Are Asian mothers influenced by Paediatricians in the USA to deprive Full Benefit of exclusive breastfeeding for first 6 months?

Most of the young Indian female Professionals and the spouses of budding professionals mostly software engineers and MBA’s in USA are falling prey to i) the conflicting messages like - “breastfeeding is a way to give children a good start in life, It’s just not the only way, We have good options to provide nutrition to infants that are not just breast feeding” ii) convenience of breast milk-feeding, ii) The Affordable Care Act’s mandating that the insurance plans must cover breast pumps, and that US employers allow mothers of children to take breaks to pump at work for up to a year after birth, iii) the middle classes have become able to more easily obtain consumer products thanks to automation and globalized manufacturing, elites have shifted their consumption patterns to more subtle status markers that enhance knowledge and health, iv) above all as their time saving strategy and v) inadequate guidance by the paediatricians regarding breastfeeding practices. The literature review indicated that Paediatricians in USA are inadequately trained in breastfeeding management and the skills needed to guide young breastfeeding mothers in the care of their new-borns.

The CDC Breastfeeding Report Card 2018 showed that initiation rates are high at 83.2%. However, less than 50% of those infants were exclusively breastfed through 3months of age and only about 25% were exclusively breastfed through 6months, highlighting how difficult breastfeeding continues to be in the United States. It is reported that among the ethnic groups Asian have the best breastfeeding rates. It was baffling that approximately 1 in 6 (17.2%) breastfed infants born in 2015 received formula supplementation within the first 2days of life.

I was also surprised to read that nearly, 24% of maternity service centres in USA provide supplements of commercial infant formula in the first 2days after birth as a general practice. These rates and practices suggest that mothers may not be getting the support they need from health care providers, and employers in the absence of family members to meet their breastfeeding goals.

On one side all professional organizations {American Academy of Paediatrics (AAP), American Association of Public Health (AAPH), American College of Obstetricians and Gynaecologists (ACOG)) are advocating strongly and influencing breastfeeding though they do not have any authority. On the other hand, there are a few publications like - The Case Against Breast-Feeding ‘The (marginal) health benefits of breastfeeding that quote ‘many of the benefits more commonly cited by breastfeeding advocates-like higher IQ and lower obesity rates-are impossible to disentangle’ are likely dissuade the neo-mothers.

These reports and my own interactions with about a dozen Indian origin mothers have led me to conclude that the disparities in breastfeeding rates are associated with variations in hospital routines in promoting feeding new-borns, independent of the populations they served and the lack of the family influences.

Therefore, there is a greater need and urgency in improving and standardizing hospital-based practices to realize the newer 2030 SDG targets.

Introduction

February and March of 2019, I was in Sunnyvale, San Francisco, CA, USA to be with my son Daughter -in Law (DIL) and their 4months old baby. I was surprised to see my DIL had started the practice of periodical direct breastfeeding coupled with pumping her breast milk and feeding the baby by 2nd month as she was advised by her Paediatrician. This, I was told to prepare the baby for top feeding once the mother needed to go to work after 4months of maternity leave. Benefits for her company employees in the US include 22-24weeks of paid leave for mothers who give birth, and 12weeks for non-birthing parent i.e. my son. Most companies also offer mothers’ Rooms in all its offices, backup childcare, parent support groups and peer mentoring from other parents as of Feb 15, 2019. Most of the young Indian female Professionals and the spouses of budding professionals mostly software engineers and MBA’s in USA are falling prey to the conflicting messages and inadequate guidance by the paediatricians regarding breastfeeding practices. Indian Primi- mothers without family support need lot of support for breastfeeding their new-born.

Materials & methods

Study setting

This is a purely qualitative study by interviewing a dozen Indian young mothers, in Bay area (San Francisco), LA, USA

Sampling, sample size

The sampling was purposive in nature, talking a to a dozen young Indian mothers most of whom (10) were Primigravida’s, all of them friends of my DIL, who had given birth to their babies in SF since January 2018 to March 2019

Data collection methodology

Data was collected. i) Personally by individual interactions using a short questionnaire. ii) Observing their breast feeding practices for attachment, positioning and suckling and satisfaction of the babies. iii) Breast milk pumping and feeding practices, perceived comfort and conveniences after seeking consent from both the lady and her husband. Each interaction lasted from 30-50minutes

Data analysis

Since the sample size was small no big data analysis was involved. The qualitative components were captured based on their experience in both breastfeeding and breast milk feeding (after pumping).

Results

All most all the mothers I interacted had resorted to breast milk feeding than to breastfeeding right from 1st month of the motherhood. All of them had learnt the skill of using breast pumps and spend lot of their time in pumping breastmilk, storing and using according to the babies’ needs as perceived by themselves. Majority had resorted to a mix of breastfeeding and breastmilk feeding for the sake of convenience and as a part of their own time planning. The Reasoning for Pumping and Bottle Feeding, a decision made before the child was born or breastfeed for a while included - i) A premature baby in the hospital NICU who couldn’t breastfeed. ii) Baby had difficulty in latching on to her breast. iii) Had to return to work or school right away. iv) Not sure if her milk supply was adequate and prefer to see or measure how much the child is getting. v) Breastfeeding was extremely painful, but she could tolerate pumping. vi) Was modest to report that she was uncomfortable with the idea of breastfeeding or. vi) she child both breast milk and infant simply did not want to breastfeed. Some of them had already introduced complementary feeding by the end of 2months.

Some of my interviewees opined that Combining Breastfeeding, Breast Milk Feeding and Formula Feeding was great experience that prompted them to breastfeed directly, pump for some feedings alternately and give the formula for others based on the recommendations like “You can choose to pump exclusively or give your child both breast milk and infant formula”. These were the mildest type of dissuading tactics mothers from exclusive breastfeeding in my opinion.

Some of them were influenced by quotes like “breastfeeding is a way to give children a good start in life, It’s just not the only way- We have good options to provide nutrition to infants that are not just breast feeding” and appeared to have been convinced of the argument. A few even quoted. The Affordable Care Act that mandates the insurance plans to cover breast pumps, and that US employers policy of allowing mothers of infants to take breaks to pump at work for up to a year after birth as justification of technical endorsement from national government.

Discussions

An estimated 70% of mothers in the United States initiate breastfeeding annually [1]. Thus approximately 3million of the more than 4million infants born in the United States each year will be breastfed for some period. The US government endorse WHO and UNICEF recommendations of breastfeeding and their commitment for implementing the same [2,3]. The CDC Breastfeeding Report Card 2018 [4], showed that initiation rates are high at 83.2%. However, less than 50% of those infants were exclusively breastfed through 3months of age and about 25% were exclusively breastfed through 6months, highlighting how difficult breastfeeding continues to be in the United States. Importantly, 60% of mothers are not reaching their breastfeeding goals, citing problems with latching, pain, inadequate milk supply and concern about maternal medications. Percentage of infants breastfed through 3months was 57.6% and Percentage of infants breastfed exclusively through 6months was 24.9%. Compared to rates for infants born in 2014, rates for infants born in 2015 increased for breastfeeding at 6 and 12months [4]. Among the ethnic groups Asian have the best breastfeeding rates [4]. The rates of exclusive breastfeeding through 3 and 6months have generally been increasing each year; however, they stayed virtually the same among infants born in 2015, compared with infants born in 2014. Approximately 1 in 6 (17.2%) breastfed infants born in 2015 received formula supplementation within the first 2days of life. In view of this situation Centres for Disease Control and Prevention funded AAP to conduct the Physician Engagement and Training focused on Breastfeeding project with an intent of engaging physicians and stakeholders to (1) increase availability and accessibility of medical provider education and training related to breastfeeding, and (2) improve capacity of medical practitioners to facilitate the safe implementation of evidence-based maternity care practices at the hospital level and within their practices, and to promote continuity of breastfeeding-related care in their communities [5]. The American Academy of Paediatrics is currently in the process of developing an office-based breastfeeding training curriculum with the goal of providing paediatricians with an improved skill set [1].

I was also surprised read that nearly, 24% of maternity service centres in USA provide supplements of commercial infant formula in the first 2days after birth as a general practice. These rates and practices suggest that mothers may not be getting the support they need from health care providers, and employers. Breastfeeding mothers particularly the primi-gravidas often need encouragement and support in the absence of family members to meet their breastfeeding goals. Majority of the family physicians and paediatricians of the mothers I met and from few other reports in USA appear to be feeling inadequately trained in breastfeeding management and may need to be empowered for the guidance in the care of breastfeeding mothers.

On one side all professional organizations {American Academy of Paediatrics (AAP), American Association of Public Health (AAPH), American College of Obstetricians and Gynaecologists (ACOG)) are advocating strongly for breastfeeding and influencing following global (WHO/UNICEF) guidelines though they do not have any authority. On the other hand there are a few individuals and agencies through publications like-The Case Against Breast-Feeding [5]. ‘The (marginal) health benefits of breastfeeding that quote ‘many of the benefits more commonly cited by advocates-like higher IQ and lower obesity rates-are impossible to disentangle from socioeconomic factors in observational studies, as Brown University economist Emily Oster points out. The few research experiments that have been done on breastfeeding outcomes don’t support the notion that breastfeeding has anything close to a make-or-break impact on child development”.

These reports and my own interactions with about a dozen Indian origin mothers have led me to conclude that the disparities in breastfeeding rates are associated with variations in hospital routines in promoting feeding new-borns, independent of the populations they served and the lack of the family influences. Therefore, there is a greater need and urgency in improving and standardizing hospital-based practices to realize the newer 2030 SDG targets. A study “Racial and Ethnic Disparities in Breastfeeding” [6], indicated that over the past decade, there has been a modest increase in the rate of “any breastfeeding” at 3 and 6months. But none of the subgroups have reached the Healthy People 2010 targets. As per recent study [4] “any breastfeeding” rate for the total US population was 43%, for the Hispanic or Latino subgroup was 46%, and for the non-Hispanic black or African American subgroup it was only 27.5%. The best breastfeeding rates of around 56% were for Asians [3]. Rates of exclusive breastfeeding were only 13% of the US population despite the recommendation to breastfeed exclusively for 6months. Thus, it appears that breastfeeding initiation rates are high, the targets for duration of any breastfeeding and exclusive breastfeeding are far from expected levels [7].

This observation contrasted with what The American Association of Paediatrics (AAP) advised [4]. The AAP recommends exclusive breastfeeding for about six months, continued breastfeeding as complementary foods are introduced and continuation of breastfeeding for one year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare1. Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not a lifestyle choice [4].

American Academy of Paediatrics (AAP) realizing the fact that Breastfeeding is immune-protective, when complementary foods are introduced and in USA for many infants, complementary feeding, including gluten-containing grains begins earlier than 6months of age, advises that this be done while the infant is feeding only breastmilk and urges paediatricians to encourage mothers to continue breastfeeding through the first year and beyond as more and varied complementary foods are introduced.

The more time a woman has at home with a baby on maternity leave, the more likely she is to breastfeed. What’s more, the body’s production of breast milk operates on a “use it or lose it” principle. Women who still want to provide breast milk after they return to work, have all the facilities at workplaces. They just need to stop and pump throughout the day at the same intervals at which a baby would eat in order to maintain their milk supply.

The Affordable Care Act mandates that insurance plans cover breast pumps, and that US employers allow mothers of children to take breaks to pump at work for up to a year after birth. As the middle classes have become able to more easily obtain consumer products thanks to automation and globalized manufacturing, elites have shifted their consumption patterns to more subtle status markers that enhance knowledge, health, and-above all-their time. Time is a luxury good, and elites’ ability to enhance and prolong it only expands this practice. Over a period of 2months stay I did literature review that suggest that the conflicting messages are leading to this action of depriving their newborn from the benefit of excusive breastfeeding.

Literature review

Breastfeeding supporting reports

A study titled “The Burden of Suboptimal Breastfeeding in the United States: A Paediatric Cost Analysis by Melissa Bartick and Arnold Reinhold (Paediatrics May 2010, 125 (5) e1048-e1056; DOI: https://doi.org/10.1542/peds.2009-1616) by The Agency for Healthcare Research and Quality (AHRQ) meta-analyses [8], that summarized excellently the health outcomes as:

a) Respiratory Tract Infections and Otitis Media: The risk of hospitalization for lower respiratory tract infections in the first year is reduced 72% if infants are breastfed exclusively for more than 4months.

b) Infants who exclusively breastfed for 4 to 6months had a fourfold increase in the risk of pneumonia compared with infants who exclusively breastfed for more than 6 months.

c) The severity as measured by duration of hospitalization and oxygen requirements of respiratory syncytial virus bronchiolitis was reduced by 74% in infants who breastfed exclusively for 4months compared with infants who never or only partially breastfed.

d) Sudden Infant Death Syndrome (SIDs): Meta-analyses noted that breastfeeding is associated with a 36% reduced risk of SIDS.

f) Celiac Disease: There was a reduction of 52% in the risk of developing celiac disease in infants who were breastfed at the time of gluten exposure

g) Diabetes: Up to a 30% reduction in the incidence of type 1 diabetes mellitus was reported for infants who exclusively breastfed for at least 3months avoiding exposure to cow milk protein

h) Economic Benefit: A detailed cost analysis concluded that if 90% of US mothers would comply with the recommendation to breastfeed exclusively for 6months, there would be a savings of $13billion per year

Breastfeeding discouraging reports

On the other hand, there are also a few confounding studies which support either breast milk feeding (pumping and bottle feeding) and or formula feeding [8,9]. If you believe that breast milk is the best food choice for your child, but you are not able to breastfeed, or you don’t want to, what can you do? That’s where pumping comes in. It’s OK to pump your breast milk and give it to your baby in a bottle. Pumping is a great way to provide your child with your breast milk without putting her to the breast.

The economic statements like “The thing we lose sight of is that even though breastfeeding’s cost is not visible, it costs so much more,” “The number of hours used to breastfeed a child for the year via AAP’s requirements is-thousands of dollars of a woman’s time that is.”. For a woman making $60,000 a year pre-tax, working 50hours per week, the monetary value of the time spent breastfeeding in the first six months-based on the average number and duration of daily feeds-is $14,250 [9]. Because the costs are not visible, it’s easier for people to tacitly judge a woman formula-feeding a young baby in a way they wouldn’t dream of doing if the woman was pushing the baby in a second-hand stroller. Without even being conscious of it, society has come to view breastfeeding as a status symbol [9]. The technical explanation of dissuading people from breastfeeding is drawn from: a) the largest randomized, controlled study of the effects of breastfeeding in the developed world, referred to as the PROBIT trial, began in Belarus in the 1990’s [10]. About half of the 17,000 mothers in the trial were randomly selected for a program that promoted breastfeeding and ultimately breastfed their children more; the others were left as a control group. The researchers did find that in this cohort, breastfeeding was correlated with lower rates of diarrhoea and eczema in infancy. But Oster’s review of the results, which Quartz confirmed, show that breastfeeding had no discernible impact on outcomes like infant mortality, respiratory infections, obesity, allergies, or IQ. b) The PROBIT trial, the largest of these studies (pdf), conducted by researchers at Ohio State University, did not find meaningful positive effects of breastfeeding. Using data from an annual survey of American households, the researchers examined health, behavioural, and academic outcomes of siblings between the ages of four and 14, from nearly 700 families where at least one child wasn’t breastfed and one of the others was. They looked at 11 measures of child wellbeing and found essentially no discernible difference between the breastfed and non-breastfed. All of this means that breastfeeding is a way to give children a good start in life. It’s just not the only way. “We have good options to provide nutrition to infants that are not just breast milk”, The most important thing is that the child is nourished [9,11-15].

Way forwards

Hospital routines to encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the American Academy of Paediatrics-endorsed WHO/UNICEF “Ten Steps to Successful Breastfeeding [2,3]. National strategies supported by the US Surgeon General’s Call to Action, the Centre for Disease Control and Prevention, and The Joint Commission should facilitate breastfeeding practices in US hospitals and communities. Family Physicians and Paediatricians play a critical role in their practices and communities as advocates of breastfeeding and thus should be knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and the techniques for managing and supporting the breastfeeding dyad. The “Business Case for Breastfeeding” details how mothers can maintain lactation in the workplace and the benefits to employers who facilitate this practice need to be aggressively implemented and monitored.

Paediatricians in USA or worldwide are not accustomed to treating adult women within their traditional scope of practice, but it is recommended that they provide medical advice and care to breastfeeding mothers. Maternal breastfeeding problems may be identified by family physicians and paediatricians in outpatient offices, hospital inpatient wards, maternity hospital nurseries, emergency departments, and urgent care clinics. Paediatricians should be skilful in describing the content of breast milk, recommend the frequency and duration of breastfeeding, assess breast milk adequacy, and, rarely discuss with mothers the contraindications to breastfeeding case by case. Paediatricians should also be able to identify difficulties and support young mothers in effective and proper latching or suckling the breast. They should also have a knowledge of available breast-pumping equipment that might aid the struggling mother if need be.

In my opinion USA needs to take following Key actions urgently

The family Physicians and paediatricians should be aware of social and cultural practices specific to the patient population in his or her geographic area and know the state-specific breastfeeding laws.

Paediatricians must make it a routine practice to discuss with all mothers and encourage them to provide exclusive breast milk for 6months.

Authorities and Volunteers should Monitor and discourage supplying of free formula and display educational materials

Every office to designate a room within the office space for breastfeeding and provide breaks every 2-3hours and encourage mothers to breastfeed in the office.

Paediatricians and nurseries should avail the services of a skilled lactation consultant especially to helpful mothers with problems in latching since patient support for such issues can be time intensive.

Insurance companies should be mandated to reimburse the costs of breastfeeding supplies like a breast-pumping kit compatible with the office’s electric breast pump, a hand pump for the mother to take home, nipple shields, breast shells, and breast milk storage bottles and labels.

Inpatient Paediatric Hospitals (IPHs) must be mandated to invest in breast pumps and breastfeeding supplies for use by all mothers of infants admitted to inpatient wards.

IPHs should provide tools (a scale sensitive enough to measure body weight before and after each feed) to measure the infant’s intake of breast milk.

States to ensure that all Maternity Hospital/Postpartum Units have met the requirements of the Baby-Friendly Hospital Initiative.

IPHs should ensure that all breastfeeding mothers make an appointment for outpatient follow up in a paediatric primary care provider’s office within the first 3days following discharge.

States to monitor and ensure that Emergency Department or Urgent Care Centres support each mother’s decision to continue breastfeeding, even if the reason for the emergency may be related to breastfeeding difficulty (e.g., infant dehydration or hyperbilirubinemia).

States to ensure that the recommendations for the use of breastfeeding equipment or medications for the mother, should preferably be recorded in the mother’s chart.

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2. WHO-Infant and Young Child feeding. Model Chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization.
3. UNICEF. Adopting Optimal Feeding Practices is fundamental to a Child's Survival, Growth and Development, but too Few Children Benefit.
4. (2018) Breastfeeding Report Card. Link: http://bit.ly/2TcNiQ7  
5. (2018) Physician Education and Training on Breastfeeding Action Plan, Recommended strategies to fill breastfeeding-related education and training gaps for providers at different career points, in different settings, and in different specialties. Link: http://bit.ly/2ThmYEm
6. Laroia N, Sharma D (2006) The Religious and Cultural Bases for Breastfeeding Practices Among the Hindu. Breastfeeding Med 1: 94-98. Link: http://bit.ly/2w5Y82h
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12. (2009) The Case Against Breast-Feeding, Hanna Rosin, The Atlantic Link: http://bit.ly/2TfMkCu
13. Sattva (2018) Breaking Breastfeeding Barriers for Working Women, Lakshmi Sethuraman, Link: impact@sattva.co.in
14. (2017) A systematic review of Breastfeeding Programs & Policies, Link: http://bit.ly/32t87v0
15. Jones KM, Power ML, Queenan JT, Schulkin J (2015) Racial and Ethnic Disparities in Breastfeeding. Breastfeed Med. 10: 186-196. Link: http://bit.ly/3cb8f6T