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Objectives New to Healthy People 2020
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MICH HP2020–27:
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Decrease the percentage of breast-fed newborns who receive formula supplementation within the first 2 days of life.
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Status: New to Healthy People 2020.
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View Objective Comments
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NACCHO - National Association of County and City Health Officials
#26 and #27: These will only help us to reach our objective #12! So glad to see them in 2020.
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Objective Clarification:
By asking for an increase in exclusivity of breastfeeding during the hospital stay, maybe questions will be asked such as: Why do so many breastfeeding babies in the US need to be supplemented? Why do 1/3 of first time mothers in the US have a delay in their milk increasing in volume? Why do breastfeeding babies in the US take longer to regain birth weight than babies born outside the US? Is it our high obesity rates, our environmental toxins, our birth practices? These are important questions to look at. By having this objective for 2020, I think researchers willing be looking for answers to these questions. Kay Hoover
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The U.S. Breastfeeding Committee supports the inclusion of this new objective. Formula is seldom medically necessary, yet in some U.S. hospitals, a significant number of breastfed babies are reported to receive formula during their hospital stay. Formula permanently changes the gut flora and impacts the immune system. Banked human milk is available and would avoid these outcomes of formula use, but hospitals seldom offer banked human milk for healthy full-term babies.
Exclusive breastfeeding during the newborn hospital stay is predictive of exclusive breastfeeding at all points measured between the early days of life and one year of age. In order to meet the Healthy People sub-objectives for exclusive breastfeeding, we need hospitals to provide basic lactation care and services that support exclusive breastfeeding. Formula supplementation without a medical reason reduces later exclusive breastfeeding rates and often sets the stage for the early cessation of breastfeeding.
This objective addresses the health care infrastructure within which individual women make infant feeding choices. Its target is the care providers rather than the mothers. A birth facility can reduce the need for supplementation by instituting evidence-based practices like skin-to-skin contact for mother and newborn, breastfeeding in the first hour of life, and rooming-in. The facility can train staff in the skills needed to support breastfeeding. The facility can keep banked frozen human milk on hand for the occasional instance when supplementation is necessary. These changes at the policy level would make a more supportive environment for each mother as she begins the breastfeeding relationship with her newborn.
In late 2009 the Joint Commission identified exclusive breastmilk feeding as one of five evidence-based core measures of perinatal care. This new standard should give hospitals the incentive to document supplementation with formula and work to decrease its use.
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.
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The American College of Nurse Midwives strongly supports the addition of this objective to Healthy People 2020.
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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. We also fully support exclusive breastfeeding, especially within the first six months of life, as recommended by numerous health authorities.
However, we are concerned that, rather than encouraging exclusive breastfeeding to begin within the first 2 days of life, this objective focuses on the exclusion of infant formula. Scientifically, the underpinnings of encouragement to exclusively breastfeed stem from observational data relating early exclusive breastfeeding to reduced neonatal mortality (e.g., Edmond et al 2006, Peds 117: e380; Mullany et al 2008 J Nutr 138:599). That evidence is derived in substantial measure from developing world settings where exclusion of pathogens by exclusive breastfeeding is an important disease reduction behavior, but also where many foods or drinks including water and tea, may be fed to the neonate as non-lacteal alternates or supplements to either breast milk or properly prepared formula. Also, UNICEF recommendations for early introduction of breast milk (i.e., within the first hour of life) strive to maximize immune factor transfer to the infant through colostrum (http://www.unicef.org/malaysia/Breastfeeding_First_Hour_of_Life.pdf). Many cultures do not recognize the unique biological value of colostrum, thus restricting or even avoiding its use. The rationale for selection of 2 days as a target seems to be more closely related to ease of data collection than to an identified health outcome.
The apparent emphasis on avoidance of formula is misplaced. UNICEF recommendations for early, exclusive breastfeeding address any non-lacteal feed. Infant formula, as the only nutritionally sufficient alternate to breast milk as a sole source of nutrition, should be distinguished from other feeds and supported as the only suitable non-lacteal feed for use in neonatal life, whenever there is a medical rationale for any feed other than breast milk. For example, one group of infants where there is increasing recognition of the medical need for potential supplementation is late preterm births. Births between 34 and 36 weeks’ gestation have increased more than preterm births less than 34 weeks’ gestation and are now estimated to make up more than 70% of all premature births (http://www.pediatriccareonline.org/pco/ub/view/AAP-Textbook-of-Pediatric-Care/394092/all/Chapter_92:_Care_of_the_Late_Preterm_Infant). The body systems of late preterm infants may be impacted in a number of ways, including developing problems with feeding that can contribute to excessive weight loss or inadequate weight gain (Wang ML, Dorer DJ, Fleming MP, et al. Clinical outcomes of near-term infants. Pediatrics. 2004;114:372-376.).
The IFC recommends MICH2020-27 be deleted. If not deleted, we recommend it be revised to state, “increase the prevalence of exclusive breastfeeding during the first hour of life; and use only properly prepared infant formula in the first 2 days where there is a medical rationale for an alternate feed, for the care and support of the mother or infant. “
* IFC members are Abbott Nutrition, Mead Johnson Nutrition, Nestlé Infant Nutrition, and Pfizer Nutrition.
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Objective Clarification, Objective Text:
This goal needs a percentage to target.
To achieve the target, hospitals, birthing centers, and professional staff will need to invest in education and support during the immediate and long term post partum period.
Breastfeeding is a learned skill. Some babies don’t latch or suck well. Some moms have varying milk production, breastfeeding can be painful, stress from family and work can make it even more difficult. Virtually all breastfeeding barriers can be overcome but usually only with sound ongoing support from experts.
Best practice is to provide 24/7 access to certified lactation consultant prior to and during the post partum period as well as classes at the hospital or birth center and ongoing consultation and learning in a web-based environment.
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ASTPHND recommends deletion:
Redundant-This objective is already addressed in objective #12.
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Objective Clarification:
To achieve this objective, hospital protocols need to address the issue and treat formula just as any other "drug" that can only be given per a request from a physician.
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Objective Text:
I suggest a change to increase the % of infants who are exclusively breastfed at hospital discharge (not sure what to use as baseline). Wouldn't it be great if 90% of infants left the hospital exclusively breastfed during their hospital stay by 2020. (Use increase % breastfed rather than decreasing the % who receive formula). Perhaps the standards used in the joint commission definitions could be used, as hospitals will be reporting rates based on the Joint Commission objective related to exclusive breastfeeding. While a few infants will be supplemented for health reasons (galactosemia, etc) and a few moms will choose to feed formula I believe that all women need to know that there is a clear distinction between infant breastmilk and infant formula and that the early supplementation can decrease milk supply.
Setting goals high means they are important.
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Objective Clarification:
This objective makes me a bit uncomfortable, particularly since am a mother who checked in to the hospital knowing I planned to use formula.
I understand that it is intended to raise the rates of breastfeeding since I am well aware (and was when I delivered) that my own milk is supposedly superior to the formula I chose to feed my son instead, but it makes me concerned about just how much pressure the staff will be under to achieve this objective (especially since no mention is made of what the percentage decrease is the true goal for newborns in one hospital vs. another) and how that will get passed along to mothers like me as their targets to "convert" and thereby raise their exclusive breastfeeding status rates.
Formula using friends of mine have told me of the nightmarish experiences they had with ultra aggressive staff practically manhandling them and their reluctant babies as they tried to force the breastfeeding to work out, but my experience was the reverse. Once the staff knew I was going to be a formula user, I practically had to beg for any kind of assistance at all since all of their attention was being given to the new moms who were at least willing to give breastfeeding a try. While they might of been assuming that I would be able to just follow the instructions on the formula can once we checked out, I still needed support and there wasn't much being offered to me and my child. Moms like me and the ones who try to breastfeed but eventually might need to use some formula before their babies can drink cow's milk need just as much education on how to do it right, what the best choice might be to start out with, and what other kinds to try if the first type doesn't agree with out babies.
The staff might only be worried about what happens under the roof of the hospital during those first two days, but those are just a tiny part of that all important first year of feeding a baby as best you can under each person's individual circumstances. Lots can change (and usually does) in those first few months with a new baby and I feel very strongly that all moms deserve equal respect, time and support from staff, something I think will be impossible to get as the hospitals will instead do whatever possible try to meet this objective as it is currently written.
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The March of Dimes Foundation strongly supports the addition of this objective to Healthy People 2020.
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Objective Clarification:
Non-medically indicated formula supplementation in the hospital is a major reason for the low exclusive breastfeeding rates in this country. This is an important objective that is necessary to meet the main objective of increasing exclsuive breastfeeding rates. Understaffed maternity units, poorly trained staff, and a lack of committment to evidence-based lactation care contribute to poor breastfeeding outcomes seen in many hospitals. Indiscriminate formula supplementation of breastfed infants in susceptible families can set the stage for allergies and diabetes.
Infant formula manufacturers contribute to inappropriate supplementation by providing free formula to hospitals and free formula gifts to mothers at discharge. This practice directly contributes to the inability to meet the Healthy People objectives related to exclusive breastfeeding and should be eliminated.
Hospitals should strive to meet the 10 Steps to Successful Breastfeeding. The US Lactation Consultant Association has expert members specially trained to help hospitals reduce their reliance on formula for solving breastfeeding problems due to lack of skill in hospital staff.
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Objective Text, Data Source:
This is an excellent objective. I would suggest changing the spelling of breastfed. Exclusive breastfeeding, exclusive formula feeding, and mixed feeding could be collected on the birth certificate information. Use of banked human milk could decrease the formula supplementation rate.
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Objective Clarification:
Would like to see this changed to within the first 7 days of life.
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Objective Clarification, Objective Text:
Add wording to address:
o Of the babies who initiate breastfeeding, 75% will be exclusively breastfed at hospital discharge.
o Increase to 50% the number of babies who are exclusively breastfed until 3 months of age.
o Increase to 25% the number of babies who are exclusively breastfed until 6 months of age.
o Increase to 95% the number of preterm infants that receive human milk (either from their own mother or from a HMBANA-certified milk bank or a reputable company as both their first feed and their continual feeding.
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Objective Clarification:
I think the emphasis of the Healthy People goals needs to be on what young children eat once they start solids, since they is what they will be most affected by for their entire lives, rather than the proportion of baby formula vs. breast milk they receive during their first year.
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Objective Clarification:
On the surface this objective makes sense as a goal, but does this objective take into account those situations where the mother is unable to breastfeed for true medical reasons (as I was under sedation for more than 9 hours after a long, complicated labor and emergency c-section)?
My situation was hardly a failure of my own or the nursing staff, as my newborn needed something to get started with while I was slowly coming out of my daze, and my husband was thrilled to be able to give our child their first feeding in the nursery.
Under this current language, our situation would be considered a failure to meet this objective, when in fact it was both medically necessary and a success in the long run. I would suggest adding an allowance for medically appropriate situations, since I wouldn't have wanted the nursing staff to have denied my baby what she needed in order to score better on some arbitrary assessment of their breastfeeding support practices.
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Objective Text:
Thank you so much for recomending reduction of formula use within the first 2 days of life. This is a very specific, targeted goal which will improve breastfeeeding outcomes.
One way of achieving this goal would be increasing staff education to nurses at every Family Birth Center in every local hospital. I know staff education is expensive, but I would encourage everyone to be creative in educating staff. Maybe create a on-line newletter, Tip of the Month mass email, bulletin board, leave articles on the staff break room table, find resources from reliable website, etc.
I also would encouage every hospital to look closely at their breastfeeding policy. Nurses should be referring back to their policy for supporting breastfeeding.
There are several resources to support a written breastfeeding policy. The Academy of Breastfeeding Medicine has sample protocols. Another resource is Clinical Guidelines for the Establishment of Excluive Breastfeeding from the International Lactation Consultant Association. The American Academy of Pediatrics has a written statement to support breastfeeding.
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Objective Text:
Thank you so much for recomending reduction of formula use within the first 2 days of life. This is a very specific, targeted goal which will improve breastfeeeding outcomes.
One way of achieving this goal would be increasing staff education to nurses at every Family Birth Center in every local hospital. I know staff education is expensive, but I would encourage everyone to be creative in educating staff. Maybe create a on-line newletter, Tip of the Month mass email, bulletin board, leave articles on the staff break room table, find resources from reliable website, etc.
I also would encouage every hospital to look closely at their breastfeeding policy. Nurses should be referring back to their policy for supporting breastfeeding.
There are several resources to support a written breastfeeding policy. The Academy of Breastfeeding Medicine has sample protocols. Another resource is Clinical Guidelines for the Establishment of Excluive Breastfeeding from the International Lactation Consultant Association. The American Academy of Pediatrics has a written statement to support breastfeeding.
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Objective Text:
This is a great objective. I have a quibble, not with the objective but with the phrasing: I understand that the word "supplementation" is routinely used--but we should work to change that. To supplement is to add value to. Formula does not supplement human milk, it replaces it with an inferior substance. I feel the word "substitution" would be more accurate and would convey more clearly what is at stake.
Maybe another goal should be to eliminate use of the word "supplementation" when speaking of formula, since it constitutes false advertising.
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I strongly support this objective. CDC research shows that breastfeeding duration rates fall rapidly when formula supplementation occurs before discharge.
Consider developing a fact sheet or guide on action steps hospitals can take to reduce formula supplementation, especially how staff can address maternal/family requests for formula.
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Objective Text:
I agree a percentage goal should be specified as well as clarification that formula should be used only when documented as medically necessary, ordered by a physician, and with written parental consent. Putting all stable mothers and infants skin to skin until first feeding would easily increase the numbers of breastfed babies and decrease the need for formula supplementation at no extra cost. Increasing the number of birth centers which practice this routinely should be included in the objectives.
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Objective Text:
Again what is the percentage that is trying to be reached. I agree that a statement regarding marketing of artificial milk be included and that diaper bags be removed from all faculities. This would then be in compliance with WHO statement on marketing of artificial formula. Also added to the statement "unless documented medically necessary and with documented consent of mother."
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There is clear evidence that removing free formula samples and other comercial products supplied by the pharmaceutical companies (formula manufacturers) from the hospitals and offices of health professionals will make this objective happen.
This objective will also require public education about this issue, as many times, parents are requesting or demanding supplementation for their baby in this hospital.
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Objective Clarification:
To achieve this goal, hospitals should not be allowed to accept free formula from the formula companies. This practice promotes the use of formula in the hospital. Hospitals should also not be banned from handing out the formula bags at discharge, which promote the use of formula at home.
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Objective Text:
Suggestion on educating general public and health care professionals on decreasing the marketing of formula within physicians offices, clinics, and hospital settings.
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This is an excellent objective.
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