PEDIATRICS Vol. 120 No. 1 July 2007, pp. 248-249 (doi:10.1542/10.1542/peds.2007-1210)
LETTER TO THE EDITOR |
Paucity of Evidence-Based Research on How to Achieve the Healthy People 2010 Goal of Exclusive Breastfeeding
Karen A. Bonuck, PhDDepartments of Epidemiology and Population Health and Obstetrics, Gynecology, and Women's Health
Montefiore Medical Center/Albert Einstein College of Medicine
Bronx, NY 10467
To the Editor.—
The evidence base for the public health import of exclusive, prolonged breastfeeding continues to expand, as shown in the article "Breastfeeding and Hospitalization for Diarrheal and Respiratory Infection in the United Kingdom Millennium Cohort Study,"1 which comes on the heels of the new Healthy People 2010 (HP2010) exclusive breastfeeding goals2 (objective 16 now reflects exclusive breastfeeding at 16–19 d and e as objectives approved for HP2010). Achieving the new HP2010 goals will require substantial effort, given dismally low rates of exclusive breastfeeding in the United States. Several years ago, Pediatrics published an analysis of federal research funding that depicted an incongruity between national priorities for breastfeeding on the one hand and research aimed at achieving Healthy People 2000 (HP2000) breastfeeding goals on the other hand.3 By the mid-2000s this incongruity had grown starker, even as the new HP2010 targets justifiably raise the bar for this public health objective.
The revised HP2010 breastfeeding objectives adopted in December 2006 set targets for 60% of women to exclusively breastfeed through 3 months and 25% to do so through 6 months. The original HP2010 breastfeeding goals for initiation (75% in early postpartum) and duration (50% and 25% at 3 and 6 months, respectively), did not aim to increase actual intensity of breastfeeding. Rather, these goals for exclusivity were adopted later as part of the HP2010 midcourse review. Although there has been progress toward the original HP2010 objectives, exclusive breastfeeding rates are disturbingly low; just 13% of infants were exclusively breastfed through 6 months, per the American Academy of Pediatrics (AAP)4 and updated HP2010 guidelines (the AAP statement acknowledged that their Committee on Nutrition supports introducing complementary foods between 4 and 6 months of age when safe and nutritious complementary foods are available). It is notable that in the January/February 2007 issue of Obstetrics and Gynecology, the American College of Obstetrics and Gynecology affirmed the stance of the AAP.5
The revised HP2010 goals follow several federal initiatives. The Surgeon General's "Blueprint for Action on Breastfeeding" in 2000 led to the National Breastfeeding Awareness Campaign. The campaign featured media outreach, with a specific focus on the risks of not exclusively breastfeeding for 6 months, along with community demonstration projects. Unfortunately, funding for the media campaign ended in 2006. The Maternal and Child Health Bureau does support the AAP's Breastfeeding Promotion in Physicians' Office Practices (BPPOP III) program, which has as a major goal the education of health care professionals.6 Although effectiveness measures will be assessed for an evaluation at the project's completion, BPPOP III was not primarily designed as a research endeavor.
The article "Does Federal Funding for Breastfeeding Research Target Our National Health Objectives?" was published in Pediatrics in 2003.3 The authors identified federally funded research projects relevant to breastfeeding from the years 1994–1996. They reasoned that those projects' results would be available to inform activities directed toward achieving HP2000 objectives. They searched the CRISP (Computer Retrieval of Information on Scientific Projects) database of federally funded research grants for projects with the keywords "infant nutrition," "breastfeeding," or "lactation."
That analysis identified 362 funded projects from 1994 to 1996 in the area of infant nutrition/breastfeeding/lactation. Of these, just 31 (8.6%) of 362 had, as a goal, to increase breastfeeding. Most such grants supported research in the basic science of human milk and lactation. Furthermore, 7.5% of the projects bore no relationship to breastfeeding per se. Rather, they pertained to human milk composition and techniques to improve artificial milks (ie, formula) or develop new pharmaceuticals and therapies. To be sure, the state of existing research around that time was poor. A meta-analysis of published reports from 1996 to 2001 of primary care–based interventions to increase breastfeeding yielded only 22 randomized, controlled trials, just 1 of which was "good quality."7
Approximately a decade later, there was a sharp drop in the proportion of federally funded research projects aimed at increasing breastfeeding rates in the United States. I conducted a comparable analysis from 2003 to 2006 using the same keywords. The exercise yielded a total of 422 projects. As in the original analysis, titles and abstracts were reviewed to identify projects that had, as a goal, to increase breastfeeding. Of these 422 projects, just 4 specified a goal (direct or indirect) of increasing breastfeeding. Thus, by the mid 2000s, just 4 (<1%) of 422 grants in the area of infant nutrition/breastfeeding/lactation were relevant to the HP2010 objectives for breastfeeding. Basic science continues to dominate.
As clinicians are increasingly expected to practice evidence-based medicine, it is imperative to determine the effects of the above-named strategies and other hospital- and pediatric provider–based practices on breastfeeding duration and exclusivity. Certainly, much remains to be learned about the basic science of human milk. However, unless more infants are actually fed greater amounts of breast milk, for longer periods of time, the knowledge gleaned from this basic science research will have limited utility. At a time when clinical and translational research is being emphasized, a reconsideration of this imbalance in funding priorities in the area of infant feeding would be welcome.
REFERENCES
- Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study. Pediatrics. 2007;119(4) . Available at: www.pediatrics.org/cgi/content/full/119/4/e837
- Agwunobi JO. Foreward. Available at: www.healthypeople.gov/data/midcourse/html/foreword.htm. Accessed May 25, 2007
- Brown LP, Bair AH, Meier PP. Does federal funding for breastfeeding research target our national health objectives? Pediatrics. 2003;111(4) . Available at: www.pediatrics.org/cgi/content/full/111/4/e360
- Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk.
Pediatrics. 2005;115
:496
–506
[Abstract/Free Full Text] - Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007;109 :479 –480[Medline]
- American Academy of Pediatrics. Breastfeeding initiatives: Breastfeeding Promotion in Physicians' Office Practices (BPPOP III) program. Available at: www.aap.org/breastfeeding/new%20bppopIII.cfm. Accessed April 20, 2007
- Guise JM, Palda V, Westhoff C, et al. The effectiveness of primary-care based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Preventive Services Task Force.
Ann Fam Med. 2003;1
:70
–78
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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