American Academy of Pediatrics Section on Breastfeeding
Summer 2009
Breastfeeding: Best for Baby and Mother Inside this issue: DC Breastfeeding 2 Coalition Advocacy Day Advocacy Training 3 Day—cont’d Chief CBC Turnover
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Research Reviews
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PA-AAP EPIC BEST PROGRAM
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SOBr Program at the NCE
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State News
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To help reach the goal of 800 members, the Section is holding a membership drive during World Breastfeeding Week. As part of this camCBCs Speak at 10 paign, we have developed new marketing materials (see above) to show WIC Meeting the importance of being a member. The Section hopes that you will SOBr Lectureship 11-12 participate in this drive by recruiting your colleagues! Please use the prepared email blasts that we will be sending over the listserv to do so. Grant—Maryland Membership in the Section is $35 for fellows and $10 for residents. For this small price you help Section leadership to work to improve the lives of babies and families through policy development, advocacy and other activities. And you also get these great benefits.
SOBr Quarterly Newsletter. Yearly educational give-aways (poster, fact sheets, videos, books). Opportunity to apply for grants and submit abstracts for the NCE. Members only pages on the Web site with publications to help you in your practice. Access to the electronic mailing list and breastfeeding experts, educational opportunities, etc). Please go to http://www.aap.org/breastfeeding/sectionOnBreastfeeding.html#membershipInfo for information on how to join or simply call the AAP Division of Membership Services at 800/433-9016, ext 5897 for assistance. Members that are recruited (and establish their membership) during this week will receive their choice of a free copy of one of the Breast Milk Solutions Videos, courtesy of Dr Jane Morton, SOBr EC member http://www.breastmilksolutions.com/ videos.html (a value of $65.00)! Breastfeeding: Best for Baby and Mother
Summer 2009
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DC Breastfeeding Coalition Advocacy Day 2009
By Sahira Long, MD, FAAP, SOBr member, Jennifer Tender, MD, FAAP, SOBr Member and DC CBC, and Michal Young, MD, FAAP, SOBr Member and DC CBC On June 10th, thirty-four women took to Capitol Hill to engage legislators in a healthy discussion about the importance of breastfeeding for mothers and babies. The visit to the Hill was the culmination of an Advocacy Day Training event spearheaded by the District of Columbia Breastfeeding Coalition (DCBFC) in collaboration with the District of Columbia and Virginia Chapters of the American Academy of Pediatrics. They took this discussion to Capitol Hill in advance of the introduction of the Breastfeeding Promotion Act (H.R. 2819, S. 1244) seeking legislative support. The members of this group engaged 6 Senators and 16 members of the House of Representatives about the merits of the bill. Representative Carolyn B. Maloney (NY) and Senator Jeff Merkley (OR) introduced the Breastfeeding Promotion Act of 2009 in both houses of Congress the following day. Fortynine states, the District of CoBreastfeeding: Best for Baby and Mother
lumbia, Puerto Rico, and the Virgin Islands already have enacted various laws protecting breastfeeding mothers, but they are not uniform and most are not comprehensive. The Breastfeeding Promotion Act will support mothers and babies by helping mothers continue to provide breast milk for their infants once they return to work. “Breast milk is better than any other source of nutrition for the human infant, however, many mothers indicate that returning to the workforce is often a deterrent to their ability to continue breastfeeding” said Sahira Long, MD, FAAP, President of the DCBFC. The Breastfeeding Promotion Act (H.R. 2819, S. 1244) includes five provisions: Amends the Civil Rights Act of 1964 to protect breastfeeding women from being fired or discriminated against in the workplace.
Protects the privacy of breastfeeding mothers by ensuring they have break time and a private place to pump (applies to employers with 50 or more employees). This collaboration of physicians and breastfeeding supporters is committed to work tirelessly to see this bill come to fruition. Medical evidence shows that breastfeeding reduces the risk of infections, diarrhea, SIDS, obesity, diabetes, asthma, and childhood leukemia in babies. It also reduces the mother's risk of breast and ovarian cancers and diabetes. “Breastfeeding is the single intervention that confers a lifetime of health benefits during infancy and beyond. Optimal healthcare begins with breastfeeding. Discussions of healthcare reform should include improving workplace support for breastfeeding women through the Breastfeeding Promotion Act” says Dr. Long.
Provides tax incentives for businesses that establish private lactation areas in the workplace, or provide breastfeeding equipment or consultation services to their employees. Provides for a performance standard to ensure breast pumps are safe and effective. Allows breastfeeding equipment and consultation services to be tax deductible for families (amends Internal Revenue Code definition of "medical care"). Summer 2009
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Learning How to Be an Advocate for Breastfeeding By Natasha Sriraman, MD, FAAP SOBr Member and VA CBC Dr Sriraman as well as many other Section on Breastfeeding Members and others participated in the DC Breastfeeding Coalition Advocacy Day—below she shares her personal account of the day. Prior to the event, we were asked to contact our state representatives to set up appointments to speak to legislators and their aides about the importance of the Breastfeeding Promotion Act. I served as a team leader to make sure that these appointments were made and that we were ready for our visit to the hill. Being from Virginia and a team leader, I was able to not only speak with my own Representatives aide, but also those of the other state districts (4 in total). Because the bill is also being introduced in the Senate, the DC Breastfeeding Coalition made appointments for us to also to meet with our Senators or their aides. Before we took to Capitol Hill, our morning started with an Advocacy Training led by the Federal Affairs office of the AAP. Cindy Pellegrini spoke to participants about the different types and levels of advocacy and how lobbying efforts by the AAP have been responsible for several children’s health bills being passed. Role-playing was also done to prepare for meetings with Congressional aides.
Pictured: Ghana Khan, Natasha Sriraman, and Mabel Martin
Our first meeting was with Senator Warner’s Congressional aide who specializes in health. She told us that Senator Warner was very supportive of the bill. However, she informed us of the importance of the CBO scoring system that each bill receives once it is introduced. It was especially enlightening to find out that when the budget is decided for bills, these monetary figures, plus the CBO scores, do NOT take prevention into account. For example, while the benefits of breastfeeding are known, many of them will not be seen until later in the future—unfortunately, these savings from prevention are not taken into account. However, when we informed her of the immediate cost savings, such as NICU hospitalizations costs, as well as federal costs associated with formula purchases for WIC, she stated the importance of including this within the bill. She asked us for detailed information about the immediate cost savings of breastfeeding. It was a great meeting, and extremely informative for all parties. The next meeting was with the Congressional aide from Glenn Nye’s office. She informed me that Representative Nye would be supportive of this bill and with the information we gave to her, she was going to write a brief and present it to Representative Nye. It was exciting to hear that he is also lending support to other health initiatives within the state. By using my patients and their stories, as well my own struggles with breastfeeding, I was able to give a ‘face’ to those women who struggle to breastfeed after returning to the workforce. Through these personal stories, I was able to highlight the importance of this bill for countless mothers all over the country. It was a great feeling, and sense of accomplishment, that my meetings on Capitol Hill could really make an impression on those Congressional aides with whom I met. Many of us developed a sense of camaraderie; working towards a common goal. A couple of weeks after our lobbying day, we received promising news from the DC Breastfeeding Coalition. Senator Merkley offered the Breastfeeding Promotion Act as an amendment to the Senate Health Committee Health Care Reform Bill, where it was ACCEPTED!!! Although this is no guarantee for the bill, this is a huge step in the right direction. We will continue to keep everyone informed about the Breastfeeding Promotion Act as it moves through the Congressional process. I thoroughly enjoyed being involved in this component of the legislative process, and look forward to future lobbying and advocacy efforts.
Breastfeeding: Best for Baby and Mother
Summer 2009
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I’ll Be Seeing You and Hello! Chief CBC Position Turns Over By Julie Ware, MD, FAAP, Past Chief CBC When Lauren suggested I write a farewell as “Chief”, I thought “No Problem”! But then, as the deadline approached, I found many excuses to put it off. It is really very hard to put into words the honor and blessing it has been to work with so many talented and hardworking individuals with our shared passion. From the first conversation I had with Larry Gartner about this job, when he explained that people with full plates tend to get things done even when the plates are heaping, I have discovered that my full plate pales in comparison to so many of the hardworking CBCs. Your devotion, hard work, and energy are truly inspirational! I thank you for all the lessons you have taught me…that disappointments are opportunities for change, that hard work really does make a difference, and that by sharing our stories we are helping mothers, babies, and pediatricians alike all across the nation. From the first days on the job, with Betty Crase as my fearless leader, trying to sort out what a “Chief” was really supposed to do; now, fast forward to the amazing Lauren Barone, who is the most efficient and brilliant task manager helping everyone to do their jobs – I am humbled. I have endeavored to be a liaison between the CBCs and the incredible Section Leadership Team, to share your concerns as well as your triumphs. I have seen you all grow from a group of individuals with a shared passion to a cohesive unit of colleagues who are the grassroots ambassadors of the entire Section on Breastfeeding and rightly noted all throughout our Strategic Plan! I would like to especially thank the CBCSC – Jenny Thomas – our new and awesome Chief, Susan Vierczhalek, Mary O’Connor, Kathie Marinelli, and Touraj Shafai, for coming forward to assist in support of the CBCs. Thanks to all the CBCs who said “Yes” when I cajoled (and yes ‘begged’) for them to give mini presentations at either NCE or ABM, to our “Disaster Team”, Diana Bienvenu and Cris Glick, along with SOBr EC member, Larry Noble for their incredible efforts on the “Infant Feeding During Disasters” Fact Sheet, all of our new CBCs who said “Yes” to joining our group, and to all of our retiring CBCs for many years of excellent service. Thank you for letting me share your stories and brag on your efforts shamelessly. Finally, I would like to thank the Section Leadership for honoring me at the Spring Meeting with a beautiful plaque; sitting at a table with my breastfeeding mentors and giants in the field has truly been a gift for me. And thank you to all of you sneaky folks who sent Jenny a picture and wrote a comment for my “memory book”. My keepsake necklace and clutch are beautiful and precious reminders of my dear friends and colleagues. Thank you… We have been through births, deaths, disasters, report cards, retirements, newbies, and about 5 million emails! And it has been a true highlight of my life to try to serve you all. The best part of it all, is that I’m not going anywhere, but I will continue to serve with you as Margreete’s Co-CBC for TN! So, let’s just leave it as, “I’ll be seeing you.”
By Jennifer Thomas, MD, FAAP, Current Chief CBC I am very grateful to have spent the last year as Julie Ware’s only “vice” and watch and help with all her hard work in advocating for the Chapter Breastfeeding Coordinators. She is a truly rare person. She is a rich mix of enthusiasm and nurturing, and the CBCs have been blessed to have her leadership. I will miss her, but am excited to be working with her as the new co-CBC from Tennessee. The CBC Steering Committee has been working hard this past year and new projects are in the works to help all of us act as ambassadors for our states and chapter. I look forward to helping with the Section’s goal of increasing membership, and sincerely hope that we all can find colleagues who are interested in helping increase the volume of the Section’s voice on behalf of breastfeeding mothers and babies. I know I’m going to enjoy getting to know the new CBCs and working with the new member of our CBC Steering Committee. I hope everyone enjoys World Breastfeeding Week and all the activities- please share them with all of us! Breastfeeding: Best for Baby and Mother
Summer 2009
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Research Review By Laura Viehmann, MD, FAAP SOBr Executive Committee Member “The Absence of Candida albicans in Milk Samples of Women with Clinical Symptoms of Ductal Candidiasis.” T.W. Hale. T.L. Bateman, M.A. Finkelman, and P. D. Berens. Breastfeeding Medicine 2009; 4(2) 57-61. Candida infections of the breast have often been treated based on clinical symptoms alone. See, for example, this passage from the Gold Book (AAP/ACOG Breastfeeding Handbook for Physicians), page 135, “Candida breast infection can be treated based on clinical symptomatology alone if no other diagnosis is apparent. It is difficult to prove that Candida is the causative organism in all situations. Because yeast is ubiquitous, cultures of skin surfaces may represent skin flora and be positive even in asymptomatic mothers.” This month’s article for review by Dr. Hale et al., reports robust evidence that Candida is not cultured more frequently from lactating women with symptoms compatible with breast infection than from asymptomatic controls. The investigators took advantage of newer methods to diagnose Candida growth by using a new growth media and measuring the presence of (1→ 3)-β-D-Glucans, from the yeast cell wall in “clean catch milk samples”. Rigorous nipple and breast cleansing by the study subjects prevented contamination by skin flora in the samples. Further studies of the milk samples provide evidence that breastmilk itself does not inhibit the growth of Candida. They examined the growth of pure C. albicans strains in human milk and in saline. A third study adding iron to similar samples confirmed that iron does promote more candida growth. This investigation focused on deep tissue pain symptoms and does not address whether Candida can cause superficial infections with nipple pain. The study only examined 34 mothers. Confirmatory studies will be helpful. The authors admit that further research to determine if symptoms are caused by a staphylococcal infection or by superficial Candida infection may be difficult to design. The take home message is to objectively evaluate what we know from evidence-based medicine and what we have practiced that may not necessarily be true. As we attempt to help women with pain during breastfeeding, one cannot over emphasize the importance of proper mechanics. Improving infant positioning and latch and carefully evaluating the infant for oromotor problems such as ankyloglossia is of utmost importance. With Hale et al.'s evidence in mind, I will be less likely to consider treatment with systemic antifungals to treat deep breast pain. I would not hesitate to continue to prescribe topical creams to assist in healing traumatized nipple tissue. Pictured: Candida albicans
Breastfeeding: Best for Baby and Mother
Summer 2009
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Research Review By Lawrence Noble, MD, FAAP SOBr Executive Committee Member
“Duration of Lactation and Maternal Risk Factors for Cardiovascular Disease.” EB Schwarz, RM Ray, AM Stuebe, MA Allison, et al. Obstet Gynecol 2009;113 974-982. Recent studies have suggested that lactation increases a mother's metabolic expenditure, improves glucose tolerance and lipid metabolism and lowers C-reactive protein levels, all of which may be of long-term benefit in reducing cardiovascular disease (CVD) risk. However, whether these benefits persist beyond menopause and affects postmenopausal CVD is uncertain. This paper explains how women who reported a lifetime history of more than 12 months of lactation were 10 times less likely to have CVD than women who had never breastfed. The report analyzed data from 139,681 postmenopausal women with a median age 63 years (range 50 – 79 years) who reported at least one live birth at the time of enrolling in the Women's Health Initiative (WHI) study. 58% reported some history of lactation, and only 6% had a cumulative history of lactation greater than 24 months, with few reporting more than 12 months of lactation per live birth. On average, 35 years had passed since last lactation. 30% of women were obese, and parous women were more likely than nulliparous women to be obese or hypertensive. Parous women, who lactated, were less likely than those who had not lactated to be obese or to have hypertension. Data was adjusted for sociodemographic factors (age, parity, race, education, income, age at menopause), lifestyle, and family history. CVD was defined as having a history of coronary heart disease, stroke, congestive heart failure, angina, peripheral vascular disease, carotid artery disease, or coronary revascularization. In fully adjusted models, those who reported a lifetime history of more than 12 months of lactation were less likely to have hypertension (odds ratio 0.88, p
