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Q&A with Dr. Lori Feldman-Winter

August 14, 2012

The Faculty Chair of NICHQ’s Best Fed Beginnings initiative discusses why breastfeeding is important and why hospitals find it challenging to fully support it.

Dr. Lori Feldman-WinterMore women than ever are breastfeeding in the US, according to new data from the Centers for Disease Control and Prevention. Despite the rise, the country still lags behind many other countries in long-term, exclusive breastfeeding, which can protect babies from health issues such as obesity, infection and other risks. Part of the reason for the lag is that a lot of mothers don’t receive effective support for breastfeeding after they give birth, says Lori Feldman-Winter, MD, MPH.

Feldman-Winter, who is the Head of Adolescent Medicine at Cooper University Hospital and has a background in pediatrics and public health, has been helping hospitals in New Jersey to boost their breastfeeding support. Now she’s taking her expertise to a national level as the National Faculty Chair of the Best Fed Beginnings project. Launched in June and led by the National Initiative of Children’s Healthcare Quality (NICHQ), the 22-month initiative will assist 90 hospitals across the country in making changes to their maternity care practices to become “Baby-Friendly” designated. This designation indicates that a hospital follows the American Academy of Pediatrics-endorsed Ten Steps to Successful Breastfeeding established by the WHO/UNICEF Baby-Friendly Hospital Initiative.

Feldman-Winter, who began her career as a molecular biologist, spoke with NICHQ's Kristina Grifantini about why supporting breastfeeding is so important, and why there is controversy around the topic. 

What is the state of breastfeeding in the US currently?

It’s definitely better than it's been in the last 30 years. Well over 75% of women choose to do some breastfeeding. Most mothers want to breastfeed, but the issue arises when it comes to how long they last. It’s really the duration of breastfeeding and particularly exclusive breastfeeding that is important. The American Academy of Pediatrics recommends exclusive breastfeeding for 6 months. Only 16% of American women meet that goal, so we have a long way to go to support mothers' decisions to exclusively breastfeed.

According to the New Jersey Pregnancy Risk Assessment Monitoring System (pdf), we know that if mothers leave the hospitals exclusively breastfeeding and are not given formula, they’re six times more likely to be exclusively breastfeeding at the 8-10 week follow-up. All that support for breastfeeding starts in the hospital.

Why is breastfeeding important?

The short-term health outcomes associated with breastfeeding include reduced ear infections and respiratory tract infections as well as gastroenteritis and diarrhea. In addition, there are long-term effects that outlast the period of breastfeeding. We know, for example, that we can help prevent obesity and reduce very serious diseases such as leukemia and autoimmune diseases in children through breastfeeding. For the mothers, breastfeeding means a reduced risk of breast and ovarian cancer.

With all of the evidence that's come out in the last several decades, it's very clear that breastfeeding is not only a personal choice, but also a public health priority for the country. We can save lives through breastfeeding, even in industrialized nations. Quite honestly, we cannot afford not to support breastfeeding, because there are considerable costs related to the adverse health outcomes.

Can you tell us more about the biology of how breastfeeding can save lives?

Infant mortality is death that occurs within the first year of a baby’s life. Most of the time, those deaths occur because of Sudden Infant Death Syndrome (SIDS), but deaths also occur because of infections of the lower respiratory tract.

Human milk is necessary in order for the infant and later the child’s immune system to function normally. Human milk sets the stage for how the baby's immune system functions and can protect against autoimmune diseases like cancers, inflammatory bowel disease, Type 1 diabetes, and others. So far, scientists have identified over 50 bioactive substances that are transferred through human milk and contribute to the baby’s immune system. There are passive elements like antibodies from the mother that protect against infections and other more active substances that actually regulate the development of the baby’s immune system. That explains many of the outcomes related to immune functions such as allergy, ability to fight infections, and proper balance of tolerance and inflammation, which is necessary to prevent autoimmune diseases.

We believe that the immune system is reliant not only on receiving human milk but on receiving only human milk to function properly. It’s been estimated that we can save about 900 lives per year if 90% of the country follows the AAP’s recommendation of about 6 months of exclusive breastfeeding.

You mentioned that breastfeeding can prevent obesity later in life. How does that happen?

The causes of obesity are very complex and there are many different reasons for the obesity epidemic. In regards to breastfeeding, it's probably a combination of both the properties of breast milk as well as the process of feeding at the breast. There are properties of human milk that modify a baby's appetite and their caloric intake. In addition to that, there is the process of feeding at the breast which is perfectly designed to permit babies to satisfy their suckling reflex without overfeeding. Unfortunately, babies will overfeed if they're given bottles—regardless of what's in the bottle—because they have a natural tendency to keep sucking.

Because obesity tracks into adulthood, breastfeeding sets the first stage of appropriate weight gain. While other factors play a role beyond infancy and toddler years, the feeding patterns, flavor preferences, and normal accumulation of body mass established through breastfeeding offset the likelihood of future obesity.

What is the value of “exclusive breastfeeding?” Are there still health benefits if an infant feeds on a mix of formula and human milk?

People ask me that all the time. The bottom line is that some breastfeeding is better than none, but it depends on the health outcome we’re discussing. If we're going to talk about gastroenteritis, where a lot of the protection in human milk is passively transferred, then absolutely some is better than none. But if we're talking about some of the diseases that lie in the exclusivity of the human milk diet then adding formula to that diet will diminish the health benefits. These diseases include certain allergies, obesity, and lower respiratory tract infections. Even when we look at ear infections, there is some passive transfer of antibodies to protect against infection, but a lot of it has to do with immunity and things that rely on exclusive breastfeeding.

We’ve been hearing a lot in the news about hospitals deciding not to give out free baby formula unless the mother asks. Why are hospitals doing that?

The problem with giving out free formula and the discharge bags is that it’s been shown in a number of studies to undermine exclusive breastfeeding. More and more hospitals have given up the practice of handing out discharge bags supplied by the formula companies.

The pushback from families comes because a lot of hospitals are just taking away the discharge bags without making any other changes. Best Fed Beginnings works to improve the care of mothers and babies in the hospital. Moms used to tell us that they would see three different attendants at the hospital and get three different pieces of advice around feeding. Now the advice is consistent and effective and everyone is competent in providing assistance. This includes basic things like positioning the baby and getting the baby to latch onto the breast, identifying if the baby is swallowing, and other tactics so the moms and babies get off to a good start. We take away the bags, but we give back the gift of optimal support, real support. For mothers who still decide to formula feed, it is available, but it is procured the same way as any other medication or medical product.

Why is there controversy around supporting breastfeeding?

Breastfeeding is a very emotional issue that speaks to the very nature of mothering. Unfortunately, many mothers get bad advice or have a bad experience from people who weren’t trained, and this leads to them not being able to breastfeed. There are some women who cannot or should not breastfeed, but they’re really the exception to the rule. There's a lot of negativity out there because we've done a bad job as a heath system in supporting a mother's choice to breastfeed; the better we get as a health system in supporting breastfeeding, the less negativity we'll see.

After the Best Fed Beginnings initiative, which we hope is just one of many phases of increasing the number of Baby-Friendly hospitals around the country, I think there will be more optimism around this issue and more women will be able to meet their goals and feel really good about their experiences. From what I’ve seen, mothers love the experience of delivering a baby at a Baby-Friendly hospital. We're excited we'll be able to offer that to more women.

What kind of support do hospitals need in becoming Baby-Friendly?

What hospitals recognize very quickly after putting better breastfeeding support into place is that they're up against barriers such as cultural shifts and practical issues that require leadership support. We can help with different steps and processes to fully implement all the changes.

We also communicate with the hospital leaders, because we recognize to really get this done the leadership has to support the frontline teams by making resources available and connecting with outside communities so the messages are clear. There's often unintentional negative press that occurs when hospitals are engaging in the process. This is because people don't really understand what it means to be Baby-Friendly. Mothers won't lose their ability to choose how to feed their baby and there will still be formula available at the hospital. I think the leadership is responsible for correcting those misperceptions and sending positive messages so that everyone inside and outside the hospital can understand what's happening.

Change is hard, and for the hospitals changing their practices and how they care for mothers and babies is difficult. But through education and support, we are sharing how to get the mother, baby and family off to a good start by supporting them from the beginning.

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