Abstract
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Several other authors have recently discussed the issues involved in developing a set of terms to accurately describe breastfeeding that illustrate how this task is more difficult and complex than it might seem at first glance.3–5 In my opinion, the terms should be simple, intuitive, and useful not only for research but also for health indicators that can be tracked for obtaining population-based statistics, and most importantly for delivery of optimal healthcare.
When I read the quotes from the qualitative studies in the current Journal article, I was reminded of a clinical encounter with a resident a few years ago. I was pleased but a bit surprised when the resident returned after speaking with the mother and examining the infant, and reported that breastfeeding was going great. The baby was exclusively breastfed and was gaining an ounce a day. A week before, this mother was having difficulties latching and was pumping and breastfeeding directly with a supplemental nursing system (SNS) at the breast. When the resident and I inquired in more detail about the feedings, she broke down crying, explaining that she was still pumping and giving the breast milk through SNS while her baby was directly breastfeeding. She was exhausted and was not sure how much longer she could keep this up. As happens in training, the resident was not wrong, but did not get the entire picture. This illustrates how there can be more than just putting a baby to the breast when we speak of breastfeeding.
We need to eliminate the term bottle feeding from the breastfeeding lexicon. Bottle feeding in the past has generally referred to feeding formula in a bottle and is confusing as many infants receive expressed breast milk (EBM) in a bottle. I like the term direct breastfeeding or, as the authors suggest, feeding at the breast. Thus breast milk feeding can occur directly at the breast or from a bottle or some other device. I agree with the authors that any breast milk that is not obtained at the breast has been expressed and should be referred to as “expressed breast milk.” My concern, with the schema as presented, is that it seems to imply that the term EBM should be reserved for mothers own milk (MOM). I would argue that we should call all breast milk provided in a device as “expressed breast milk”, with a modifier MOM, milk bank, informal shared, and purchased to further differentiate them.
Table 2 of the mentioned article suggests terms for various scenarios regarding the source of breast milk and how the infant gets the milk, along with an attempt to specify proportions of each behavior and milk source. It, however, does not provide for length of storage before consumption. This table illustrates the complexities in defining breastfeeding and I feel it is a reasonable proposal.
As I said at the outset, I feel the time now is to define breastfeeding precisely in terms of the source of breast milk and, if expressed, how it was stored and delivered. Our terminology, however, may be an emotionally charged issue for some parents, especially mothers who for whatever reason could not directly breastfeed and are pumping to provide milk for their infants. For this reason, as always in our clinical encounters, we need to be open to using “breastfeeding” in general terms, but follow-up with respectful questions to elicit an accurate breastfeeding history.
My dream is for ABM to develop a template with these terms for electronic medical records that could easily capture information that not only would improve patient care but could also be a treasure trove of useful clinical data to guide future goals and policies. In reflecting upon this issue and the many individuals involved in developing policies and providing care to mothers and infants, I feel Labbok and Starling were wise when they called for a meeting of stakeholders to sort out these complexities. That said, the authors of the article in this issue have made a great start.