Objective Clarification, Objective Text, Data Source, Status: The U.S. Breastfeeding Committee (USBC) applauds the retention of this objective. Ever since the health objectives for 1990 were published in 1980, better infant feeding practice has been a national health goal. Improvements are sought in three areas: initiation (more mothers taking up breastfeeding), duration (more babies being breastfed at six and twelve months of age), and quality (higher rates of exclusive breastfeeding). There is ample and increasing evidence that these improvements would bring positive health effects—-short-term and long- term—-for both mother and child, the two partners in the breastfeeding relationship.
Breastfeeding is a cross-cutting issue that is uniquely relevant to each of the four goals of Healthy People 2020.
1) Breastfeeding, especially exclusive breastfeeding, is the normal method of care, protection, and nourishment for humans at the start of life. Breastfeeding can help promote health and prevent disease throughout the life span. In addition to providing unmatched nutrition, breastfeeding enhances immune system development and gut health. It reduces the risk of several conditions that are major national health concerns, including asthma, cancer, cardiovascular disease, diabetes, and obesity.
2) Breastfeeding, especially exclusive breastfeeding, offers powerful protection against the effects of poverty and is a key strategy to reduce health disparities between the rich and the poor. Yet infant feeding is itself an area that shows large disparities by geography, race/ethnicity, socioeconomic status, maternal age, and maternal education. Thus, we believe that making breastfeeding a national priority would help to reduce disparities in breastfeeding rates, offering better health to many families that are currently at a disadvantage.
3) The social and physical environment—including family, community, health care system, workplaces, businesses, schools, transportation, and the media—exerts an enormous influence on breastfeeding success, often putting up barriers to improving duration and exclusive breastfeeding rates. Thus, we welcome the emhasis in HP2020 on identifying and improving the social determinants of health.
4) Breastfeeding is a relationship between two people at different ages and stages of development. The medical contraindications to breastfeeding are few. Breastfeeding is “upstream” disease prevention and health promotion that is available to nearly 100% of the four million babies born in America every year and to nearly 100% of the women who give birth. Because of its potential for a positive effect on the health of almost every future citizen, we recommend that breastfeeding be prioritized as a national health objective.
An increase in one behavior—-breastfeeding—-can positively impact ten percent of the Healthy People 2010 objectives, for nearly one hundred percent of the population.
In the current national debate on health care, cost is a central topic. A recent paper submitted for publication contained an analysis of the impact of breastfeeding on the direct and indirect costs of ten pediatric diseases, as well as the cost of premature death. The authors found that the current sub-optimal breastfeeding rates are costing the United States a minimum $13 billion a year and incurring over 900 excess child deaths, compared to the costs if 90% of US families could comply with the recommendation to breastfeed exclusively for 6 months.
Events of the past decade have prompted a new emphasis on emergency preparedness in America. Babies and young children are among the most vulnerable people in disaster situations, but a breastfeeding mother can provide her baby or young child with food, water, protection, and care. Thus every mother who extends her duration of breastfeeding is contributing to emergency preparedness in her community.
The breastfeeding targets of the previous national health plans were modest. Even so, progress has been slow. The national rate of breastfeeding initiation has improved an average of 1% per year since 1980, but the 6-month duration has improved only one-third that fast. The evidence base for breastfeeding continues to grow, but the gap between evidence and practice is still too wide. We hope that HP2020 will help raise public awareness about the role of infant feeding in growing a healthy nation.
Data from 2006 showed that 19 states had met at least one of the 2010 sub-objectives and 10 states had met all five. We believe it is time to raise the targets. In addition, since the World Health Organization recommends a minimum of two years of breastfeeding, we suggest adding a sixth sub-objective to start tracking the percent of U.S. children who are breastfeeding at 24 months.
Breastfeeding data, disaggregated by several key categories, are already being collected and reported annually through several national surveys. Breastfeeding data-gathering has improved markedly over the last decade. Now that we have the tools to measure progress, this is a good time to put more resources into making progress.
USBC welcomes the design of HP2020 as a relational database. We are excited by the possibility of linking our objective(s) with other health objectives where breastfeeding can play a role in prevention.
USBC looks forward to the implementation of HP2020, and especially applauds the Health in All Policies concept. “ Health in All Policies” means that actions to improve health are not expected only from the health sector and the public health community. Breastfeeding protection, promotion, and support are needed throughout all sectors, wherever there are women with babies and young children. Cross-agency collaboration is crucial to provide a pro-breastfeding infrastructure for American families. The involvement of multiple agencies has been of significant benefit for the work of USBC, and we urge the DHHS Office of Health Promotion and Disease Prevention to foster further collaboration on implementation of HP2020, with built-in, defined leadership roles to avoid accountability gaps.
Because of its value as a cost-effective primary prevention strategy and its broad, cross-cutting scope, we urge you to consider breastfeeding as a candidate to be a national priority objective!
The US Breastfeeding Committee (USBC) is an independent nonprofit coalition of 34 national professional and educational organizations, plus seven government agency partners. USBC works closely with a network of breastfeeding coalitions in every U.S. state and territory.

Anonymous on 12/31/2009 7:56:00 PM

Objective Clarification: I strongly support the objective and agree with those who suggested increasing the breastfeeding rates at each age by at least 10% compared with 2010. I also have some comments about the International Formula Council's suggestions:
1) "exclusive and continued breastfeeding should be part of a broader goal of optimal nutrition for infants, whether through breastfeeding or formula feeding, the only safe and recommended alternative to breastfeeding."
Given current scientific literature, there is no justification for the use of the word "optimal" to describe formula feeding. Formula is a substitute for human milk which provides nutrition, nothing more. In situations where no breastfeeding or human milk is possible (e.g. rare medical conditions such as galactosemia, maternal use of a rare, truly contraindicated medication, etc in the setting where donor milk is unavailable) infant formula is the substitute of choice. Despite the IFC's assertion, however, formula is actually not the only safe and recommended alternative to breastfeeding. The order of substitutes for breastfeeding is as follows:

a) mother's own expressed milk - the ideal substitute for breastfeeding in cases of maternal-infant separation due to either work or illness, also the ideal substitute for breastfeeding when feedings at the breast don't work despite proper lactation assistance
b) pasteurized donor milk - there is a growing body of evidence for the important role of donor milk in the health of infants, particularly preterm infants; if it weren't for the cost and availability issues, donor milk would be the ideal replacement milk for infants who cannot be breastfed or get mother's own milk. It should be the first consideration for preterm or sick infants who cannot get their own mother's milk, and should be covered by health insurance plans for such conditions.
c) infant formula

2) "HP2020 goals should focus on infant health outcomes by including the breastfeeding goal under a broader objective that emphasizes the outcomes of interest, such as appropriate weight gain, reduced incidence of acute infectious diseases in children...."
How interesting that the formula companies on one hand try to discredit the evidence ("no conclusive evidence of a causal relationship between breastfeeding and decreased risk of these diseases") while at the same time suggesting that breastfeeding be recommended for promoting the very health outcomes they claim are not based on good evidence.
I disagree with this recommendation which tries to hide breastfeeding inside something broader. Breastfeeding is of importance not only for infant and child heath but also maternal health, and it has been so eroded in this society that it needs to be addressed as a health objective in its own right.

3)“Women have the right to proper nutrition, to decide how to feed their children and to full information and appropriate conditions that will enable them to carry out their decisions.” "....despite the best efforts of government, industry, and other health organizations to encourage breastfeeding, a proportion of mothers in the United States cannot or choose not to breastfeed for a variety of reasons."
It seems disingenuous for formula companies to advocate for full information when they are often the source of misinformation regarding breastfeeding through their marketing initiatives. Although there are some mothers who truly cannot breastfeed, (and these mothers should absolutely receive the support and appropriate information needed to mitigate the harmful results,) the majority who currently cannot breastfeed are hindered by various barriers, at least some of which relate to the pervasive formula marketing through hospitals and doctors' offices. As for women who choose not to breastfeed, it is fine if they make a fully informed decision. They should be provided with teaching that will help them formula feed in the safest and most economical way (i.e. they should not be handed free ready-to-feed formula in the hospital but rather taught how to mix and prepare formula safely during their hospital stay.) However, few mothers currently make a fully informed decision. Again, the formula industry has played a role in portraying formula as convenient and wholesome, playing up positive images of bottle-feeding while damning breastfeeding with faint praise. This portrayal help tip the balance for mothers who were not fully informed about the potential health risks to their infant and themselves of not breastfeeding, especially if they try to breastfeed and meet with difficulties, including lack of support from the father or other relatives/friends. How easy it is to switch to formula feeding when the potential risks are minimized while formula feeding is pictured in such a positive light.

I hope that those who are considering all these comments will take into account the fact that the International Formula Council has a vested interest in preserving (and growing) the market for infant formulas. Although they are clearly a stakeholder in this process, their comments are not purely motivated by interest in health, as they try to suggest.

I recommend strengthening the objectives as much as possible. If the earlier goals had not been set where they were, I wonder whether we would now have an initiation rate of 74%. Now we need to set higher goals for breastfeeding rates at all ages, as well as setting high goals for exclusive breastfeeding, which is associated with the most dramatic positive health outcomes. It shouldn't matter if the goals seem too high. That should be an impetus for finding solutions to the multifaceted barriers mothers and babies currently face in this country in trying to initiate and continue optimal breastfeeding.
Alicia Dermer, MD, FABM, IBCLC

College on 12/31/2009 6:34:00 PM

Objective Clarification, Objective Text: The Wyoming WIC Program strongly supports this objective, but also feels that it would be helpful to have a sub-objective or a separate objective that is focused on increasing the number of mothers who exclusively breastfeed their infants.

ACNM on 12/31/2009 12:18:00 PM

Status: The American College of Nurse-Midwives strongly supports this objective.
Teaching about and support of breastfeeding is an essential component of the care midwives give. Women randomized to midwife-led models of care were more likely to initiate breastfeeding and that all women should be offered midwife-led models of care. (The Cochrane Database of Systematic Reviews 2009 Issue 4).
ACNM strongly supports efforts to decrease the racial disparities in breastfeeding rates. Populations with higher rates of neonatal and infant mortality stand especially to benefit from increased rates of breastfeeding.
We urge collaboration between maternal and infant healthcare providers to achieve Healthy People 2010 and 2020 goals to decrease the United States cesarean delivery rate. Women who had a cesarean section experienced a significant delay in initiating breastfeeding compared with women giving birth vaginally (p<0.001). (Birth 29:2. June 2002)

International Formula Council on 12/31/2009 11:58:00 AM

Objective Clarification, Objective Text: The International Formula Council (IFC) appreciates the opportunity to provide comments on the proposed Healthy People 2020 Objectives. The IFC is an association of manufacturers and marketers of formulated nutrition products, e.g., infant formulas and adult nutritionals, whose members are based predominantly in North America.* We fully support and commend the aim of Healthy People 2020 to improve the health of all infants. The IFC supports breastfeeding as the ideal infant feeding method and supports this particular HP2020 objective as a sub-objective. However, we have several suggestions related to the overall objective of improving infant feeding.

Broader Goal Focused on Optimal Infant Nutrition
We believe HP2020 objectives should be based on broad health outcomes rather than goals for specific factors associated with health outcomes. Thus, exclusive and continued breastfeeding should be part of a broader goal of optimal nutrition for infants, whether through breastfeeding or formula feeding, the only safe and recommended alternative to breastfeeding.

A review of the scientific literature finds support for the benefits of breastfeeding, especially regarding the possible effects in reducing the incidence of acute pediatric infections (e.g., diarrhea, respiratory or ear infections). However, for chronic illnesses such as cardiovascular disease, diabetes, and obesity, environmental and genetic factors play a significant role in disease development and there is no conclusive evidence of a causal relationship between breastfeeding and decreased risk of these diseases. In such situations residual confounding may explain the observed differences. Indeed, recent evidence from a large randomized prospective trial of breastfeeding promotion, the PROBIT trial in Belarus, shows that despite substantial increases in breastfeeding, there were no long term differences in obesity, asthma, allergy, dental caries, maternal or infant behavior. At the same time, formula-fed infants in the U.S. have documented growth, development, and long-term health outcomes similar to breastfed infants. HP2020 goals should focus on infant health outcomes by including the breastfeeding goal under a broader objective that emphasizes the outcomes of interest, such as appropriate weight gain, reduced incidence of acute infectious diseases in children, and achievement of highly nutritious diets in infancy and young childhood (supported by assessment of nutritional status).

Identification of Infant Formula as the Only Safe and Recommended Alternative to Breast Milk
We are pleased that, through a concerted effort by the health community, government, industry (including Healthy People 2010 goals and objectives), and industry, recorded breastfeeding rates in the United States have increased during the past decade. However, despite the best efforts of government, industry, and other health organizations to encourage breastfeeding, a proportion of mothers in the United States cannot or choose not to breastfeed for a variety of reasons. Parents should be informed that the AAP, the U.S. Food and Drug Administration, the United States Department of Health and Human Services, the U.S. special supplemental food program for Women, Infants and Children (WIC) and leading health professional organizations recognize that, in those instances where infants are not breastfed during the first year of life, iron-fortified infant formula is the only safe and recommended alternative. The provision of such information is consistent with the World Health Organization’s Global Strategy for Infants and Young Child Feeding, which states: “Women have the right to proper nutrition, to decide how to feed their children and to full information and appropriate conditions that will enable them to carry out their decisions.”

Healthy People 2010 notes at Goal 16-19, “Universal breastfeeding is not recommended in the United States,” but does not offer an alternative for those mothers who do not breastfeed. Accordingly, HP2020 objectives should state that for those mothers who cannot or choose not to breastfeed infant formula is the only safe and recommended alternative. Such a recommendation would be consistent with WIC program guidelines and the WHO’s Expert Consultation on the Optimal Duration of Exclusive Breastfeeding, which state that while exclusive breastfeeding is recommended for six months, “some mothers will be unable to, or choose not to, follow this recommendation. These mothers should also be supported to optimize their infants’ nutrition.”

WIC-Specific Breastfeeding Goal
There is also a need to set breastfeeding goals specific for the WIC population. As noted in a 2006 Pediatrics article, “Breastfeeding rates among WIC participants have lagged behind those of non-WIC mothers for the last 25 years,” and “Healthy People 2010 goals for breastfeeding will not be reached without intervention.” We recommend the Secretary’s Advisory Committee and HP2020 organizers consider adding a goal specifically supporting an increase in WIC breastfeeding rates. Further, HP2020 could systematically rank the barriers to increased breastfeeding and prioritize those variables that have greatest impact for intervention, including employment obligations and lack of workplace accommodations to support breastfeeding.

I. Cato Research. Comprehensive Evaluation of the Available Literature Regarding Health Disparities Between Breastfed Infants and Non Breastfed Infants. 2006.
II. The American Academy of Pediatrics, Committee on Nutrition. Iron Fortification of Infant Formula. Pediatrics. 1999;104:119-123.
III. Rebecca Williams and Isadora Stehlin. Breast Milk or Formula: Making the Right Choice for Your Baby. U.S. Food and Drug Administration, Food Consumer Magazine, updated 1998. http://www.fda.gov/fdac/reprints/breastfed.html
IV. The U.S. Department of Health and Human Services. http://www.4woman.gov/breastfeeding/index.cfm?page=520
V. Food and Nutrition Service, U.S. Department of Agriculture. How WIC Helps. 2004. http://www.fns.usda.gov/wic/aboutwic/howwichelps.htm#feeding%20practices
VI. The World Health Organization. Global Strategy for Infant and Young Child Feeding. 2003.
VII. The World Health Organization. Expert Consultation on the Optimal Duration of Exclusive Breastfeeding. 2001. http://www.who.int/nutrition/publications/optimal_duration_of_exc_bfeeding_report_eng.pdf
VIII. Ryan and Zhou. Lower Breastfeeding Rates Persist Among the Special Supplemental Nutrition Program for Women, Infants, and Children Participants, 1978-2003. Pediatrics. Vol. 117 April 2006, pp. 1136-1146. http://pediatrics.aappublications.org/cgi/content/abstract/117/4/1136

* IFC members are Abbott Nutrition, Mead Johnson Nutrition, Nestlé Infant Nutrition, and Pfizer Nutrition.

Dan Dubovsky on 12/31/2009 11:05:00 AM

Objective Clarification, Objective Text: There needs to be an addition to this objective that addresses increasing the proportion of mothers who do not use alcoholic beverages during breastfeeding of their babies. There is research that finds that alcohol is transmitted to the baby through breast milk. Since the brain continues to develop after birth, and alcohol effects the developing brain, it can be very detrimental for women who use alcoholic beverages to breastfeed. Leaving this out of this objective runs the risk of brain damage in infants who are breastfed by mothers who used alcohol during breastfeeding. The myth remains that drinking, especially beer, during breastfeeding increases lactation. This must be dispelled.

American Society for Nutrition on 12/31/2009 10:42:00 AM

Objective Clarification: This is an important objective and one that the American Society for Nutrition supports. Achieving progress in this area will require an increase in the proportion of women who (a) have access to maternity leave and (b) have a longer maternity leave in order to facilitate greater breastfeeding success rates. A convention of the International Labor Organization recommended 14 weeks maternity leave.

Los Angeles County Department of Public Health on 12/31/2009 1:50:00 AM

Objective Text: MICH12 Consider including a sub-objective “Increase the proportion of mothers who exclusively breastfeed their babies”

NYC Dept of Health and Mental Hygiene on 12/30/2009 5:03:00 PM

Objective Text:
Add a sub-objective on increasing number of preterm babies who are breastfed.

NYS Dept of Health Division of Nutrition on 12/30/2009 3:35:00 PM

Objective Clarification, Objective Text: Comment: Protection, promotion, and support of breastfeeding are critical public health needs. As a public health measure, breastfeeding has great potential to enhance infant and maternal health. However, improving both initiation and longer duration of breastfeeding are public health challenges. According to the US Surgeon General, every hour of every day, almost 500 new mothers across the United States face the same decision: how to feed their newborns. A fundamental aspect of the protection and promotion of health is to ensure individuals are able to make informed decisions in supportive environments. We have an ethical responsibility to ensure that mothers are fully aware of the health consequences of their infant feeding decisions. Breast milk is the best source of infant nutrition. The benefits of breastfeeding are well-recognized, including protection against otitis media, gastroenteritis, severe lower respiratory infections, and necrotizing enterocolitis. In addition, breastfeeding is associated with lower rates of sudden infant death syndrome, childhood obesity, type 2 diabetes, and leukemia. The maternal health benefits of breastfeeding were also identified, including reduced risk for type 2 diabetes, as well as breast and ovarian cancers. In light of the important maternal and child health benefits of breastfeeding, health professional organizations, including the American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Nurse-Midwives, American Dietetic Association, and American Public Health Association, among others, officially recommend that most infants breastfeed for at least 12 months. These organizations also recommend that for about the first six months infants be exclusively breastfed, meaning that they not be given any foods or liquids other than breast milk. Furthermore, the American Academy of Pediatrics (AAP) emphasizes that most mothers and babies can and should breastfeed exclusively for the first 6 months and subsequently in combination with other foods until at least 12 months and as long as mutually desired by mother and child thereafter (AAP 2005). The AAP defines exclusive breastfeeding as an infant’s consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications.
Source: www.surgeongeneral.gov/library/publichealthreports
Objective clarification: It would be helpful to further expand on this objective to include increasing the proportion of workforce establishments that have breastfeeding friendly policies.
Recommendations to expand the objective text: “Increase the proportion of childcare centers that have breastfeeding friendly policies.”

Anonymous on 12/30/2009 11:01:00 AM

Objective Clarification, Objective Text, Data Source: This measure would be more effectively tracked if it were narrowed to:
- 3 months
- 6 months
- 12 months

To be successful in long term breastfeeding moms need support after the initial postpartum period. New challenges continually emerge, such as the introduction of solids, teething, decreases in milk supply, etc. Best practice is to provide outreach during the pregnancy, immediately after birth, during the transition period if mom returns to work, and at 6 and 12 months intervals.
During a 12 months study of 24 corporations spanning all industries and population diversities, 61% found breastfeeding support most helpful when delivered during and after their maternity leave.

State and Territorial Public Health Nutrition Dire on 12/29/2009 7:57:00 PM

Objective Text: ASTPHND recommends modification:
Add-
Older than 1 year of age

Anonymous on 12/27/2009 6:33:00 PM

Objective Text: how do we accomplish these objectives? so important to have peer counselors esp for minority groups.
we need to work with hospitals to ensure that babies and moms do not get separated during those first hours after birth. so many hospitals still have nurseries where babies spend hours and many excused are used to speed the babies there instead of leaving them skin to skin with mom.
we need to look at what makes the start of breastfeeding so difficult for many couplets-all these interventions such as inductions, C/S, pharmacological pain relief during labor effect the dyad very much.

AWHONN on 12/23/2009 12:21:00 PM

Objective Clarification, Objective Text:
Rewrite Objective: Increase the proportion of mothers who breastfeed their babies.
a. Initiation prior to hospital discharge
b. Sustained, exclusive human milk feeding for 3 months
c. Sustained, exclusive human milk feeding 6 months
d. Sustained human milk feeding for 12 months

Rationale: AWHONN supports breastfeeding as the optimal method of infant nutrition. Many women return to work after approximately three month of maternity leave. In the absence of national workplace lactation support requirements, sustained human milk feeding for 3 months is an important benchmark.

Anonymous on 12/22/2009 6:40:00 PM

Objective Text, Data Source: The CDC immunization survey data shows that by 2006, 28 states met the HP 2010 objective of 75% initiation (http://www.cdc.gov/BREASTFEEDING/DATA/NIS_data/ )and the national initiation rate is about 74%, to I suggest increasing the initiation goal to 80% by 2020. (Well achievable if we maintain the same rate of increase.)

It is very important for those of us in public health to have a national standard to strive for in setting our state and local goals. The exclusive breastfeeding goals and the duration goals are also important for setting a standard for state and local goals.

Anonymous on 12/22/2009 3:01:00 PM

Objective Text: I support Kay Hoover's suggestion that all the Healthy People 2010 goals be retained, and that 10% of babies be breastfed at age 2 be added.

Anonymous on 12/21/2009 11:51:00 PM

Objective Clarification: I understand and agree with the focus of so many of these objectives to increase breastfeeding, but assert that another objective (or sub-objective) should be added to drive home the fact to all new parents that the only other alternative to breastmilk that is safe and healthy to drink during a child's first year is baby formula. Just one viewing of Good Morning America's recent report of poor Appalachian families feeding their babies sugary soft drinks like Mountain Dew drove home the need to formally spell this out all the more for me (as a dental student) despite it being common sense to so many, it is obviously not common sense to all.

Breastfeeding supporters might not like to admit that formula is in fact a better alternative than other options, but just ask any dentist what the long term impact on small children of improper feeding and oral hygiene practices can be and they will undoubtably support my proposed objective as well.

March of Dimes Foundation on 12/21/2009 9:28:00 AM

Status: The March of Dimes Foundation strongly supports retaining this objective in Healthy People 2020..

Tanya S. on 12/18/2009 1:11:00 PM

Objective Clarification: All sub-objectives should increase their goals by 10%.

Marsha Walker on 12/18/2009 8:50:00 AM

Objective Clarification: All sub-objectives should increase their goals by 10%.

Anonymous on 12/18/2009 8:47:00 AM

Objective Clarification: This objective should increase each sub-objective by 10%.

Kay Hoover on 12/17/2009 5:31:00 PM

Objective Clarification, Data Source: I would like to recommend adding another sub-objective:
10% of babies be breastfed at 2 years
The WHO recommends breastfeeding for 2 years and beyond because it is healthier for the individual.
A question to collect this information could be added to the immunization records.

Lactation Consultant on 12/17/2009 4:43:00 PM

Objective Text: I am in support of the baby friendly hospital initiative and truly believe that hospitals should be prohibited from dispensing formula to new moms for free. Giving away free cans of formula has been shown to undermine breastfeeding success. Also, hospitals and clinics should be staffed with Lactation Consultants, specialists in the field, that are capable of assisting new mothers with concerns and questions about breastfeeding. If someone has a heart disease issue, a heart specialist is available, if someone has a orthopedic issue, an orthopedic specialist comes to visit; so should mothers with breastfeeding issues have access to specialized care, which should be reimburseable through insurance. For those with older infants, to allow extended breastfeeding, low or minimal cost, or no cost (paid through insurance), breastpumps should be easily accessible for all mothers.

Anonymous on 12/17/2009 11:17:00 AM

Objective Clarification: The consensus really has become to recommend breastfeeding through the first year of age - to remain consistent with nationally and globally recognized recommendations - it is important to include increasing the percentage of women who breastfeed their infants through 12 months of age - perhaps 25%.

Anonymous on 12/15/2009 2:04:00 PM

Objective Clarification: The real obstacle to breastfeeding for as long as is recommended, if at all, if being able to do so when one has to go back to work outside of the home and leave their baby with a caregiver other than themselves. Ensuring that all new moms are able to continue to nurse by being able to pump their milk safely and securely is what truly influences their decision to breastfeed at all and for how long. More attention should be given to changing the policies of their employers rather than the moms to make sure this happens.

Elizabeth Munoz Life University Student on 12/11/2009 9:33:00 AM

Objective Clarification: Breastfeeding is of vital importance for both mother and baby, specially during the first months of birth. It is one of the first emotional bonds between mother and baby. Increasing education for expectant mothers, emphasizing on the health benefits and vital nutrients the baby will receive, would help reach this objective. Increase in participation of Baby-Friendly hospitals and health care facilities; allowing the mother and baby to remain together in the same room will help build that interaction and bond between them, and lets mothers breastfeed on their own time. Establishing more work policies and providing facilities for breastfeeding, providing child-care on work site and allowing mothers breaks to breastfeed can also be some approaches towards reaching the goal. I believe there is still much to be done for reaching the objective but with the appropriate promotion and education it can be reached.

Anonymous on 12/11/2009 9:31:00 AM

LPontiousRN on 12/9/2009 4:15:00 PM

Objective Clarification: Baby/nursing friendly policies to be instituted in hospitals...unless baby is sick, requiring treatment that cannot be given at mother's bedside, baby should not be removed from mother's room. Skin to skin contact for first hour of life. Some evidence is emerging in research that use of epidurals may be associated with breastfeeding problems. Another approach, WIC and Medicaid, as well as food stamps, benefits could be increased in some way for breastfeeding mothers (financial incentive).

Amaya on 12/9/2009 1:06:00 PM

Objective Clarification: Increasing the number of women who breastfeed their babies is a very good objective. However the tactics used to make this objective a reality are missing. It is a fact that minorities are less likely to breastfeed their babies so clearly expectant mothers should be informed of the benefits of breastfeeding. They should also be made aware of how cost effective breastfeeding can be, baby formula should not be a first choice. I believe that if more hospitals become breastfeeding friendly and allow mothers that bonding time with their child through breastfeeding instead of letting the mother leave with a can of formula the objective will be more easily met.

Anonymous on 12/9/2009 1:02:00 PM

Objective Clarification: Increasing the number of women who brestfeed their babies is a very good objective. However the tactics used to make this objective a reality are missing. It is a fact that minortities are less likely to brestfeed their babies so clearly expected mothers should be informed of the benefits of breastfeeding. They should also be made aware of how cost effective breastfeeding can be, baby formula should not be a first choice. I believe that if more hospitals become breastfeeding friendly and allow mothers that bonding time with their child through breastfeeding instead of letting the mother leave with a can of formula the objective will be more easily met.

Anonymous on 12/7/2009 7:50:00 PM

Objective Clarification, Objective Text, Data Source: Add comments that suggest Objective Clarification, recommendations to update the Objective Text, information on the Data Source, and detail on the Status.
RE: exclusive through 3 months.. very difficult to get data extracted. would recommend it be tied to routine well child visit at 4 months.

Suzanne Haydu MPH RD on 12/7/2009 3:01:00 PM

Objective Clarification, Objective Text: Add: Increase to 25% the number of infants who breastfeed until 12 months of age or older.

DHSPS on 12/7/2009 12:40:00 PM

Objective Clarification: Suggest breaking breastfeeding out into the following categories or timeframes: a) initiation, b)breastfeeding at 3 mos., c) breastfeeding at 6 mos., and d) breastfeeding at 12 mos. It would also be nice to get a better definition for what is considered initiation of breastfeeding. The 2010 definition was too broad.

Katrina on 12/3/2009 12:46:00 PM

Objective Text, Status: Add comments that suggest Objective Clarification, recommendations to update the Objective Text, information on the Data Source, and detail on the Status.

First, Healthy People 2010 has percentages with each subpart (a, b, c). What are the percentages here for a, b, c, d, & e? This is great goal, but what are we doing to help women achieve this goal? As a working mother who breastfed 2 children, a professional seeking to become an IBCLC, and a certified pediatric nurse practitioner, I understand that there are many factors that contribute to and prohibit successful breastfeeding. First, it is how this issue is handled by OB/GYN and CNM's. Education MUST begin during this time. Breast is not best it is NORMAL and optimal! Formula is a foreign protein and suboptimal. The number of women who physically cannot breastfeed is very small, and these women should not be made to feel bad for their inability to breastfeed, but MOST women CAN breastfeed. Second, maternity leave is far too short to promote breastfeeding. The mother has barely recovered from the delivery by this time. Plus, 6 weeks is not enough time for the mother and infant to establish a good bond and successful routine. Countries with longer paid maternity leave seem to be more successful at increasing breastfeeding duration. Honestly, 6 weeks is barely enough time for a mother who is human milk substitute feeding. Children need their parents to grow and develop appropriately. Third, places of employment MUST support mothers. Flexible hours, longer maternity leave (paid if at all possible), options for child care or bringing the child to work, are all things businesses need to consider. Legislation may be necessary to really improve the workplace environment. Breastfeeding decreases infant mortality, decreases maternal and infant morbidity, subsequently creating a healthier society. We aren't just talking about feeding a baby here- we are talking about the family and community's entire future!

Winchymum on 12/1/2009 9:56:00 PM

Objective Clarification: Can't help but feel that this objective puts the women who cannot breastfeed (and they really do exist, I was one on them!) under more pressure than they already put themselves under to try to do the best for their children within their abilities.

It also ignores the impact that many other foods young children receive both while they might still be breastfeeding and especially after they are weaned might do far more damage to the child's future health than if they had been fed formula at any point. Think french fries, sugary juices, etc...Gotta imagine that a diet heavy in those kinds of solid foods would probably undo any good breastfeeding might have done for them.

Anonymous on 11/30/2009 11:41:00 AM

Objective Clarification, Objective Text: I agree with those who state that knowledge of the risks of not breastfeeding need to be exposed. When I had my first child, I was taught that "breast is best." I had no idea that formula had risks for my baby. It wasn't until my daughter was a few weeks old and I considered weaning her did I find out that there were risks involved with not breastfeeding. This information needs to get out and health care workers have got to let moms know the truth--that breastfeeding is normal. It's NOT "best"; it's what your baby is supposed to receive. The only way I found out that formula had risks was when I posted information on an on-line breastfeeding support board. It is absurd that these risks were never mentioned to me by my ob/gyn, the nurses at the hospital where I delivered, or my daughter's pediatrician. Instead, I had to find it out from an anonymous poster on a message board and research it further on my own.

I also agree that those formula bags need to be banned from hospitals. When I delivered my second baby in 2008, there was a black diaper bag containing a canister of Enfamil waiting for me in my post-partum room. What kind of message does that send?

Renee Schwalberg on 11/30/2009 9:46:00 AM

Objective Clarification, Objective Text: I was involved in the development of this objective for Healthy People 2010, and at the time the only consistent source of data on breastfeeding was the Ross Labs Mothers Survey. I assume that's why the original objective refers to the proportion of MOTHERS who breastfeed. However, we now have a number of Federally-supported surveys that address breastfeeding, including the NIS, NHANES, and the NSCH, all of which actually count the percentage of INFANTS who are breastfed. Therefore, I recommend that we reword the objective. Thanks.

Anonymous on 11/25/2009 4:55:00 PM

Objective Clarification: I agree with Anonymous on 11/14/2009 11:43:00 PM that breastfeeding support needs to be provided at all stages of the journey. There are no statements about making available peer counseling groups for post-partum support. They could be provided by the delivery hospital, La Leche, local health depts or the WIC program.
What are the goals for the proportion of excl. breastfeeding at 3 mos & 6 mos?

Winchymum on 11/18/2009 3:50:00 PM

Objective Clarification: This is a perfectly fine objective to shoot for, but as a mom who did a combination of breast and formula feeding for my children, great care should be taken to make sure it isn't achieved by reducing the support given to moms who choose for whatever reason to feed with formula. There was an obvious difference in the amount of attention I got with when I was was in hospital with my first child who I was dead set on making breastfeeding work for (we last 4 months until I had to go back to work), and the amount I got when my second was born since I opted to bottle feed from the start since I had to go back to work in only 4 weeks. I could hardly find a nurse to help me out, since it seems they were spending all there time holding the hands of the breastfeeding moms, and I had to figure out bottlefeeding a newborn myself. It isn't as easy as just reading the instructions on the can, and I certainly left the hospital feeling a lot less prepared than I was with my first, and that certainly wasn't in the best interests of my child regardless of how I chose to feed her.

MGlass on 11/18/2009 1:46:00 PM

Objective Text, Data Source: There MUST be an objective added to increase the number of Baby Friendly hospitals (BFHI). BFHI covers all the lapses in support facing nursing moms, lapses which are reflected in the troubling data: unchecked formula marketing, all health care providers of pregnant and new mothers properly educated, hospitals giving research-based care, and support upon discharge among others. It is measurable and data are easy to obtain. One of the CDC performance indicators is the number of babies born in Baby Friendly hospitals. This dovetails nicely. Having a HP 2020 objective would go a long way in influencing hospitals that good breastfeeding support is critical to the care they give their patients. This is one goal, one step, that could potentially positively affect the data for all the other breastfeeding goals.

dianamiller on 11/16/2009 9:39:00 AM

Objective Text: This is the objective data. What we are discussing are the strategies for accomplishment. Where would we like to see the data collected from? What does the CDC use for their data collection? Why the NIS?

dianamiller on 11/16/2009 9:18:00 AM

Objective Clarification: This objective should not stand alone. It needs to be blended into all areas of perinatal and preconceptive care in order to be acccomplished. UNICEF/WHO's "Baby Friendly Hospital Initiatives" should be incorporated into the objectives for improved infant/child care. This is a MAJOR way to accomplish this objective.

Anonymous on 11/14/2009 11:46:00 PM

Objective Clarification, Objective Text: Pat Bucknell IBCLC, RLC
In order to increase the proportion of mothers who breastfeed, we need to have support for the mother at all steps in her breastfeeding journey; before she has her baby by encouragement from her health care provider, in the hospital with Board Certified Lactation Consultants available, after she is discharged with lactation therapy by Board Certified Lactation Consultants available and covered by private insurance and Medicaid, and if she is returning to work support from her employer with a private place to pump her breastmilk during the workday.

Anonymous on 11/14/2009 11:43:00 PM

Objective Clarification, Objective Text: In order to increase the proportion of mothers who breastfeed, we need to have support for the mother at all steps in her breastfeeding journey; before she has her baby by encouragement from her health care provider, in the hospital with Board Certified Lactation Consultants available, after she is discharged with lactation therapy by Board Certified Lactation Consultants available and covered by private insurance and Medicaid, and if she is returning to work support from her employer with a private place to pump her breastmilk during the workday.

Sue Bedard MSN IBCLC on 11/13/2009 4:25:00 PM

Objective Clarification, Objective Text: We need to shift the focus to the risk of not recieving any human milk. That mother's milk is a health decision and not a choice between two equals breast or bottle. We need to ban professionals from marketing ABM (formula) in the form of diaper bags and coupons. And finally to begin to seriously address the barriers to continuing to provide milk beyond 6 weeks of age - how working outside the home or traveling makes breastfeeding more difficult. The choice is between working and staying home NOT working and breastfeeding/expressing milk

ngpowers on 11/13/2009 9:43:00 AM

Status: This is a critical element of primary prevention for overweight/obesity as well as a number of important health indicators. We must prioritize policies that promote mothers staying with their babies from birth through the first three years of life. Also, workplace arrangements that allow the children to be onsite or close by for mothers to have access to the CHILD - not just breastpumps.

Anonymous on 11/13/2009 8:26:00 AM

Objective Clarification, Objective Text: Adding more emphasis on the "Risks of NOT breastfeeding" may have a greater impact than continuing to state the benefits of breastfeeding.
Marie Ivey, RN,CLC

Anonymous on 11/11/2009 2:35:00 PM

Objective Clarification, Objective Text: I support the proposed change to the breastfeeding objectives. Staff at the DHHS who worked on these objectives should be recognized for its work on this very important document.

Regarding the following proposed objective: Increase the percentage of women giving birth who attend a postpartum care visit with a health worker. I ask DHHS to consider the following sub-bullet:
· Increase the proportion of these health workers who are trained in providing breastfeeding support.

Background: The Washington State WIC program has one of the highest initiation rates in the country. Over 84% of WIC clients initiate breastfeeding. Unfortunately, by the second day of life, over 27% on these infants were given infant formula. By 4 weeks of age, only 66% are still breastfeeding – close to a 20% drop! (2008 Washington State WIC Program data)

I have heard more and more reports of the infant’s first physician visit occurring in the hospital with the following visit not scheduled until 6 weeks post partum. This is a huge gap in care. Post partum coordination of care for the breastfeeding dyad is often non-existent. This is especially true for low-income women who do not have the resources to seek out and pay for care.

Regarding the proposed objective: Among women delivering a live birth, increase the percentage who receive preconception care. I ask DHHS to consider adding the following statement to the list of key recommended preconception behaviors:
· “Discussed how to prepare for breastfeeding/how to successfully initiate breastfeeding” is not listed. Below this proposed objective is a list of key recommended preconception behaviors.

Background: CDC has identified Educating Mothers as an evidenced-based intervention that works. Breastfeeding education should be added as a key behavior.

Regarding the proposed objective: Increase the percentage of facilities that provide recommended care for lactating mothers and their babies. I ask DHHS to add the following suggested action steps:

· Increase the percentage of facilities that have discharge planning that includes follow-up breastfeeding support.
· Increase the percentage of facilities that allow lay workers who speak the same languages as the patent population and are trained in providing breastfeeding support to be an integral part of early post partum breastfeeding support.

Background: I have heard of many situations of how non-English speaking women received less than adequate breastfeeding support in hospitals. Even English-speaking low-income women received inadequate care. Often, the mothers wished to breastfeed only to find that their infants were given supplemental formula without their knowledge or consent. The disparities of breastfeeding among low –income women and women of color will continue unless attention is given to provide culturally relevant breastfeeding support during this critical time in the baby’s life.
Thank you for considering my comments

Anonymous on 11/9/2009 6:41:00 PM

Objective Text: I think more women need to be educated on how beneficial breastfeeding can be for both her and her child. Many women ignore this factor because they do not know how beneficial it can actually be. I think it is a good idea to try to prevent hospitals from giving women free formula, but I also think more education on breastfeeding and its benefits should be provided earlier on in the pregnancy. This will give the pregnant woman more time to consider what is right for her.

Anonymous on 11/5/2009 1:37:00 PM

Objective Text: The easiest way to increase the number of women who breastfeed is to ban the currently widespread practice of sending free formula home from the hospital. This practice undermines mom's confidence in her ability to breastfeed, and is done strictly as a marketing tactic for the formula companies. There should be legislation that prevents formula companies from doing so.

Amy Kaplan, RD

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