Abstract
Readers of this journal need not be convinced regarding the evidence-based short and long medical benefits of an infant feeding diet based on the provision human milk exclusively for about 6 months and supplemented by appropriate complementary food till at least 1 year of age. These benefits relate to the association of such an infant feeding schedule with decreased respiratory disease, gastroenterological infections, sudden infant death syndrome, obesity, and type-1 diabetes, and, most importantly, increased cognitive function and, in turn, with a decreased risk in mothers of breast cancer and possibly ovarian cancer and type 2 diabetes.1–3
Given these universally agreed on recommendations, the recent publication of the results of the latest Centers for Disease Control and Prevention (CDC) Maternity Practices in Infant Nutrition and Care (mPINC) 4 survey is both encouraging and disheartening. When pairing these data from the mPINC survey with the latest CDC Breastfeeding Report Card 5 (which is based on the results of the 2017 National Immunization Survey) this seemingly paradoxical situation is even more apparent. Even more striking (if not perplexing) in face of these data are the proposed United States Healthy People Goals for 2030. 6
So what are the data presented in these reports (remembering that they reflect the reality before the coronavirus disease 2019 [COVID-19] pandemic and for the sake of the focus of this editorial are clearly U.S.-centric). The mPINC is the CDC's biannual survey of U.S. hospitals that collates, among other items, data as to the actual practices and policies regarding newborn feeding, hospital-based breastfeeding education and support, and discharge planning. The latest data are from the 2018 survey and summarize the reports from 71% of the nearly 3,000 eligible U.S. maternity services. What is striking is that the national scores related to postpartum care of the infant, including the practice of early skin to skin care, rooming in, exclusive breastfeeding, structured feeding education, and support range from 70 to 92 (maximum 100) with an overall satisfactory score relating to actual feeding practices of 82.
When one matches these results with the data of the Breastfeeding Report Card one is not surprised that it reports that 84% of newborn are breastfed, confirming that the initiation of breastfeeding in the hospital setting is “not the problem.” What is, however, the reality is that as the Report Card notes the rate of exclusive breastfeeding at 3 months is 47% and at 6 months it is only 26%, whereas the frequency of “any” breastfeeding at 6 months is only 58% and at 12 months it is only 35%!
This reality clearly documents that the only a quarter of U.S.-born infant have the potential of fully acquiring the earlier noted medical and developmental benefits of a human milk diet and not even a half of infants receive any degree benefits from the recommended year-long ingestion of human milk.
Given this situation, it is most surprising that the published Healthy Infant Goals for 2030 (yes, 8+ years from now) is that 42% of infants should be exclusively breastfeeding at the targeted 6 months and that human breast milk continue to be the diet source of milk for 12 months for 54% of infants. Reviewing these “target goals,” one cannot help but to sense somewhat of a defeatist attitude wherein the goals are so much lower than the universal recommendations (be it of the American Academy of Pediatrics, American College of Obstetrics and Gynecology, and surely that of the Academy of Breastfeeding Medicine). Setting the goal at <50% than what is desired is potentially counterproductive as it effectively legitimates nonexclusivity of breastfeeding for the first critical months of life and the use of formula way before 1 year.
No less perplexing to me is the focus of public health organizations desire to label follow-up formula and the like as breast milk substitutes (with all the subsequent legal and code implications) in a situation when more than two thirds of infants at 1 year of life have long stopped breastfeeding and are not expected, even in 2030, to be breastfeeding at this age. The real-world option in the developed countries is for mothers to choose to feed their infant either with whole cow's milk or formula and the relative benefits and disadvantages of these two options is what should be discussed and debated. Arguing that follow-up formula is a breast milk substitute for a population that has long stopped nursing and is not expected to continue with feeding of a human milk diet just does not make sense to many.
These issues are clearly not relevant to the developing world where persisting with breastfeeding beyond 1 year is the norm. In those countries the challenge is to provide adequate complementary food after 6 months and to minimize social disruption of the traditional infant care practices (a disruption abetted at times by the manufacturers of breast milk substitutes by their marketing practices of such products for infants in the first year of life). The public health battle is different for the United States and other developed countries, as in such locations the policy should be to take the recommendations of about 6 months exclusivity and 1 year of feeding human milk seriously.
The concern that follow-up formulas, with their increased sugar content, may play a role in the ongoing obesity epidemic cannot be resolve by labeling them as a breast milk substitute. This is at best potentially confusing and irrelevant to a public (both lay and professional) wherein breastfeeding has long ceased for the majority of such children who are over 1 year of age. The concern of the nutritional quality of such formulas is a legitimate concern and should be addressed as such. It should not distract us from battling for the appropriate social and public health policies that will facilitate breastfeeding in the first year of life at the desired rate, be it paid maternity/parental leave, a breastfeeding supportive work environment, and most importantly a conceptual change by our professional colleagues to a belief that feeding human milk in the first year of life really does make a health difference. Simply put, our goals should match our beliefs and let us fight the right war!