Dear all - I didn't realize not everyone could see this. Please notice Dr.
Lawrence's references to IBCLC's. Sincerely, Toby Gish RN, IBCLC (Haifa,
Israel)

http://archpedi.ama-assn.org/issues/v155n5/ffull/ped00623.html

  Ruth A. Lawrence, MD


THE VALUE of breastfeeding and human milk for the average infant has been
well-documented and supported by the American Academy of Pediatrics in its
landmark policy statement, in which the academy recommends that infants be
exclusively breastfed for at least 6 months, continue to be breastfed for
the next 6 months while weaning foods are added, and then for as long
thereafter as mother and infant wish.1 The World Health Organization and the
United Nations International Children's Emergency Fund have also made very
strong statements regarding the value of human milk.2 Most recently, the
Department of Health and Human Services, Office of Women's Health, has
published "Breastfeeding: The HHS Blueprint for Action on Breastfeeding."
This important document outlines the strategic plan for the United States to
increase the initiation and duration of breastfeeding.3

It does not, however, allude to the dilemma of the very low-birth-weight
(VLBW) infant. None of these statements mention the dilemma of the VLBW
infant.4 It has also been documented that human milk provides tremendous
benefits to the premature infant. It is more easily digested and readily
tolerated by the premature infant, and therefore can be provided many weeks
earlier than artificial formula.5 Human milk provides antibodies and other
infection protection properties that assist the fragile low-birth-weight
infant in resisting infection5; however, the overall success rate of
breastfeeding among women who deliver prematurely is low.6

The authors, Drs Pinelli, Atkinson, and Saigal, have presented the results
of a randomized trial of breastfeeding support in VLBW infants.7 They point
out that the available data vary tremendously on initiation and duration of
breastfeeding because of the variabilities of the studies, including the
range of prematurity included and the very definition of breastfeeding. They
point out that breastfeeding a premature infant poses far greater challenges
for the mother than feeding an infant carried to term, who goes to the
breast shortly after birth. Although a number of articles have been
published regarding pumping milk while a premature infant is hospitalized,
and issues of maintaining milk supply before the infant goes to the breast,
little has been said about maintaining breastfeeding following discharge.8,
9 According to the authors, the main purpose of this study was to determine
if a supplementary structured breastfeeding counseling program (SSBC) for
parents of preterm infants, as compared with conventional hospital-based
breastfeeding support (CHBS), will improve the duration of lactation and
success of breastfeeding after discharge from the hospital, and through 1
year corrected age. This study is carefully planned, appropriately
randomized, and well documented. At first glance, it would seem that the
results indicate that a special program to support these mothers has little
effect.

The authors themselves point out some significant reasons why they found no
difference between support and nonsupport, including the fact that both
groups were highly motivated to breastfeed. The population was relatively
socioeconomically advantaged, and the community independently provided
significant resources, including lactation consultants, public health
nurses, family physicians, and breastfeeding support groups. There are,
however, some important points to glean from this report. First, little is
said about the outcome difference between multiparas and primiparas. A
review of the demographics indicates that 41% of the study group and 39% of
the control group had other children at home. No mention is made of previous
experience breastfeeding, and if it was for 1 or more other children.
Assessing the current data, separating out the multiparas might indeed
reveal significant differences. Assessment of the support system available
to a given mother independent of the study was not clear, so it may have
also influenced the results by having mothers with significant personal
support systems in the control group.

The role of the lactation consultant is mentioned, and the intervention
group did have the services of a lactation consultant. Any mother who is
breastfeeding in the community and having some problems with milk volume or
low weight gain of her infant would benefit from the services of an
international board-certified lactation consultant (IBCLC). It is noteworthy
that all lactation consultants do not have the same background and
credentials; therefore, assuring that the individual is board certified and
licensed is important. It may well be that finding an IBCLC for all women
who wish to breastfeed a low-birth-weight infant prior to the discharge from
the hospital, with accessible continued follow-up with this expert, may well
enhance the long-term success of breastfeeding these fragile infants. The
authors point out that more than 50% of mothers in both groups experienced
breastfeeding problems at home through the first 6 months. Thus, the
services of an IBCLC might well make a significant difference. They also
noted that mothers who discontinued breastfeeding prior to 12 months did so
because they perceived they were not producing enough milk. Further, they
also observed that in both groups of mothers, the most utilized resource for
advice on breastfeeding was indeed a lactation consultant.

From this very carefully orchestrated study, one might conclude that
breastfeeding is valuable to the VLBW infant and that extended breastfeeding
through the first year of life is important, but the accomplishment of this
goal is challenging. Obviously, the mothers who succeeded in this study had
resources of support and consultation. To confirm the value of this support
and consultation, a study that involves low-income women with access to
marginal or no resources might well provide the statistical power necessary
to prove the effect. In the meantime, however, developing a support system
for breastfeeding that begins during hospitalization and continues for as
long as the infant is breastfed at home should be the goal of all neonatal
intensive care units.




Author/Article Information


Ruth A. Lawrence, MD
Department of Pediatrics, Box 777
University of Rochester Medical Center
601 Elmwood Ave
Rochester, NY 14642






REFERENCES



1.
American Academy of Pediatrics Work Group on Breastfeeding.
Breastfeeding and the use of human milk.
Pediatrics.
1997;100:1035-1039.
MEDLINE


2.
World Health Organization/United Nations Children's Emergency Fund.
Protecting, Promoting and Supporting Breastfeeding: The Special Role of
Maternity Services.
Geneva, Switzerland: World Health Organization; 1989.



3.
Department of Health and Human Services.
HHS Blueprint for Action on Breastfeeding.
Washington, DC: US Dept of Health and Human Services; 2000.



4.
Yip E, Lee J, Sheehy Y.
Breast-feeding in neonatal intensive care.
J Paediatr Child Health.
1996;32:296-298.
MEDLINE


5.
Lucas A.
Enteral nutrition.
In: Tsang RC, Lucas A, Uauy R, et al, eds. Nutritional Needs of the Preterm
Infant: Scientific Basis and Practical Guidelines. Baltimore, Md: Williams &
Wilkins; 1993:209-223.



6.
Lefebvre F, Ducharme M.
Incidence and duration of lactation performance among mothers of
low-birth-weight and term infants.
CMAJ.
1989;140:1159-1164.
MEDLINE


7.
Pinelli J, Atkinson SA, Saigal S.
Randomized trial of breastfeeding support in very low-birth-weight infants.
Arch Pediatr Adolesc Med.
2001;155:548-553.
ABSTRACT  |  FULL TEXT  |  PDF


8.
Meier PP, Engstrom JL, Mangurten HH, et al.
Breastfeeding support services in the neonatal intensive-care unit.
J Obstet Gynecol Neonatal Nurs.
1993;22:338-347.
MEDLINE


9.
Serafino-Cross P, Donovan PR.
Effectiveness of professional breastfeeding home-support.
J Nutr Educ.
1992;24:117-122.

             ***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html