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Stanford University School of Medicine

A Q&A with breastfeeding expert Susan Crowe

Breastfeeding provides numerous health benefits for mother and baby, but the mechanics of getting started can prove challenging for both parties. What's more, continuing through the recommended 12 months or more, with exclusive breastfeeding for the first six months, can be tricky for busy moms.

Promising news arrived in this year's Breastfeeding Report Card, issued by the U.S. Centers for Disease Control and Prevention (CDC), which documents statistics about breastfeeding practices and supports in states. Susan Crowe, MD, director of outpatient breast feeding medicine services at Lucile Packard Children’s Hospital and an obstetrician and gynecologist at Stanford, is one of the educators helping more hospitals, workplaces and new parents latch on to breastfeeding-friendly practices. She answers questions on the subject below.

The latest CDC Breastfeeding Report Card showed improvement over the last 10 years in the number of women who breastfed their babies at least some of time during the first year of life. What medical or cultural factors do you think have most significantly influenced change in this direction?

There are multiple factors that have likely influenced this increase. The majority of women choose to breastfeed their babies, and the quality of maternity care they receive during the hospital stay has a direct impact on breastfeeding success. The Maternity Practices in Infant Nutrition and Care (mPINC) survey, which has been sent out every two years by the CDC since 2007, shows that our country is improving hospital care practices and helping to support women to establish breastfeeding. For example, more babies and mothers are spending time together after delivery. And when babies and moms share a hospital room, often referred to as "rooming-in," moms find it easier to learn when their babies are ready to eat by watching for infant feeding cues. In addition, the mPINC survey has shown that 54.4 percent of infants in 2011 received skin-to-skin contact after a vaginal birth, up from 40.8 percent in 2007. Both of these practices increase breastfeeding success and lead to higher rates of breastfeeding.

The CDC report notes that skin-to-skin practice - placing a newborn directly on the mother’s skin after birth - is becoming more common in hospitals. How do you educate hospital staff and new parents to encourage this practice? What barriers still exist?

In the ideal setting, infants are placed skin-to-skin (STS) on the mom's chest immediately after delivery. The infant can be dried there, and then the infant will go through natural developmental stages that will lead to a baby suckling at the breast. This process often takes longer than 30 minutes, but most babies will latch on to the breast with minimal assistance if allowed to be together skin-to-skin with their mother. Although this process sounds simple, there are many barriers that exist - some are preventable, but others are not. At delivery, some babies require immediate attention from a pediatric team in order to have a smooth and safe transition to breathing after birth. An infant may require oxygen supplementation at delivery, which is difficult to provide without temporary separation from the mom. A mom may experience a medical emergency that prevents her from being able to hold her baby immediately. During a C-section, a baby can be placed STS at delivery, but an additional hospital staff member must be present to ensure that the baby is properly cared for and observed during the time after delivery. That being said, most situations allow for STS time to take place very soon (if not immediately) after birth. At LPCH, we are educating moms during their pregnancies about the importance of STS, and a multidisciplinary task force has been formed to educate staff and remove barriers to STS both at vaginal and C-section deliveries.

What are some of the medical benefits of skin-to-skin contact? What, if any, are the risks?

The medical benefits of STS at delivery extend beyond breastfeeding. Babies who are STS more easily maintain normal body temperatures, blood sugars and heart rates. They also cry less and have a better chance of successfully breastfeeding. There are no known risks to STS when mother and infant do not require other medical treatment.

According to a 2012 study in Pediatrics, a gap exists between the number of women who intend to breastfeed and the number who are successful in doing so exclusively for the first three months. In your experience, what are some of the reasons mothers change their plan and introduce formula?

The article you refer to demonstrated that although more than 85 percent intended exclusive breastfeeding for at least three months, only 32 percent achieved their goals. In my experience, there are various reasons for this gap. Mothers may change their minds and introduce formula initially because they may not have enough information about how breastfeeding is established. For example, a breastfeeding baby may need to feed very frequently - often referred to as "cluster feeding" - as the initial milk supply is being established. Some moms may interpret this natural behavior as a need to supplement the baby with formula. In the absence of a medical indication for formula use, the use of supplemental formula during this time may interfere with the establishment of a sufficient milk supply. Without proper support, this supplementation can spiral into a situation where the baby actually needs formula to meet their nutritional needs, milk supply further diminishes, and unintended weaning may occur. I have often seen mothers introduce formula because they are in pain while feeding their babies. In order to nurse efficiently, a baby needs to have a proper latch. Some babies and mothers experience this latch without any interventions, but other dyads may require a lot of initial support. If a mother is experiencing pain while breastfeeding, it is critical for her to seek the assistance of an expert (often a lactation consultant) to address the problem immediately.

Are there particular benefits to breastfeeding, as opposed to bottle-feeding breast milk that has been pumped?

There are certainly some benefits to directly breastfeeding over pumping milk and bottle feeding. Although pumping allows the wonderful benefits of providing breast milk when mothers and babies are separated or when premature babies aren't yet able to nurse directly, pumping overall is a lot more work for the mom than direct breastfeeding. Once direct breastfeeding is well established, the milk is always ready at the right temperature. There is no need to prepare a middle-of-the-night bottle. There are no pump parts to wash. There is no need for refrigeration during travel. In addition, there are medical benefits that may be greater with direct feeding. A baby directly feeding will stop feeding when they are full, which may help prevent obesity later in life. That being said, the majority of the medical benefits to breastfeeding are still provided by pumped/expressed milk, and a woman should be supported in doing what she chooses to do to provide this milk for her baby. Women are fortunate to have various pumps available that help them to maintain breastfeeding even when they are separated from their infants. Some women even have an overabundance of breast milk, and they are able to donate their pumped breast milk to milk banks which then supply this valuable resource to infants in intensive care units.

Previously: A call to protect and encourage breastfeeding, A ban on baby-formula freebies, Lessons from a reservation: Clinic provides insight on women’s health issues, Stanford expert discusses breastfeeding techniques and Breastfeeding: “Not only a lifestyle choice”

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