The AAP's 2012 Breastfeeding Policy Statement: Is There Anything New?

All of us who are supporters of breastfeeding wear multiple hats, be it as clinicians, researchers, educators, public health policy advocates, or role models, and thus I feel free to take this opportunity to switch headgear from my role as President of the Academy of Breastfeeding Medicine (ABM) to don the chapeau of my other “official capacity,” that is, as the retiring Chair of the Policy Committee of the Breastfeeding Section of the American Academy of Pediatrics (AAP) and as lead author of the new AAP Policy Statement on “Breastfeeding and the Use of Human Milk,” ¹ published in March 2012. I had had the opportunity of co-authoring the previous (2005) AAP Breastfeeding Policy Statement ² with my long-term mentor and colleague Dr. Lawrence Gartner, and it was my turn, this time around, to team up with Dr. Richard Schanler to revise and update this basic and much-anticipated document.

Thus, as a result of this personal experience, I can surely reflect on what is new and or different in the 2012 Statement as opposed to the 2005 version, and how the new Policy Statement reflects what has changed in the global atmosphere regarding breastfeeding. At the risk of beginning with the negative, let me state what the new statement is not about and why the focus has shifted. In contrast to the 2005 statement, a decision was made not to publish a detailed breastfeeding management document, as it was felt there is no lack of such texts or manuals, both for the professional and for the mother. In fact, the new AAP Policy Statement specifically and explicitly acknowledges that it is the role of organizations such as the ABM to develop and publish up-to-date management protocols, and the references of the AAP Statement confirm this decision.

So what then is the new focus? Simply put, it is to emphasize the need for a conceptual change in our understanding of the process of breastfeeding and to realize that an individual mother's decision to breastfeed her infant should not be conceived as a lifestyle choice but rather as a critical and basic health decision for her infant's immediate and long-term welfare. To support this concept great detail was presented as to “health disadvantages of not breastfeeding,” leading to negative consequences, such as an increased risk (of tens of a percent) in developing allergies including asthma, upper and lower respiratory tract and gastrointestinal infections, inflammatory bowel disease, and crib death. In addition, data were presented as to the long-term beneficial effects of breastfeeding in lowering the risk of developing obesity, cardiovascular disease, diabetes, and hematologic malignancies. Most importantly, was that the protective effect of breastfeeding was noted to be related to the duration and degree of exclusivity of breastfeeding. As a result, the previous AAP recommendation for exclusive “breastfeeding for about 6 months “followed by introducing complementary foods while continuing breastfeeding for 1 year and longer as mutually desired by the mother and infant was resoundingly reconfirmed!

What followed from this understanding of the public health implications of these data was the conclusion that there must be an emphasis on creating a supportive environment to facilitate a mother's initiating breastfeeding in the hospital and for her to continue at home in breastfeeding exclusively at least until the desired target of 6 months. To that end the Policy Statement discusses at length the system changes that are needed in the hospital postpartum period (such as adopting the World Health Organization's recommended “10 Steps to Successful Breastfeeding”). Furthermore, it was emphasized that there is need to understand that just teaching the medical and nursing staff how to supervise and manage the mother–infant breastfeeding dyad is not enough without focusing on how to dispel the misguided notion (still held by all too many hospital personnel) of the equivalency of human milk and commercial formula. In addition, the vital supportive role the family physician and/or pediatrician play in the critical days and weeks after the birth when the mother–infant dyad are establishing their routines, in the responsibilities that employees have in creating a breastfeeding-friendly environment in the workplace, was discussed. Epidemiologic data were presented that highlighted the extreme variation in breastfeeding rates in different populations, emphasizing the importance of sociodemographic and cultural variables that are associated these disparities, thus leading to the conclusion that there is a need to address these issues from a population public health perspective and not solely on an individual basis.

Other specific recommendations included the emphasis on the importance of the exclusive feeding of human milk to high-risk premature infants, as both a protective prophylactic measure against the development of necrotizing enterocolitis and for the enhancement of neurocognitive development. The bottom line from these data is that in the absence of mother's own milk, donor milk from supervised milk banks should be the first alternative. In turn, monitoring of growth should be based on the new World Health Organization's “standard” growth curves as opposed to the Ceners for Disease Control and Prevention's “reference curves,” as the World Health Organization's curves reflect accurately the normative pattern of the growth potential of the breastfed infant.

Of course, in the opinion of the authors all the above emphasis is not in place of the need to develop and expand the education programs for healthcare providers and lactation counselors, and programs that both the AAP and ABM have developed such as the WEPKTN (What Every Physician Needs To Know) course or the AAP residency curriculum surely serve that end. However, the new Policy Statement clearly emphasizes that the focus solely on the individual health professional and the mother will not suffice without the expansion and implementation of population-wide public health policies such as the Baby Friendly campaign and the enactment of labor laws that require employers to routinely provide breastfeeding or pumping facilities, while demonstrating that these policies are in the best business interest of the business side and bottom line of companies.

So yes, there is a difference in the 2005 and 2012 AAP Policy Statements, and not only in citing of newer references, but primarily in emphasis on the broader public health consequences of what and how the mother chooses to feed her newborn infant. In turn, the 2012 Statement emphasizes that we professionals need to get beyond our responsibilities for the individual maternal–infant dyad and that we must incorporate the new principles and concepts into our own daily activities if we are to ultimately to become true advocates and supporters of breastfeeding worldwide.