Breastfeeding & Public Health 2012

1. Breastfeeding & Public Health 2012

3. Objectives Students will be able to: • Identify advantages to increasing breastfeeding rates in the population • List 2020 Healthy People goals for breastfeeding • Access population-based breastfeeding data and describe patterns of breastfeeding in the US • Use knowledge about the physiology of breastfeeding to advocate for policies that support breastfeeding

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

5. 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.

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

7. AHRQ: Positive Findings for Infants

8. 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

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

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

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

12. AHRQ: Positive Maternal Outcomes

13. 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

14. Long-Term Protective Maternal Effects? • Wicklund et al, Pub Health Nutr, 2011: Finland; 16-20 years post partum, women who bf < 6 mos. had higher body fat mass, fat mass% and android region fat than women who bf > 6 mos. • Bobrow et al, Int J Obesity, 2012: UK Million Women Study (postmenopausal); Mean BMI lower among women who had breastfed, showing dose response 1% lower for every 6 months of breastfeeding; controlled for SES, smoking, PA.

15. Wicklund et al, Pub Health Nutr, 2011:

16. Wicklund et al, Pub Health Nutr, 2011:

17. 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

18. 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 • Note ADA position statement 2009 – environmental benefits not included….. *USBC

19. 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

20. 2007 Health Styles Survey

21. Healthy People Goals and Breastfeeding Data

23. 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

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

25. 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%

26. 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

27. Optimal Duration of Exclusive Breastfeeding: Cochrane, August 2012 • 23 studies (11 from developing countries): Infants who are exclusively breastfed for six months experience less morbidity from gastrointestinal infection than those who are partially breastfed as of three or four months, and no deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for six months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea.

28. Exclusive Breastfeeding

29. Healthy People 2020; & Report Card

30. Percent of Children Ever Breastfed by State among Children Born 2000 2004 2007

31. Racial and Ethnic Differences in Breastfeeding Initiation and Duration, by State --- National Immunization Survey, United States, 2004—2008. Weekly March 26, 2010 / 59(11);327-334

32. FIGURE. Prevalence of initiating breastfeeding* among Hispanics, non-Hispanic whites, and non-Hispanic blacks --- National Immunization Survey, United States, 2004--2008† Racial and Ethnic Differences in Breastfeeding Initiation and Duration, by State --- National Immunization Survey, United States, 2004—2008. Weekly March 26, 2010 / 59(11);327-334

33. Percent of Children Breastfed at 6 Months of Age by State 2000 2004 2006 2007

34. Percent of Children Breastfed at 12 Months of Age by State 2004 2006 2007

35. Percent of Children Exclusively Breastfed Through 3 Months of Age among Children born 2007 2005 National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

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

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

38. Percentage of children <six months old exclusively breastfed (2000-2006) http://www.unicef.org/nutrition/index_24824.html

39. Percentage of infants under the age of six months who are exclusively breastfed, 1995–2010 http://www.childinfo.org/breastfeeding_progress.html

41. State of the World’s Mothers Report, 2012: Save the Children

42. Assurance:What Works to Support Breastfeeding?

43. 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

44. The CDC Guide to Breastfeeding Interventions, 2005Six evidence-based interventions • Individual: • Educating mothers • Professional support • Intrapersonal: • Peer support/counseling programs • Institutional • Maternity care practices • Media and social marketing

45. Breastfeeding Policy Documents

46. Supporting Breastfeeding Mothers & Families Worksites & Childcare Healthcare Legislation

47. Mothers & Families

48. Support for healthy breastfeeding mothers with healthy term babies. Cochrane, May 2012 • “All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support that is only offered reactively, in which women are expected to initiate the contact, is unlikely to be effective; women should be offered ongoing visits on a scheduled basis so they can predict that support will be available.”

49. The Surgeon General’s Call to Action to Support Breastfeeding Actions for Mothers and Their Families: 1. Give mothers the support they need to breastfeed their babies. 2. Develop programs to educate fathers and grandmothers about breastfeeding. Actions for Communities: 3. Strengthen programs that provide mother-to-mother support and peer counseling. 4. Use community-based organizations to promote and support breastfeeding. 5. Create a national campaign to promote breastfeeding. 6. Ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding

50. Worksites & Child Care