When the American Academy of Pediatrics (AAP) updated its breastfeeding guidelines this summer, local breast and human milk advocates say they wanted to shout “It’s about time!” from the rooftops. But, they say, guidelines are nothing without social and workplace policies to back them up.
Washington state has a strong record when it comes to new parents initiating breastfeeding – 92.5 percent start off feeding their babies at the breast at birth. Three months later, nearly 75 percent are still nursing, a number that drops to about 50 percent by one year of age according to the Centers for Disease Control and Prevention’s 2020 Breastfeeding Report Card.
Still, we’ve got a ways to go before Washington fully reflects the recommendations laid out in the Academy’s updated guidelines, the first such update in a decade.
When possible, just the breast to 6 months
As in its 2012 update, the new guidelines continue to call for exclusive breastfeeding through the first 6 months of life.
“Human milk is all a baby needs for the first six months of life,” said Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC, lead author of the reports, written by the AAP Section on Breastfeeding. “Breast milk is unique in its nutrients and protective effects, and really quite remarkable when you look at what it does for a child’s developing immune system.”
AAP and the World Health Organization both stress that exclusive breastfeeding to 6 months supports infant brain and immune system development while improving motor and intellectual development. Research shows that it also decreases risk of infant mortality as well as chronic diseases like childhood asthma.
Support for breastfeeding beyond age 2
The most significant change to the guidelines is in the area of long-term breastfeeding/human milk use. The AAP now recommends continued breastfeeding through age 2 “and beyond” if both mother and child desire to continue. In the 2012 update, the academy recommended continued breastfeeding up to one year.
Explaining the change in a news release, AAP pointed to the benefits of long-term breastfeeding to mother and child: “Preliminary data reveal that human milk in the second year of life continues to be a significant source of macronutrients and immunologic factors for growing toddlers.” Studies and meta-analyses also have confirmed the impact of breastfeeding longer than 12 months on maternal health, in decreasing maternal type 2 diabetes mellitus, hypertension, breast cancer and ovarian cancer rates.”
It’s a move that local breastfeeding advocates applaud and hope will normalize healthy nursing timeframes for parents, pediatricians and the public. They also hope it will increase exclusive followed by long-term breastfeeding rates in Washington, which currently put the state somewhere in the middle of the state-by-state rankings.
According to the Washington State Department of Health, despite the high initiation rates, only about 60 percent of babies are still being exclusively breastfed at the three-month mark and that number drops to less than 30 percent by six months. Several Seattle-area lactation consultants said the old guideline language was, in part, responsible for these curtailed rates as well as the fact that only half of babies breastfed at birth are still doing so at one year.
The language in old AAP guidelines “created a false narrative that breastfeeding past one year is somehow abnormal and that it is important for parents to wean immediately at one year,” says Betsy Hoffmeister, IBCLC, a Seattle-based lactation consultant.
In contrast, the new guidelines “encourage the pediatrician to think of breastfeeding/human milk feeding as normal and feeding past a year as normal,” Hoffmeister says. “It gives the pediatrician the language to provide a framework for parents to think about breastfeeding as something that can end naturally when both parties are ready, rather than as having a clearly demarcated end: You need to stop at one year. As this language trickles down, it may create a cultural change, where pediatricians suggest to parents that they breastfeed as long as all parties involved are happy — including into toddlerhood.”
Putting a stop to ridicule and stigmatization
UW/Seattle Children’s Pediatrician Dr. Beth Ebel, vice president of the AAP’s Washington Chapter and director of Harborview Injury Prevention and Research, agrees with that assessment. It is also echoed in the AAP guidelines:
“Mothers who decide to breastfeed beyond the first year need support,” as the new AAP recommendations note, adding that parents “often report feeling ridiculed or alienated in their choice and conceal their breastfeeding behavior to minimize unsolicited judgment and comments. There is evidence that only one-half of mothers who breastfeed past 1 year discuss their decision with their pediatric primary care provider and that 38% of women who reported that their provider was unsupportive of breastfeeding past the first year elected to change their pediatric primary care provider.”
“These recommendations help all of us,” Dr. Ebel says. “Often, moms haven’t felt comfortable discussing breastfeeding with their child’s pediatrician. We all need to support breastfeeding families in a nonjudgmental way. This is an opportunity to rethink, look at the data and follow the science that states if moms want to continue breastfeeding their baby beyond a year of life, there are benefits, and they absolutely should be supported to do so.
“I really like that this statement focuses on that work, on this crucial work of nonjudgmental support for families,” she adds.
Longtime Seattle-area lactation consultant Renee Beebe, IBCLC, was thrilled the report spoke to that elephant in the proverbial breastfeeding room:
“No more shaming of people who breastfeed beyond infancy!”
More training for pediatricians?
Some local advocates called for more breastfeeding training for pediatricians. But Dr. Mollie Greves Grow, MD, MPH, associate professor of pediatrics and associate program director for the University of Washington Pediatrics Residency, says locally trained pediatricians receive lactation training via numerous avenues.
“I’ve never heard anyone recommend stopping at a year because of the guidelines,’ Greves Grow says. She advises families that the timing of when mom and baby are ready to wean is a mutual decision. However, she says, “There is always benefit of more training.”
Ebel, Hoffmeister, Beebe and other breastfeeding advocates interviewed for this story all stressed that any cultural shift toward supporting breastfeeding into toddlerhood has to happen at the societal and policy level as well as the clinical level.
Increased breastfeeding rates: a policy issue
They say breastfeeding parents in Washington need better maternity leave, workplace breastfeeding accommodations, public facilities with breastfeeding rooms, equitable access to lactation consultants and other initial and ongoing support. Ebel stressed that all insurance companies should be mandated to cover breast pumps. She stressed that all workplaces need to provide paid time and a location for mothers to pump or feed their babies during the workday. According to the Washington State Department of Health, only 38 percent of employers in this state offer worksite lactation support programs.
Like Ebel, Hoffmeister says she is gratified that the AAP statement offers “at least a nod toward acknowledging gendered language” and recognizing the changing shapes of families. But while hopeful, Hoffmeister admits she’s skeptical the new guidelines will succeed in increasing long-term breastfeeding here or elsewhere given this “adamantly pro-formula era in which many parents are anxiously seeking out European organic formula whether their milk supply is excellent or not.”
Support for those who don’t or can’t breastfeed
The new AAP statement does acknowledge parents who cannot or should not breastfeed, noting they need the same support from their pediatrician.
“Not everyone can breastfeed or continue breastfeeding for as long as desired for various reasons, including workplace barriers,” said the guidelines author Younger Meek. “Families deserve nonjudgmental support, information and help to guide them in feeding their infant.”
Still, both Hoffmeister and Dr. Ebel worry that parents who read the new guidelines but struggle with breastfeeding or who, for whatever reason, are unable to offer their babies human milk could feel stigmatized or like they are failing their babies.
“”The messaging around the new AAP language should not be construed as recommending that all parents must provide human milk for two years, but rather that it gives breathing room for those who choose to,” says Hoffermeister. “Parents who are suffering with postpartum mood disorder, who have insufficient milk supply for medical reasons, need to be surrounded by loving support as they make truly difficult decisions.”
And, says Dr. Ebel, “They need to feel comfortable bringing up barriers with their care team so that they can be considered together.”
A call for health and policy equity
Local breastfeeding advocates stress that adequate support for all nursing parents – and system, societal and policy changes to make that support happen – are critical if the state and country are ever to achieve equity in breastfeeding and child health outcomes:
“To me, the most important part is directly addressing the inequity in human milk feeding outcomes,” Hoffmeister says. “The chart illustrating the different rates of breastfeeding between non-Hispanic Black parents and all other groups is deeply distressing, although not new or surprising.”
“We are failing to meet the needs of Black and Brown babies and parents and the results are fatal,” Hoffmeister says.
Below are the AAP’s key breastfeeding recommendations:
- The AAP recommends exclusive breastfeeding for about 6 months, with complementary food introduction at about 6 months, and as mutually desired by mother and child, and the AAP supports continued breastfeeding until 2 years or beyond.
- The AAP recommends that birth hospitals or centers implement maternity care practices that improve breastfeeding initiation, duration, and exclusivity, such as those in the WHO Ten Steps to Successful Breastfeeding, as monitored by the CDC.
- Pediatricians need to provide information so that parents can make an informed feeding decision. The parental feeding decision should be fully supported, without pressure or guilt by any member of the health care team.
- Parents giving birth should be supported to breastfeed through early initiation of skin-to-skin contact and frequent breastfeeding, with skilled lactation support readily available in maternity care facilities.
- Pediatricians are encouraged to use current resources, such as LactMed, to provide guidance and avoid disrupting breastfeeding unnecessarily, even temporarily, because most maternal conditions, medications, and vaccinations are compatible with breastfeeding.
- Pediatricians need to be knowledgeable about the health benefits of breastfeeding and breastfeeding management and skillful in providing culturally congruent breastfeeding care. Pediatricians can implement breastfeeding-supportive policies and practices in their offices and be ready to partner with community resources to improve breastfeeding support. Pediatricians and pediatric practices may consider partnering with lactation specialists to support breastfeeding parents and children.
- Pediatricians play a role in advocating for socially and culturally sensitive policies that support breastfeeding families and can work to address inequities in the delivery of care in the office, the hospital, and the community to eliminate disparities in breastfeeding.
- Pediatricians can assist parents who have given birth to preterm and other vulnerable infants to establish a full supply of milk by working with hospital staff to facilitate early, frequent milk expression. Pasteurized donor human milk is recommended for very low birth weight infants when the mother’s milk is not available or as a supplement to the mother’s milk.
- Policies that protect breastfeeding, including universal paid maternity leave, the right of a woman to breastfeed in public, insurance coverage for lactation support and breast pumps, on-site child care; universal workplace break time with a clean, private location for expressing milk, the right to feed expressed milk, and the right to breastfeed in child care centers and lactation rooms in schools are all essential to supporting families in sustaining breastfeeding.
- National breastfeeding rates through the age of 2 years should be tracked and data should be stratified by known breastfeeding disparities by national public health infrastructure. These data should be stratified by race, ethnicity, and socioeconomic demographics for known breastfeeding disparities by states, local health departments, hospitals, and pediatric practices, because these data will inform areas that need improvement.
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