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The WHO indicates that breastfeeding is the most effective preventive measure to improve child health and survival (1). The goal of this symposium was to highlight cutting edge and late-breaking policies, programs, and research to address the chronic problem of suboptimal breastfeeding practices worldwide. Key public health policies and interventions that pertain to improving global breastfeeding rates were addressed. Speakers noted the changing environment for investment in breastfeeding promotion, the availability of new tools to measure changes in hospital and community environments to support breastfeeding, the development of models that permit the translation of efficacy research into large-scale programs, and recent work demonstrating the savings in health-care costs that could be accrued from improved breastfeeding. Finally, symposium speakers called for well-targeted research to address gaps in our current knowledge for breastfeeding promotion and support.
Dr. Chessa Lutter of the Pan American Health Organization opened the session by sharing global breastfeeding data indicating positive trends. Exclusive breastfeeding has remarkably improved in most countries, whereas the duration of any breastfeeding has increased less dramatically. She noted that breastfeeding exclusivity is only weakly correlated with the duration of breastfeeding at a national level, suggesting that these behaviors have distinct influences. The most dramatic increase in duration of breastfeeding has occurred in Brazil, where the median duration of any breastfeeding was <3 mo in 1974, but had climbed to ~11 mo by 2002. This dramatic increase was attributed to a series of public health interventions, including social marketing, training, and commitment to the WHO code for marketing of breast milk substitutes. Dr. Lutter then shared an interim analysis of novel data available from the World Breastfeeding Trends initiative (WBTi), which was developed by the International Baby Food Action Network. The WBTi provides quantitative data on 15 indicators of breastfeeding action based on the WHO/UNICEF Global Strategy for Infant and Young Child Feeding. Analysis of WBTi scores for 22 countries showed that country improvements in breastfeeding are significantly associated with higher WBTi scores, suggesting the importance of policy and programmatic initiatives to global trends in breastfeeding. However, survey data from Latin America and the Caribbean suggest that many countries have also recently reduced their investments in breastfeeding. Will reduced investment cause backsliding of breastfeeding improvements? Time will tell, but there is cause for concern.
The second presentation, given by Dr. Laurence Grummer-Strawn from the CDC, focused on the dramatic progress in breastfeeding promotion and support that has occurred in the United States over the past few years. A sea change in attitude and policy has occurred, such that breastfeeding is now a public health priority, reflected in a coordinated federal effort with broad, multisectoral support. The past few years have involved building capacity in public and private sectors and major changes in data and reporting systems. New investments in breastfeeding promotion and support have been made through the Women, Infants, and Children program; the Affordable Care Act; and other programs. Dr. Grummer-Strawn presented updated information from the Maternity Practices in Infant Nutrition and Care initiative, updates on national breastfeeding data from the National Immunization Survey, the new Healthy People 2020 goals, and the 2011 Surgeon General’s Call to Action to Support Breastfeeding and described other innovative ways that the CDC/US Government is supporting breastfeeding. Dr. Grummer-Strawn was commended by members of the symposium audience for the exciting progress in the United States on breastfeeding promotion and support.
Dr. Rafael Perez-Escamilla of Yale University gave the third presentation, which addressed the evidence and approach to scaling up and sustaining breastfeeding promotion and support worldwide. In his presentation, Dr. Perez-Escamilla detailed the essential findings of a cutting-edge systematic review commissioned by the Gates Foundation. The review identified country case studies, qualitative research studies, observational quantitative studies, 1 cost-effectiveness study, and 1 randomized community trial. Factors influencing a scale-up were identified through a systematic review of data from 28 low- and middle-income countries. Factors that facilitate scale-up include evidence-based advocacy; political will and legislation; workforce training and program implementation at the facility and community levels; communications campaigns, research, monitoring, and evaluation; and multisectoral engagement and coordination. Key scale-up barriers include widespread violation of the WHO Code, inadequate maternity leave policies and work environments for breastfeeding, and lack of access to breastfeeding support during the first 72 h after delivery. Dr. Perez-Escamilla then proposed the dynamic “Breastfeeding Gear” conceptual model for successful scale-up of programs. This social marketing-driven model depicts “gears” representing each of the scale-up facilitating factors. A master gear, representing the intersectoral coordination element, allows the specific program “gears” to move in synchrony and at the right pace. This model has already proved useful for understanding the different levels of success with the national breastfeeding programs in Brazil compared with Mexico and is helping the government of Mexico design the new architecture of their program.
Dr. Melissa Bartick of Harvard University then addressed the economic impact of breastfeeding in the United States. She reported that a stunning $13 billion would be saved by society if 90% of US mothers could comply with recommendations to breastfeed exclusively to 6 months. This represents a tremendous increase from past estimates as a result of a more comprehensive approach to the conditions included, based on systematic review estimates. The conditions that contribute most to the cost burden of suboptimal breastfeeding are sudden infant death syndrome, necrotizing enterocolitis, and lower respiratory tract infection, followed by otitis media. Her published research on the economic impact of breastfeeding focused on infant and child outcomes; she is now working with a team to assess the economic impact of breastfeeding on maternal outcomes. Dr. Bartick pointed out a series of methodological issues involved in cost-benefit analysis and that assessment of the economic impact is even more difficult when addressing maternal outcomes. Difficulties in cost-benefit analysis for maternal outcomes arise from less robust quantification of health benefits for the mother and the lag time between maternal exposure and outcomes (e.g., breast cancer).
Finally, Dr. Ardythe Morrow of Cincinnati Children’s Hospital summarized the set of talks and indicated the need for research to guide efforts that help increase breastfeeding rates beyond current levels. She argued for the need to target high-risk populations with low breastfeeding rates and identify interventions that work best in specific subpopulations. What factors optimize an intervention in different settings? How do we take proven interventions to scale in different settings? There is need for more research on cost-effectiveness, best practices for professional training and staffing for breastfeeding support, population-specific marketing, and how to promote and support breastfeeding in workplace and child care environments. But, she argued, research priorities must also encompass deeper understanding of the most common breastfeeding difficulties and more effective lactation management strategies and tools. Many women initiate breastfeeding only to face multiple impediments and wean prematurely. Top-ranking concerns of mothers worldwide include ineffective infant suckling, adequacy of her own milk supply, and nipple pain. Outcomes research indicates that delayed onset of lactation >72 h after delivery strongly predicts early supplementation and early cessation of breastfeeding, yet not enough is known about the causes of delayed onset of lactation to adequately prevent its occurrence.
The session ended with robust discussion and apparent consensus that we have the road maps for scaling up breastfeeding promotion and support, but that the investment of governments and funding agencies will be key for conducting needed research and implementation of what we know works.
Both authors have read and approved the final version of this paper.