Abstract
AAP's current headquarters are in Elk Grove Village, IL, and it has a simple mission statement: to assure the health and life success for all children. But while doing that, also support the pediatricians who care for those children.
There are about 62,000 members of the AAP, representing almost three-quarters of all practicing pediatricians in the country. There are chapters in all 50 states, Canada, and the Virgin Islands. The AAP is the largest pediatric organization in the world and has extensive interactions with international pediatric organizations. The AAP mission statement supports the health and well-being of all children, not just children in America.
Forty-two percent of AAP members are young, so it is a vibrant young specialty. Over half of the membership is female, which is reflective of several different areas of medicine, but certainly the Academy is on the forefront of this trend. Almost all the residents, the physicians in training to be pediatricians, are already members of the AAP.
There are three of us on the National Executive Committee who help oversee the day-to-day business of the Academy. Each of the 10 districts has a chairperson, and these chairs represent the remainder of the Board of Directors, which meets three times a year in person and every month by conference call. Within each district, there are three or more state chapters, normally one per state, but sometimes there are several chapters in one state.
There are 49 Sections, breastfeeding being one of those, nine Councils, and 28 National Committees, all actively staffed by the Academy in Elk Grove Village. These entities produce most of our policy and science. Committees are normally scientific or topic task-oriented groups as opposed to sections, which also have an advocacy agenda.
The Section on Breastfeeding has about 500 members and is growing. There are 78 Chapter Breastfeeding Coordinators who work at the local level. The Section has an Executive committee and a 15-person Leadership Team. There is a six-person Chapter Breastfeeding Coordinator Steering Committee, which identifies and disseminates the latest “best practices” relating to promoting breastfeeding and advocating for breastfeeding.
The Academy has had a number of successes in recent years, including the Affordable Care Act, which contains improved payments for pediatricians and a good healthcare benefit package for children that reflects our Bright Futures Guidelines for Health Supervision. Everything the Academy undertakes is based on its pillars, principles, and/or strategic priorities, which make up the strategic agenda. The pillars are access, quality, and finance. The principles are health equity, medical homes, and the profession of pediatrics. These rarely change.
What does change are AAP strategic priorities. The current strategic priorities of the AAP are special health care needs of foster children, early brain and child development, and epigenetics. These are in either the planning, implementation, or integration stages. Eventually they will become operational programs of the Academy. This assures ongoing attention to important issues relating to child health and pediatric practice.
Past strategic priorities, such as tobacco, obesity, and disaster preparedness, are now a part of the operation of the Academy. Consider tobacco. The Richmond Center is funded by the Flight Attendants Medical Research Foundation, and it is an ongoing part of Academy activity.
Evidence-based literature is rapidly accumulating that factors related to epigenetics and early brain and child development determine life course and success. As with previous strategic priorities, these will eventually be ongoing operations within the Academy. Epigenetics research has revealed that there are changes in gene expression that do not necessarily manifest themselves with changes in DNA structure or alignment. There are actions and reactions, including DNA methylation, histone modification, and micro-RNAs, that affect the genes of children, sometimes even prenatally. These changes are related to environmental, parental, and other influences that can affect lifelong health, success, and well-being. The AAP has established a Primary Care Institute to look at how we infuse epigenetics into the field of general pediatrics and how pediatricians can help assure that epigenetics facilitates and enhances the success of a child's life, as opposed to detracting from it.
Early brain and child development is similar. There are things that happen to mommy and daddy before they even know each other, before they conceive, and certainly after they conceive and birth a child, that actually affect the life of that child. One of those things is chronic stress. Most families and infants can handle acute stress, such as giving a baby a shot. Baby and family quickly recover to their baseline level of stress. Tolerable stress, such as losing a parent, is severe, but it too recedes to baseline. Toxic stress such as abuse and neglect, however, may not return to baseline, especially if a child is not rooted and grounded in a supportive family and community and can result in untoward outcomes in childhood, adolescence, and adult life.
Breastfeeding has a role in protecting from chronic stress and other adverse outcomes and helps build resilience early in life. It also promotes optimal health outcomes for mothers and children, prevents infections, reduces healthcare costs, and is environmentally conscious.
Human milk is best for babies. It provides essential fatty acids, docosahexaenoic acid (DHA), etc., that formula companies try to duplicate. Breastmilk DHA is superior to that of other sources.
Breastfeeding is an essential strategy for the Academy's agenda regarding epigenetics and early brain and child development. This science will influence policy and politics as well as society's priorities relating to exclusive breastfeeding in early infancy. There was a recent article in Pediatrics demonstrating that breastfed babies show advantages in cognitive development. 1
The AAP has been a strong partner for breastfeeding advocacy at the federal, state, and local levels. The Healthy People 2010 goal of initiating breastfeeding in new mothers was reached before 2010.
The problem is that none of the populations studied, including middle-, upper-, and lower-income families, sustained breastfeeding at 3 and 6 months. Something is happening between the time the child leaves the newborn nursery and the 3-month checkup. Of particular concern are young African-American females, those below 20 years of age, who are less likely to initiate or sustain breastfeeding. This may be one of the significant disparities and inequities in our healthcare delivery system. These mothers want to do what is best for their child, but something happens that does not allow them to initiate and/or continue breastfeeding. Strong, sustained advocacy is needed to correct these disparities and inequities.
There is a recent article in Pediatrics that showed 85% of women who deliver in hospitals that promote breastfeeding planned to breastfeed their infants for the first 3 months of life. 2 Only 32% actually did. Marriage, a prior baby, and initiating breastfeeding in the first hour of life all contributed to success in breastfeeding at 3 months. Other contributing factors to success include no supplemental formula and no pacifiers while in the hospital. Pacifiers are encouraged once breastfeeding is established. Smoking and obesity reduce the odds of success in maintaining breastfeeding at 3 months. Less than 5% of hospitals meet all 10 criteria to be “Baby Friendly.”
The Healthcare Effectiveness Data and Information Set and National Committee for Quality Assurance measures, pay for performance, quality goals, and other validations of clinical care need a focus on best practices regarding initiation and maintenance of breastfeeding.
One way the Academy supports breastfeeding is through the Community Access to Child Health (CATCH) program. It gives grants to pediatricians who want to make a difference in their community regarding access to care or health equity issues. Breastfeeding is one of the things they have targeted to work on. The CATCH program also funds resident physicians, pediatricians in training, with some of these CATCH grants. The AAP has had 17 planning grants, nine implementation grants, and 13 resident grants devoted to breastfeeding. There have also been several community pediatric training initiative grants, which infuse a breastfeeding curriculum into residency programs. Finally, there have been five Healthy Tomorrows Partnerships for Children (a program shared with the Federal Maternal and Child Health Bureau) grants devoted to breastfeeding.
CATCH grantees get into their communities, hold focus groups, form peer support groups, develop collaborations with WIC [Special Supplemental Nutrition Program for Women, Infants and Children] offices, and plan and implement home visitation for adolescent mothers. The Academy's healthychildren.org Web site is also a resource for breastfeeding information and support.
The Academy is active in advocacy at the federal level. The Section on Breastfeeding has a designated liaison to the AAP Washington office staff and lobbyists. Through this activity the Academy was actively involved in making certain that the Internal Revenue Service recognizes breast pumps and other items that facilitate breastfeeding within Health Savings Accounts. The Breastfeeding Promotion Act has been folded into the Affordable Care Act, and it mandates reasonable break time for nursing mothers. Employers must have a place for nursing mothers to express breastmilk or to breastfeed other than a bathroom, and it has to be a clean area. There is still work to be done, including having refrigerators available.
The Medical Food Equity Act is being reintroduced. It calls for payment for amino acids and protein supplements so premature babies can breastfeed. The Birth Defects Prevention, Risk Reduction and Awareness Act has also been reintroduced. It supports information for mothers who are breastfeeding. We need to get these bills over the finish line in the next session of Congress.
Dr. Regina Benjamin, our Surgeon General, has developed the Interagency Working Group on Breastfeeding, and the AAP is working with other advocates to get funding for this vital activity.
If a state is moving to develop policies or laws that are unfriendly to breastfeeding, such as banning breastfeeding in public, the AAP's Elk Grove Village State and Chapter Affairs Office can get involved.
The Academy is leading an international effort to save babies. It has had a successful neonatal resuscitation program for years, but this uses sophisticated equipment. In the developing world, however, somewhere between 1 million and 2 million babies die every year simply because they do not take their first breath. There is often a birth attendant, but she is focused on the health of the mother and the dangers of bleeding. If the baby does not breathe within the first minute, there is nobody there to help.
The AAP has participated in the development of an evidence-based approach to resuscitate babies at birth, called Helping Babies Breathe. It is low-tech, requiring only a bag and mask. The project is actively supported by the Laerdal Foundation. The program is training the trainers in a number of countries now. Birth asphyxia and infections are leading causes of death in developing countries for babies before their fifth birthday. If we successfully implement Helping Babies Breathe, it will save about half of these 1 million to 2 million babies who would die because they do not take their first breath. Someone trained in basic resuscitation will be at deliveries to focus on the baby.
Another million babies could be saved if breastfeeding is better promoted internationally. The World Health Organization has been out front on this issue, and the AAP is working through the International Pediatric Association and others.
In the United States, immigrant breastfeeding mothers are sometimes separated from their infants. Congress is currently debating a law that would prevent the taking of an individual away from a family when that would cause harm to the family. The Academy will be actively involved in promoting the passage of this legislation.
The efforts of the AAP to promote breastfeeding are varied, but all support the goal of helping children. We welcome your support of our efforts.
Footnotes
Disclosure Statement
No competing financial interests exist.