FAQs, Myths, and Misconceptions about Breastfeeding

Juliet Sio Aguilar, M.D., M.Sc.(Birm) Professor of Pediatrics University of the Philippines Manila

WHO and UNICEF: Global Strategy for Infant and Young Child Feeding (2002)

To revitalize focus on impact of feeding practices on nutritional status, growth and development and health, and ultimately the survival of infants and young children .health and other relevant sectors protect, promote and support exclusive breastfeeding for six months and continued breastfeeding up to two years or beyond

I dont have much milk. Can I feed my baby with an infant formula and still continue breastfeeding?

Why Exclusive BF for First Six Months of Life

Infants 0-5 months

Not

BF

7-fold increased risk for diarrheal deaths 5-fold increased risk for death from pneumonia
Partially

BF

2-fold increased risk for deaths from diarrhea or pneumonia

Black RE et al. Where and why are 10 million children dying every year? Lancet 2003; 361: 226.

Why Continue BF Beyond Six Months of Life

Infants 6-11 months

Not

BF

2-fold increased risk for deaths from diarrhea or pneumonia

Black RE et al. Where and why are 10 million children dying every year? Lancet 2003; 361: 226.

Under 2 years old

Cohort

study in Cebu: Failure of initiation or cessation

of BF

8-10 fold increased risk for diarrheal death

Yoon PW et al. Effect of not breastfeeding on the risk of diarrheal and respiratory mortality in children under 2 years of age in Metro Cebu, The Philippines. Am J Epidemiology 1996; 143: 1142.

Breastfeeding and Disease Prevention

Exclusive breastfeeding for at least 6 mos Dose-dependent effect of BF duration on obesity
Arenz S et al. Int J Obesity 2004: 28: 1247.

Exclusive breastfeeding for at least 4 mos Breastfeed for at least 6 mos

Halken S. Pediatr Allerg Immunol 2004: 15 Suppl 16: 9. Wright AL et al. Thorax 2001; 56:192.

Caution in severe maternal asthma Exclusive breastfeeding for at least 4 mos Delay introduction of cows milk until 4 mos
Kimpimaki et al. Diabetologia 2001; 44: 63.

Other Potential Problems of Nonexclusive BF

Nipple confusion High risk of lactation failure

92%

of subjects felt milk output inadequate

Mathur GP et al. Indian Pediatr 1992; 29: 1541.

Im sick. Is it safe to breastfeed my baby?

Maternal Infections

BF not contraindicated in most infections

Common minor infections Varicella (onset within 6 days

of delivery or 2 days

postpartum)

Give ZIG to uninfected neonate and separation from mother until she is noninfectious

CMV Passive transfer of maternal antibodies For as long as mothers are not recent converters if infant is term For preterms: benefits of BF outweigh risk of CMV transmission Freezing and pasteurization can significantly viral load in milk Toxoplasmosis Antibodies found in breast milk

Maternal Hepatitis B Carriers

With appropriate immunoprophylaxis: no additional risk in breastfed infant even if mother is HBeAg positive

Hill JB et al. Obstet Gynecol 2002; 99: 1049. Tseng AKY et al. Lancet 1988; 2: 1032. Beasly PR et al. Lancet 1975; 2: 740.

Maternal Tuberculosis

Current Recommendations
Best

way to prevent TB in infants of infected moms: timely and properly administered chemotherapy for moms Mothers can breastfeed exclusively for

Minimum of 4 mos 6 mos if infant is growing appropriately Should continue BF with adequate complementary food up to 2 years or beyond

Joint Statement of the Division of Child Health and Development, Global Tuberculosis Programme, Global Programme for Vaccines and Immunization and Reproductive Health of the World Health Organization. Update No. 23, Feb 1998.

Breastfeeding and Maternal Tuberculosis

Management categories: of diagnosis of active PTB

Before

Timing

delivery

>2 mos <2 mos

After

delivery

<2 mos >2 mos

Joint Statement of the Division of Child Health and Development, Global Tuberculosis Programme, Global Programme for Vaccines and Immunization and Reproductive Health of the World Health Organization. Update No. 23, Feb 1998.

Diagnosis of Maternal Tuberculosis

>2 mos before delivery

Get

<2 mos after delivery

sputum smear just before delivery

Negative: Treat mom + BCG at birth Positive: Treat mom + INH 6 mos + BCG after INH

Treat mom + INH 6 mos + BCG after INH

<2 mos before delivery

>2 mos after delivery

Treat mom + INH 6 mos + BCG after INH

Treat mom + INH 6 mos + BCG after INH if not given at birth

Breastfeeding and Maternal Tuberculosis

Additional key in management

Monitor

infants health during the 1st year of life for signs of TB Continue breastfeeding whether or not child develops TB
Joint Statement of the Division of Child Health and Development, Global Tuberculosis Programme, Global Programme for Vaccines and Immunization and Reproductive Health of the World Health Organization. Update No. 23, Feb 1998.

Maternal HIV

Transmission Risks to Infants

Without

any intervention before or during delivery: 15-30% Breastfeeding: 10-20%

LINKAGES Project. Academy for Educational Development.

April 2004.

Should mothers with HIV be advised to BF?

It depends.
If BM substitutes are acceptable, affordable, feasible, sustainable and safe greater chances of survival if fed artificially

If BM substitutes are prohibitively costly, access to clean water poor, health care limited exclusive BF safest option

Reducing Risk of HIV Transmission

Reduce total duration of BF if being breastfed

Shift

to BM substitutes as soon as resources become affordable/available

Prevent and promptly treat oral lesions in infants and breast problems Take antiretroviral drugs
Single

dose of nevirapine to mother in labor and infant after delivery (Uganda trial)
42% reduction at 6 weeks 35% reduction at 12 months

Two-yr Morbidity & Mortality Among Children Born to HIV-infected Mothers

Long-term safety of infant feeding interventions aimed at reducing breast milk HIV transmission in Africa (Cote dlvoire) HIV-infected moms given peripartum antiretroviral prophylaxis Infant feeding interventions

Artificial feeding Exclusive breastfeeding and early cessation from age 4 mos PLUS nutritional counseling and clinical management for 2 yrs Occurrence of morbid events (diarrhea, ARI, malnutrition) and severe events (hospitalization or death)
Becquet R et al; Ditrame Plus Study Group. PLoS Med 2007; 4: e17.

Outcome variables

Two-yr Morbidity & Mortality Among Children Born to HIV-infected Mothers

Becquet R et al; Ditrame Plus Study Group. PLoS Med 2007; 4: e17.

Two-yr Morbidity & Mortality Among Children Born to HIV-infected Mothers

Becquet R et al; Ditrame Plus Study Group. PLoS Med 2007; 4: e17.

Its hot in the Philippines. Wouldnt my baby become dehydrated if I do not give extra water?

Supplemental Water in Breastfeeding?

Fat Protein 3.8% 0.9%

Lactose 7.0%

Water 88.1%

Water Lactose Fat Protein Others

Lawrence RA. 1994. Breastfeeding: A Guide for the Medical Profession. 4th ed. St. Louis: Mosby-Year Book, Inc.

Im on medications. Can I continue breastfeeding?

Maternal Drug Intake

Contraindications few
Anticancer

drugs; radioactive substances

Use with caution

Anticonvulsants

and psychiatric drugs

(sedative effect) Estrogens, thiazide diuretics, ergometrine (inhibit lactation) Chloramphenicol, tetracyclines, metronidazole, quinolones
WHO Department of Child and Adolescent Health and Development. Breastfeeding and Maternal Medication. 2002.

Im underweight. Is my breast milk adequate for my baby?

Maternal Malnutrition

Can malnourished mothers breastfeed successfully?

Yes

except in severe PEM Babies may suck more vigorously, frequently or longer if BM supply low Easier and less expensive to feed malnourished mom than to expose baby to risk of bottle feeding
LINKAGES Project. Academy for Educational Development. July 2004.

Maternal Micronutrient Supplementation

Vitamin A
Single

dose of 200,000 IU after delivery (not later than 6-8 weeks)

Thiamin, riboflavin, vit B6, vit B12, iodine, selenium

Levels

in breast milk easily affected by maternal

diet

Folate, calcium, iron, copper, zinc

Remain

relatively high in breast milk despite low maternal reserves Supplement to protect maternal reserves

Appropriate Complementary Feeding

Foods rich in iron

Term

infants: introduced around 6 mos Preterms, LBW and infants with hematologic disorders: earlier than 6 mos

Food diversity
Especially

for BF children beyond 1 yr old Strongly and consistently correlated with growth Early introduction of starchy gruels (< 6mos) associated with stunting
AAP Policy Statement on Breastfeeding. Pediatrics 2005; 115: 496. Onyango A et al. Int J Epidem 1998; 27: 484.

I cant beat my smoking and drinking habit. Can I breastfeed even if I smoke cigarettes and take alcoholic beverages?

Maternal Smoking

Infants exposed to environmental tobacco smoke experience health risks Components of tobacco in breast milk
moms should no. of cigarettes to <15 sticks/day to risk of nicotine poisoning Risks in infants: apenic attacks, hyperexcitability, vomiting
BF
Luck W and Nau H. J Pediatr 1985; 107: 816.

Risk of respiratory illness during 1st yr of life 7x in formulafed infants vs BF infants when moms smoked

BF may still be protective vs respiratory illness

Becker AB et al. Arch Pediatr Adol Med 1999; 153: 689.

Maternal Smoking
Not a contraindication Smoking hygiene

Avoid

smoking within the home. Use air purifier if cannot be avoided. Never smoke in the car or near the infant in closed areas or take infant to smoky environment Smoke only immediately after BF and at least 1 hrs prior to BF
AAP Policy Statement on Breastfeeding. Pediatrics 2005; 115: 496. Pulley KR and Flanders-Stepans MB. J Perinatal Ed 2002; 11: 28.

Maternal Alcohol Intake

Alcohol
Concentrated

in breast milk Its use can inhibit milk production

Recommendation
Avoid

alcohol For occasional single, small drink:

Avoid BF for 2 hrs after the drink
AAP Policy Statement on Breastfeeding. Pediatrics 2005; 115: 496.

Im very tired from work. Is it safe to breastfeed my baby?

Stress and Breastfeeding

Breast milk panis

No

scientific basis among lactating moms

Impact of stress on milk supply

Variable

Some able to cope well despite extreme pressures

In

early weeks of lactation

Fatigue the most detrimental factor to milk production
Lawrence RA. 1994. Breastfeeding: A Guide for the Medical Profession. 4th ed. St. Louis: Mosby-Year Book, Inc.

I no longer have the energy to breastfeed my baby. But I know breast milk is best. What shall I do?

Psychosocial Risk Factors Associated with BF Discontinuation

Prospective cohort study

Managed

care setting Sacramento, CA, USA RCT to home visits vs clinic-based follow up Face-to-face interview postpartum, telephone interviews at 2 wks and 12 wks 1163 mother-newborn pairs
Taveras EM at al. Pediatrics 2003; 112: 108.

Psychosocial Risk Factors Associated with BF Discontinuation

Results
BF

rates
87% initiated BF 75% BF at 2 wks 55% BF at 12 wks

Multivariate analysis BF at 12 wks

Encouragement from clinician to BF OR = 0.6 [95% CI: 0.4, 0.8] Lack of confidence to BF at 1-2 day interview OR = 2.8 [95% CI: 1.02, 7.6] Early BF problems OR = 1.5 [95% CI: 1.1, 1.97]
Taveras EM at al. Pediatrics 2003; 112: 108.

BF discontinued at 2 wks

Spousal Support

Reported as a major factor influencing breastfeeding rates

Arora S et al. Pediatrics 2000; 106(5): e67.

Controlled trial of 280 mothers considering breastfeeding + partners in Naples, Italy Intervention: training session for partners on management of BF

Pisacane A et al. Pediatrics 2005; 116: e494.

Spousal Support Training

Parameters Full BF at 6 mos Perceived milk insufficiency Intervention Group (%) 25 12 Control Group (%) 15 43 P 0.05 0.001

Mixed feeding Full BF at 6 mos despite problems

10 24

33 4

0.001 0.001

Pisacane A et al. Pediatrics 2005; 116: e494.

Early Routine Clinic Visit Breastfeeding

on

1st 4 weeks postpartum: period with greatest decrease in BF rates

Single visit within 2 weeks after birth 226 mother-infant pairs in Chambery, France Conducted by trained clinicians Multivariate analysis associated with exclusive BF at 4 weeks
Labarere J et al. Pediatrics 2005; 115: e139.

Early Clinic Visit on eBF at 4 wks: Multivariate Analysis

Characteristics Intervention group Epidural anesthesia Gestational age at delivery Expected BF duration of > 4 mos Adjusted Odds Ratio 2.44 0.32 3.44 2.49 95% CI 1.18-5.03 0.13-0.76 1.2-9.82 1.12-5.53

Labarere J et al. Pediatrics 2005; 115: e139.

Lets all help bring back the breastfeeding culture.