Giving “All” Babies a Great Start,Nutrition Matters

Introduction

Human breast milk feeding is an evidence-based cost-effective healthcare intervention with abysmal acceptance within certain regions of the United States. According to the Surgeon General's Call to Action to Support Breastfeeding, ¹ although evidence reveals there are many benefits to support better health outcomes for the infant and the mother, cultural norms, lactation problems, and access to education about breastfeeding become barriers that tend to supersede these benefits. In addition, racial, cultural, and socioeconomic disparities to breastfeeding exist in African American (AA) women, which can be linked strongly to imbedded government, healthcare access, and business policies. To that end, the issues of racism and sexism constituted by the racist history of subjugation of AAs being perceived as not human (property), and the objectification of AA women, treated as either nurse maids or concubines, have magnified the need for health equity.^2,3

Impediments to breast milk feeding are institutionalized at many levels: maternity leave and work policies, the sexualization of the female breast, and public breastfeeding was banned at one time in the State of Georgia. ⁴ Recent studies show most of these laws have been amended to shepherd breastfeeding practices through the validation of the mother's rights to nurse their infants in public. Health equity can be realized when policies are revised to provide women with an optimal level of health. Achieving Healthy People 2020 goals for breastfeeding improves maternal child health, and yet the disparity widens.

Breastfeeding continues to be a health equity issue, and major implications to social norms are the lack of support and essential training from the healthcare delivery model. I am a champion of change and will continue to move the needle on this important issue.

Experience

As an infertility specialist, I was very active in the clinical setting in the 1990s to the early 2000s. I will never forget going to visit one of our babies and seeing that the mother's milk did not flow. She did not have the opportunity to breastfeed, but there were women at the time who were donating their breast milk. I asked the question to the nursing team, “What is the screening process for donating breast milk?” This took place when many were not thinking about screening.

Another example was during my training at Grady Memorial Hospital during the 1980s, when we were doing ∼10,000 deliveries a year. I witnessed many teen pregnancies, and although there were discussions being convened about breastfeeding, nobody was having those meaningful conversations about donor milk options for premature babies when a mother's milk was not available. When preterm babies were delivered, most people were giving the babies formula.

These early experiences and questions led me to my passion of framing models of care for disconnected individuals that would make an impact to the health outcomes of the infant and the mother.

Opportunities

These experiences have informed my work as President and Dean of Morehouse School of Medicine. I also sit on the board of United Health Group, the largest insurance company in the world. ⁵ I also sit on the Association of American Medical Colleges' Council of Deans and am a council member of the National Center for Advanced and Translational Science (NCATS). I am also a founding board member of Kaiser Permanente School of Medicine and a board member in the Nemours Foundation, which have two children's hospitals. And lastly, I sit on the advisory team for NICQ Med as medical director, which is a donor milk company. As I sit on each of these boards or advisory councils and think about being asked to speak on this topic, I think about the advocacy required to give every baby a healthy start, and ask how each of the organizations can play a role from care delivery to care coverage to research. This is one of the reasons that really reconnected me to breastfeeding, as well as my being passionate about breastfeeding and donor milk for the varied benefits to the mother and her child.

Benefits of Breastfeeding

There is overwhelming evidence that breast milk is the most desired sustenance for infants, typically improving their health and saving money for families. I do not think any of us would deny this reality. The impact on the health of the mother and the baby and the cost saving to society if a baby is breastfed or breast milk fed is important. Research suggests that it is the preferred nourishment for infants in the first year of life. The flavor in the breast milk also exposes children to a wide range of tastes. When infants start to eat solid foods, breastfeeding introduces them to a better variety of foods; this has different effects than formula on infants' metabolism and hormones such as insulin.

There are benefits to breastfed infants and children and maternal risk reduction from breastfeeding. The Georgia Department of Public Health reports a 50% reduction on acute otitis media and a 30–40% reduction in types 1 and 2 diabetes in children who have been breastfed. ⁶

The Centers for Disease Control and Prevention (CDC) highlights breastfeeding as one of the many health benefits for the infant and mother; the data suggest about 14.5% of women, infants, and children (WIC) participants, between 2 and 4 years of age, had obesity issues. ⁷ I think we need to do much more research in this area, because, most women are concerned about weight loss in those first 6–12 months after the baby is born. Breastfeeding can burn up to 500 calories. ⁷ This allows mothers to lose weight and be able to return to a prepregnancy size sooner. However, exclusive breastfeeding delays the return of the menstrual cycle. In addition, women who breastfeed for a year or more are less likely to develop hypertension, diabetes, hyperlipidemia, and cardiovascular disease. ⁸

Barriers and Disparities

Wet nurses were the first breast milk donors. The first formal breast milk bank, coined as Human Milk Banking, was founded in Austria 1909, and quickly spread globally to the United States at the Boston Floating Hospital and all of the world. ⁹ Although there have been improvements in the initiation rates of breastfeeding, sustaining those rates beyond weeks to 6 months continue to be a challenge among minority women. At breastfeeding initiation, we can see good rates of breastfeeding: 60% for black women as compared with 70–80% for Hispanic and White women. However, at 6 months those rates have dropped to 45% for Hispanic women, 40% for white/Caucasian women, and <30% for black/AA women. We also observe that the addition of formula of breastfeeding, as a supplement to breastfeeding, may vary by gender of the baby, whether we have a male or female child. Again, this may serve as an indication of the mother's ability to keep pace with the requirements of the child.

In general, fewer non-Hispanic black infants are breastfed compared with non-Hispanic white infants, and Hispanic infants and younger mothers are less likely to ever breastfeed than mothers at the age of 30 years or older. Furthermore, perinatal depression complicates one out of seven pregnancies with an adverse effect. In addition, screening for maternal depression in newborn visits with the pediatrician may also help identify those mothers in need.

Structural challenges—particularly those imposed by the health system and, perhaps unintentionally, enhanced by policy—must be considered. The greatest success of breastfeeding starts with education during the prenatal period. So, although it has been reported in the past that WIC mothers were 12% less likely to initiate breastfeeding, ¹⁰ more recent data indicated no negative association at 3 months postpartum. ¹¹

We must start with educating women on breastfeeding as one of the most significant memorable events one can experience between a mother and her child. It is how we shape this narrative in a positive manner, which influences the possibilities of WIC or any population of mothers breastfeeding beyond 3 months. It becomes a story of “and,” not an “or.” WIC then becomes a backup plan to ‘breastfeeding,” but what we want them to do, clearly, is to breastfeed. Comorbidities, antenatal depression, and postpartum depression are real, and how we support women doing the transition to the first 6 weeks postdelivery to those first 6 days when we are really overwhelmed is important. Antenatal depression is usually a precursor for postpartum depression and should be properly treated. It is estimated that 7–20% of women are affected by this condition. The impact that it may have on breastfeeding is unclear and should be discussed with the provider to ensure for appropriate care of both, the mother and child. Another barrier, which is seldom discussed, is clinical provider uncertainty. When a patient has a complication during childbirth, the provider can be uncertain as to the best path forward. Depending on the clinical challenge, the provider must weigh the best options to reduce stress on the mother. Sometimes, the provider will think that breastfeeding is a stressor—and advise against it.

We will need to work with our providers in the clinical setting to talk with them and go through a regimen of assessment, such as what are the drugs that really are going to be harmful? What drugs are acceptable? What are the circumstances and risks that are not going to provide a positive experience for the mothers? How do we mitigate these adverse outcomes and associated risks, and still afford the opportunity for the appropriate bonding and the nutritional opportunities for the child? Establishing a breastfeeding protocol in this regard demonstrates continuity of care. ⁷

Education

Hospital policies are improving as a result of the many disruptions in healthcare. The sensitivity around the privacy of the mothers must improve by offering culturally sensitive and culturally relevant strategies, depending on who that patient is. I believe this is a critical part of the medical education learning construct and must be taught and adopted as “the” transformative cultural model for optimal care. Just because it is taught does not mean that it is part of the culture (standard).

Many medical schools are creating educational scenarios around team-based learning. Interprofessional teams have been very helpful for us in helping our medical students and residents to understand how to partner with the mothers in this regard. The algorithm for this engagement considers the environment: where the women are breastfeeding, what the boundaries should be, what women feel comfortable with, and what level of engagement they feel comfortable with. Exactly what are the issues that are happening in the workforce that give women the opportunity to have the time? How do we advocate for policies that allow women to take the time to pump or nurse at work without being penalized?

The Affordable Care Act

The Affordable Care Act (ACA) gave us significant gains in health disparities. It did make some differences beyond access. It removed some of the structural barriers, increased the access for AAs and Hispanics, and it also removed some structural barriers specifically for breastfeeding and gave reasonable break time for mothers to express. The ACA also gave a place other than a bathroom that would be shielded from view, free from the intrusion of a coworker or public. The result is an overall increase in breastfeeding by 10% and 21%.

In another study, breast pumps covered under the ACA and provided to patients significantly increased the amount of time that mothers breastfed their babies. Giving pumps and allowing them to be covered under insurance made a difference. ³ One of many continued challenges is the disparity in birth outcomes, which is a significant health disparity in birth outcomes based on race in the 21st century. Preterm births, low birth weight, and infant mortality are greater for AAs than for non-Hispanic infants and nonwhites.

All Babies Matter

Studies show that AA women lag when choosing to breastfeed, and some of this is attributed to the lack of proper education of nutritional benefits. Our annual conference this year, in honor of Henrietta Lacks, will be on infant and maternal mortality. In September 2018, Morehouse School of Medicine will bring together a wide variety of thought leaders to discuss breastfeeding and other issues, including maternal fetal aspects, gynecological issues, and how opioid use is plaguing children and mothers. This event is open to the public. All babies matter, and every baby deserves a healthy start. In 2015, the overall preterm birth rate was 9.6%. For non-Hispanic blacks it was 13.4%. For non-Hispanic whites, it is 8.9%. In 2015, the preterm birth rate for black infants was 51% higher than for white babies.

This is just the marginal cost of morbidities by birth weight adjusted for infant socioeconomic status. When sepsis, hypoxic injury, necrotizing enterocolitis (NEC), and bronchopulmonary dysplasia are considered, all four morbidities, we can see the cost go up and up based on gestational age and size. These are significant, and we are seeing them every day, and not necessarily making as much headway as we want.

Milk Is the Gold Standard

A mother's own milk may be the gold standard, but sometimes it is not available. Therefore, when starting to talk about very low-birth-weight babies, I am talking about babies <1,500 g—we want to be able to see whether we can have donor milk available to them.

Premature births are the leading cause of infant deaths. ¹² Human milk has been proven to reduce the incidence of NEC as 450,000 babies are born annually in the United States, and the premature birth rate is 11.5%. The American Academy of Pediatrics has recently issued a policy statement on the guidelines for using donated human milk and commercial milk banks, and the World Health Organization has recommended that all pediatric foods be sterile when dealing with children at the greatest risk. They have also recommended use of human milk when the mother's own milk is unavailable.

Nutrition and growth make a lasting impact. Why human donor milk? Because there is bovine milk, and there is human donor milk, now available with fortifiers and supplements. ¹³ The challenge is that we do not have studies that have shown that human donor milk, either alone or human donor milk with fortifiers, performs better than preterm formula in neonatal outcomes.^13,14 More studies are required that compare donor milk with and without fortifiers with formula over different weeks of the preterm baby's life span for growth and neurological development.

When you compare bovine milk with human milk, you see that bovine milk is associated with a higher cost than human milk. Considering 100% human milk diet cost-effectiveness for babies, we see a net savings of about $8,167 per infant. However, research suggests that after the cost of donor human milk is accounted for, between U.S. $8,167 and $9,669 can be saved per neonatal intensive care unit (NICU) infant by reducing the incidence, NEC, and total parenteral nutrition days. ¹⁵ This was done by considering the cost of the number of days of the babies in the NICU, how soon the babies went home, or whether they had to have surgeries. One must always consider the total cost of care.

Most formula is fortified, and studies must be conducted to determine whether these fortifiers are necessary and beneficial. Even if a fortifier is added and the cost is increased, I do not believe that will exceed the cost of keeping a baby in the ICU, and if the chances of NEC are decreased, I believe it is worth it. I think this type of study needs to be done, because what we want to do is to prevent NEC—clearly, surgical NEC, but we clearly want to even prevent medical NEC.

The longer the babies are in the NICU, the higher the chance that they may get sepsis or something else.

I recently asked for data by current procedural terminology (CPT; which is a medical code set of descriptors to report various types of procedures) CPT code, on babies who get donor milk. Guess what? There is no real CPT code for donor milk in NICUs. After combing through records and natural language processing to determine who receives donor milk, it appears that the first 6 days really can make a difference, that is when we see the earliest onset of growth. Is that significant? We do not know. Again, we need more research to determine whether the first 2, 3, 6, or 10 days make the difference. We do know that asking the right questions, in a compliant manner, can lead to the right answers for babies.

There are disparities in hospital-reported breast milk usage. ¹⁶ According to a recent Morbidity and Mortality Weekly Report from the CDC, people of color who live in zip codes with safety-net hospitals have a significantly smaller chance of accessing donor milk. The percentage of babies receiving a mother's own milk, of course, and then considering a percentage of NEC babies receiving banked donor milk go down significantly if people live in a zip code where there is a safety net hospital.

Why do women choose to be donors? I have heard the conversation about women choosing to be donors to make money to pay for their lifestyle; it is interesting that we do not ask this question about men who donate sperm. I am an infertility specialist, and I know that we had men who donated sperm every week; nobody ever asked them why they were donating their sperm every week.

Most of these women who donate are very responsible. They understand the process and most of these women are doing it because they had a preterm child. Women who have had preterm children and can make larger donations are previous donors. As the use of donor milk continues to outpace demand, we will need to understand more about this altruistic group of women.

Finally, it is very important that there is a donor process. One part of this protocol may include testing for use of harmful drugs, alcohol, and so on, which may be harmful during pregnancy to the unborn fetus. Once you have done the individual testing, when it is aggregated, the milk needs to be tested again to make sure it is safe for the infant to consume.

There is a debate whether there is an advantage to nonfrozen versus frozen. In my opinion, it would be very nice if you do not have to have it frozen. All donor milk should be nutritionally labeled. Therefore, we need to make sure there are standards.

Solutions

Targeted interventions at hospitals that serve a high proportion of non-Hispanic black residents can ensure more equitable access to breast milk for all high-risk infants. In addition, further investigation is necessary to understand the factors in the variation of breast milk use in NICUs. We must also continue to provide education and access to equipment.

Breast milk is the recommended nutrition for all infants. It is particularly beneficial for preterm infants. We know about the increased risk for preterm births. We also know that they have the lowest breastfeeding rates.

We must increase initiation and continuation of breastfeeding among AA women and acknowledge the systemic barriers such as access, lack of probreastfeeding business and government policies, and the vestiges of history.

We need to put our money where it is most needed. Health equity is about giving people what they need, when they need it, in the amount they need to reach their optimum level of health. So, we know there is a significant disparity in breastfeeding, and we need to concentrate our efforts on those populations that have lower success rates.

If we know that donor milk can help preterm babies, and minority populations have the highest rate of preterm birth, then we need to ensure that they have access to donor milk when mother's milk is not available. ¹⁷ That is what equity is.