Abstract
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As the protocol documents in its introduction, “infant formula supplementation of healthy neonates in hospital is all too common and that supplementation with infant formula is associated with decreased exclusive breastfeeding rates in the first 6 months and an overall shorter duration of breastfeeding.” Recent U.S. statistics from the Centers for Disease Control and Prevention (CDC) 1 note that although the initiation rate of breastfeeding is approaching 82%, <52% of mothers are still breastfeeding at 6 months with an exclusive breastfeeding rate of 44% at 3 months and 22.3% at 6 months. Furthermore, 17% of breastfeeding infants are documented to having received supplementation with formula during the immediate postpartum period, a figure that far exceeds realistic and justified infant medical needs. These statistics reinforce the critical value of a clearly written and implemented set of guidelines for appropriate clinical management of the mother–infant dyad, and thus the ABM Protocol is more than welcome.
The protocol is matched by the recent publication by the Cochrane Library 2 of a report entitled “Support for healthy breastfeeding mothers with health term babies,” which reviewed and evaluated the effectiveness of different intervention programs. The key findings were what worked the best was structured, regular face-to-face contacts with the mothers by professional and/or lay peer supporters both in the postpartum period and in the follow-up in the weeks after discharge. The key seems to be the personal contact with knowledgeable individuals although there is only minimal data to suggest that any specific program or system works better than the other. This conclusion is also supported by the recently published report of the U.S. Preventive Health Services, 3 which also emphasized the role of the individual support of the mother than any formalistic system or specific written policies.
In reviewing all the documents what cries out is the critical need for prospective properly randomized studies comparing specific support programs, not just program “A” versus “routine,” that is, all too often no program. Not surprisingly, the new protocol always works better than nothing, but leaves us with the feeling that we need more evidence-based data. These studies all too often remind one of the results of the classic factory productivity studies of the 1930s that were dubbed the “Hawthorne effect.” This phenomenon was defined as a behavioral result that was not a result of a specific change or procedure, but rather a result just because “a” change was made. The original study was in a factory in Hawthorne, Illinois, that documented that a change in lighting affected productivity. Productivity did increase, but in the end it was surmised that productivity increased only because of the increased attention to the workers because of the study. What happened was that as soon as the study ended, productivity decreased despite the increased lighting. This led to the conclusion that the initial result had nothing to do with the increased lighting, but rather just to the existence of the study per se.
Thus, the published study by Puapornpong in this issue comparing two different specific techniques to support breastfeeding in mothers who underwent cesarean section is most welcome. Hopefully it will be the harbinger of other studies comparing two or more techniques (along with a “placebo arm”). Yes, modern scientific methodology is long overdue in breastfeeding studies and, hopefully, we are in the right path with Breastfeeding Medicine showing the way.