American Academy of Pediatrics new policy statement on breastfeeding.

The American Academy of Pediatrics (AAP) released a policy statement titled "Breastfeeding and the Use of Human Milk" in the February 2005 issue of Pediatrics. This replaces their previous statement issued in 1997 and reflects advances in scientific knowledge and clinical management of breastfeeding. Over 200 supporting publications are referenced.

The statement reviews the challenges to improving rates of exclusive breastfeeding including lack of education, disruptive hospital practices, lack of postpartum support, maternal work leave, lack of support from family and from knowledgeable health care providers as well as misinformation from media.

The health benefits of breastfeeding for the infant as well as for the mother are well articulated. The AAP statement clarifies when and why breastfeeding is contraindicated, as well as conditions that are not contraindications. There are specific recommendations for healthy term infants as well as recommendations for high-risk infants.

In the United States, the number of women who start breastfeeding has increased since 1990. However, the number of babies who are breastfeeding exclusively at six months has not increased significantly. The challenge in promoting breastfeeding is to encourage and support women in breastfeeding exclusively until at least six months. The health benefits for both baby and mother are well documented and several international organizations recommend exclusive breastfeeding for at least the first year.

There are many factors that influence a woman's decision to wean or nurse. Accurate and thorough information is one. Support from the mother's partner, her family and community, as well as health care providers is another factor and is addressed in this statement. Lack of paid family leave and lack of support in the workplace are two major issues that we as educators, parents, health care providers should continue to discuss more vigorously.

Pediatricians, as well as other health care professionals, are given specific guidelines for helping mothers begin and maintain successful breastfeeding. This is important information for all labor assistants and childbirth educators to review. Many of the recommendations are for practices that are central to the midwifery model of care. Although it does not specifically mention labor assistants and childbirth educators, this policy does affirm the value of the informed care and support that they provide.

The current AAP guidelines reach beyond the individual pediatrician's practice and extend to supporting breastfeeding in hospitals, medical schools, and in our communities and our country as a whole. It is in alignment with several other official policies, such as the Department of Health and Human Services "Healthy People 2010 Initiative" and "The Ten Steps to Successful Breastfeeding" as outlined by UNICEF/WHO.

Below is a brief summary of the AAP recommendations on breastfeeding for healthy term infants. It would be an effective tool for discussion in childbirth classes or in prenatal meetings and will help your clients to advocate for mother and child focused policies.

For the complete, detailed publication, please refer to the AAP website at: http://aappolicy.aappublications.org/cgi/content/full/ pediatrics; 115/2/496.

Summary of Recommendations on Breastfeeding Healthy Term Infants.

1. Human milk is recommended for all healthy term infants. All parents should be fully informed about the research, benefits, and techniques for breastfeeding. If the mother is not able to breastfeed, her infant should be given expressed human milk until she is able to successfully do so. Pumping is advisable to maintain milk production and should be encouraged to continue until a mother is able to directly breastfeed. It is important to weigh the benefits of breastfeeding against the risks of not receiving human milk.

2. Involvement and understanding from the partner is an important part of successful breastfeeding. Both parents need to be educated about breastfeeding, prenatally as well as after the birth. Medications that can affect the infant's alertness and ability to nurse should be minimized. Procedures that can negatively affect the infant's feeding ability such as excessive or unnecessary suctioning should be avoided.

3. Immediately after birth, healthy infants should stay on the mother's chest, in direct skin-to-skin contact, until the first feeding is complete. The mother's body will thermoregulate to meet the infant's needs and is the best source of warmth for the infant. Healthy and alert newborns are able to locate the nipple and latch on without interference or assistance.

All routine procedures, such as Apgar scores and physical assessments can be done while the infant is in skin-to-skin contact with the mother. Weighing, measuring, bathing, eye prophylaxis, and Vitamin K and other needle sticks should be delayed until after the first feeding. Unless medically necessary, the newborn should remain with the mother throughout the entire recovery period.

4. "Human milk is the optimum nutrition for newborns". Unless it is ordered by a physician, there is no need to supplement breast milk with anything else.

5. Pacifiers should not be introduced until after breastfeeding is well established. The exception to this is for non-nutritive sucking and oral training for premature infants.

6. Breastfeeding is best initiated by continuous rooming-in throughout the day and night. During the first few weeks of breastfeeding, mothers should be encouraged to have 8 to 12 feedings every 24 hours. During this time the baby should be fed at least every four hours, waking the infant if necessary. Mothers should nurse from both breasts during each feeding, alternating the side that feeding begins to equally stimulate and drain each breast.

After breastfeeding is well established, the baby may feed less frequently, still at a minimum of 8 feedings in a 24 hour period. Feedings will occasionally increase during growth spurts or when milk production needs to increase.

Mothers should be encouraged to respond to the first signs of hunger, such as rooting, increased alertness and sucking motions. Crying is the last and most stressful sign of hunger.

7. During the postpartum hospital stay, breastfeeding mothers should be given professional support twice a day and each visit should be documented in her records. Any problems seen at the hospital should be addressed before the family leaves, with a clear plan of management that both the parents and medical team understand.

8. Infants who are breastfeeding should be seen by a pediatrician, or other health care professional who is knowledgeable about breastfeeding, between the third and fifth day of life. The infant should be examined for weight, signs of adequate hydration or jaundice and review the infant's elimination (wet and soiled diapers) pattern. The vist should also include an assesment of an actual feeding to check proper latch and transfer of milk. It should also include a review of the mothers' experience of pain/engorgement, etc. A weight loss of more than 7% will require further evaluation of breastfeeding and assistance to improve milk production and feeding.

9. All breastfeeding infants should be seen for a second visit at two or three weeks of age. The infant should again be checked for weight gain and the mother should be given any further information, support and encouragement that is necessary.

10. Exclusive breastfeeding provides for optimal growth and development for at least the first six months of life and protects against diarrhea and respiratory tract infections. Breastfeeding is recommended for at least a year and can continue for as long as is comfortable for both mother and child.

For healthy term infants, food rich in iron should be given starting around six months of age. For babies who were preterm, low birth weight or had hematologic disorders, iron supplementation may begin before 6 months.

Introducing solid foods is determined by the baby's preference and ability, usually between 4 and 8 months of age. Water, juice and other fluids are not necessary, even in hot climates, and in fact may introduce contaminants and empty calories. Infants who stop breastfeeding before 12 months should receive an iron-fortified infant formula, but not cow's milk.

"Increased duration of breastfeeding confers significant health and developmental benefits for the child and the mother. There is no upper limit to the duration of breastfeeding and no evidence of psychological or developmental harm from breastfeeding into the third year of life or longer".

11. After the infant has fed, but within the first six hours of life, it is recommended that a breastfed infant receive 1.0 mg. of Vitamin K1 oxide to prevent hemorrhage. Intramuscular Vitamin K1 is recommended because it provides better stores of Vitamin K. Oral administration of Vitamin K is not recommended unless repeaed doses are giving during the first four months of life.

12. It is recommended that breastfed infants receive 200 IU of vitamin D drops daily in the first 2 months and continue until the child is drinking 500ml. of vitamin D fortified milk or formula. Human milk does not contain enough Vitamin D to prevent rickets. Exposure to sunlight usually facilitates Vitamin D production. However, too much exposure to sunlight carries risks of sunburn or skin cancer and sunscreen inhibits vitamin D production.

13. Babies six months and younger do not require supplementary fluoride. After 6 months, and up to 3 years old, fluoride may be supplemented depending on the fluoride concentration in water, other food and fluid and toothpaste.

14. In order to assist the comfort and success of breastfeeding, the infant should sleep in close proximity to the mother.

15. In the case of hospitalization, a breastfeeding mother should be encouraged to keep nursing her infant. If direct nursing is not possible, the mother should be supported in pumping and feeding her infant expressed milk.

Pediatrics, Vol. 115, No. 2, February 2005