The Section on Breastfeeding of the American Academy of Pediatrics (AAP) appreciates the comments submitted regarding the most recent policy statement, “Breastfeeding and the Use of Human Milk,” published in the March 2012 edition of Pediatrics. The AAP joins with other professional groups in the assessment that the preponderance of evidence confirms the great benefits of breastfeeding. The Agency for Healthcare Research and Quality review1 provides recent evidence that formula feeding and early weaning from breastfeeding are associated with health risks. We recommend all health care practitioners who take care of mothers and infants know the health outcomes associated with breastfeeding as an important step in being able to support a mother’s decision to breastfeed.
We address the following Letters to the Editor:
To Drs Sendelbach and Sanchez, regarding varicella exposure and breastfeeding, the policy follows the recommendation of the AAP Red Book, page 718 of the 28th edition: “Airborne and contact precautions are recommended for neonates born to mothers with varicella.” Thus, our statement, “mothers who develop varicella 5 days before through 2 days after delivery should be separated from their infants, but their expressed milk can be used for feeding” is consistent. The suggestion of using a single intramuscular dose of varicella-zoster immune globulin along with airborne and contact precautions while being cared for together and in a negatively ventilated room is intriguing and with further evidence may become a standard recommendation in the future.
Similarly, we have chosen to be consistent with the Centers for Disease Control and Prevention it its recommendations for H1N1 exposure: that mothers acutely infected with H1N1 influenza should temporarily be isolated from their infants until they are afebrile, but they can provide expressed milk for feeding. The experience you cite, which is in press, will be useful in future formulations of guidelines for H1N1 in the breastfeeding mother. In both of these situations, we recommend continued receipt of mothers’ own milk, and thus, hospitals need to ensure adequate support by protecting the mother’s milk supply through early initiation and frequent effective breast-milk expression.
To Drs McGuire, Sendelbach, and Sanchez, regarding the recommendation that clinicians should use pasteurized donor human milk if no mother’s own milk is available. Mother’s own milk, fresh or frozen, is the preferred diet for all preterm infants. For infants with a birth weight <1500 g, human milk should contain a human milk fortifier. If mother’s own milk is unavailable for this population of infants despite significant lactation support or is medically contraindicated, then fortified pasteurized donor milk is the preferred diet. Previous statements commented that we should consider pasteurized donor milk. Data on the acute protective effects of human milk as well as long-term benefits to neurodevelopmental outcome are now reported frequently.2–7 The putative mechanisms underlying the role of human milk on protection from necrotizing enterocolitis (NEC) cannot be ignored. In fact, all enteral treatment strategies shown to reduce NEC to some degree were “borrowed” from our knowledge of human milk constituents: immunoglobulin A, lactoferrin, polyunsaturated fatty acids, acetylhydrolase, oligosaccharides, erythropoietin, glutamine, epidermal growth factor, and probiotics. Indeed, recent data evaluating an appropriately fortified exclusive human milk diet demonstrated marked reductions in NEC and surgery for NEC.5 In the separate arm of that study, extremely preterm infants not receiving their own mother’s milk had less NEC and NEC surgery if they were fed the exclusively human milk diet compared with preterm formula.6
Thus, these studies encourage us to recommend human milk diets, but they do not imply that no additional research needs to be done. In fact, the Section on Breastfeeding hopes this statement stimulates more research to understand the mechanisms of the protective effects, to ensure quality control and potentially improve the pasteurization process, to understand the role of cow’s milk products compared with human milk–derived products, to use exclusive human milk technology to concentrate bioactive factors (because there is variance among women), to extend investigations to larger preterm infants, and, most important, to ensure that donor milk is only used an adjunct to mother’s own milk and encourage all efforts to assist mothers in maintaining their lactation. Cost-benefit analyses that demonstrate a favorable balance to the cost of purchasing the milk should encourage third-party payers to agree that there is a cost benefit when human milk is used. Furthermore, because human milk has medical benefits beyond its nutritional value, this should serve as additional incentive for governmental and private medical insurance to provide complete financial coverage for its use.
To Dr Dórea, thank you for your added comments. Regarding breastfeeding and environmental toxins, we acknowledge the use of human milk as a vehicle for testing for environmental toxins is often exploited and may be helpful in monitoring population exposure; however, we also agree that the presence of these toxins would not outweigh the risk of not breastfeeding and would therefore not alter our recommendations for breastfeeding based on exposures. We recommend with continued breastfeeding the maternal diet should limit possible risks from intake of excessive mercury and other contaminants, such as those from eating certain fish.
Regarding the association between vaccine-related problems and breastfeeding, the studies cited are from developing countries and not relevant to the populations targeted by this policy. We acknowledge breastfeeding as a method of pain relief not only for vaccination but also for heel sticks and other painful procedures. The policy also addresses the immunologic benefits of breastfeeding particularly with regard to immune modulation and the case for exclusive breastfeeding.
Finally, the comments about smoking and breastfeeding indicate that our message may have been misinterpreted. We recommend breastfeeding even if a mother chooses to smoke tobacco and also recommend that she quit smoking and not smoke around her infant. Given that smoking interferes with the protective effect of respiratory illness, it is assumed that breastfeeding mitigates the increased risk of respiratory illness. Furthermore, the assumption that breastfeeding mothers who smoke must also have smoked during pregnancy is an inaccurate assumption. Mothers may abstain during pregnancy but resume smoking after delivery despite choosing to breastfeed. It should also be noted that infants of smoking mothers may consume less milk and have slow weight gain. In summary, we recommend breastfeeding even for mothers who choose to smoke, but pediatricians should encourage smoking cessation.
To Ms Risch, regarding the protection against atopic dermatitis (AD), we agree that there are many conflicting publications on this association. Nevertheless, the Agency for Healthcare Research and Quality review1 is the most contemporary meta-analysis done in developed countries, and it points to an association between exclusive breastfeeding and reduced risk of AD in families with a positive history of atopy. Furthermore, when modifiable versus nonmodifiable risk for AD is taken into consideration, the majority of the risk is nonmodifiable, but where the risk may be attenuated, exclusive breastfeeding for 4 months has the largest effect.8
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- Copyright © 2012 by the American Academy of Pediatrics