Journal Watch Pediatrics
March 28, 2005
  Clinical Practice Guideline Watch
 
The Section on Breastfeeding of the American Academy of Pediatrics recently  
released a policy statement. Such statements, which the AAP issues far more  
often than guidelines, are often accompanied by extensive references, but the  
level of evidence supporting each recommendation is unrated. Many policy  
statements contain important information for practitioners. Here are highlights  
of the statement on breast-feeding: 
 
    *   Numerous benefits of breast-feeding for both child and mother (e.g.,  
decreased risk for breast cancer) are well documented.

    *   There are few contraindications for breast-feeding; it is not  
contraindicated for mothers who are hepatitis-B surface antigen-positive,  infected 
with hepatitis C virus, or seropositive for cytomegalovirus infection  (see 
article for complete list).

    *   Infants should be placed in direct skin-to-skin contact with their 
mothers  immediately after birth.

    *   Breast-feeding newborns should not receive supplements (water, 
glucose  water, formula, etc.) unless medically necessary.

    *   Pacifiers should be avoided until breast-feeding is well  established.

    *   At first, mothers should be encouraged to breast-feed infants 8 to 12 
 times each day.

    *   All breast-feeding infants should be seen at 3 to 5 days of age by a  
pediatrician or nurse knowledgeable about breast-feeding.

    *   Exclusive breast-feeding is sufficient for optimal growth until about 
6  months of age.

    *   Complementary iron-rich foods should be introduced gradually 
beginning  around 6 months of age.

    *   Introduction of complementary foods as early as 4 months of age may 
be  indicated by unique needs or feeding behaviors of individual infants.

    *   Vitamin D drops containing 200 IU should be given to all breast-fed  
infants starting in the first 2 months of life.

    *   Breast-fed infants do not require supplementary fluoride during the 
first  6 months; after that, the need for supplementation depends on the 
fluoride  concentration in the water supply.



Comment
We continue to fall short of the Healthy People 2010 breast-feeding goals: an 
 initiation rate of 75%; breast-feeding rates of 50% at 6 months and 25% at 1 
 year. Although initiation rates approach 70%, rates at 6 months (33%) and 1 
year  (18%) remain low. Although it is difficult to argue with most of these 
AAP  recommendations, there are areas of controversy: First, many 
breast-feeding  experts are uncomfortable with the recommendation that all breast-fed 
babies  receive vitamin D, particularly those who are light-skinned and receive 
sunlight  exposure during the first few months of life. Second, iron sufficiency 
may not  be as good in breast-fed infants as in formula-fed infants at 9 
months, so  adequate provision of iron-rich complementary food is important. Third, 
the  statement clearly supports the adequacy of breast milk alone until 6 
months of  age, but I believe that eating is a learned behavior and that 
introducing some  solids sooner may help infants master this complicated behavior. 
Finally,  follow-up at 3 to 5 days after birth may not be soon enough for 
first-time  breast-feeding mothers. As I have cautioned before (see JW Pediatr 
Adolesc Med  Aug 9 2004), keep an eye on breast-fed babies with a gestational age of 
35-37  weeks born to new moms who are discharged on Thursday or Friday — 
these infants  are at high risk for hyperbilirubinemia. I believe it is safer to 
have some  contact with the mother within 2 days of discharge to ensure 
breast-feeding  adequacy. 
— Howard Bauchner, MD

 
Nikki Lee RN, MS, Mother of 2, IBCLC, CCE
Maternal-Child Adjunct  Faculty Union Institute and University
Film Reviews Editor, Journal of Human  Lactation
Support the WHO Code and the Mother-Friendly Childbirth  Initiative

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