Breastfeeding & Public Health

2008

Functions of Public Health

Assessment
Policy Development
Assurance

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

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

Benefits of Breastfeeding
Health outcomes
Infant short term
Infant long term
Maternal

Economic
Environmental

Breastfeeding and the Use of Human Milk

American 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.

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

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

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.

Limitations of Breastfeeding
Outcome Studies
Definitions of breastfeeding;
misclassification
Lack of randomization; confounding &
residual confounding
Wide range in quality of evidence

AHRQ: Positive Findings for Infants

% less in BF

Acute otitis media

Atopic dermatitis
GI infection

(exclusive BF 3-6 mos.)

(exclusive BF 3 mos)

(infants breastfeeding)

Lower respiratory tract diseases

Asthma (in young children) no family hx, family hx
Obesity

50%
42%
64%
72%
27%, 40%
4, 7, 24%

Type I diabetes

19, 27%

Type 2 diabetes

39%

Childhood leukemia
Sudden Infant Death Syndrome
Necrotizing enterocolitis

15, 19%
36%
4-82%

AHRQ: Equivocal or insignificant

infant outcomes
Cognitive development in term or preterm
infants
CVD
Infant mortality in developed countries

AHRQ: Positive Maternal

Outcomes
% less in BF

Maternal Type II Diabetes (reduction in risk per

4, 12%

year of lactation)

Postpartum depression
Breast cancer (reduction per year of
lactation)
Ovarian cancer

association

4.3, 28%
21%

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

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

Breastfeeding and risk of obesity

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

Harder et al. Am J Epidemiol.

2005 (17 studies)
Length of
Odds Ratio for
Breastfeeding Risk of Obesity

95% CI

<1

1.00

0.65, 1.55

1-3

0.81

0.74, 0.88

4-6

0.76

0.67, 0.86

7-9

0.67

0.55, 0.82

0.68

0.50, 0.91

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

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.

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

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

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

Moses Lake Breastfeeding Data

Moses Lake Resident Survey (N = 254)

Statements about the
Community

%
Agree

%
Disagree

Babies in our community are more

likely to be bottle-fed first 6
months

55.1%

28.3%

It is not customary to breastfeed a

baby in public

61.0%

26.4%

Brzezney A. Unpublished Data (2003)

Moses Lake Resident Survey (N = 254)

Statements about
Worksites

%
Agree

%
Disagree

Workplaces in our community

make it easier for mother to
bottle-feed

61.4%

21.3%

Workplaces in our community

make it easier for mother to
breastfeed

8.7%

67.3%

(Barrier) Mothers dont want to

breastfeedmothers must
return to work

87.8%

3.5%

Brzezney A. Unpublished Data (2003)

Moses Lake Resident Survey (N = 254)

Statements about
Childcare
(Barrier) Mothers dont want to
breastfeedbaby starts
attending day care

%
Agree

%
Disagree

71.7%

14.2%

Brzezney A. Unpublished Data (2003)

Assessment
Rates of Breastfeeding and
Exclusive Breastfeeding

Percent of U.S. children who

were breastfed, by birth year

Breastfeeding Among U.S. Children Born 1999

2005, CDC National Immunization Survey

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 womens movement in
white well educated families

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

Healthy People Goals and

Breastfeeding Data

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

Healthy People 2010: Increase the proportion

of mothers who breastfeed their babies
Goal

US
Baseline

US
2004

WA
2004

WA
2005

Early
postpartum

75%

64%

74%

88%

90%

At 6
months

50%

25%

42%

57%

57%

At one
year

25%

16%

21%

32%

33%

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

Demographics of Breastfeeding
(NIS 2004)

Percent of Children Ever Breastfed by State

among Children Born in 2004

National Immunization Survey, Centers for Disease Control and Prevention,

Department of Health and Human Services

Percent of Children Ever Breastfed by State

among Children Born in 2005

Percent of Children Breastfed at 6 Months of

Age by State among Children Born in 2004

National Immunization Survey, Centers for Disease Control and

Prevention, Department of Health and Human Services

Percent of Children Breastfed at 6 Months of

Age by State among Children Born in 2005

Percent of Children Breastfed at 12 Months of

Age by State among Children Born in 2004

National Immunization Survey, Centers for Disease Control and

Prevention, Department of Health and Human Services

Percent of Children Breastfed at 12 Months of

Age by State among Children Born in 2005

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%

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

Exclusive Breastfeeding
US
2004

US
2005

WA WA 2005
2004

Through
3
months

31

36

50

45

Through
6
months

11

12

23

21

National Immunization Survey, Centers for Disease Control and

Prevention, Department of Health and Human Services

Rates of Exclusive Breastfeeding at

3 months (NIS, 2004)
Maternal Education
Less than high school
High school
Some college
College graduate
Income/poverty ratio
< 100
100 - 184
185 - 340
>350

%
24
23
33
42
24
29
34
39

Rates of Exclusive Breastfeeding at

3 months (NIS, 2004)
Education
Hispanic
White, non-Hispanic
Black, non-Hispanic
Asian, non-Hispanic
Other
Mothers age at birth of child
< 20
20-29
> 30

%
31
33
20
31

17
26
35

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

Percent of Children Exclusively Breastfed Through

3 Months of Age among Children born in 2005
(Provisional)

Percent of Children Exclusively Breastfed

Through 6 Months of Age among Children
Born in 2004

National Immunization Survey, Centers for Disease Control and

Prevention, Department of Health and Human Services

Percent of Children Exclusively Breastfed

Through 6 Months of Age among Children
Born in 2005

Assurance:
Evidence-Based Interventions
The CDC Guide to Breastfeeding
Interventions, 2005

Six evidence-based interventions

Individual:
Educating mothers
Professional support

Intrapersonal:
Peer support/counseling programs

Institutional
Maternity care practices

Media and social marketing

Four Interventions: Effectiveness not

established, encourage rigorous evaluation
1. Use contermarketing techniques to limit the
negative impact of formula marketing
2. Improve the knowledge, skills and attitudes of
health care providers re breastfeeding
3. Increase public acceptance of breastfeeding
4. Provide assistance to breastfeeding mothers
through hotlines or other information sources

Policies to Support
Breastfeeding
Key policy documents
Worksites
Healthcare
Legislation

Breastfeeding Policy Documents

1984

U.S. Surgeon Generals Workshop

1990

Innocenti Declaration, WHO and UNICEF

2000

Healthy People 2010: Objectives

2000

HHS Blueprint for Action on Breastfeeding

2001

US Breastfeeding Committee Strategic Plan

2003

WHO: Global Strategy for Infant and Young Child

Feeding

2003

WA State Nutrition & Physical Activity Plan

Key Policy Documents: Worksites

Global Strategy for Infant &
Young Child Feeding

Innocenti Declaration
WHO/ UNICEF (1990)

WHO/ UNICEF (2003)

Women in paid employment

obstacles to breastfeeding
can be helped to continue
within theworkplace
breastfeeding by bring
must be eliminated
provided with minimal enabling
conditions. paid maternity
leave, part- time work
arrangements, onsite crches,
facilities for expressing and
storing breastmilk and
breastfeeding breaks.

HHS Blueprint: Worksites

1. Facilitate breastfeeding or breastmilk
expression at the workplace by providing
private rooms, commercial grade breastpumps,
milk storage arrangements, adequate breaks
during the day, flexible work schedules and
onsite childcare facilities.
2. Establish family and community programs that
enable breastfeeding continuation when women
return to work in all possible settings.
3. Encourage childcare facilities to provide quality
breastfeeding support.

CDC Healthstyle Survey 2006

(Nationally representative postal survey N~5000)
Agree

Neither
Disagree
agree/
Disagree

I believe employers should provide

flexible work schedules, such as
additional break time, for
breastfeeding mothers

51

32

18

I believe employers should provide

extended maternity leave to make it
easier for mothers to breastfeed.

49

31

19

Healthstyle Survey, cont.

Agree

Neither
agree/
Disagree

Disagree

I believe employers should provide

a private room for breastfeeding
mothers to pump their milk at work.

47

29

24

I would support tax incentives for

employers who make special
accommodations to make it easier
for mothers to breastfeed.

30

34

36

WA Healthy Worksite Survey

Content: Measures policies, & environments to support
healthy nutrition, physical activity, breastfeeding and to
discourage tobacco use.
Population: WA businesses with 50+ employees, selected
from WA Department of Employment Security.
Sampling: Representative geographic sample across WA.
900 contacted, 540 responded.
Administration: Fall 2005. 15 minute phone survey of HR
managers, conducted by Gilmore. Repeat in 2007.
Background: DOH STEPS/CDNPA/Tobacco collaboration

Of the 400 Businesses with

Female Employees < age of 50:
11% had a specific policy to support
breastfeeding
82% provided flexible scheduling to allow
employees adequate break time to
breastfeed or pump/express breast milk
31% had a designated room or location
(not counting bathroom stalls) for mothers
to breastfeed or pump/express breast milk

Characteristics of Breastfeeding
Rooms

Key Policy Documents: Childcare

HHS Blueprint for
Action

WA State Nutrition & Physical

Activity Plan

(2000)

(2003)

Safe storage
Follow mothers
instructions
Provide quiet and
comfortable place for
mothers

Assure thatchild care facilities

are breastfeeding friendly.
Follow guidelines of
Breastfeeding coalition of
Washington.

Key Policy Documents: Health Care

Global Strategy for Infant &
Young Child Feeding

WA State Nutrition &

Physical Activity Plan

WHO/ UNICEF (2003)

(2003)

Virtually all mothers can

Support King County
breastfeed provided they have model breastfeeding
accurate information, and
standards.
support within their families
and communities and from the
health care system. They
should also have access to
skilled practical help from, for
example, trained health
workers, lay and peer
counselors, and certified
lactation consultants

Key Policy Documents: Health Care

International Code of
Marketing of Breastmilk
Substitutes

Innocenti Declaration
WHO/ UNICEF(1990)

WHO (1981)

No facility of a health care

system should be used for the
purpose of promoting infant
formula or other products

obstacles to
breastfeeding within the
health systemmust be
eliminated

Health workers should

encourage and protect
breastfeeding

every facility providing

maternity services fully
practices all ten of the Ten
Steps to Successful
Breastfeeding

HHS Blueprint: Health Care System

1. Train health care providers who provide
maternal and child care on the basics of
lactation, breastfeeding counseling and
lactation management during coursework,
clinical and in-service training and continuing
education.
2. Ensure that breastfeeding mothers have
access to comprehensive, up-to-date, and
culturally tailored lactation services provided by
trained physicians, nurses, lactation
consultants and nutritionists/dietitians.

Health Care System, cont.

3. Establish hospital and maternity center
practices that promote breastfeeding,
such as the Ten Steps to Successful
Breastfeeding.
4. Develop breastfeeding education for
women, their partners, and other
significant family members during the
prenatal and postnatal visits.

National Survey of Maternity Care Practices

in Infant Nutrition and Care (mPINC)
2,546 hospitals, 121 birth centers in the 50
states, DC, Puerto Rico
35 questions; 7 categories

labor and delivery,

breastfeeding assistance,
mother-newborn contact,
newborn feeding practices,
breastfeeding support after discharge,
nurse/birth attendant breastfeeding training and
education,
structural and organizational factors related to
breastfeeding
MMWR. June 13, 2008 / 57(23);621-625

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5723a1.htm#fig

mPINC: Key Findings

70% of facilities reported providing discharge
packs containing infant formula samples to
breastfeeding mothers
88% of facilities taught the majority of mothers
techniques related to breastfeeding
24% of facilities reported giving supplements
(and not breast milk exclusively) as a general
practice with more than half of all healthy, fullterm breastfeeding newborns
MMWR. June 13, 2008 / 57(23);621-625

Prospective Cohort Study to

Compare Breastfeeding
Environments in Moses Lake
and Centralia

Moses Lake & Centralia

Moses
Lake

Centralia

247

250

White

71%

90%

Hispanic

42%

24%

< HS grad

25%

24%

WIC/MSS

69%

75%

2.3

2.2

Total participants

Mean number of
children

Hospital Policies
Moses
Lake

Centralia

Lactation consultant
visited mother

45%

30%*

Newborn given something

other than breastmilk in
hospital

57%

55%

Newborn given a pacifier

51%

58%

Moses Lake

Centralia

Mother was
given free
formula

91%

80%*

Mother given
coupons for
formula

82%

76%
p = 0.003

Moses Lake

Centralia

Mother referred
to support group

20%

14%

Mother received
follow-up on
breastfeeding

29%

40%*
*p = 0.025

State Breastfeeding Legislation

Breastfeeding in public: 18 states give the
right to breastfeed in any place it is legal to be
Employment: 10 states encourage employers to
support breastfeeding mothers
Jury duty: 7 states exempt breastfeeding
mothers from jury duty
Family law: three states require breastfeeding
status to be considered in divorce or custody
decisions.

WA Breastfeeding Legislation
1. Amendment to indecent exposure law
A person is guilty of indecent exposure if he
or she intentionally makes any open and
obscene exposure of his or her person or
the person of another knowing that such
conduce is likely to cause reasonable affront
or alarm. The act of breastfeeding or
expressing breast milk is not indecent
exposure.

WA breastfeeding legislation
Am employer may use the designation infant
friendly on its promotional materials if the
employer has an approved workplace
breastfeeding policy addressing at least the
following:
Flexible work schedule, place to nurse/express with
handwashing facilities and refrigerator

DOH to approve employers, but no funds to do

this, so no worksites have been designated

CDC Breastfeeding Report Card

2007 Process Indicators
Percent of live births occurring
at facilities designated as Baby
Friendly (BFHI)
Number of IBCLCs ** per 1000
live births
Number of state health dept
FTEs dedicated to
breastfeeding

US
3.31

WA
8.97

2.12

4.15

81

CDC Report Card, cont.

US
46

WA
yes

State legislation about

lactation and employment

14

yes

Presence of an active
statewide breastfeeding
coalition

43

yes

State legislation about

breastfeeding in public
places

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