women in the United States who test positive for human immunodeficiency virus (5), (40). Women with insulin-dependent diabetes mellitus can nurse successfully but require additional support to manage increased energy needs and alterations in insulin needs to maintain metabolic control and enhance lactogenesis. Lactation is appropriate for women with systemic lupis erythematosus, hypertension, Crohns’ disease, and many other chronic diseases if medications are chosen carefully. Resources are available to assist in evaluating the safety of drug use in lactation (5), (41). The few classes of drugs that contraindicate breast-feeding during use include radioactive isotopes, chemotherapeutic drugs, lithium, ergotamine, lactation-suppressing drugs, and recreational drugs. Contamination of breast milk with environmental pollutants is a concern when mothers have had specific exposure to heavy metals or insecticides. In situations where maternal exposure and probability of transfer in breast milk lipids are determined to be significant, analysis of milk is recommended with decisions regarding safety made from estimated average intake (27). Infants with Special Needs The advantages of breast-feeding and use of human milk are particularly salient for infants with special needs. One of the most common and yet challenging situations is that of infants born prematurely. The unique nutritional qualities of human milk, including the protein/amino acid and lipid composition, offer advantages with respect to digestibility and feeding tolerance, maturation of the gastrointestinal tract, and neurologic development. The relatively high requirements for certain nutrients, including protein, calcium, phosphorus, and zinc are generally not met for infants weighing less than 2,000 g unless the human milk is fortified. Discussion of the controversy of fortification of mother's own milk vs use of donor milk is beyond the scope of this position, but remains an issue of considerable interest (42). Human milk has also been successfully and advantageously used for infants with cleft palate; inborn errors of metabolism, especially phenylketonuria; cystic fibrosis (with pancreatic enzyme replacement); and Down syndrome (5). In each of these situations, the major challenge remains the achievement and maintenance of an adequate milk supply. As soon as special needs of an infant become evident, care providers should provide anticipatory support and be alert to early signs or symptoms of feeding difficulties so effective early intervention can be initiated. Infants with a strong family history of allergic disease are also likely to benefit from extended breast-feeding by minimizing both the exposure to and entry through the gastrointestinal tract of foreign proteins, the latter protection especially provided by the secretory immunoglobulin A in human milk. Roles and Responsibilities of Dietetics Practitioners All health care professionals have a responsibility to support breast-feeding through active lactation management. ADA, the International Lactation Consultant Association, La Leche League International, Nursing Mothers’ Counsel, and local breast-feeding task forces are avenues for professional and volunteer efforts to promote and support breast-feeding. Prenatal lactation education or consulting are also viable practice options for dietetics professionals. Dietetics practitioners in prenatal clinics, obstetrics practices, and WIG clinics have a responsibility to educate women before a decision is reached about feeding method. Furthermore, critical review of undergraduate and graduate training programs in dietetics is recommended. Curriculums that are appropriate for various levels of expertise and application are available (43) and may be useful in developing standards of education that will ensure that training will strengthen dietetics professionals’ understanding of lactation management. Hundreds of dietitians have been trained as certified lactation educators over the past decade (44). With this advanced training in lactation support and management, dietitians can be educators of physicians and other health care professionals and key care providers, particularly in pediatric and family practice settings. Dietetics practitioners may also play a role in research on issues such as cost-effectiveness and maternal and infant nutrition outcomes related to breast-feeding, especially for women and infants with special needs. Research is needed first to understand and then to eliminate barriers to successful breast-feeding, with careful attention to specific cultural influences. ADA members are needed to support cultural changes that will eliminate barriers to lactation. In several states, legislation has been enacted to preserve a woman's right to nurse her infant in public. Further efforts to support change in policies to allow longer family leave; family friendly employers with on-site day care facilities and/or nursing/pumping rooms; breast-feeding support personnel/lactation consultants; and attainment of reimbursement for lactation consultation and management for maternal or infant considerations will support lactation duration. Dietetics practitioners’ professional, volunteer, education, and research efforts must be aimed at breaking the barriers to initiation and continuation of breast-feeding. Clinical bias in favor of human milk substitutes must be recognized where it exists and appropriate lactation support and management techniques should be incorporated into clinical protocols. Sociocultural structures and practices that foster successful sustained breast-feeding should be recognized and actively supported. Breast-feeding promotion activities should continue to support initiation, but broadly based additional efforts are clearly needed to increase duration rates of breast-feeding. The establishment of breast-feeding for at least 6 months, but optimally for at least one year, as a cultural norm supported by medical, social, and economic practices is a fundamental cornerstone of true promotion of wellness. ■ ADA Position adopted by the House of Delegates on March 16, 1997. This position is in effect until December 31, 2000. The American Dietetic Association authorizes republication of the position paper, in its entirety, provided full and proper credit is given. Requests to use portions of the position must be directed to ADA Headquarters at 800/877-1600, ext 4896, or hod@eatright.org ■ Recognition is given to the following for their contributions: Authors: Nancy F. Krebs, MD, RD, and Maureen A. 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