American Academy of Pediatrics on Breastfeeding

Every few years the AAP changes their stand on issues. This is the comparison on what they used to say about breastfeeding and how they changed it from 1997 to 2005. They have a website that is a link to their initiative to promote breastfeeding as well.  Here is the  link to the overview of the  current policy. And here is the actual link to the policy.

Summary of Changes

AAP policy statement:

 

1997 Policy Statement 2005 Policy Statement 
The breastfed infant is the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short and long term outcomes. 

 

 

Exclusive breastfeeding is the referenceor normative model against which all alternative feeding methodsmust be measured with regard to growth, health, development,and all other short- and long-term outcomes. 

They also state that exclusive breastfeeding: “has been shown to provide improved protectionagainst many diseases and to increase the likelihood of continuedbreastfeeding for at least the first year of life.”

 

Exclusive breastfeeding is considered
“sufficient tosupport optimal growth and development forapproximately thefirst 6 months of life and provides continuingprotection againstdiarrhea and respiratory tract infection.”

 

Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately thefirst 6 months after birth.100 

It is recommended that breastfeedingcontinue for at least 12 months, and thereafter for as long asmutually desired.104

 

Exclusive breastfeeding has been shown to provide improved protectionagainst many diseases and to increase the likelihood of continuedbreastfeeding for at least the first year of life. 

Breastfeeding should be continued for at least the first yearof life and beyond for as long as mutually desired by motherand child.185

When direct breastfeeding is not possible, expressed human milk, fortified when necessary for the premature infant, should be provided. [The] humanmilk-fed premature infants receive significant benefits withrespect to host protection and improved developmental outcomescompared with formula-fed premature infants.1322A full section on ADDITIONAL RECOMMENDATIONS FOR HIGH-RISK INFANTS was added.

It  addresses issues such as the importance of skin to skin contact and the use of BANKED human milk.

Benefits listed were:incidence and/orseverity of diarrhea,1-5 lower respiratory infection,6-9 otitismedia,3,10-14 bacteremia,15,16 bacterial meningitis,15,17 botulism,18 urinary tract infection,19 and necrotizing enterocolitis.20,21 … a possible protectiveeffect of human milk feeding against sudden infant death syndrome,22-24 insulin-dependent diabetes mellitus,25-27 Crohn’s disease,28,29 ulcerative colitis,29 lymphoma,30,31 allergic diseases,32-34 and other chronic digestive diseases.35-37 Breastfeeding has alsobeen related to possible enhancement of cognitive development.38,39

… health benefits for mothers [include] lesspostpartum bleeding and more rapid uterine involution.40 Lactationalamenorrhea, an earlier return to prepregnant weight,41 delayed resumptionof ovulation with increased child spacing,42-44 improved bone remineralizationpostpartum45 with reduction in hip fractures in the postmenopausalperiod,46 and reduced risk of ovarian cancer47 and premenopausalbreast cancer.48

 

 

Additional benefits identified

  • decreasing the incidence and/or severity of late onset sepsis in preterm infants
  • Type 2 diabetes
  • Leukemia
  • Hodgkin disease
  • Overweight and obesity
  • hypercholesterolemia
  • asthma
  • ·the use of breastfeeding as analgesia during painful procedures
Social and economic benefits to the nation,including reduced health care costs and reduced employee absenteeismfor care attributable to child illness [which] allows the parentsmore time for attention to siblings and other family duties andreduces parental absence from work and lost income. The cost benefit of breastfeeding is identified as “decreased annual healthcare costs of $3.6 billion in the United States” 
It has been estimated that the 1993 cost of purchasing infant formula for the first year after birth was $855. Decreasedcosts for public health programs such as the Special SupplementalNutrition Program for Women, Infants, and Children (WIC)99
Breastfeeding has environmental benefits. Nothing specific mentioned. “Decreasedenvironmental burden for disposal of formula cans and bottles;Decreased energy demands for production and transport ofartificial feeding products
Encourage routine insurance coverage for necessary breastfeeding services and supplies, including breast pump rental and thetime required by pediatricians and other licensed health careprofessionals to assess and manage breastfeeding. The savings to the country and the families would be offset to some unknown extent by increased costs for

  • physician and lactation consultations,
  • increased office-visit time, and
  • cost of breast pumps and otherequipment.

 

Costs should be covered by insurance paymentsto providers and families.

 

The infant in the US whose mother has been infected with HIV should not breastfeed.  In countries with populations at increased risk for other infectious diseases and nutritional deficiencies resulting in infant death, the mortality risks associated with not breastfeeding may outweigh the possible risks of acquiring HIV.
  • Continues recommending that mothers in with HIV not breastfeed in the United States.  Cites a study that showed mothers with HIV in Africa who exclusively breastfed for 3-6 months did not increase the risk of HIV transmission to the infant, whereas infants who received mixed feedings had a higher rate of HIV infection compared with infants who were exclusively breastfed.

 

Hepatitis was not mentioned.Despite the demonstrated benefits of breastfeeding, there are some situations in which breastfeeding is not in the best interestof the infant. These include the infant with galactosemia,53,54 the infant whose mother uses illegal drugs,55 the infant whosemother has untreated active tuberculosis, and the infant in theUnited States whose mother has been infected with the human immunodeficiencyvirus.56,57 Although most prescribed and over-the-countermedications are safe for the breastfed infant, there are a fewmedications that mothers may need to take that may make it necessaryto interrupt breastfeeding temporarily. These include radioactiveisotopes, antimetabolites, cancer chemotherapy agents, and a smallnumber of other medications.
  • Another section has been added to list the “conditions that are NOT contraindications to breastfeeding, such as:
  • Mothers who are positive for hepatitis B and C.
  • a small number of other medications”).
    • mothers who have beenexposed to low-level environmental chemical agents,118,119 and
    • mothers who are seropositive carriers of cytomegalovirus (CMV)(not recent converters if the infant is term).
    • Although they recommend that they do not smoke or drink, neither totally rules out a mother from breastfeeding.
    • For the great majority of newborns with jaundice and hyperbilirubinemia,breastfeeding can and should be continued without interruption.In rare instances of severe hyperbilirubinemia, breastfeedingmay need to be interrupted temporarily for a brief period.
Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding,preferably directly, or by pumping the breasts and feeding expressedbreast milk, if necessary.
  • The new policy also clearly encourages health care professionals to promote exclusive breastfeeding even when direct breastfeeding is not possible by using expressed breast milk and stresses that when there is a known contraindication:

consider whether the contraindication may betemporary, and if so, advise pumping to maintain milk production.

Father not mentioned The new policy has acknowledged the evidence of the importance of the father in supporting breastfeeding and encourages “education for both parents before and after delivery … as an essential component”
Procedures that may interfere withbreastfeeding or traumatize the infant should be avoided or minimized.
  • Additional ways to assist in supporting breastfeeding are listed such as:

Avoid procedures that interfere with breastfeeding or may traumatize the infant including unnecessary, excessive, and overvigoroussuctioning of the oralcavity, esophagus, and airways to avoidoropharyngeal mucosalinjury that may lead to aversive feedingbehavior

Skin to skin is not mentioned Immediate postpartum care:  

  • Health care professionals are urged to allow the infant to be  “placed and remain in direct skin-to-skincontact with their mothers immediately after delivery untilthe first feeding is accomplished”
    • In addition they list the procedures to use with “The alert, healthynewborn infant”  Including:
      • Drythe infant,
      • assign Apgar scores, and performthe initial physicalassessment while the infant is with themother.
      • They encourage the use of “The mother isan optimal heat source for the infant.” and state that HCP should:
        • Delay weighing,measuring, bathing, needle-sticks, and eye prophylaxisuntilafter the first feeding is completed.

 

Supplements and pacifiers shouldbe avoided whenever possible and, if used at all, only after breastfeedingis well established.93-98  The appropriate and inappropriate use of pacifiers are clearly listed
10 to 15 minutes on each breast Timing of infant feeding is now more flexible – as the feeding should be from both breasts “for as long a period as the infant remains at the breast:”
…all breastfeeding mothers and their newborns should be seen by a pediatrician orother knowledgeable health care practitioner when the newbornis 2 to 4 days of age. In addition to determination of infantweight and general health assessment, breastfeeding should beobserved and evaluated for evidence of successful breastfeedingbehavior. 

 

 

 

 

 

 

 

 

All newborns should be seen by 1 month of age.99

The AAP continues to urge their members to see infants at around 3 – 5 days of ageThisvisit should includeinfant weight; physical examination,especiallyfor jaundiceand hydration; maternal history of breastproblems(painfulfeedings, engorgement); infant eliminationpatterns(expect3–5 urines and 3–4 stools per dayby 3–5daysof age; 4–6 urines and 3–6 stoolsper day by5–7days of age); and a formal, observed evaluationofbreastfeeding,including position, latch, and milk transfer.Weight loss inthe infant of greater than 7% from birth weightindicates possiblebreastfeeding problems and requires moreintensive evaluationof breastfeeding and possible interventionto correct problemsand improve milk production and transfer.

Breastfeedinginfants should have a second ambulatory visitat 2 to 3 weeksof age so that the health care professionalcan monitor weightgain and provide additional support and encouragementto themother during this critical period.

Gradual introduction of iron-enrichedsolid foods in the second half of the first year should complementthe breast milk diet.102,103 They encourage the delay of solids until after 6 months, explaining:“Introductionof complementary feedings before 6 months of agegenerally doesnot increase total caloric intake or rate ofgrowth and onlysubstitutes foods that lack the protective componentsof humanmilk.”
No mention of benefit or risk of breastfeeding beyond 12 months. In order to protect mothers who breastfeed for longer than what is usually seen in the US, they state: “There is no upper limit to the duration of breastfeedingandno evidence of psychologic or developmental harm from breastfeedinginto the third year of life or longer.”
(vitamin D for infants whose mothers are vitamin D-deficientor those infants not exposed to adequate sunlight; iron for thosewho have low iron stores or anemia). Vitamin K (1.0 mg IM) and Vitamin D  (200 IU daily from 2 months of age) are recommended, but not fluoride treatment.
Appropriateinitiation of breastfeeding is facilitated by continuous rooming-in.91 In order to encourage frequent and cue-led infant feeding, they recommend, even after hospital discharge that: “Mother and infant should sleepin proximity to each other tofacilitate breastfeeding.”
Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions.75-77 When direct breastfeeding isnot possible, expressed human milk, fortified when necessary forthe premature infant, should be provided.78,79 A new section on the High Risk Infant: Hospitals and physicians should recommend human milk for prematureand other high-risk infants either by direct breastfeeding and/orusing the mother’s own expressed milk.13 Maternal support andeducation on breastfeeding and milk expression should be providedfrom the earliest possible time. Mother-infant skin-to-skincontact and direct breastfeeding should be encouraged as earlyas feasible.204,205 Fortification of expressed human milk isindicated for many very low birth weight infants.13 Banked humanmilk may be a suitable feeding alternative for infants whosemothers are unable or unwilling to provide their own milk. Humanmilk banks in North America adhere to national guidelines forquality control of screening and testing of donors and pasteurizeall milk before distribution.206208 Fresh human milkfrom unscreened donors is not recommended because of the riskof transmission of infectious agents.
Before advisingagainst breastfeeding or recommending premature weaning, the practitionershould weigh thoughtfully the benefits of breastfeeding againstthe risks of not receiving human milk.
ROLE OF PEDIATRICIANS IN PROMOTING AND PROTECTING BREASTFEEDING

  1. Promote and support breastfeeding enthusiastically. In consideration of the extensive published evidence for improved outcomesin breastfed infants and their mothers, a strong position on behalfof breastfeeding is justified.
  2. Become knowledgeable and skilled in both the physiology and the clinical management of breastfeeding.
  3. Work collaboratively with the obstetric community to ensure that women receive adequate information throughout the perinatalperiod to make a fully informed decision about infant feeding.Pediatricians should also use opportunities to provide age-appropriatebreastfeeding education to children and adults.
  4. Promote hospital policies and procedures that facilitate breastfeeding. Electric breast pumps and private lactation areasshould be available to all breastfeeding mothers in the hospital,both on ambulatory and inpatient services. Pediatricians are encouragedto work actively toward eliminating hospital practices that discouragebreastfeeding (eg, infant formula discharge packs and separationof mother and infant).
  5. Become familiar with local breastfeeding resources (eg, Special Supplemental Nutrition Program for Women, Infants, and Childrenclinics, lactation educators and consultants, lay support groups,and breast pump rental stations) so that patients can be referredappropriately.111 When specialized breastfeeding services areused, pediatricians need to clarify for patients their essentialrole as the infant’s primary medical care taker. Effective communicationamong the various counselors who advise breastfeeding women isessential.
  6. Encourage routine insurance coverage for necessary breastfeeding services and supplies, including breast pump rental and thetime required by pediatricians and other licensed health careprofessionals to assess and manage breastfeeding.
  7. Promote breastfeeding as a normal part of daily life, and encourage family and societal support for breastfeeding.
  8. Develop and maintain effective communications and collaboration with other health care providers to ensure optimal breastfeedingeducation, support, and counsel for mother and infant.
  9. Advise mothers to return to their physician for a thorough breast examination when breastfeeding is terminated.
  10. Promote breastfeeding education as a routine component of medical school and residency education.
  11. Encourage the media to portray breastfeeding as positive and the norm.
  12. Encourage employers to provide appropriate facilities and adequate time in the workplace for breast-pumping.

 

ROLE OF PEDIATRICIANS AND OTHER HEALTH CARE PROFESSIONALS IN PROTECTING, PROMOTING, AND SUPPORTING BREASTFEEDING is long and very specific. In addition to the recommendations from the 1997 policy they added:

  • Promote breastfeeding as a cultural norm and encourage familyand societal support for breastfeeding.
  • Recognize the effectof cultural diversity on breastfeedingattitudes and practices
  • Work collaboratively with the dental communityto ensure thatwomen are encouraged to continue to breastfeedand use goodoral health practices.
  • Encouragehospitals to provide in-depth training inbreastfeeding forall health care staff (including physicians)and have lactationexperts available at all times.
  • Provideeffective breast pumps and private lactation areas forall breastfeedingmothers (patients and staff) in ambulatoryand inpatient areasof the hospital.
  • Advise mothers to continue their breastself-examinations ona monthly basis throughout lactation andto continue to haveannual clinical breast examinations by theirphysicians. (Previously had encouraged women to go to MD AFTER weaning – this is an important step, if moms are to continue to breastfeed for over 12 months…!)
  • Encourage child care providers to supportbreastfeeding andthe use of expressed human milk provided bythe parent.
  • Support the efforts of parents and the courtsto ensure continuationof breastfeeding in separation and custodyproceedings.
  • Provide counsel to adoptive mothers who decideto breastfeedthrough induced lactation, a process requiringprofessionalsupport and encouragement.
  • Encourage developmentand approval of governmental policiesand legislation that aresupportive of a mother’s choice tobreastfeed.
  • · Promote continued basic and clinical research in the field ofbreastfeeding.

 

 

 

 

 

 

U:BFPoliciesAAP Policy Statementscomparison chart.doc