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The Quiet Underground is Quiet No More. Extended Breastfeeding is Officially Out of the Closet.

November 27th, 2012 by avatar

My first reaction to the now-infamous Time magazine cover was to groan out loud. Like many of you, I was horrified by that cover’s mean-spirited tone. If we didn’t get the message from the picture, there was also the antagonistic caption: “Are you mom enough?” It wasn’t until later that I recognized that this cover, and the controversy that followed, actually reflected a positive shift. Many things had changed since I first became aware of this topic more than 20 years ago.

In 1992, I was just finishing my post-doctoral fellowship at the University of New Hampshire and was expecting my second baby.  My first experience had gone not particularly well, so I spent months educating myself about birth, breastfeeding, and postpartum. During this time, I became friends with Dr. Muriel Sugarman. We were both on the board of a local child abuse organization in Massachusetts. Muriel was a child psychiatrist at Harvard’s Massachusetts General Hospital and an amazing ally to the breastfeeding community. She was interested in long-term breastfeeding and had collected some data. (“Long-term” was operationally defined for that study as “six months or longer.”)  We started working on it together, and bit by bit, had some findings to report.

We submitted one of our first articles on weaning ages to [a well-known journal in pediatrics].  Consistent with studies in other parts of the world, when weaning was child led, it tended to occur at ages 2.5 to 3. So far, so good.

But then there were our outliers….the babies who weaned at age 5…and a couple of babies were even older. The reviewers, all women we later learned, went completely nuts. If it had been up to them, we would have been both rejected…and flogged. (Eighteen years later, these are still the worst reviews I’ve ever received.) They hated us, our study, and mostly definitely our “weird” mothers.

I wasn’t sure what to do next, until a colleague handed me an article called, “Darwin takes on mainstream medicine.” It described how extended breastfeeding, babywearing, and cosleeping  conferred a survival advantage for moms and babies, and was presented at the American Association for the Advancement of Science meetings. That was radical stuff in the mid-1990s. I sacked our introduction and rewrote it using this framework.

The next question was where to send the revised manuscript. I called a pediatric researcher I knew in Philadelphia. He said, “Oh, I never send articles to [well-known pediatric journal]. They’re mean!” That had certainly been my experience. He recommended Clinical Pediatrics, where we got a much more positive reception. The article came out. We were happy. End of story….or so we thought.

In 1997, AAP Statement on Breastfeeding was released. Controversy swirled around that statement for months about one bit in particular: that women breastfeed for at least 12 months and “as long thereafter as is mutually desired.” I was going about my business, blithely unaware that Muriel and I were smack in the middle of the controversy. What reference did the AAP cite to support “as long thereafter as is mutually desired”? You’ve got it: Sugarman and Kendall-Tackett (1995)!

That paper taught me a lot. Ten years later, when I applied for APA Fellow, I identified it as one of the most important in my career. I learned firsthand about the intense negative stigma surrounding extended breastfeeding. I was equally amazed to discover a quiet underground of women who were defying cultural norms and nursing their older babies right under the radar of family, friends, and healthcare providers. Avery described this phenomenon as “closet nursing,” and noted that extended breastfeeding had a lot in common with revealing sexual orientation. Brave souls who chose to be up front faced marginalization—or worse.

Through much of the decade that followed publication of our article, Muriel and I, along with Liz Baldwin and Kathy Dettwyler, frequently had to write letters to courts and child protection agencies on behalf of mothers who were being investigated for child abuse. Their crime? Extended breastfeeding.

Which brings us up to the present time. Yes, the Time magazine article said mean things. But look at it this way: extended breastfeeding is being discussed in a mainstream publication. In addition, thanks to social media, the “quiet underground” is quiet no more. I’ve been amazed at outpouring of support from both celebrities—and ordinary moms—speaking opening and positively about extended breastfeeding. It was something I couldn’t even imagine in 1995. I think it’s safe to say that extended breastfeeding is officially out of the closet.

In closing, I’d like to suggest that we all owe a debt of gratitude to Drs. Ruth Lawrence and Larry Gartner, and the other brave members of the 1997 AAP Committee on Breastfeeding. Their statement did much to move extended breastfeeding out of the margins and into the public square (and Muriel and I were happy to have a small part in that). We still have a ways to go. But let’s take a moment and savor this small victory.

And to the members of the 1997 AAP Committee, I say this: We, the quiet underground, salute you!

The two articles published from that data set are:

Kendall-Tackett, K.A., & Sugarman, M. (1995). The social consequences of long-term breastfeeding.  Journal of Human Lactation, 11, 179-183.

Sugarman, M., & Kendall-Tackett, K.A. (1995). Weaning ages in a sample of American women who practice extended nursing. Clinical Pediatrics, 34(12), 642-647.

 About Kathleen Kendall-Tackett

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press, a new small press specializing in women’s health. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. www.KathleenKendall-Tackett.com

 

American Academy of Pediatrics, Breastfeeding, Guest Posts, Research , , , , , , , ,

Parental Autonomy in Decision Making: A Follow-Up to the AAP’s Newborn Male Circumcision Policy Statement

September 5th, 2012 by avatar

Deena Blumenfeld follows up my recent post on the AAP’s new policy statement on circumcision with a great look into what it means to have parental autonomy for minor children and how childbirth educators need to look out into the faces of their students, recognizing that the families in our classes come from a wide variety of backgrounds and bring a diverse set of cultural norms as they enter the world of parenthood. – SM

On Monday, August 27, 2012 the American Academy of Pediatrics released their new Policy Statement on Male Circumcision. This is a follow-up post to the Science & Sensibility post written last week by Sharon Muza. In that post, Sharon did a lovely job of explaining the Policy statement and asking some pertinent questions to us, the childbirth educators, regarding how this affects the classes we teach.

Photo Image Creative Commons Anthony J

The majority of other pregnancy, birth and parenting organizations have played it very safe, by doing nothing more than noting that the AAP has updated their policy. ACOG affirms and supports the AAP’s policy on circumcision, but it is the obstetricians who do the majority of the circumcisions in a hospital setting, so this is logical.  I’ll be the brave one and step out into the frying pan.

This article is not intended to examine every aspect of the policy for its validity, strength of evidence or research points left untouched. My intention is not to debate condom usage, Medicaid, money, the usability of the Africa studies or the fact that the AAP did not mention anything about the function of the foreskin. Enough of this dissecting is going on elsewhere online, in both conference rooms and living rooms.

I wanted to look at the AAP’s circumcision policy statement from a different perspective. In much of the coverage I’ve read online, I find much vitriol, anger and self-defensiveness, as well as overly aggressive behavior and dismissive or patronizing attitudes. This is entirely unsurprising. Circumcision has been a “hot button” issue for many years. This reaction comes not only from the mainstream media and individuals but also from the anti-circumcision organizations as well.

I’d now like to look at something that has been touched on, but glossed over by the mainstream media with regards to this policy. It’s also been virtually ignored by the opponents of circumcision as well.

That is, these series of statements made by the AAP in their policy statement:

“Parents should determine what’s in the best interests of their child.”

“Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.”

“Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being. Reasonable people may disagree; however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well. It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.” (Emphasis mine)

 “It emphasizes the primacy of parental decision-making…”

This theme of parental choice is written throughout the document, overshadowing the medical evidence presented.

Circumcision is a fundamental part of the core belief system for many people, whether stemming from religious practice or social norms. When we have new scientific evidence that is in contrast to such a core belief, people feel rattled and defensive. A mother recently said,

“I really think they took a stance on the issue because Medicaid dropped coverage. And I agree that it should be covered. But now those of us who choose to leave our sons intact can be left to feel irresponsible.” (Emphasis mine)

On the medical side, just as we do with prenatal testing, medications or procedures during labor, vaccines for our children, etc., we look at the benefits of the treatment and the risks. We compare these to our own risk tolerance levels and then decide “Is this treatment / medication / procedure right for me?”

On the softer, but no less valid side, are our belief systems. We use our religion, our upbringing, and our societal norms to help us determine the right course of action. For example, a Jehovah’s Witness will decline a blood transfusion or other blood products because it is not within their framework. There are those who say this is “silly” or “dangerous,” yet we respect this practice in hospital because it is appropriately respectful of that individual’s autonomy.

When it comes to circumcision, the decision making process should be no less than it is for any other medical procedure. Primum non nocere, first do no harm, must include religious beliefs and societal norms to preserve patient autonomy. By ignoring these, in favor of a strictly medical practice, the physician does emotional harm to the patient. If we are to foster an environment of trust and respect between doctor and patient, then the doctors need to respect the patient’s social norms and mores. Conversely, the patient must respect the doctor’s position providing the best evidence to support or oppose a procedure / treatment / medication, etc.

With circumcision, the patient is an infant. This presents an interesting ethical dilemma. The medical decision may or may not jive with the parents’ personal paradigm. The infant has not the capacity to make the decision for himself. He is, by legal definition, incapable of making such choices for himself, and at a practical level a two day old baby cannot understand nor communicate his desires or reservations about circumcision.  Therefore the decision regarding circumcision lies solely with his parents and the argument for infant or child autonomy becomes moot. The AAP acknowledges as much.

 “The practice of medicine has long respected an adult’s right to self determination in health care decision making. This principle has been operationalized through the doctrine of informed consent. The process of informed consent obligates the clinician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives so the patient can make an informed choice. As a general rule, minors in the United States are not considered competent to provide legally binding consent regarding their health care, and parents or guardians are empowered to make health care decisions on their behalf.”

This brings me full circle to the first post regarding the AAP’s policy on circumcision and Sharon’s question regarding how as childbirth educators, do we address this in class? Personally, I find it a daunting topic to broach, and I have a vain hope that all my students are having girls, so that I don’t need to discuss it at all.

It’s a tough game of balance to negotiate my own bias towards leaving boys intact, the factual information I need to provide to my students, and their predetermined decision regarding circumcision. From the AAP’s recent policy statement;

 “There is fair evidence that parental decisions about circumcision are shaped more by family and sociocultural influences than by discussion with medical clinicians or by parental education.”

“For parents to receive nonbiased information about male circumcision in time to inform their decisions, clinicians need to provide this information at least before conception and/or early in the pregnancy, probably as a curriculum item in childbirth classes. Information to assist in parental decision-making should be made available as early as possible.”

So, I do broach the subject. I find most parents are receptive and open to the information I offer in class. The comments I hear most are “Oh, I didn’t know I couldn’t go with my son for the procedure.” “I didn’t know I had a choice, I thought everybody circumcised.” “That’s how they do it?!?”

Parents need to know all of their options, with regards to circumcision. Do it, or not; do it in hospital, in the doctor’s office or at home in a religious setting; do it now, do it later; benefits and risks, and so on.

 They also need to know that their upbringing, social norms, religion, etc. matter. Not only does the AAP think they matter, but I do too. I don’t walk in my student’s shoes. I don’t know their life experience, their religion or their conventions. We are relative strangers, yet we discuss some very personal topics. I find it imperative that I give my students all the information I can, so they can make the best choices for their family.

“Be kind, for everyone you meet is fighting a hard battle.” -Plato

We can never fully understand from whence another person’s opinions rise. Our beliefs polarize us. The middle is often lost in the shuffle because we defend our ideals to the death. The other person is wrong, no matter what. Somewhere along the way we lost compassion and empathy. When we have such strong feelings towards another group we lose sight of the others’ humanity.  “Remember, the other person is you.” – Yogi Bhajan

 Please, keep your sense of compassion when discussing the issue of circumcision with new parents in your classes and with those whom you interact with online.

 “If you want others to be happy, practice compassion. 

If you want to be happy, practice compassion.”

Dalai Lama

American Academy of Pediatrics, Babies, Childbirth Education, Circumcision, Evidence Based Medicine, Guest Posts, informed Consent, Newborns, Parenting an Infant, Research, Social Media , , , , , , ,

American Academy of Pediatrics Releases Revised Policy on Newborn Male Circumcision

August 27th, 2012 by avatar

photo licensed by creative commons handmaidenbymaria

On August 27th, 2012, the American Academy of Pediatrics (AAP) released their updated policy on newborn male circumsion along with their updated technical report reviewing current research. This official statement follows a week or so of speculation in the media that the AAP’s new statement would fall on the side of supporting newborn male circumcision, stating that the benefits outweigh the risks.

The new policy statement replaces the last AAP recommendation on this topic released in 1999 (1). The just released statement makes the following recommendations:

  • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.

  • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.

  • Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.

  • Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

  • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.

  • Elective circumcision should be performed only if the infant’s condition is stable and healthy.

  • Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.

  • Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.
    • Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.

    • If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.

  • Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:
    • Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;

    • Teach the procedure and analgesic techniques during postgraduate training programs;

    • Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;

    • Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.

  • The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.

As a result of research by the AAP Task Force commissioned for the purpose of updating their policy statemen, specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/ sensitivity or sexual satisfaction. This task force was made up of AAP representatives from specialty areas, including anesthesiology/ pain management, bioethics, child health care financing, epidemiology, fetus and newborn medicine, infectious diseases (including pediatric AIDS), and urology. The Task Force also included members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the CDC

Male circumcision consists of the removal of some or all of the foreksin (prepuce) from the penis. It is one of the most commonly performed procedures in the world and in the United States is most commonly done during the newborn period. The current estimated rate of male circumcision in the United States ranges from 42% to 80% among various populations.(2–6)

Circumcision rates were highest in the Midwestern states (74%), followed by the Northeastern (67%) and Southern states (61%). The lowest circumcision rates were found in the Western states (30%) (See Table 1)

Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990

The AAP discussed the ethical issues of newborn male circumcision, recognizing that the law allows parents or guardians to make medical decisions on behalf of the minors that they are responsible for, when provided unbiased information by a health care provider and taking into account cultural, religious, ethnic traditions and medical factors. The parents or guardians should be advised to take this into consideration. The AAP reccomends HCPs counseling families that are choosing to circumcise their male newborns to use a qualified medical provider in a medical facility rather than a traditional/religious provider in a nonmedical environment. There was also discussion on counseling parents about the potential risks of delaying the procedure beyond the newborn period, The AAP Task Force stated that there is less risk to the child when the procedure is done as a newborn.

Prevalence of male circumcision, according to self-report; United States, 1999–2004 Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990.full.pdf+html

The AAP does acknowledge that this procedure is elective and the parents should be informed that this is considered an elective procedure.

The AAP Task Force, in their technical report, shares their current literature review and research findings that provided for the basis of each of the current recommendations. Additionally, the technical report discusses studies that provide information on risks and complications of this elective procedure. The technical report is a comprehensive review of the information the AAP used to formulate their current recommendations and I encourage you to not only read it for your own information, but to have it available as a resource for parents who are looking for the full statement and the research behind it.

Future Research is Needed

The Task Force identified important gaps in their knowledge of male circumcision and urges the research community to seriously consider these gaps as future research agendas are developed. Although it is clear that there is good evidence on the risks and benefits of male circumcision, it will be useful for this benefit to be more precisely defined in a US setting and to monitor adverse events. Specifically, the Task Force recommends additional studies to better understand:

photo licensed by creative commons Nina Matthews Photography

  • The performance of elective male circumcisions in the United States, including those that are hospital- based and nonhospital-based, in infancy and subsequently in life.
  • Parental decision-making to develop useful tools for communication between providers and parents on the issue of male circumcision.
  • The impact of male circumcision on transmission of HIV and other STIs in the United States because key studies to date have been performed in African populations with HIV bur- dens that are epidemiologically dif- ferent from HIV in the United States.
  • The risk of acquisition of HIV and other STIs in 0- to 18-year-olds, to help inform the acceptance of the procedure during infancy versus deferring the decision to perform circumcision (and thus the procedure’s benefits) until the child can provide his own assent/consent. Because newborn male circumcision is less expensive and more widely available, a delay often means that circumcision does not occur. It will be useful to more precisely define the prevention benefits conferred by male circumcision to inform parental decision-making and to evaluate cost-effectiveness and benefits of circumcision, especially in terms of numbers needed to treat to prevent specific outcomes.
  • The population-based incidence of complications of newborn male circumcision (including stratifications according to timing of procedure, type of procedure, provider type, setting, and timing of complications [especially severe and non- acute complications]).
  • The impact of the AAP Male Circumcision policy on newborn male circumcision practices in the United States and elsewhere.
  • The extent and level of training of the workforce to sustain the availability of safe circumcision practices for newborn males and their families.

The Role of The Childbirth Educator

The decision of whether to circumcise a male newborn is frequently made early in the pregnancy and even before conception.(7-9) In a cross-sectional study of parents of 55 male infants presenting to a family practice clinic for a well-child visit, 80% of parents reported that the circumcision decision was made before a discussion occurred with the clinician about this issue. Only 4% of parents reportedly discussed circumcision with their clinician before the pregnancy.(6) This finding is substantiated by the 2009 AAP survey of 1620 members with a response rate of 57%, in which most respondents reported that parents of newborn male patients generally do not seek their pediatrician’s recommendation regarding circumcision; only 5% reported that “all” or “most” parents “are uncertain about circumcision and seek their recommendation” about the procedure. (10) There is fair evidence that parental decisions about circumcision are shaped more by family and socio- cultural influences than by discussion with medical clinicians or by parental education.(7, 11)

The AAP states that parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception and/or early in pregnancy, which is when they are making choices about circumcision.

I found it interesting that research indicated that most parents have most likely made a decision on newborn male circumcision prior to participating in any childbirth classes that they may be attending. I also know that talking about circumcision in a childbirth class can be a sticky, uncomfortable and emotional discussion for both attendees and educators. It may be difficult but it is important to share information on this topic in the same way that we share other information about pregnancy, labor, birth and parenting; providing resources, sources of information and avenues for additional information that the parents can access later for information.

I invite you to share your thoughts on the new AAP recommendation on newborn male circumcision and how you discuss this topic in your childbirth classes. Do you avoid speaking about it altogether because it makes you uncomfortable? How do you bring it up? What do you do when the topic becomes emotional amongst participants? Will you change what you do based on this newly released recommendation? I invite discussion but ask that you follow Science & Sensibility’s policy on participation and keep all comments polite and respectful. – SM

References

  1. American Academy of Pediatrics. Circumcision Policy Statement. Task Force on Circumcision. Pediatrics. 1999;103(3):686– 693. Reaffirmation published on 116(3): 796
  2. Centers for Disease Control and Prevention (CDC). Trends in in-hospital newborn male circumcision—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2011;60(34): 1167–1168
  3. Warner L, Cox S, Kuklina E, et al. Updated trends in the incidence of circumcision among male newborn delivery hospitalizations in the United States, 2000-2008. Paper presented at: National HIV Prevention Conference; August 26, 2011; Atlanta, GA
  4. Overview of the Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; 2009. Available at: www.hcup-us. ahrq.gov/overview.jsp
  5. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005;173(3):978–981
  6. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis. 2007;34(7): 479–484
  7. Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract. 1999;12(1):16–20
  8. Walton RE, Ostbye T, Campbell MK. Neonatal male circumcision after delisting in Ontario. Survey of new parents. Can Fam Physician. 1997;43:1241–1247
  9. Ciesielski-Carlucci C, Milliken N, Cohen NH. Determinants of decision making for circumcision. Camb Q Healthc Ethics. 1996;5 (2):228–236
  10. American Academy of Pediatrics. Periodic Survey of Fellows: Counseling on Circumcision. Elk Grove Village, IL: American Academy of Pediatrics; 2009
  11. Binner SL, Mastrobattista JM, Day MC, Swaim LS, Monga M. Effect of parental education on decision-making about neonatal circumcision. South Med J. 2002;95 (4):457–461

American Academy of Pediatrics, Childbirth Education, Circumcision, informed Consent, Newborns, Parenting an Infant, Research , , , , , , , ,

Donor Milk and Milk Banks; A Gift That Saves Lives

August 7th, 2012 by avatar
This week, in recognition of World Breastfeeding Week,  I am attending a fundraiser in my community, Seattle, for the Northwest Mothers Milk Bank, (NWMMB) which includes a reception and screening of the documentary, Donor Milk.  I am excited to support this important mission and am looking forward to viewing the film and participating in the Q&A afterwards with the filmmakers, NWMMB team members, a donor mom and a physician who routinely prescribes donor breastmilk for patients.
Science & Sensibility’s Lisa Baker and Deena Blumenfeld discussed the newest American Academy of Pediatrics’ statement on Breastfeeding and the Use of Human Milk, Donor Milk for Preterm Infants and the formation of a donor milk bank in Calgary, Alberta, Canada in some posts earlier this year.
I wanted to learn more about Northwest Mothers Milk Bank right in my own backyard, so I contacted Scotti Weintraub, Executive Board Member for the organization to get some of my questions answered.
Sharon Muza: Whose idea was it to start the NWMMB?

Scotti Weintraub:  A group of local lactation professionals had been talking about the need for a milk bank for several years.  In spring 2008, enough people were talking about it that an open meeting was held for anyone interested in starting a milk bank.  From that initial meeting grew the beginnings of a board of directors and a committed group of volunteers.

Sharon Muza: Why Portland, OR and the Pacific Northwest?

Scotti Weintraub:  Right now the closest nonprofit milk banks are in Denver and San Jose.  Oregon and Washington have the highest breastfeeding rates in the country so it makes sense that we’d have a milk bank in the Northwest.   Our volunteer effort grew in Portland and we incorporated as a nonprofit in Oregon.

Photo courtesy of NWMMB

 Sharon Muza: How has the vision of a milk bank been received in your community?

Scotti Weintraub: Very positively!  People involved in lactation are extremely supportive of our mission and want to see a milk bank open.  When we talk to the public, we often get asked, “Shouldn’t Portland already have a milk bank?” They are right – it would make sense that Portland and the Northwest would already have a milk bank.

Potential donor moms have been also very interested and supportive. We have a great deal of education and outreach work to do in the broader medical community.  The research is strongly in support of the use of donor milk and it is evidence-based best-practice.  But there are some who have been slow to embrace the unknown and have questions.  Part of our work up to and from here is to educate medical professionals and increase the use of donor milk.

Sharon Muza: Have there been any concerns or less supportive comments or actions?

Scotti Weintraub: Overwhelmingly people have supported our efforts.  When we are questioned about the safety of donor milk or why it’s so important, we point to the clear research.  Similarly, the AAP, WHO and the Surgeon General have all advocated donor milk as the next best food for babies if their own mom’s milk isn’t available.

Photo courtesy of NWMMB

 Sharon Muza: Are you modeling your bank after one already in existence?

Scotti Weintraub: The Human Milk Banking Association of North America has been hugely helpful in our start-up process.  Member milk banks have graciously shared their insight, time and wisdom.  We are modeling as much as can on their success.

But each community is unique and each milk bank is unique in its structure, how it’s funded and how it operated within its community. The Northwest Mothers Milk Bank is an independent 501c3 organization whereas many milk banks are part of a larger hospital system or hospital foundation.

 Sharon Muza: How many human milk banks are there in the US right now?

Scotti Weintraub: Right now there are 11 operating milk banks in the US.  There are several that are considered “Developing” like NWMMB – meaning that we have met some criteria set out by HMBANA and are in the works.  A couple other milk banks are not yet considered “Developing” but are moving in that direction.  Here’s the list.

Sharon Muza:  What is the cost to families who need milk?

Scotti Weintraub: Milk banks charge processing fees to cover the costs of screening donors, processing, pasteurizing, and culturing the milk and shipping.  This fee is set by the individual milk bank based on their costs, so we don’t yet know what NWMMB will charge for processing fees.

Donor milk that is dispensed while a baby is in the hospital is charged through the hospital.  Some of our NW hospitals are providing donor milk to their patients and are absorbing the costs into their budgets.  Some insurance companies cover donor milk.  There is more work to be done encouraging insurance companies to cover the costs of donor milk.

Photo courtesy of NWMMB

Since we are not yet open, I will share the policy from Mothers’ Milk Bank Austin, TX

“When your baby is hospitalized, the milk processing fee and shipping are billed to the hospital, and subsequently your insurance company. If a baby is not hospitalized, the fee will be billed to you. Texas Medicaid currently covers the cost for donor milk for a limited period of time, when medically necessary. If your family has private insurance, we encourage you to file a claim. We are happy to work with the family, the baby’s healthcare provider and insurance company to obtain coverage. If necessary, we can establish a payment plan. All babies with a medical need for milk, whose moms cannot provide milk, are eligible to receive it for at least a limited time, regardless of ability to pay.”

 Sharon Muza: What is the cost to collect, test, process and distribute milk?

Scotti Weintraub:  Nonprofit milk banks do not recoup their processing costs with the processing fees they charge and must raise additional funds.  Costs vary a bit depending on volume, equipment, etc.

Sharon Muza: Who will the milk be available to?  How will priority be determined?

Scotti Weintraub: Donor milk is available by prescription only.  Priority is given to the sickest and most vulnerable infants depending upon availability.  So there is a triage system for dispensing milk, especially during times of low supply.

 Sharon Muza: Under what circumstances are babies most likely to need donor milk?

Scotti Weintraub:

  • preterm birth
  • failure to thrive
  • malabsorption syndromes
  • allergies
  • feeding/formula intolerance
  • immunologic deficiencies
  • pre- or post-operative nutrition
  • infectious diseases

 Sharon Muza: What if a family cannot afford the milk?

Scotti Weintraub: Families are not turned away due to inability to pay.

 Sharon Muza: How is the donor milk tested and treated to insure its safety?

Scotti Weintraub: Here’s how the milk is processed.  The milk is pasteurized and then cultured to ensure the absence of bacteria.  Frozen donor milk is thawed, nutritionally analyzed, cultured, pooled and poured into bottles, then pasteurized at 62.5 C in a shaking water bath or automatic pasteurizer. Pasteurized milk is quick-cooled, then frozen at -20’C. Microbiological cultures are obtained by an independent laboratory from individual donors’ deposits prior to pasteurization and pooling, and from each batch of milk after pasteurization. This is done to verify that no heat-resistant pathogens are present before pasteurization, and that there is zero growth of bacteria after the heating process.

Sharon Muza: What are the obstacles to establishing the Northwest Mothers Milk Bank?

Scotti Weintraub: Fundraising!  If someone gave us a check for $150,000 tomorrow we could be open in a matter of months.  We have raised over $300,000 but must raise the remaining $150,000 before we can open.  As soon as we have secured the necessary funds, we will work quickly to open.

 

Photo courtesy of NWMMB

Sharon Muza: How much milk do you anticipate moving through your milk bank yearly?

Scotti Weintraub: We anticipate processing at least 40,000 ounces (more than 312 gallons) a year.  We also know that we are shipping a large volume of milk out of the region right now.  For instance, in June we shipped over 5,700 ounces of donated milk from four of our Donor Drop Off Sites to other milk banks.  And that’s only the milk from less than half of our current drop-off sites (the others haven’t yet reported their volume).  We anticipate growing the number of drop-off sites and donors once we open.  So we expect to have a large volume right away.

Sharon Muza: How can childbirth educators help spread the word about donor milk in their classes, both for potential donors and those in need?  

Scotti Weintraub: Everyone who works with pregnant and new parents can play a role in spreading the word.  Childbirth educators can tell expectant families about the availability of donor milk should they need it (most have no idea what donor milk is or that they could access it) and let them know that donation is also possible, if they have an abundance.

You can also encourage medical facilities and providers to utilize donor milk for their patients.  Find out if donor milk is available in your area NICUs and family birth units.  Share information about research and best practices to encourage the use of donor milk.

Sharon Muza: Can nursing mothers with babies of any age donate milk? Do you try and match new mothers’ milk with new babies?

Scotti Weintraub: Each milk bank sets their own donor requirements based on the HMBANA guidelines.  Generally milk is accepted from babies less than one year old.  All milk donations are pooled – meaning that the milk from 3-5 donors is mixed together within one batch.  This ensures even distribution of the milk components.  Occasionally, specialized milk is available – for instance preterm milk or dairy-free milk.

NWMMB Education Vid from Bob Eggleston on Vimeo.

Sharon Muza: What are some of the benefits of donor milk for babies?

Scotti Weintraub: According to the AAP, these are the benefits:

  • lower rates of necrotizing enterocolitis (NEC) and sepsis
  • fewer readmissions to hospital
  • higher intelligence testing scores and higher total brain volume
  • lower rates of retinopathy of prematurity
  • lower blood pressure and low-density lipoprotein concentrations
  • improved leptin and insulin metabolism

Sharon Muza: Can older children with severe allergies have access to the milk?

Scotti Weintraub: Milk is sometimes available to older children or adults for a variety of conditions depending on availability.

Sharon Muza: Any final comments to share with our educators and other birth professionals and readers? 

Scotti Weintraub: Donor milk is lifesaving for our most vulnerable babies and it’s very cost effective.  Just for NEC,

“Research shows that necrotizing enterocolitis (NEC), which donor human milk can help prevent, will increase a baby’s length of hospital stay by two weeks at an additional cost of $128,000 to $238,000. In addition, reductions in other complications such as sepsis through the use of donor human milk instead of formula means that the baby goes home sooner with fewer medical issues – and stays healthier.”

The remaining investment needed to open the NWMMB is less than the cost of ONE case of NEC!

Childbirth Educators, do you talk about donor milk and milk banks in your childbirth and breastfeeding classes?  How would you bring up this subject?  Do you think it is important to talk about with expectant and new parents?

Do any of our readers work in a facility that has human milk available for the tiniest patients in the hospital?

Have any of our readers chosen to donate breastmilk or been on the receiving end with their child?  I would love to hear your experiences. – SM

 References

American Academy of Pediatrics. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2012; 129: e827–e841.

Arnold LDW. The cost-effectiveness of using banked donor milk in the neonatal intensive care unit: prevention of necrotizing enterocolitisJ Hum Lact May;18, 2002, (2):172-7

Boyd, CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis.  Archives of Disease in Childhood – Fetal and Neonatal Edition 2007;92:F169-F175

Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 1.

McGuire, W, Anthony MY. Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: systematic review Arch Dis Child Fetal Neonatl Ed. 2003 8 F11-F14.

Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast milk for feeding preterm or low birth weight infants (review). Cochrane Database of Systematic Reviews 2007; 1-41.

Silvestre D, Ruiz P, Martinez-Costa C, Plaza A, Lopez MC. Effect of pasteurization on the bactericidal capacity of human milk. J Hum Lact. 2008 Nov;24(4):371-6. Epub 2008 Sep 10.

Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O’Shea TM. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. 2007. J Perinatol Jul;27(7):428-33

Sullivan S et al.  An Exclusively Human Milk-Based Diet Is Associated with a Lower Rate of Necrotizing Enterocolitis than a Diet of Human Milk and Bovine Milk-Based Products The Journal of Pediatrics 2010; 156:562-7.

Tully DB, et al. Donor milk: what’s in it and what’s not.  J Hum Lact. 2001. 17: 152-155.

United States Breastfeeding Committee. Statement on the Safe Use of Donor Human Milk. Washington, DC: United States Breastfeeding Committee. 2008.

 

 

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Highlights of, and thoughts regarding the AAP’s Policy Statement “Breastfeeding and the Use of Human Milk”.

February 29th, 2012 by avatar

On Monday, February 27, 2012, the American Academy of Pediatrics (AAP) published its revised policy statement, Breastfeeding and the Use of Human Milk.  Since presenting the best, evidence based information to our students, clients and patients is paramount, we suggest you read the publication thoroughly.  In this article I will highlight some of the key things to note.

“The AAP reaffirms its recommendation of exclusive breastfeeding for about 6 months, allowed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.”

This is current to what we’ve been teaching.  However the note at the end about “as mutually desired by the mother and infant” is encouraging with regards to the WHO’s recommendations: “Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.”   So, the AAP doesn’t go as far with regards to extended breastfeeding as does the WHO, but they acknowledge that there are benefits to breastfeeding longer than one year.

Breastfeeding rates over all have increased slightly over the last decade, but we still have a huge disparity with regards to the age of the mother, as well as the racial and socio-economic background of the mother.  Strikingly:

“Furthermore, 24% of maternity services provide supplements of commercial infant formula as a general practice in the first 48 hours after birth. These observations have led to the conclusion that the disparities in breastfeeding rates are also associated with variations in hospital routines, independent of the populations served. As such, it is clear that greater emphasis needs to be placed on improving and standardizing hospital based practices to realize the newer 2020 targets.”

That said, it would appear that we need to encourage our hospitals to become Baby Friendly.  In the policy statement, they give us the statistics on the lack of Baby Friendly compliance in the U.S.  The AAP encourages hospitals to practice the 10 Steps and says “the rate of exclusive breastfeeding during the hospital stay has been confirmed as a critical variable when measuring the quality of care provided by a medical facility.”

The publication addresses a wide range of illnesses ameliorated by breastfeeding.  It is noted whether the percent lower risk was with regards to any breastfeeding, or by number of months of breastfeeding.  Unsurprisingly, a fair number of conditions had reduced risk the longer the mother breastfed.  Please refer back to the policy statement for details.

SIDS: 

“…note that breastfeeding is associated with a 36% reduced risk of SIDS.” 

Pacifier Use: 

“Given the documentation that early use of pacifiers may be associated with less successful breastfeeding, pacifier use in the neonatal period should be limited to specific medical situations. These include uses for pain relief, as a calming agent, or as part of structured program for enhancing oral motor function. Because pacifier use has been associated with a reduction in SIDS incidence, mothers of healthy term infants should be instructed to use pacifiers at infant nap or sleep time after breastfeeding is well established, at approximately 3 to 4 weeks of age.”

Is your baby smarter because you breastfed her? The short answer is yes for infants exclusively breastfed for 3 months or longer as well as for preterm infants, however:

“Consistent differences in neurodevelopmental outcome between breastfed and   commercial infant formula–fed infants have been reported, but the outcomes are confounded by differences in parental education, intelligence, home environment, and socioeconomic status.”

Guidelines for premature infants include:

“The potent benefits of human milk are such that all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used.”

Maternal outcomes are also discussed – everything from breastfeeding aiding the involoution of the uterus after birth, to reduced rates of many diseases, including breast cancer and ovarian cancer:

“Cumulative duration of breastfeeding of longer than 12 months is associated with a 28% decrease in breast cancer (OR: 0.72; 95% CI: 0.65–0.8) and ovarian cancer (OR: 0.72; 95% CI: 0.54–0.97). Each year of breastfeeding has been calculated to result in a 4.3% reduction in breast cancer.”

With regards to vitamin and mineral supplements, the AAP recommends the Vit. K shot over the oral version because “the oral dose is variably absorbed and does not provide adequate concentrations or stores for the breastfed infant”.  They do, however, recommend delaying the shot until after the baby’s first breastfeeding.

Vit. D supplements are suggested for all breastfed infants upon release home because:

“Vitamin D deficiency/insufficiency and rickets has increased in all infants as a result of decreased sunlight exposure secondary to changes in lifestyle, dress habits, and use of topical sunscreen preparations.” 

Supplementary fluoride is not recommended under 6 months of age.

There are many other good data points of note in this policy statement, including information on the economic benefits of breastfeeding, contraindications to breastfeeding, charting normal infant growth and specific data points on individual diseases, etc.

I’ll leave you with this concluding statement:

“Pediatricians also should serve as breastfeeding advocates and educators and not solely delegate this role to staff or nonmedical/lay volunteers. Communicating with families that breastfeeding is a medical priority that is enthusiastically recommended by their personal pediatrician will build support for mothers in the early weeks postpartum.”

…..

“Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue.”

How do we as educators and birth professionals address this?  We support evidence-based practices, yet at the same time we say we support a parent’s right to make an informed choice.  How will you incorporate what you’ve read here, and in the AAP’s policy statement, into your classes?

Baby Friendly Initiative, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Practice Guidelines , , , ,