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Marylands Commitment to BreastfeedingBegin with an end in mind1

1Disclosure I have no real or apparent conflict of interest that have direct bearing on the subject matter being presented.2Learning Objectives

Identify the benefits of breastfeeding related to patient safety and health outcomes.

Explain how Maryland hospitals are moving towards being more supportive of breastfeeding.3Breastfeeding: A Public Health IssueOptimal infant nutrition

Prevention of acute and chronic disease

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The American Academy of Pediatrics recommends babies be fed nothing but breast milk for about the first 6 months and continue breastfeeding for at least 1 year. Breastfeeding must be the established way infants are fed. This may be a shift in the cultural norm in the United States but it is imperative to address as breastfeeding (especially exclusive breastfeeding) in relation to prevention of both acute and chronic disease has been well studied.4Breastfeeding: A Health Disparities IssueHealth disparities are associated with - Poverty- Education- Race/Ethnicity

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You cannot talk about breastfeeding without framing it in the broader picture of health disparities. The single biggest disparity is that the poorer you are the more likely your health will be worse. Education and race/ethnicity are also huge factors in relation to health disparities.5Breastfeeding is a great equalizerExclusive and extensive breastfeeding reduces the risk for many diseases.

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There is overwhelming evidence that exclusive and extensive breastfeeding can reduce the risk of many infectious and chronic diseases. At birth, infants should be given the opportunity to be exclusively breastfed for as long as possible to have better health outcomes in the long term.6Infant Health OutcomesRisk of hospitalization for lower respiratory tract infections in the first year is reduced 72% if infants are breastfed exclusively for more than 4 months.

Exclusive breastfeeding for more than 3 months reduces the risk of otitis media by 50%.

Breastfeeding and the Use of Human Milk, Pediatrics 20127Source: American Academy of Pediatrics Policy Statement - Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129; e8277Infant Health Outcomes Feeding preterm infants human milk is associated with a 58% reduction in the incidence of necrotizing enterocolitis (NEC).

Breastfeeding is associated with a 36% reduced risk of SIDs.

Breastfeeding and the Use of Human Milk, Pediatrics 20128

Source: American Academy of Pediatrics Policy Statement - Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129; e8278Infant Health Outcomes There is a 52% reduction in the risk of developing celiac disease in infants who were breastfed at the time of gluten exposure.

Breastfeeding is associated with a 31% reduction in the risk of childhood inflammatory bowel disease.

Breastfeeding and the Use of Human Milk, Pediatrics 20129The critical protective factor appears to be not the timing of the gluten exposure but the overlap of breastfeeding at the time of the initial gluten ingestion. Thus, gluten-containing foods should be introduced while the infant is receiving only breast milk and not infant formula or other bovine products.Different patterns in intestinal colonization in breastfed versus commercial infant formula-fed infants may add to the preventative effect of human milk.Source: American Academy of Pediatrics Policy Statement - Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129; e8279Infant Health Outcomes There is a 15% to 30% reduction in adolescent and adult obesity rates if any breastfeeding occurred in infancy compared with no breastfeeding.

There is up to a 30% reduction in the incidence of type 1 diabetes mellitus for infants who exclusively breastfed for at least 3 months, thus avoiding exposure to cow milk protein.

Breastfeeding and the Use of Human Milk, Pediatrics 201210Long-term positive effects of breastfeeding include weight control and feeding self-regulation. These are only a few of the positive infant health outcomes that are being studied.Source: American Academy of Pediatrics Policy Statement - Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129; e82710Maternal Health OutcomesDecreased postpartum blood loss.

More rapid involution of the uterus.

Breastfeeding and the Use of Human Milk, Pediatrics 201211

Source: American Academy of Pediatrics Policy Statement - Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129; e82711Maternal Health OutcomesEach year of breastfeeding has been calculated to result in a 4.3% reduction in breast cancer.

Breastfeeding and the Use of Human Milk, Pediatrics 201212Source: American Academy of Pediatrics Policy Statement - Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129; e82712Maternal Health Outcomes 21% reduction in ovarian cancer

12% reduction in diabetes mellitus

Ip, Agency for Healthcare Research and Quality, 200713

Source: Ip, Agency for Healthcare Research and Quality, 200713

Identifies barriers to breastfeedingRecommends actions for Mothers and familiesCommunitiesHealth care providers and facilitiesEmployers Public health leadershipResearchers14In the Surgeon Generals Call to Action to Support Breastfeeding, specific actions are recommended for various groups in order to address the barriers to continued breastfeeding for those moms who have chosen to breastfeed.

Of course there are a multitude of factors that influence a moms decision to taper or stop breastfeeding includingfamily and cultural factors; community, health care systems and providers, employers, and policies

14Affordable Care Act Preventive Services Womens HealthWell-woman visitsGestational diabetes screeningDomestic violence screeningFDA-approved contraceptive methodsBreastfeeding support, supplies and counselingHPV DNA testingSexually transmitted infections counselingHIV screening and counseling

15Effective August 1, 2012 the Affordable Care Act (ACA) expands health coverage to include breastfeeding support, supplies and counseling.15The Joint CommissionPerinatal Care Core Measure SetElective deliveryCesarean sectionUse of antenatal steroidsHealthcare-associated bloodstream infections in newbornsExclusive breast milk feeding

16Beginning January 1, 2014, maternity hospitals delivering at least 1,100 infants annually must report on exclusive breast milk feeding. The Joint Commission defines exclusive breast milk feeding as newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines. Breast milk feeding includes expressed mothers milk as well as donor human milk, both of which may be fed to the infant by means other than suckling at the breast.16

A Snapshot of Breastfeeding in Maryland17

17Marylands Breastfeeding Report Card 2013http://www.cdc.gov/breastfeeding/pdf/2013BreastfeedingReportCard.pdfhttp://www.usbreastfeeding.org Categories of Infant Feeding

Healthy People 2020 Breastfeeding Objectives2013 CDC Breastfeeding Report Card Maryland RatesEver Breastfed81.9%69.4%Breastfed at 6 months60.6%52.0%Breastfed at 1 year34.1%24.2%Exclusively breastfed at 3 months46.2%29.3%Exclusively breastfed at 6 months25.5%15.1%Reduced percent of breastfed newborns receiving formula supplementation in first two days of life (goal)14.2%22.9%18You can see that in Maryland, our ever breastfed rate is 69.4%. Breastfed at 6 months is 52% and dropping off to 24.2% at one year. Exclusively breastfed at 3 months is 29.3% and at 6 months 15.1%. As you can see our initiation rates are relatively high but continued, sustained breastfeeding is an area for improvement.Marylands rates are in line with the U.S. National rates: 76.5% ever breastfeed, 49% breastfeeding at 6 months, 27% breastfeeding at 12 months, 37.7% exclusive breastfeeding at 3 months and 16.4% breastfeeding at 6 months.18Maryland PRAMS Report2011 Births19

Pregnancy Risk Assessment Monitoring System - Length of time infant was breastfed:63% of mothers surveyed breastfed 8 weeks or more. 10% breastfed 4 7 weeks, 12% breastfed less than 4 weeks and 15% never breastfed.1920

Based on PRAMS data, of the 15% who never breastfed, a greater number are black, non- Hispanic mothers. Young age and less education also had a negative impact on breastfeeding initiation. This data supports that the same health disparities are apparent in Maryland as noted nationally.2021

Nearly all births in the United States occur in hospital settingsMost women in Maryland give birth in a hospital setting.Studies have shown that a majority of women intend to breastfeed prenatally, but there is a gap between prenatal intentions and post discharge actions. Data from around the world clearly indicates the positive impact of improved hospital policies on breastfeeding initiation, duration, and exclusivity.

21Breastfeeding Support in Maryland Facilities Many opportunities exist to protect, promote, and support breastfeeding mothers and infants in Maryland. Maternity Practices in Infant Nutrition and Care In Maryland 2009 mPINC Survey 22National data from the CDC mPINC survey indicate that barriers to breastfeeding are widespread during labor, delivery and postpartum care as well as in discharge planning.

Statistics on breastfeeding duration and exclusivity as well as disparities in breastfeeding rates among minority populations, prompted the development of a model breastfeeding policy that would guide hospitals in their role to improve Marylands breastfeeding support.

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Marylands GoalAll Maryland Birthing Hospitals will obtain or initiate Baby-Friendly certification or adhere to the Maryland Hospital Breastfeeding Policy Recommendations23Recognizing the vital role that hospitals play in the success of breastfeeding, the Maryland Department of Health and Mental Hygiene (DHMH) has established the goal for all Maryland birthing hospitals to obtain or initiate Baby-Friendly certification or adhere to the Maryland Hospital Breastfeeding Policy Recommendations.

23On the Path to Continuous Quality Improvement24

To help Maryland hospitals work toward this goal, DHMH formed a workgroup to review current hospital policies and compose breastfeeding policy recommendations that will strengthen and improve current maternity care practices in Maryland hospitals. A stakeholders meeting was held to present these recommendations and obtain initial feedback. Subsequently, this feedback was incorporated into the draft recommendations. These recommendations were posted on the DHMH website for public comment in February of 2012. Over 130 comments were received, evaluated and incorporated into the policy, where appropriate. The result of this initiative is the DHMH 2012 Maryland Hospital Breastfeeding Policy Recommendations. The DHMH 2012 Maryland Hospital Breastfeeding Policy Recommendations provide specific criteria for hospitals to assess their current level of breastfeeding support in preparation for applying for Baby-Friendly status. All of the recommendations in the Maryland Hospital Breastfeeding Policy are consistent with and will help hospitals move towards the requirements of the BFHI. Please note that these recommendations are for healthy, full term infants.

24The Ten Recommendations for Improved Breastfeeding SupportThe ten Maryland Hospital Breastfeeding Policy recommendations are based on the Baby Friendly Hospital Initiative 10 Steps. The Maryland policy steps differ in that first, Marylands policy recommendations are meant to encompass breastfeeding only. Policies related to use of breast milk substitutes are assumed to be found under an Infant Formula (or breast milk substitute) Feeding Policy. Secondly, some of Marylands steps are in a different order than the BFHI. This does not diminish the importance of each step. In addition, the content of the steps focuses upon the same issues as that of the BFHI 10 Steps. 25A policy helps to:ensure consistent, effective care for mothers and babiesprovide a standard of practice that can be measuredsupport actions# 1: Have a written policy that is routinely communicated to all health care staff# 1: Have a written policy that is routinely communicated to all health care staffThe written policy should include all of the 10 recommendations in order to be comprehensive and meet the requirements of both Marylands Hospital Policy Recommendations and the Baby Friendly Hospital Initiative.

26Train on all of the Ten RecommendationsTraining assists staff to implement these steps# 2: Train all health care staff in skills necessary to implement the policy# 2: Train all health care staff in skills necessary to implement the policy

The second step is about training.Training allows all present to understand the reasoning behind each step and allows understanding in how to implement each step of the policy.

27Discuss the importance of breastfeeding with pregnant women and highlight practices that support the initiation of breastfeeding

#3: Inform all pregnant women about the benefits and management of breastfeeding#3: Inform all pregnant women about the benefits and management of breastfeeding

The third step focuses on educating pregnant women about breastfeeding. The goal here is to provide education for pregnant women so they can make an informed decision about how they will feed their newborns. And, when they breastfeed, this information will also help them initiate practices that are likely to lead to successful breastfeeding experiences.

28Facilitate skin-to-skin contact and early initiation of breastfeeding

#4: Help breastfeeding mothers initiate breastfeeding within 1 hour of birth#4: Help breastfeeding mothers initiate breastfeeding within 1 hour of birth

The fourth step concentrates on what can be done immediately after birth to enhance the success of breastfeeding. Placing the baby skin-to-skin, immediately after birth and early initiation of breastfeeding set the new breastfeeding dyad on the path to successful breastfeeding. 29Teach parents to identify early feeding cuesTeach parents expected normal newborn behaviors related to feeding

#5: Encourage breastfeeding on demand

#5: Encourage breastfeeding on

Step five concentrates on teaching parents to understand and respond when a breastfed baby is hungry and identify early feeding cues and other normal newborn behaviors related to feeding. 30#6: Show breastfeeding mothers how to breastfeed and how to maintain lactation, even if they are separated from their infantsAssist a mother to learn the skills of positioning and attaching her baby, as well as the skill of hand expressionHelp a mother to maintain breastfeeding when separated from the baby#6: Show breastfeeding mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

This step focuses on assisting a mother in positioning her baby at the breast, and how to teach her to attach her baby (proper latch-on) as well as hand expression of breast milk. Finally, this step will focus on how to help a mother to maintain breastfeeding when separated from the baby.

31Minimize separation of mothers and infants for routine careTeach parents that both mother and infant will be healthier and happier if kept together#7: Practice rooming in encourage breastfeeding mothers and infants to remain together 24 hours a day#7: Practice rooming in encourage breastfeeding mothers and infants to remain together 24 hours a day

This step focuses on minimizing the separation of mothers and infants for routine care. In addition, teach parents that both mother and infant will benefit from being kept together.

32Support successful breastfeeding Providing anything other than breast milk at this time interferes with the establishment of successful breastfeeding

#8: Give breastfed infants no food or drink, other than breast milk, unless medically indicated#8 (step #6 in Baby Friendly): Give breastfed infants no food or drink, other than breast milk, unless medically indicated

The goal here is to focus on breastfeeding. Have mother and baby practice the new skill they are learning and allow the process to establish the milk supply necessary. Feedings other than breast milk at this time interfere with the ability to do this.

33Pacifiers and artificial nipples can interfere with the establishment of breastfeedingDetermine medical need when using pacifiers

#9: Give no pacifiers or artificial nipples to breastfeeding infants in the hospital, unless medically indicated#9: Give no pacifiers or artificial nipples to breastfeeding infants in the hospital, unless medically indicated

Pacifiers and artificial nipples can interfere with establishing and maintaining breastfeeding, as infants suck differently on the breast than they do on an artificial nipple. However, pacifiers may be necessary at certain times. This step requires that medical need for use of pacifiers be determined. For example, pacifiers may be used during painful procedures, such as circumcision, but should be discarded immediately after the procedure.34Discuss with a mother how to find support for breastfeeding after she returns home#10: Foster the establishment of breastfeeding support groups and refer breastfeeding mothers to them on discharge from the hospital or clinic#10: Foster the establishment of breastfeeding support groups and refer breastfeeding mothers to them on discharge from the hospital or clinic.

Many hospitals have their own breastfeeding support groups. Some develop them along with the implementation of the other parts of the recommendations, while others network with resources and support groups in the community to support breastfeeding families.

35 Referrals for Breastfeeding Support36Lactation ConsultantsHospital Support GroupsWICLa Leche LeagueInternational Lactation Consultant Association (ILCA)Maryland Breastfeeding Coalition (MBC)

Support for breastfeeding is available through many different organizations.36Letters of Commitment3723 hospitals signed letters of commitment to meet Maryland Best Practices.

9 hospitals have expressed their intent to be certified as Baby-Friendly.

As of July 31, 2013, 23 hospitals have signed letters of commitment to meet Maryland Best Practices and 9 hospitals have expressed their intent to be certified as Baby-Friendly.These commitments bring us full circle in supporting breastfeeding in Maryland. The following 23 hospitals have signed letters of commitment to meet Maryland Best Practices - Anne Arundel Medical Center, Carroll Hospital Center, Memorial Hospital at Easton, Frederick Memorial Hospital, Garrett County Memorial Hospital, Greater Baltimore Medical Center, Holy Cross Hospital, Johns Hopkins Bayview Medical Center, Laurel Regional Hospital, Medstar Montgomery Medical Center, Medstar Southern Maryland Hospital Center, Mercy Medical Center, Peninsula Regional Medical Center, Prince Georges Hospital Center, Sinai Hospital, St. Agnes Hospital, Union Hospital of Cecil County, University of Maryland Medical Center, University of Maryland Baltimore Washington Medical Center , University of Maryland Charles Regional Medical Center (formerly Civista), University of Maryland St. Joseph Medical Center, Washington Adventist, Western Maryland Health System.Nine hospitals have expressed their intent to be certified as Baby-Friendly - Calvert Memorial Hospital, Howard County General Hospital, Johns Hopkins Hospital, Medstar Franklin Square Medical Center, Medstar Harbor Hospital, Medstar St. Marys Hospital, Meritus Medical Center, Shady Grove Adventist Hospital, Upper Chesapeake Medical Center.

3738 Thank you for supporting breastfeeding in Maryland

38 Questions39

39 Works Cited40American Academy of Pediatrics Policy Statement (2012). Breastfeeding and the Use of Human Milk, Pediatrics, 129(4): e827-e841.

Ip S, Tufts-New England Medical Center. Evidence-based Practice Center., United States. Agency for Healthcare Research and Quality. Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality; 2007.

U.S. Department of Health and Human Services. The Surgeon Generals Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. http://surgeongeneral.gov

United States Breastfeeding Committee (USBC). Implementing the Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding. Revised. Washington, DC: United States Breastfeeding Committee, 2010.