Breastfeeding Support

and Promotion

Joan Younger Meek, MD, FAAP

AAP Section on Breastfeeding
Benefits of Breastfeeding

Children

Maternal

Societal
 Benefits of Breastfeeding
Species specific
Organic
Norm for infant feeding
Minimizes exposure to
foreign protein
Host protection
Optimal development Photo Roni M. Chastain, RN

outcomes

AAP Pediatrics 2012;129:e827-841.

 Breastfeeding should be viewed as a natural extension of the
nurturing and nourishing that the mother provides for the
growing fetus in utero. During the pregnancy, the breasts
prepare to nourish the young, whether the mother intends to
breastfeed or not.
Milk of different mammalian species is not interchangeable.
Cows milk, even when altered in the form of commercially
available infant formula, is not the optimal feeding to support
infant growth and development.
Breast milk is also the original organic feeding for babies
no processing, no unnecessary additives, and custom
designed for each baby
 Young infants may become sensitized to cow milk protein
when it is incorporated into the diet at an early age. Human
milk minimizes exposure to foreign proteins and provides
virtually all of the nutrients most term infants require, with the
exception of vitamin D, which will be discussed later. Although
it is uncommon, some infants, while exclusively breastfeeding,
can be sensitized by the mothers consumption of cow milk
based products.
 Benefits of Breastfeeding

Customized
Promotes appropriate
growth pattern
Provides multiple hormones
and growth
factors
Promotes mother-infant Photo Roni M. Chastain, RN

attachment
 Human milk is a complex substance that contains many
compounds not provided in infant formula. Human milk is
customized to most appropriately meet the growth and
developmental needs of the baby. The production of
human milk is quite sophisticated.

The composition of the milk changes throughout the day,

during the course of a feeding, and throughout the period
of lactation.
 Mothers who deliver their babies prematurely produce
milk that is somewhat different than the milk that mothers
produce for term infants.
 Overall, the somatic growth pattern seen in breastfed
infants seems to be more appropriate, resulting in a
reduced risk for obesity later in life.

Human milk contains a number of hormones and other

factors that promote growth of the infant. As noted, the
hormonal response in both mother and infant from the
nursing relationship facilitates strong attachment of
mother and infant, felt to be highly mediated by oxytocin.
 Immune Benefits

Secretory IgA and other immunoglobulins

Antiviral and antibacterial factors
Cellular immune components
Cytokines, including interleukins
Enzymes
Nucleotides
 Childhood Growth

Photo Joan Younger Meek, MD, FAAP

 Human milk provides growth promoting factors.
Breastfed babies also exhibit better satiety control, so
the exclusively breastfed infant should be the norm for
infant growth.

All children should have growth parameters measured at

each well child visit.
 The Global Strategy for Infant and Young Child Feeding
issued a joint 2002 WHO/UNICEF statement that
breastfeeding is an unequalled way of providing ideal
food for the healthy growth and development of infants.
These standards included the recommendation that
infants should be exclusively breastfed for the first six
months of life to achieve optimal growth, development
and health.
 Thereafter, they should receive adequate and safe
complementary foods while breastfeeding continues up
to 2 years or beyond. Nutrition plays a crucial role in the
early months and years of life. The strategy indicates
that lack of breastfeeding can increase risk for ill-health
with life long effects, including poor school performance,
impaired intellectual and social development, or chronic
diseases
 The WHO growth standards establish breastfeeding as a
biological norm and the breastfed infant as the standard
for measuring healthy growth. Previous charts relied
upon a random mixture of breastfed and artificially fed
infants. The current standards are based upon a pooled
sample from 6 participating countries including Brazil
(South America), Ghana (Africa), India (Asia), Norway
(Europe), Oman (Middle East), and USA (North America),
instead of just children from one country, as was the case
for the 2000 CDC charts.

 The global standard shows how children should grow

under optimal conditions, and is not just a description of
how they do grow at a particular time and place.
The WHO standards provide tools to recognize sub-
optimal or excessive weight gain, demonstrate that
children born in different regions of the world and given
optimal conditions, have the potential to grow and
develop within the same range of height and weight for
age, and provide a tool to measure normal growth as an
expression of health. They are currently available for
children aged birth to 5 years and include weight, length,
head circumference, and BMI (body mass index).
 The full set of charts, as well as the methodology for
their development, may be downloaded at
www.who.int/nutrition. These growth standards have
been recommended by the AAP and the CDC for
monitoring growth of children birth-24 months of age in
the US and are available on the CDC website.
Breastfeeding and Maternal Infant Health
Outcomes in Developed Countries
Current evidence demonstrates breastfeeding
associated with reduction in risk of:
Acute otitis media
Non-specific gastroenteritis
Severe lower respiratory tract infections
Atopic dermatitis
Asthma in young children
Obesity
Type 1 and type 2 diabetes
Childhood leukemia
Sudden infant death syndrome (SIDS)
Necrotizing enterocolitis

Ip S, et al: Breastfeeding and Maternal and Infant Health Outcomes in

Developed Countries, April 2007. Agency for Healthcare Research
and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/brfouttp.htm
Breastfeeding and Maternal Infant Health
Outcomes in Developed Countries
Current evidence demonstrates breastfeeding
associated with reduction in risk of:
Acute otitis media
Non-specific gastroenteritis
Severe lower respiratory tract infections
Atopic dermatitis
Asthma in young children
Obesity
Type 1 and type 2 diabetes
Childhood leukemia
Sudden infant death syndrome (SIDS)
Necrotizing enterocolitis

Ip S, et al: Breastfeeding and Maternal and Infant Health Outcomes in

Developed Countries, April 2007. Agency for Healthcare Research
and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/brfouttp.htm
 The report published in April 2007 by the Agency for
Healthcare Research and Quality, based upon research
conducted by the Tufts-New England Medical Center
Evidence-Based Practice Center and commissioned by
the Office on Womens Health of the Department of
Health and Human Services, is summarized on the slide.
 The report included systematic reviews/meta-analyses,
randomized and non-randomized comparative trials,
prospective cohort and case-control studies published in
English and which had a comparative arm with formula
feeding or different duration of breastfeeding.
The report noted that the breastfeeding literature includes many
observational studies, that there were limited randomized controlled
clinical trials, that definitions of breastfeeding and exclusive
breastfeeding were not consistent among the studies, that some
studies failed to control for confounding factors, and that there was
not always reliable data collection regarding other feeding
behaviors.
Using the rigorous criteria outlined, the study did identify
sufficient evidence in the published literature to support
the associations noted on the slide.
Benefits of Breastfeeding
Dose Dependency EBF=Exclusive breastfeeding
BF=Breastfeeding
Acute otitis media 50% less with EBF > 3-6 months
Atopic dermatitis 42% less with EBF > 3 months
Gastroenteritis 64% less with any BF vs. none
Lower respiratory tract disease and hospitalization 72% less
with EBF > 4 months
Asthma 40% less with BF > 3 months with positive family history
Obesity 24% less with any BF
Type 1 DM 30% less with BF > 3 months
Type 2 DM 40% less with any BF vs. None
Cancer:
Acute lymphocytic leukemia 20% less with BF >6 months
Acute myelogenous leukemia 15% less with BF >6 months
SIDS 36% less with any BF > 1 month

Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in
Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality, 2007.
http://www.ahrq.gov/clinic/tp/brfouttp.htm

AAP Pediatrics 2012;129;e827-41.

 Many of the benefits of breastfeeding are dose
dependent. The longer the child is breastfed, the greater
the benefits. For some benefits, the greater the period of
exclusive breastfeeding, the better the protection.

This slide summarizes the benefits which were published

by the Agency for Healthcare Research and Quality and
summarized in the AAP Policy Statement.
 Child Health Benefits

Decreased rates of:

Celiac disease
Inflammatory bowel disease
Hypertension
Hypercholesterolemia

AAP Pediatrics 2012;129;e827-41.

 There are other benefits associated with breastfeeding
as well, which may not appear until later childhood or
adult life. Multiple studies have demonstrated a
decreased incidence of the conditions noted on
the slide. The explanations for these
associations are multifactorial. Significant
factors include the effect of human milk on the
developingimmune system and the
lack of exposure to foreign protein
to which the immune system must respond.
 Childhood Obesity
One of the most significant childhood
health problems in the U.S.
Affects 20% of children in the U.S., with
up to 30% classified as overweight for
age
Incidence decreased in the breastfed
population
Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, Structured Abstract. April
2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/brfouttp.htm
AAP Section on Breastfeeding: Breastfeeding and the Use of Human Milk, Pediatrics 2005;115:496-506.
Evidence on the Long Term Effects of Breastfeeding: Systematic Reviews and Meta-analyses, World Health
Organization 2007, Geneva, Switzerland.
http://www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159523_0.htm
 Several evidence-based reviews have identified breastfeeding
as a preventative measure in reducing childhood
overweight and obesity. Causes for obesity are
multifactorial, including genetic factors, however, early infant
feeding behaviors appears to play a role. Breastfed
babies are better able to control their intake than
are bottle fed infants, who are often encouraged to finish
every last drop in the bottle. In addition, the way the baby
metabolizes human milk, and the gut response to human milk
is different than that seen with infant formula.
 Breastfeeding and Obesity
Obesity defined as a BMI > 95%ile for age
Data from the Pediatric Nutrition Surveillance
System
177,304 children followed up to 60 months
Controlled for gender, ethnicity/race, BW
Dose-responsive protective effect against obesity at
age 4 years in non-Hispanic whites
Greatest protection with breastfeeding for > 12
months
Grummer-Strawn LM, Mei Z: Does Breastfeeding Protect Against Pediatric Overweight?
Analysis of Longitudinal Data From the Centers for Disease Control and Prevention Pediatric
Nutrition Surveillance System. Pediatrics 2004;113:81-86.
 A large scale study published by Lawrence Grummer-Strawn,
Ph.D., and colleagues demonstrated the protective effect of
breastfeeding on childhood obesity, especially in the white

population. The study showed that breastfeeding

has a dose dependent effect on obesity, such
that, the longer the breastfeeding, the greater
the protection against obesity.
 Obesity Prevention

Encourage breastfeeding
Extent and duration of breastfeeding have
been found to be inversely associated with
risk of obesity in later childhood, possibly
mediated by physiologic factors in human
milk as well as by the feeding and parenting
patterns associated with nursing.

AAP Policy Statement, Committee on Nutrition, Pediatrics 2003; 112:424-430.

 Cognitive Benefits
Human milk
Contains fatty acids, nucleotides,
oligosaccharides, and taurine
to enhance neural and retinal
development
Enables child to reach full
developmental potential

Human milk fat

Provides essential fatty acids
Provides long-chain polyunsaturated fatty acids,
including docosahexaenoic acid
(DHA) and arachidonic acid (ARA)
 Breastfeeding Outcomes for
Premature Infants
Lower rates of Improved
Sepsis Leptin and insulin
Nectrotizing enterocolitis metabolism
Retinopathy of Neurodevelopmental
prematurity outcomes
Metabolic syndrome
Blood pressure
Low-density lipoprotein
levels
AAP Pediatrics 2012;129:e827-841.
 There are significant short and long-term benefits of
feeding human milk to premature infants, in addition to
those seen for term infant. The premature infant is
especially at risk for infectious complications.
Premature infants breastfed, or fed mothers
expressed milk, have lower rates of bacterial
sepsis and necrotizing enterocolitis.
 Maternal Health Outcomes
from Breastfeeding
Decreased postpartum
bleeding
More rapid uterine
involution
Decreased menstrual
blood loss
Increased child spacing

Photo Amy Kotler, MD, FAAP

AAP Pediatrics 2012;129:e827-841.
 Mothers who breastfeed are at decreased risk of excessive or
prolonged bleeding postpartum. Suckling at the breast causes
maternal release of oxytocin, which constricts the
myoepithelial cells of the uterine wall. Mothers who
breastfeed also experience decreased risk of
developing ovarian cancer and have a lower
incidence of breast cancer.

Women who breastfed their infants during their reproductive

years seem to have a decreased risk of osteoporosis
in the postmenopausal years, although some studies have
shown conflicting results.
 Maternal Benefits of
Breastfeeding BF=Breastfeeding

Type 2 diabetes mellitus 4-12% less for each year of

BF for women w/out history gestational DM
Pre-menopausal breast cancer 4.3-28% less for each
year of BF
Ovarian cancer 21% less for any vs. no BF and
evidence for dose response
Postpartum depression less for short term BF vs. no
breastfeeding

Ip S et al: Breastfeeding and Maternal and Infant Health Outcomes in

Developed Countries, April 2007. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/brfouttp.htm
 There is a dose dependent relationship between the
maternal benefits of breastfeeding and the length and
duration. The Agency for Healthcare Review and Quality

review of the evidence indicated a decrease in type

2 diabetes, premenopausal breast cancer,

ovarian cancer, and postpartum depression
with breastfeeding.
 Maternal Outcomes

Breastfeeding associated with decreased

risk of
rheumatoid arthritis
obesity
cardiovascular disease

AAP Pediatrics 2012;129:e827-841.

 Lactational Amenorrhea Method
Have mothers
menses returned?
Yes
No
Is mother supplementing Advise
regularly or allowing long Yes another method
periods without breastfeeding? of family
planning.
No

Is the baby older than Yes

6 months?
Reprinted from Contraception. 1997;55:328, Multicenter study
No of the Lactational Amenorrhea Method (LAM): I. Efficacy,
duration,and implications for clinical application,
Labbok MH et al, with permission from Elsevier
There is a 1%2% risk
of pregnancy.
This slide illustrates the contraceptive contribution of
breastfeeding. For the first 6 months after delivery, breastfeeding
mothers are at very low risk of conceiving another child IF all
three of the following conditions are met:

There are no long intervals between feedings

The mother continues exclusively breastfeeding
during the daytime and throughout the night
The mother has not had the return of her
menstrual cycles
 When all 3 of these conditions are met, the protection against
conception is at least 98%, equivalent to oral contraceptive
agents. But a woman should begin use of another method of
contraception IF
She has introduced formula or solids
Her baby is sleeping long intervals
Her menstrual periods have resumed
Her baby is older than 6 months
 The Economic Benefits of
Breastfeeding
U.S. Department of Agriculture
$3.6 billion dollars would be saved annually
if US breastfeeding rates increased to that
recommended in Healthy People 2010
guidelines
Projected figures were based on analysis of
decreased otitis media, gastroenteritis, and
necrotizing enterocolitis cost savings only
J Weimer: U.S.D.A., Food Assistance and Nutrition Research Report No. 13, March 2001
http://www.ers.usda.gov/publications/fanrr13
 Burden of Suboptimal
Breastfeeding in the US
Analyzed saving for those conditions validated by
the AHRQ report:
necrotizing enterocolitis
otitis media
gastroenteritis
hospitalization for lower respiratory tract infections
atopic dermatitis
sudden infant death syndrome
childhood asthma
childhood leukemia
type 1 diabetes mellitus (type 2 DM excluded)
childhood obesity

Bartick M: The Burden of Suboptimal Breastfeeding in the United

States: A Pediatric Cost Analysis. Pediatrics online April 2010.
 Burden of Suboptimal
Breastfeeding in the US
Results: If 90% of US families could comply with
medical recommendations to breastfeed
exclusively for 6 months, the United States would
save $13 billion per year and prevent an excess
911 deaths, nearly all of which would be in infants
($10.5 billion and 741 deaths at 80% compliance).
Conclusions: Current US breastfeeding rates are
suboptimal and result in significant excess costs
and preventable infant deaths. Investment in
strategies to promote longer breastfeeding
duration and exclusivity may be cost-effective.
Bartick M, Reinhold A. The Burden of Suboptimal Breastfeeding in the United
States: A Pediatric Cost Analysis. Pediatrics. 2010;125:e1048.
 A more recent study was published in Pediatrics, using a
similar method of cost analysis as was used in the 2001
study, and computing costs if 80-90% of US families
breastfed exclusively for 6 months. For the calculation,
the authors used 2005 Centers for Disease Control and
Prevention breastfeeding rates and 2007 dollars.
 Community Benefits

Breastfeeding is convenient, saves money,

and is green
Reduced health care costs
Lower employee absenteeism
Convenient and cost effective
Environmentally friendly
Decreased energy demands for production
and transport of infant formula
 Increasing the frequency and duration of breastfeeding
benefits all members of society.

Breastfed infants require fewer visits to the doctors office for

illness, antibiotic prescriptions, hospitalizations, and days of
absence from work for employed parents.
 Breastfeeding is more convenient for the motherno bottles
to prepare; no formula to purchase, transport, and refrigerate
when traveling; and no diaper bags full of bottles, nipples,
cans of formula, water, or warming equipment. Human milk is
always available when mother is available and is always
ready to feed at precisely the right temperature.

Breastfeeding is more environmentally friendlyfewer bottles,

nipples, and cans of formula, all of which must be
manufactured, distributed, and disposed of at an
environmental cost.
 Summary of Breastfeeding Benefits

Promotes optimal health outcomes for

mothers and children
Prevents infectious diseases for children
Assures that children meet their full
developmental potential
Reduces health care costs
Is environmentally conscious