Breastfeeding & Public Health 2009

1. Breastfeeding & Public Health 2009

2. Functions of Public Health • Assessment • Policy Development • Assurance

3. Levels of Influence in the Social-Ecological Model Structures, Policies, Systems Local, state, federal policies and laws to regulate/support healthy actions Institutions Rules, regulations, policies & informal structures Community Social Networks, Norms, Standards Interpersonal Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs

4. Objectives Students will be able to: • Identify advantages to increasing breastfeeding rates in the population • List 2010 Healthy People goals for breastfeeding • Access population-based breastfeeding data and describe patterns of breastfeeding in the US • Apply evidence-based approaches to improve breastfeeding rates • Use knowledge about the physiology of breastfeeding to advocate for policies that support breastfeeding

5. Benefits of Breastfeeding • Health outcomes • Infant – short term • Infant – long term • Maternal • Economic • Environmental

6. Breastfeeding and the Use of Human MilkAmerican Academy of Pediatrics, 2005 • “Human milk is species-specific, and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding.”

7. Health Benefits for Infant: AAP • Lowered risk of infectious diseases in both developed and developing countries: diarrhea, respiratory tract infection, otitis media, bacterial meningitis, botulism, UTI, necrotizing enterocolitis, bacteremia • Enhanced immune response to polio, tetanus, diptheria, haemophilus influenza immunization • Possible lowered risk of sudden infant death syndrome • Possible lowered risk of diabetes (type 1 & 2),leukemia, Hodgkin disease, lymphoma • Probable enhanced cognitive development • Provides analgesia to infants during painful procedures

8. Health Benefits for Mother: AAP • Possible reduction in hip fractures after menopause • Less postpartum bleeding & more rapid uterine involution • Reduced risk of breast and uterine cancer • Increased child spacing

9. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries(Agency for Healthcare Research and Quality, 2007) • Systematic reviews/meta-analyses, randomized and non-randomized comparative trials, prospective cohort, and case-control studies on the effects of breastfeeding • English language • Studies must have a comparative arm of formula feeding or different durations of breastfeeding. Only studies conducted in developed countries were included in the updates of previous systematic reviews. • Studies graded for methodological quality.

10. Limitations of Breastfeeding Outcome Studies • Definitions of breastfeeding; misclassification • Lack of randomization; confounding & residual confounding • “Wide range in quality of evidence”

11. AHRQ: Positive Findings for Infants

12. AHRQ: Equivocal or insignificant infant outcomes • Cognitive development in term or preterm infants • CVD • Infant mortality in developed countries

13. AHRQ: Positive Maternal Outcomes

14. AHRQ: Equivocal or insignificant maternal outcomes • Effect of breastfeeding in mothers on return-to-pre-pregnancy weight was negligible • Effect of breastfeeding on postpartum weight loss was unclear • Little or no evidence for association with osteoporosis

15. Breastfeeding and Obesity: Reviews & Meta-analysis • Owen et al. Pediatrics. 2005 • 61 studies • Odds ratio = 0.87 (95% CI 0.85-0.89) for reduced risk of later obesity associated with breastfeeding compared to formula • Arenz et al. Int J obes relat metab disord. 2004 • 9 studies met criteria • Odds Ratio = 0.78, 95% CI (0.71, 0.85) protective effect of breastfeeding for obesity • Found dose response • Harder et al. Am J Epidemiol. 2005

16. Breastfeeding and risk of obesity Does Breastfeeding Reduce the Risk of Pediatric Overweight? CDC. 2007

17. Harder et al. Am J Epidemiol. 2005 (17 studies)

18. Breastfeeding & Obesity: Support for the Evidence • Secular trends • Trend for increased breastfeeding is opposite that for obesity • Dose Response • Some studies find, others do not • Plausible mechanisms • Changes in leptin production and sensitivity • Lower energy and protein intake in breastfed infants • Insulin response to feeding; higher in formula fed infants • Differences in the feeding relationship; self-regulation of energy intake • Changing composition of human milk during feedings

19. Dubois et al. Public Health Nutrition, 2003 • Social inequalities in infant feeding during the first year of life. The Longitudinal Study of Child Development in Quebec (LSCDQ 1998-2002) • “Social disparities in diet during infancy could play a role in the development of social and health inequalities more broadly observed at the population level.”

20. Economic Costs of Formula Feeding(US Breastfeeding Committee) • Families: ~$2,000 for the first year • Employers: loss of productivity, increased absence, more health claims • Health care: 3.6 billion a year to treat infant illnesses, $331-475 per child for one HMO • Food assistance: costs to support breastfeeding mothers in WIC are 55% the cost for providing formula

21. Environmental Benefits of Breastfeeding(ADA Position Paper, 2005) • Human milk is a renewable natural resource. • Produced and delivered to the consumer directly • Formula requires manufacturing, packaging, shipping, disposing of containers • 550 million formula cans in landfills each year* • 110 billion BTUs of energy to process and transport* • Breastfeeding delays return of menses, increases birth spacing, limits population growth *USBC

22. Barriers to Breastfeeding (ADA Position Paper 2005) • Individual: Inadequate knowledge, embarrassment, social reticence, negative perceptions • Interpersonal: Lack of support from partner and family, perceived threat to father-child bond • Institutional: Return to work or school, lack of workplace facilities, unsupportive health care environments • Community: discomfort about nursing in public • Policy: aggressive marketing by formula companies

23. 2007 Health Styles Survey

24. Moses Lake Breastfeeding Data

25. Moses Lake Resident Survey (N = 254) Brzezney A. Unpublished Data (2003)

26. Moses Lake Resident Survey (N = 254) Brzezney A. Unpublished Data (2003)

27. Moses Lake Resident Survey (N = 254) Brzezney A. Unpublished Data (2003)

28. Assessment Rates of Breastfeeding and Exclusive Breastfeeding

30. Percent of U.S. children who were breastfed, by birth year Breastfeeding Among U.S. Children Born 1999—2006, CDC National Immunization Survey

31. Exclusive Breastfeeding

32. Percent of U.S. breastfed children who are supplemented with infant formula, by birth year1

33. Percent of U.S. Breastfed infants who are supplemented with infant formula

34. The resurgence of breastfeeding at the end of the second millennium(Wright and Schanler, J Nutr. 131, 2001) • Between 1971 and 1995 increase was for all groups. • Between 1984 and 1995 increase was in groups less likely to breastfeed (low income, low education, African American, WIC) • Early resurgence of breastfeeding concurrent to “natural childbirth” and women’s movement in white well educated families

35. More recent increases associated with: • Increased knowledge of the benefits of breastfeeding by professionals (AAP 1997) • Successful breastfeeding interventions - especially in WIC • 47% of US infants on WIC • early 90s brought increased WIC & for breastfeeding promotion and increased maternal food package for BF

36. Healthy People Goals and Breastfeeding Data

37. National Immunization Survey • Random-digit--dialed telephone survey conducted annually by CDC • Nationally representative data • Breastfeeding questions first added in 2001 • Data organized by birth cohort, not year of data gathering • 2004 data from 17,654 infants

38. Healthy People 2010: Increase the proportion of mothers who breastfeed their babies

39. Healthy People 2010: Increase the proportion of mothers who breastfeed their babies

40. Does Breastfeeding Reduce the Risk of Pediatric Overweight? CDC. 2007

41. Demographics of Breastfeeding(NIS 2004)

42. Percent of Children Ever Breastfed by State among Children Born 2004 2005 2006

43. Percent of Children Breastfed at 6 Months of Age by State 2006 2004 National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

44. Percent of Children Breastfed at 12 Months of Age by State 2006 2004 National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

45. New 2010 Breastfeeding Objectives added in 2007 • To increase the proportion of mothers who exclusively breastfeed their infants through age 3 months to 60% • To increase the proportion of mothers who exclusively breastfeed their infants through age 6 months to 25%

46. Exclusive breastfeeding: definition • Exclusive breastfeeding is defined as an infant receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines

47. Exclusive Breastfeeding

48. Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)

49. Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)

50. Percent of Children Exclusively Breastfed Through 3 Months of Age among Children born in 2004 National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services