Australian Pediatric Breastfeeding Policy
The Paediatrics & Child Health Division (Division) of The Royal Australasian College of Physicians (RACP) encourages and supports the promotion of breastfeeding. Breastfed infants have improved neurodevelopment (1,2,3,4) and a lower incidence of infections (5,6) allergic disease (7,8,9) and diabetes (10,11) when compared to formula-fed infants. Breastfed infants also have better feed tolerance, less physiological gastroesophageal reflux (12) and a lower incidence of necrotising enterocolitis (13,14). Most of these benefits have been demonstrated in randomised clinical trials although there remains the possibility that some of the benefits are due to factors associated with the choice to breastfeed rather than breastmilk itself (15).
Formula, although superior to cows milk, is not the same as breastmilk and does not confer the same advantages. The nutritional composition of breastmilk is unique with narrow ranges for most nutrients, and many additional factors which are not in formula. The WHO Code, endorsed by the World Health Association in 1981, aims to protect the well-being of all infants through the protection and promotion of breastfeeding.
In Australia, breastmilk or formula is recommended for the first year. Longer duration of breastfeeding appears to increase the benefits, however, the minimal duration for optimal benefit remains unclear. For neurodevelopment, at least four months appears necessary (2,4,16).
Breastfeeding is almost universally successful when there is good management and no medical intervention or exposure to alternative feeding methods. There is evidence that offering a breastfeed within the first few hours of birth is good for mothers, infants and for ongoing breastfeeding (17,18). "Rooming-in", or keeping the infant with the mother for 24 hours a day, has been shown to facilitate breastfeeding and promote bonding without disturbing the mother unduly (19,20,21). The early use of bottles and dummies can interfere with the establishment of breastfeeding reducing both the infant's sucking capacity and stimulation of the breasts, with the likely result of delayed and poor establishment of lactation (22). Offering complementary feeds, whether water, glucose or formula, when there is no medical reason, has been shown to adversely affect the establishment and maintenance of successful breastfeeding (23,24). There is also a need to recognise the possible dangers associated with bottle feeding such as contamination of feeds, infection and reconstitution (25).
Promotion of successful breastfeeding is hindered by existing barriers, such as community attitudes towards breastfeeding in public places, and lack of role models in our society. Breastfeeding is not always easy and some mothers may need assistance. A perception of inadequate milk supply is often given as a reason for ceasing breastfeeding, even if the infant is thriving. This is especially common in the first six weeks, before the infant has established a pattern of feeding and sleeping, and irritability is common. There are good support groups available to Australian mothers such as midwives, lactation consultants and the Nursing Mothers' of Australia Association. Continuing breastfeeding may be particularly difficult for mothers who join or rejoin the workforce within a year of delivery.
The weight percentiles and body composition of breastfed infants differ from those of infants who are formula-fed. In general breastfed infants tend to grow rapidly in the first few months and then grow at a slower rate than current percentiles. Therefore their weight may appear to be faltering after three months when plotted on current growth charts even when they are healthy (26).
Healthy breastfed babies do not need other fluids (27). The introduction of weaning foods from 4-6 months is important developmentally, and probably nutritionally for the prevention of iron deficiency anaemia (28).
There are a few contraindications to breastfeeding and these include HIV infection and active tuberculosis. The use of a small number of maternal medications prohibits breastfeeding (e.g. cytotoxic and immuno-suppressive drugs and gold salts). Almost all drugs will pass from the maternal blood to the breastmilk but, for most, only about 1-2% of the maternal dose appears. However, the use of some drugs may require the concentrations in breastmilk or infant blood to be monitored. Advice will vary depending on the dose and duration of treatment and is readily available form Drug Information Centres at Women's and Children's Hospitals.
* The Division supports the WHO International Code of marketing of Breast Milk Substitutes (1981) and the Voluntary Agreement of the Marketing in Australia of Infant Formulae (1992).
* The Division supports the NH&MRC Infant Feeding Guidelines for Health Workers (1996). These guidelines outline methods for the encouragement and promotion of breastfeeding and the management of feeding difficulties in the Australian community. They include guidelines for safe bottle-feeding.
* Paediatricians should encourage the critical evaluation at each step in health care during pregnancy, the confinement and the postnatal period, to determine any factors which may benefit or hinder the establishment of successful breastfeeding.
* Where appropriate, they should encourage the development of local practice guidelines which increase the chances of successful breastfeeding. For example, mothers should be encouraged to put their baby to the breast as soon as practicable after delivery; mothers should be encouraged to have their baby "room-in" with them while in the postnatal ward; healthy term infants should not be offered bottles or dummies during the establishment of breastfeeding.
* All paediatricians who treat children in the first year of life or teach about child health should know in detail about the physiology and techniques of breastfeeding and should be able to discuss and manage any clinical problems.
* Paediatricians should encourage the inclusion of the breastfeeding topics in the undergraduate medical curriculum, and in postgraduate courses for paediatricians, obstetricians, general practitioners, midwives, maternal and child health nurses and relevant others.
* Paediatricians should be advocates in encouraging the community to value breastfeeding and to welcome breastfeeding in public places and the workplace. They should promote social and industrial changes that make it easier for working mothers to continue breastfeeding e.g. these might include work-based facilities for expressing breastmilk or feeding, and encouragement or incentive for employers to provide work-based facilities for child care.
* As part of postnatal care, mothers should be taught how to express breastmilk and how to clean and sterilise any equipment that may be used to offer expressed breastmilk or fluids according to the NH&MRC guidelines on the storage and pooling of human milk.
* Every woman should be enabled to make an informed decision about how she wishes to feed her baby. Some women will choose not to breastfeed. Their right to make that choice should be respected and supported.
* Paediatricians should encourage flexibility and maternal autonomy in breastfeeding. Where assistance is necessary, paediatricians should be aware of services that provide such support and where possible refer mothers for additional support from qualified advisers experienced in the management of lactation.
* Paediatricians should consult their local drug information centre before suggesting that breastfeeding be interrupted or ceased because of maternal medications.
* Any baby who is persistently unsettled and/or has inadequate weight gain should be seen by a medical practitioner and, if necessary, referred to a paediatrician for further assessment.