Foreword
The5yearssincethepublicationoftheseventh editionofthisexcellentbookhavebeenatimeof incredibleadvancesinunderstandingseveralpreviouslyunknownphysiologicandbehavioralprocesses directlylinkedtoorassociatedwithbreastfeeding andbeautifullydescribedinthisnewvolume.
Thesefindingschangeourviewofthemotherinfantrelationshipandsignalanurgentneedto completelyreviewpresentperinatalcareprocedures. Thesenewresearchresultsincludetheobservation that,whenaninfantsucklesfromthebreast,there isalargeoutpouringof19differentgastrointestinal hormones,includingcholecystokinin,gastrin,and insulin,inbothmotherandinfant.Severalofthese hormonesstimulatethegrowthofthebaby’sand themother’sintestinalvilli,thusincreasingthesurfaceareafortheabsorptionofadditionalcalories witheachfeeding.Thestimulusforthesechanges istouchingthenippleofthemotherortheinside oftheinfant’smouth.Thestimulusinbothinfant andmotherresultsinthereleaseofoxytocininthe periventricularareaofthebrain,whichleadstoproductionofthesehormonesviathevagusnerve. Thesepathwayswereessentialforsurvivalthousands ofyearsago,whenperiodsoffaminewerecommon, beforethedevelopmentofmodernagricultureand thestorageofgrain.
Thediscoveryoftheadditionalsignificanceofa mother’sbreastandchesttotheinfantcomesfrom thestudiesofSwedishresearcherswhohaveshown thatanormalinfant,placedonthemother’schest, andcoveredwithalightblanket,willwarmormaintainbodytemperatureaswellasaninfantwarmed withelaborate,high-techheatingdevices.Thesame researchersfoundthat,wheninfantsareskin-to-skin withtheirmothersforthefirst90minutesafterbirth, theyhardlycryatallcomparedwithinfantswhoare dried,wrappedinatowel,andplacedinabassinet.In addition,theresearchersdemonstratedthatifa
newbornisleftquietlyonthemother’sabdomenafter birthheorshewill,afterabout30minutes,gradually crawluptothemother’sbreast,findthenipple, self-attach,andstarttosuckleonhisorherown.
Itwouldappearthateachofthesefeatures—the crawlingabilityoftheinfant,theabsenceofcrying whenskin-to-skinwiththemother,andthewarmingcapabilitiesofthemother’schest—evolved geneticallymorethan400,000yearsagotohelp preservetheinfant’slife.
Researchfindingsrelatedtothe1991Baby FriendlyHospitalInitiative(BFHI)ofWHOand UNICEFprovidedinsightintoanadditionalbasic process.AftertheintroductionoftheBFHI,which emphasizedmother-infantcontactwithanopportunityforsucklinginthefirst30minutesafterbirth andmother-infantrooming-inthroughoutthe hospitalstay,therehasbeenasignificantdropin neonatalabandonmentreportedinmaternityhospitalsinThailand,CostaRica,thePhilippines, andSt.Petersburg,Russia.
Akeytounderstandingthisbehavioristhe observationthat,ifthelipsofaninfanttouch themother’snippleinthefirsthalfhouroflife, themotherwilldecidetokeeptheinfantinher room100minuteslongeronthesecondandthird daysofhospitalizationthanamotherwhoseinfant doesnottouchhernippleinthefirst30minutes.It appearsthattheseremarkablechangesinmaternal behaviorareprobablyrelatedtoincreasedbrain oxytocinlevelsshortlyafterbirth.Thesechanges, inconjunctionwithknownsensory,physiologic, immunologic,andbehavioralmechanisms,attract themotherandinfanttoeachotherandstarttheir attachment.Aspointedoutbackinthefifthedition,astrong,affectionatebondismostlikelyto developsuccessfullywithbreastfeeding,inwhich closecontactandinteractionoccurrepeatedly whenaninfantwishesandatapacethatfitsthe
x Preface
withscissorsandpastewithglue.Aprocessthat usedtobesimpleismuchmorecomplicated, nowrequiringtheexpertiseofcomputerwizards. DavidLawrence(myson,Rob’sbrother)entered everychapterdigitallyandcreatedtheextensive tablesandcharts,keyboardingwiththespeedof soundfromraw,handwrittenmanuscript.Inmy office,JaneEggimanprintedcopyaftercopy.Adina Flynn,aborncomputerwizard,rescuedfreshdata fromlibraryarchives,searchingoutthemanycitations,bibliographies,andelusivedetails.Ithankall
thelactationconsultantsandmedicaldoctorswho havecalledthecenterwiththeirchallengingclinicalissues.
IcontinuetobegratefultoRosemaryDisney (1923–2014)forthecreationoftheenduring breastfeedingsymbolonthecover.Ithankmy friendsandfamilywhohavetoleratedmyhome andofficeinchaoswith23pilesofreprints, oneforeachchapter,spillingoverthefloor,along withboxesofreferencebooks,pamphlets, anddisks.
CHAPTER 19 InducedLactationandRelactation(IncludingNursinganAdoptedBaby)and Cross-Nursing...............................................................................................................667
CHAPTER 20 ReproductiveFunctionDuringLactation......................................................................688
CHAPTER 21 TheCollectionandStorageofHumanMilkandHumanMilkBanking......................712
CHAPTER 22 BreastfeedingSupportGroupsandCommunityResources.............................................743
CHAPTER 23 EducatingandTrainingtheMedicalProfessional........................................................754
Appendices
APPENDIX A CompositionofHumanMilk........................................................................................766
APPENDIX B NormalSerumValuesforBreastfedInfants..................................................................768
APPENDIX C HerbalsandNaturalProducts......................................................................................770
APPENDIX D PrecautionsandBreastfeedingRecommendationsforSelectedMaternalInfections.........776
APPENDIX E ManualExpressionofBreastMilk...............................................................................792
APPENDIX F TheStorageofHumanMilk........................................................................................794
APPENDIX G MeasurementsofGrowthinBreastfedInfants...............................................................797
APPENDIX H OrganizationsInterestedinSupportingandProvidingMaterialsforBreastfeeding.......803
APPENDIX I BreastfeedingHealthSupervision...................................................................................808
APPENDIX J AcademyofBreastfeedingMedicineProtocols1-21......................................................817
Protocol#1:GuidelinesforBloodGlucoseMonitoringandTreatment ofHypoglycemiainTermandLate-PretermNeonates............................817
Protocol#2:GuidelinesforHospitalDischargeoftheBreastfeeding TermNewbornandMother:”TheGoingHomeProtocol“......................825
Protocol#3:HospitalGuidelinesfortheUseofSupplementaryFeedings intheHealthyTermBreastfedNeonate...................................................831
Protocol#4:Mastitis...................................................................................................840
Protocol#5:PeripartumBreastfeedingManagementfortheHealthyMother andInfantatTerm..................................................................................845
Protocol#6:GuidelineonCo-SleepingandBreastfeeding.............................................851
Protocol#7:ModelBreastfeedingPolicy......................................................................856
Protocol#8:HumanMilkStorageInformationforHomeUseforHealthy Full-TermInfants....................................................................................861
TheRevolutioninInfantFeeding
Thereisareasonbehindeverythinginnature. ARISTOTLE
Thediscussionisover!Humanmilkisforthe humaninfant.Thisboldstatementwasmadeby DavidMyers,MD,oftheAgencyforHealthcare ResearchandQuality(AHRQ)atthefirstBreastfeedingSummitonthetwenty-fifthanniversary (2009)oftheSurgeonGeneral’sWorkshopon Breastfeedingoriginallyheldin1984inRochester, NewYork.1 Thedataconfirmingthebenefitsof breastfeedingforbothinfantandmotherare overwhelming.
IthasbeenfurtherproclaimedbytheAmerican AcademyofPediatrics(AAP)2 thatitisnotamatter ofchoice;itisamatterofpublichealth.Nolonger arethemajorhealthagenciesandorganizationstiptoeingaroundtheissue.Breastfeedingisthenorm forinfantsacrosstheentireworld.Otherchoices areacompromise.Gettingtothispointinthethird millenniumhasbeenanarduoustask.
Breastfeedinghasassumedacriticalroleinpublic health,childhealth,childnutrition,childsurvival, maternalhealth,andnationalandinternationalstrategies.Breastfeedinginitiationrateshaveincreased substantially,anddurationrateshavebegunto improve.Discrepanciesamongculturescontinue.
Scientistshaveprovidedtheevidence-based dataforclinicianstotakeanaggressivestandin promoting,protecting,andsupportingbreastfeeding.Womenhaveheardthemessageandaremakinginformeddecisionstobreastfeedtheirchildren. Peersupportisbecominganimportantelementof successinallsocioeconomicgroups.Programscontinuetotargethigh-riskgroupswhohavenotbeen breastfeedinginrecentdecades.
Thismovementisnotwithoutobstacles.The fearofinducingguiltinthosewhodonotchoose tobreastfeedisstillamajordefensethathealth
careprovidersusefornotmentioningit.There isnoscientificevidence tosupportthisposition, andthereisevidencethatwomendonotfeel guiltywhentheyhavemadeaninformeddecision. Otherbarriersarepresentedbyformulamanufacturersthathavebeenhastilydevelopingadditives forformulainanefforttoadvertisecowmilk andsoymilkformulasassimilartohumanmilk, eventhoughthebenefitsofmother’smilkare significant.
Scientistsandcliniciansconfrontedwithquestionsofinfantnutritionarealsobeingchallenged inthepopularpressbyreportersandfreelance writers,someofwhommayevenrepresentmothers withpersonalargumentsorvendettas.Decadeshave beenspentinthelaboratorydecipheringthenutritionalrequirementsofthegrowingneonate.Aconsiderablygreaterinvestmentintime,talent,and moneyhasbeenputtowardthedevelopmentof anidealsubstituteforhumanmilk.Atthesametime, artificialfeedinghasbeendescribedastheworld’s largestexperimentwithoutcontrols.12 Inveterinary medicine,carefulstudiesofthescienceoflactation inotherspecies,especiallybovine,havebeenperformedbecauseofthecommercialsignificanceof aproductiveherd.
Advancesintechnologyhaveallowedthegatheringofmuchdataabouthumanmilk,whichunarguablyisbestforhumaninfants.Moreofthe world’sfinestscientistshaveturnedtheirattention tohumanlactation.Timeandtalentareproviding awealthofresourceinformationaboutthis remarkablefluid—humanmilk.Olddogmasare beingreviewedinthelightofnewdata,andpreviousdataarebeingreworkedwithnewermethods andtechnology.Aworldwideinterfaceforthe
Figure1-1. Nationaltrendsin rateofbreastfeeding.Datasource: pre-1999,RossMothersSurvey2,4,5; 1999-present,CDC,NIS.(Modified fromGrummer-StrawnLM,Shealy KR:Progressinprotecting,promoting,andsupportingbreastfeeding, BreastfeedingMed 4(Suppl1):533, 2009.)
Percent breastfeeding
FormerSurgeonGeneralDavidSatcherdeveloped theHealthandHumanServicesBlueprintfor ActiononBreastfeedingin2000,saying,“Breastfeedingisoneofthemostimportantcontributions toinfanthealth.Inaddition,breastfeeding improvesmaternalhealthandcontributeseconomicbenefitstothefamily,healthcaresystem, andworkplace.”7
Eachsurgeongeneralhastakenastrongand visiblestandonbreastfeeding.In2011,theU.S. DepartmentofHealthandHumanServices released“TheSurgeonGeneral’scalltoactiontosupportbreastfeeding.”Thisreportisavailableat http:// www.surgeongeneral.gov/library/calls/breastfeeding/ index.html (accessed11Dec2014).
Anothertargetedneedforthenationwaspublic educationaboutthesubject.8 Toputbreastfeeding inthemainstreamandtoclassifyitasnormal behavior,educationhastostartwithpreschoolers andcontinuethroughtheeducationalsystem. Coursesinbiology,nutrition,health,andhuman sexualityshouldincludethebreastandits functions.
NewYorkStatehastakenaleadershipposition foreducationofitsyouth.In1994,acurriculum fromkindergartenthroughtwelfthgradewas jointlydevelopedbytheDepartmentofEducation andtheDepartmentofHealth* andreviewedby teachersandschooldistricts.Thecurriculumis notaseparatecoursebutprovidesrecommendationsabouthowtoincludeage-appropriateinformationonbreastfeedingandhumanlactation throughouttheschoolyears.Theseniorhighschoolmaterialsaremoredetailedandaredesigned
*NewYorkStateHealthDepartment:Breastfeeding:firststepto goodhealth—abreastfeedingeducationactivitypackagefor gradesK-12.Albany,NY,1995,NYSHealthResearchInc.
tobeincludedinsubjectmatterregardingreproductionandfamilylife.
Thiscommitmenttopolicyforbreastfeeding hasbeenpartoftheCodeforInfantFeedingof theWorldHealthAssembly,describedasthe WorldHealthOrganizationCode(WHOCode). TheWHOCodeseekstoprotectdeveloping countriesfrombeinginundatedwithformulaproducts,whichdiscouragebreastfeeding,because infantsurvivalinthesecountriesdependsonbeing nourishedatthebreast.9–12
Althoughthemajorcountriesoftheworld endorsedtheWHOCodein1981,theUnited Statesdidnot.Finally,onMay9,1994,President Clintonsupportedtheworldwidepolicyofthe WHOInternationalCodeofMarketingofBreast MilkSubstitutesbyjoiningwiththeothermember nationsattheWorldHealthAssemblyinGeneva, signalingatremendouspolicyshift.Despitemany effortsbytheUnitedStates,Italy,andIrelandto addweakeningamendments,theSwazilanddelegation,speakingfortheAfricannations,votedto strengthentheresolutionevenmore,andall amendmentsweredropped.Onebyone,allthe countries,includingtheUnitedStates,agreedto Resolution47.5,anditwasratified.13
Thebattletocontrolformuladistributionworldwidehasnotbeenwon.Thepandemicofacquired immunodeficiencysyndrome(AIDS)hasprovided anewreasontodistributeformulatodeveloping countriestostopthespreadofhumanimmunodeficiencyvirus(HIV)toinfantsfromtheirHIVpositivemothers.Carefulstudiesoftheissueshave provedthatexclusivebreastfeedingisprotectivefor thefirst6monthsoflife.Itistheadditionofherbal teasandotherfoodsthatirritatethegutandallow invasionbythevirus.
Box1-1 providesasummaryofinterventions presentedattheSurgeonGeneral’sWorkshop.1
Afederallyfundednationalconferenceheldin 1994inWashington,DC,cametothesameconclusionsasin1984.AconferenceheldinWashington,DC,sponsoredbytheAcademyof BreastfeedingMedicine(ABM)andtheKellogg Foundationfocusedonafollow-up25yearsafter theoriginalSurgeonGeneral’sWorkshoplooked
atdisparityissues.Progressisillustratedin Figure1-2
Althoughtheserecommendationshavebeen promotedsince1984,manyhospitalsandhealth carefacilitieshavenotachievedthem.14 Asaresult, UnitedNationsChildren’sFund(formerlyUnited NationsInternationalChildren’sEmergencyFund,
BOX1-1.KeyElementsforPromotionofBreastfeedingintheContinuumofMaternalandInfant HealthCare
1.Primarycaresettingsforwomenofchildbearingage shouldhave:
•Asupportivemilieuforlactation
•Educationalopportunities(includingavailability ofliterature,personalcounseling,andinformation aboutcommunityresources)forlearningabout lactationanditsadvantages
•Readyresponsetorequestsforfurther information
•Continuityallowingfortheexposureto,and developmentovertimeof,apositiveattitude regardinglactationonthepartoftherecipientof care
2.Prenatalcaresettingsshouldhave:
•Aspecificassessmentatthefirstprenatalvisitof thephysicalcapabilityfor,andemotional predispositionto,lactation.Thisassessment shouldincludethepotentialroleofthefatherof thechildandothersignificantfamilymembers. Aneducationalprogramabouttheadvantagesof, andwaysofpreparingfor,lactationshould continuethroughoutthepregnancy
•Resourcepersonnel—suchasnutritionists/ dietitians,socialworkers,publichealthnurses, LaLecheLeaguemembers,childbirtheducation groups—forassistanceinpreparingforlactation
•Availabilityandutilizationofculturallysuitable patienteducationmaterials
•Anestablishedmechanismforapredeliveryvisit tothenewborncareprovidertoensureinitiation andmaintenanceoflactation
•Ameansofcommunicatingtothein-hospital teamtheinfant-feedingplansdevelopedduring theprenatalcourse
3.In-hospitalsettingsshouldhave:
•Apolicytodetermineapatient’sinfant-feeding planonadmissionorduringlabor
•Afamily-centeredorientationtochildbirth, includingtheminimumuseofintrapartum medicationsandanesthesia
•Amedicalandnursingstaffinformedabout,and supportiveof,waystofacilitatetheinitiationand continuationofbreastfeeding(includingearly mother-infantcontactandreadyaccessbythe mothertoherbabythroughoutthehospitalstay)
•Theavailabilityofindividualizedcounselingand educationbyaspeciallytrainedbreastfeeding coordinatortofacilitatelactationforthose planningtobreastfeedandtocounselthosewho havenotyetdecidedabouttheirmethodofinfant feeding
•Ongoingin-serviceeducationaboutlactation andwaystosupportit.Thisprogramshouldbe conductedbythebreastfeedingcoordinatorfor allrelevanthospitalstaff
•Properspaceandequipmentforbreastfeedingin thepostpartumandneonatalunits.Attention shouldbegiventotheparticularneedsofwomen breastfeedingbabieswithspecialproblems
•Theeliminationofhospitalpractices/policies thathavetheeffectofinhibitingthelactation process(e.g.,rulesseparatingmotherandbaby)
•Theeliminationofstandingordersthatinhibit lactation(e.g.,lactationsuppressants,fixed feedingschedules,maternalmedications)
•Dischargeplanningthatincludesreferralto communityagenciestoaidinthecontinuing supportofthelactatingmother.Thisreferralis especiallyimportantforpatientsdischarged early
•Apolicytolimitthedistributionofpackagesof freeformulaatdischargetoonlythosemothers whoarenotlactating
•Thedevelopmentofpoliciestosupportlactation throughoutthehospitalunits(e.g.,medicine, surgery,pediatrics,emergencyroom)
•Theprovisionofcontinuedlactationsupportfor thoseinfantswhomustremaininthehospital afterthemother’sdischarge
4.Postpartumambulatorysettingsshouldhave:
•Acapacityfortelephoneassistancetomothers experiencingproblemswithbreastfeeding
•Apolicyfortelephonefollow-up1to3daysafter discharge
•Aplanforanearlyfollow-upvisit(withinfirst weekafterdischarge)
•Theavailabilityoflactationcounselingasa meansofpreventingorsolvinglactation problems
•Accesstolaysupportresourcesforthemother
•Thepresenceofasupportiveattitudebyallstaff
•Apolicytoencouragebringingtheinfantto postpartumappointments
•Theavailabilityofpublic-community-health nursereferralforthosehavingproblemswith lactation
•Amechanismforthesmoothtransitionto pediatriccareoftheinfant,includinggood communicationbetweenobstetricandpediatric careproviders
referredtothemilkoftheassasbeingthebestsubstituteforhumanmilkatanyagewhennourishmentwasanissue.Themilkofanassislowin solidscomparedwiththatofmostspecies,lowin fatandprotein,andhighinlactose.
From AD 1500to1700,wealthyEnglishwomen didnotnursetheirinfants,accordingtoFildes,18 wholaboriouslyandmeticulouslyreviewedinfant feedinghistoryinGreatBritain.Althoughbreastfeedingwaswellrecognizedasameansofdelaying anotherpregnancy,thesewomenpreferredtobear anywherefrom12to20babiesthantobreastfeed them.19 Theyhadanotionthatbreastfeeding spoiledtheirfiguresandmadethemoldbeforetheir time.Husbandshadmuchtosayabouthowthe infantswerefed.Wetnurseswerereplacedby feedingcerealorbreadgruelfromaspoon.The deathrateinfoundlinghomesfromthispractice approached100%.
TheDowagerCountessofLincolnwroteon“the dutyofnursing,duebymotherstotheirchildren”in 1662.20 Shehadborne18children,allfedbywet nurses;onlyonesurvived.Whenherson’swifebore achildandnursedit,thecountesssawtheerrorof herways.ShecitedthebiblicalexampleofEve, whobreastfedCain,Abel,andSeth.Shealsonoted thatJob39:16statesthattowithholdafullbreastis tobemoresavagethandragonsandmorecruel thanostrichestotheirlittleones.Thenoblewoman concludedherappealtowomentoavoidhermistakes:“Benotsounnaturalastothrustawayyour ownchildren;benotsohardyastoventureatender babetoalesstenderbreast;benotaccessorytothat disorderofcausingapoorerwomantobanishher owninfantfortheentertainingofaricherwoman’s child,asitwerebiddinghertounloveherownto loveyours.”
Towardtheendoftheeighteenthcenturyin England,thetrendofwetnursingandartificial feedingchanged,partiallybecausemedicalwriters drewattentiontohealthandwell-beingand mothersmademoredecisionsaboutfeeding theiryoung.
Ineighteenth-centuryFrance,bothbeforeand duringtherevolutionthatsweptLouisXVIfrom thethroneandbroughtNapoleontopower,infant feedingincludedmaternalnursing,wetnursing,artificialfeedingwiththemilkofanimals,andfeeding ofpapandpanada.7 PanadaisfromtheFrench panade,meaningbread,andmeansafoodconsisting ofbread,waterorotherliquid,andseasoningand boiledtotheconsistencyofpulp(Figure1-4). Themajorityofinfantsborntowealthyand middle-incomewomen,especiallyinParis,were placedwithwetnurses.In1718,Dioniswrote, “Todaynotonlyladiesofnobility,butyettherich andthewivesoftheleastoftheartisanshavelost thecustomofnursingtheirinfants.”Asearlyas
Figure1-4. Pewterpapspoon,circa AD 1800.Thinpap,a mixtureofbreadandwater,wasplacedinbowl.Tipofbowl wasplacedinchild’smouth.Flowcouldbecontrolledby placingfingeroveropenendofhollowhandle.Ifcontents werenottakenasrapidlyasdesired,onecouldblowdown onhandle.
1705,lawscontrollingwetnursingrequiredwet nursestoregister,forbadethemtonursemorethan twoinfantsinadditiontotheirown,andstipulated thatacribshouldbeavailableforeachinfant,topreventthenursefromtakingababytobedandchancingsuffocation.21 OnthebirthofthePrinceof Wales(laterGeorgeIV)in1762,itwasofficially announced:wetnurse,Mrs.Scott;drynurse,Mrs. Chapman;rockers,JaneSimpsonandCatherine Johnson.17
Amoreextensivehistoricalreviewwouldreveal otherexamplesofsocialproblemsinachievingadequatecareofinfants. 22 Longbeforeourmodern society,somewomenfailedtoaccepttheirbiologic roleasnursingmothers,andsocietyfailedto provideadequatesupportfornursingmothers (Figure1-5).* Breastfeedingwasmorecommon andoflongerdurationinstableerasandrarerin periodsof“socialdazzle”andloweredmoralstandards.Urbanmothershavehadgreateraccessto alternatives,andruralwomenhavehadtocontinue tobreastfeedingreaternumbers.12
Inthe1920s,womenwereencouragedtoraise theirinfantsscientifically.“Raisingbythebook” wascommonplace.TheU.S.governmentpublished InfantCare,referredtoasthe“goodbook,” whichwasthebibleofchildrearingreadbywomen fromallwalksoflife.Itemphasizedcodliveroil, orangejuice,andartificialfeeding.Aquotefrom Parents magazinein1938reflectstheattitudeof women’smagazinesingeneral,underminingeven thestaunchestbreastfeeders:“Youhopetonurse him,butthereareanalarmingnumberofyoung motherstodaywhoareunabletobreastfeedtheir
*TheNationalConventionofFranceof1793passedlawstoprovidereliefforinfantsofindigentfamilies.Theprovisionsare quitesimilartothoseinourpresent-daywelfareprograms.23
babiesandyoumaybeoneofthem.”24 Apple detailedthetransitionfrombreastfeedingtoraising childrenscientifically,bythebook,andpreciselyas thedoctorprescribes.25
Thereareencouragingtrends,however.The acceptanceorrejectionofbreastfeedingisbeing influencedintheWesternworldtoagreaterdegree bytheknowledgeofthebenefitsofhumanmilk andbreastfeeding.Culturalrejection,negativeattitudes,andlackofsupportfromhealthprofessionals arebeingreplacedbywell-educatedwomen’sinterestinchildrearingandpreparationforchildbirth.26 Thishascreatedasystemthatencouragesaprospectivemothertoconsidertheoptionsforherself andherinfant.27–29 TheattitudeintheWestern worldtowardthefemalebreastasasexobjectto theexclusionofitsabilitytonurturehasinfluenced youngmothersinparticularnottobreastfeed.The emancipationofwomen,whichbeganinthe1920s, wassymbolizedbyshorthair,shortskirts,contraceptives,cigarettes,andbottle-feeding.Inthesecondhalfofthetwentiethcentury,womensoughtto bewellinformed,andmanywantedtherightto choosehowtheyfedtheirinfants.
Thefirstactionbeganinthe1940swhenEdith Jackson,MD,ofYaleUniversitySchoolofMedicineandtheGrace-NewHavenHospitalwas awardedafederalgranttoestablishtheFirst Rooming-InUnitintheUnitedStates.Thisproject includedthefirstprogramtopreparewomenfor childbirthmodeledaftertheBritishobstetrician GrantlyDick-Read’s ChildBirthWithoutFear.This
wasdevelopedwiththeDepartmentofObstetrics toreducematernalmedicationduringbirthand keepmotherandbabyalertandtogether.Of course,itincludedbreastfeeding.Traineesfrom thisprograminPediatricsandObstetricsspread acrossthecountrystartingprogramselsewhere. MotherschimedinwhenLaLecheLeaguewas organizedinthelate1950s.ProfessionalorganizationssuchastheAAP,AmericanCollegeofObstetricsandGynecology(ACOG),andAmerican AcademyofFamilyPractice(AAFP)wereslowto speakoutastheywrestledwiththegriptheformula companieshadonmedicaleducation.
Thegreatsuccessofthemother-to-motherprogramoftheLaLecheLeagueandotherwomen’s supportgroupsinhelpingwomenbreastfeedor, aswithInternationalChildbirthEducationAssociation(ICEA),inhelpingwomenplanandparticipateinchildbirth,isanexampleofthepowerof socialrelationships.30 Raphael31 describedthedoula asa“friendfromacrossthestreet”whocamebyatthe birthofanewbabytosupportthemother.Shewould “motherthemother.”Thedoulaisnowknownasa keypersonforlactationsupport,especiallyin thefirstcriticaldaysandweeksafterdelivery.
Bryant32 exploredthesocialnetworksinher studyoftheimpactofkin,friend,andneighbornetworksoninfant-feedingpracticesinCuban,Puerto Rican,andAnglofamiliesinFlorida.Shefoundthat thesenetworksstronglyinfluenceddecisionsabout breastfeeding,bottle-feeding,useofsupplements, andintroductionofsolidfoods.Networkmembers’ adviceandencouragementcontributedtoasuccessfullactationexperience.Theimpactofthe healthcareprofessionalisinverselyproportional tothedistanceofthemotherfromhernetwork. Thehealthcareworkermustworkwithintheculturalnormsforthenetwork.Forindividualsisolated fromtheirculturalroots,thehealthcaresystem mayhavetoprovidemoresupportandencouragementtoensurelactationsuccessandadherenceto healthcareguidelines.33
Thetrendininfantfeedingamongmotherswho participatedintheWomen,Infants,andChildren (WIC)programinthelate1970sandearly1980s wasanalyzedseparatelybyMartinezandStahl34,35 fromthedatacollectedbyquestionnairesmailed quarterlyaspartoftheRossLaboratoriesMothers Survey.Theresponsesrepresented4.8%ofthe totalbirthsintheUnitedStatesin1977and 14.1%ofthetotalbirthsintheUnitedStatesin 1980.WICparticipantsin1977,includingthose whosupplementedwithformulaorcowmilk,were breastfeedinginthehospitalin33.6%ofcases. Asteadyandsignificantincreaseoccurredinthe frequencyofbreastfeeding;itroseto40.4%in 1980(p < 0.5).WICdatacontinuetobecollected, andthetrendshaveparalleledothergroups.
Figure1-5. ArnoldSteamSterilizeradvertisement.(From NYMedJ June22,1895.)
TheFoodandConsumerService(FCS)ofthe U.S.DepartmentofAgriculture(USDA)entered intoacooperativeagreementwithBestStart,a not-for-profitsocialmarketingorganizationthat promotedbreastfeedingtodevelopaWICbreastfeedingpromotionprojectthatwasnationalinscope andimplementedatthestatelevel.Theprojectconsistedofsixcomponents:socialmarketingresearch,a mediacampaign,astaffsupportkit,abreastfeeding resourceguide,atrainingconference,andcontinuing educationandtechnicalassistance.Withanannual $8millionbudgetforWIC,theproject’sgoalsare toincreasetheinitiationanddurationofbreastfeedingamongclientsofWICandtoexpandpublic acceptanceandsupportofbreastfeeding.BreastfeedingwomenarefavoredintheWICprioritysystem whenbenefitsarelimited;theycancontinueinthe programforayear,butthosewhodonotbreastfeed arelimitedto6months.Allpregnantparticipantsof WICareencouragedtobreastfeed.
MontgomeryandSplett36 reportedtheeconomicbenefitsofbreastfeedinginfantsformothers enrolledinWIC.ComparingthecostsoftheWIC programandMedicaidforfoodandhealthcarein Colorado,administrativeandhealthcarecostsfora formula-fedinfantminustherebateforthefirst 180daysoflifewere $273higherthanthosefor thebreastfedinfant.Thesecalculationsdidnot includethepharmacycostsforillness.Whenthese figuresweretranslatedtolargeWICprogramsin high-costareas(e.g.,NewYorkCity,LosAngeles) andmultipliedbymillionsofWICparticipants,the savingsfrombreastfeedingweresubstantial (Table1-2).Ifthegoalof75%breastfeedingwomen bytheyear2010hadbeenrealizedamongWIC recipients,thecostsavingscouldhavebeenatleast $4millionamonthfortheWICprogram.36 Since 2000,WICprogramshaveenergeticallypromoted breastfeeding,butthestreetvalueofthepackage forbottle-feedershasbeenpopular.AnewWIC packagehasbeendevelopedandslowlysupported throughthesystem.Itincreasedthefoodallowance forlactatingwomen.Progresscontinuesslowly.
TheWICprogram,throughtheextensiveactions ofthedirectorsandstaff,hasincreasedthenumbers ofWICmotherschoosingtobreastfeed.Manyprogramshavehiredandtrainedpeersupportmothers withbreastfeedingexperiencetohelpotherclients.
FrequencyofBreastfeeding
Datacollectedinthe1970sintheRossLaboratoriesMothersSurveyMR77-48,whichincluded 10,000mothers,revealedageneraltrendtoward breastfeeding.37 In1975,33%ofthemothers startedoutbreastfeeding,and15%werestillbreastfeedingat5to6months.In1977,43%ofthe
DatacollectedfromMartinezGA,StahleDA:Therecent trendinmilkfeedingamongWICinfants, AmJPublicHealth 72:68,1982;RyanAS,RushD,KriegerFW:Recentdeclines inbreastfeedingintheUnitedStates,1984through1989, Pediatrics 88:719,1991;KriegerFW:Areviewof breastfeedingtrends.PresentedattheEditor’sConference, NewYork,September1992;RossLaboratoriesMothers Survey,unpublisheddata,Columbus,Ohio,1992;Mothers Survey,RossProductsDivision,AbbottLaboratories, unpublisheddata,1998;RyanAS:Theresurgenceof breastfeedingintheUnitedStates, Pediatrics 99:2,1997 (electronicarticle);MothersSurvey,RossProductsDivision, andAbbottLaboratories—BreastfeedingTrends2002.
mothersleftthehospitalbreastfeeding,and20% werestillbreastfeedingat5to6months.Other studieshaveshownaregionalvariation,witha higherpercentageofmothersbreastfeedingon theWestCoastthanintheEast.
Acontinuationofthestudyofmilk-feedingpatternsin1981intheUnitedStatesbyMartinezand Dodd34 showedasustainedtrendtowardbreastfeedingin55%ofthe51,537newmotherscontactedbymail.Althoughmotherswhobreastfeed continuetobemorehighlyeducatedandhavea higherincome,thegreatestincreaseinbreastfeeding occurredamongwomenwithlesseducation.From
