Section on Breastfeeding
COCME Top Three Education Topics
1.
Feeding complications in the late preterm infant
a. Over the last 15 years, the proportion of all US births that were late preterm, between 34
and 37 weeks gestation, increased from 7.3% to 9.1%. Late preterm infants are often the
size and weight of term infants and may be treated the same by parents and health care
professionals. The late preterm infant is physiologically and metabolically immature and
at higher risk of developing medical complications, such as, temperature instability,
hypoglycemia, respiratory distress, apnea, jaundice, and feeding difficulties. They have a
higher rate of hospital readmission for jaundice, suspected sepsis and feeding difficulties.
Breastfed late-preterm infants are 1.8 times more likely to require subsequent hospitalrelated care and 2.2 times more likely to be readmitted than breastfed terms infants.
Pediatricians caring for late preterm infants need to understand the risks of early
discharge of late preterm infants and develop strategies for successful breastfeeding of
late preterm infants to prevent neonatal morbidity. These strategies include close followup, frequent feedings at eight to twelve times per day, use of breast pumping to increase
supply, use of positions that support the infant’s head, careful assessment of the infant’s
latch, and the need to follow urine and stool output and weight carefully.
b. Literature to support this topic includes:
i. William A. Engle, Kay M. Tomashek, Carol Wallman and the Committee on
Fetus and Newborn: "Late-Preterm" Infants: A Population at Risk. Pediatrics
2007 120: 1390-1401.
ii. Adamkin DH: Feeding Problems in the Late Preterm Infant. Clin Perinatology
2006; 33(4): 831-837.
iii. Watchko JF: Hyperbilirubinemia and Bilirubin Toxicity in the Late Preterm
Infant. Clin Perinatology 2006; 33(4): 839-852.
iv. Meier P, Furman L, Degenhardt M: Increased Lactation Risk for Late Preterm
Infants and Mothers: Evidence and Management Strategies to Protect
Breastfeeding. Journal of Midwifery & Women’s Health 2007; 52(6):579-587.
2.
Skill-based workshops on breastfeeding support techniques
a. Breastfeeding is the preferred form of infant nutrition and promotes optimal growth,
development, and health outcomes. Pediatricians play a key role in the initiation and
continuation of breastfeeding among their patients. Many pediatricians did not receive
adequate training about breastfeeding during medical school or residency training.
Surveys published by Freed and colleagues in the 1995 demonstrated that more than 90%
of pediatric residents and pediatric practitioners board certified within the previous 3-5
years believed that pediatricians should be involved in breast-feeding promotion,
however, clinical knowledge and experience did not suggest a high degree of
competency. Pediatricians did not recognize the benefits of breastfeeding and could not
routinely give appropriate management advice. Of practicing pediatricians, more than
70% recommended more time devoted to direct patient interaction and practice of
counseling and problem-solving skills and responded that residency training did not
adequately prepare pediatricians to promote breast-feeding. While lactation consultants
and nurses also provide support for breastfeeding mothers and babies, it is important for
pediatricians to understand basic breastfeeding techniques, to be able to evaluate
effectiveness of breastfeeding, and to be able to troubleshoot when breastfeeding mothers
and babies are experiencing difficulties. As the “captain of the ship,” pediatricians need
to supervise the care provided by lactation consultants or nursing personnel. The
opportunity to observe mothers breastfeeding and to become familiar with the use of
breastfeeding technology, as appropriate, enhances the ability of pediatricians to provide
adequate support for their breastfeeding patients.
b. Literature to support this topic includes:
i. Freed GL, Clark SJ, Lohr JA, Sorenson JR. Pediatrician involvement in breastfeeding promotion: a national study of residents and practitioners. Pediatrics
1995; 96;490-4.
March 2008
Section on Breastfeeding
ii. Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians’ practices and attitudes
regarding breastfeeding promotion. Pediatrics 1999; 103:e35.
iii. Section on Breastfeeding: Breastfeeding and the Use of Human Milk.
Pediatrics 2005; 115:496-506.
iv. Krogstrand KS, Parr K. Physicians ask for more problem-solving information to
promote and support breastfeeding. J Am Diet Assoc 2005; 105:1943-1947.
v. DiGirolamo AM, Grummer-Strawn LM, and Fein SB. Do perceived attitudes of
physicians and hospital staff affect breastfeeding decisions? Birth 2003; 30:94100.
vi. Taveras EM, Ruowei L, Grummer-Strawn L, Richardson M, Marshall R, Rego
VH, Miroshnik I, Lieu TA. Opinions and practices of clinicians associated with
continuation of exclusive breastfeeding. Pediatrics 2004; 113:283-290.
vii. Dillaway HE, Douma ME. Are pediatric offices “supportive” of breastfeeding?
Discrepancies between mothers’ and healthcare professionals’ reports. Clin
Pediatr 2004;43:417-430.
3.
Safe sleep for infants and impact on breastfeeding
a. Close proximity between mothers and babies is optimal for facilitating breastfeeding
behaviors, and frequent feeding during both daytime and nighttime enhances breastmilk
production. The “Back to Sleep” recommendations have decreased the incidence of
SIDS, however, SIDS continues to be the leading cause of death in infants over 1-month
of age. Smoke exposure, soft sleep surfaces, and overheating have been shown to
increase risk of SIDS. Use of pacifiers has been associated with decreased risk of SIDS,
however, early introduction of pacifiers may interfere with breastfeeding. With current
SIDS prevention recommendations, bed sharing is discouraged, yet some literature
supports the fact that unimpaired, non-smoking mothers sleeping on safe surfaces might
be able to sleep in proximity with the infant safely. In the face of SIDS risk and
conflicting recommendations in the literature, pediatricians are left trying to balance
cultural beliefs regarding breastfeeding and infant sleep, use of pacifiers and impact on
breastfeeding, and safe sleep recommendations. It is important for pediatricians to
understand all of the evidence regarding infant sleep in order to help parents make
informed decisions regarding infant sleep.
b. Literature to support this topic includes:
i. Task Force on Sudden Infant Death Syndrome: The Changing Concept of
Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies
Regarding the Sleeping Environment, and New Variables to Consider in
Reducing Risk. Pediatrics 2005; 116:1245-1255.
ii. McKenna JJ, Ball HL, Gettler LT: Mother-infant cosleeping, breastfeeding and
sudden infant death syndrome: What biological anthropology has discovered
about normal infant sleep and pediatric sleep medicine. American Journal of
Physical Anthropology 2007; 134 (S45):133-161.
iii. Gessner BD, Porter TJ, Eidelman AI, Gartner LM, Bartick M, Pelayo R, Owens
J, Mindell J, Sheldon S: Bed sharing with unimpaired parents is not an important
risk for sudden infant death syndrome. Pediatrics 2006; 117: 990-994.
iv. Mosko S, Richard C, McKenna J: Infant arousals during mother-infant bed
sharing: implications for infant sleep and sudden infant death syndrome
research. Pediatrics 1997; 100(5):841-849.
v. Moon R, Horne R, Hauck F: Sudden infant death syndrome. The Lancet 2007;
370:1578-1587.
vi. Moon RY, Kington M, Oden R, Iglesias J, Hauck FR: Physician
recommendations regarding SIDS risk reduction: a national survey of
pediatricians and family physicians. Clin Pediatr 2007; 46(9):791-800.
vii. Baddock SA, Galland BC, Taylor BJ, Bolton DP: Sleep arrangements and
behavior of bed-sharing families in the home setting. Pediatrics 2007;
119(1):e200-7.
March 2008