Wisconsin Public Television University Place Wednesday Nite at the Lab  Anne Eglash Why Breastfeeding Matters  August 3, 2011 UP609   cc >> Tom Zinnen: Welcome, everybody, to Wednesday Nite at the Lab. My name is Tom Zinnen. I work here at the UW-Madison Biotechnology Center. I also work for UW Extension Cooperative Extension. And on behalf of those folks and Wisconsin Public Television and the Wisconsin Alumni Association, thanks again for coming to Wednesday Nite at the Lab. We do this every Wednesday night, 50 times a year. Tonight I'm delighted to be able to introduce to you Dr. Anne Eglash who is a clinical professor in the Department of Family Medicine here at the University of Wisconsin-Madison in the School of Medicine and Public Health. She's a board certified family physician and a lactation consultant. She spends most of her time practicing clinical medicine in Mount Horeb. She's the medical director of the outpatient lactation program at Meriter Hospital and is heavily involved in breastfeeding medicine teaching with the UW medical students as well as residents from the Departments of Pediatrics, Family Medicine, and Obstetrics and Gynecology. 

She's a co-founder of the Academy of Breastfeeding Medicine and the Mothers' Milk Association of Wisconsin. In addition, she is the medical director of the Mothers' Milk Bank of the Western Great Lakes, an emerging donor human milk bank. She sits on the editorial board for Breastfeeding Medicine journal and has published several articles pertaining to breastfeeding. Dr. Eglash also has a regular podcast series pertaining to the clinical practice of breastfeeding medicine. Her research interests include chronic breast pain in nursing woman, nipple shield use among health professionals, and milk sharing among lactating mothers. Please join me in welcoming Dr. Eglash to Wednesday Nite at the Lab. [APPLAUSE]  >> Anne Eglash: Thank you for having me. As many of you probably know, this is world breastfeeding week so this is part of the celebration and sharing the information about breastfeeding and the importance. And so I thought today, can you hear me? Okay. Maybe I'll just readjust this. 

That's better? Okay. I might just hold this. I'm usually better at that. What I want to do today is talk about why breastfeeding matters in the United States. Because I think we've lost track of why breastfeeding is important here. I think we still understand that breastfeeding is very important in Third World countries where there's not the guarantee of clean water and adequate food. And we seem to see more disasters in other countries than we do here. But breastfeeding is very important in this country, and I'm hoping to convince all of you of that. So first we'll review why breastfeeding lost favor in the United States, and then we'll talk a little bit about how breastfeeding made its resurgence in the United States. We'll talk about who's most at risk in the United States if not breastfed and the importance of breastfeeding in reducing chronic illnesses. 

We'll also review our barriers to increasing breastfeeding rates in our country. This is, I just want to share this statue, this was at Buckingham Palace in London. I was very shocked and surprised and pleased to see this statue of a mother nursing her baby. Most of the information I'm going to talk about today regarding the history of losing breastfeeding in our culture comes from Dr. Rima Apple who is a professor in the history of medicine at the University of Wisconsin. She wrote a wonderful book called Mothers and Medicine which was published in 1987, and if any of you have an interest in this history, I strongly advise this book. So before the 1800s breastfeeding was considered an essential role of motherhood, and women were generally assumed that breastfeeding, having children, breastfeeding, nurturing the family was their major role. One physician quote that Dr. Apple has in her book is no woman is fit to have a child who is not fit to nurse it. And women who couldn't nurse knew that their children would be at risk for death, and so they hired wet nurses. So before the mid-1800s, physicians were not involved in infant feeding. In fact, the whole field of pediatrics was very sparse. 

Many babies didn't survive. There was a very high infant mortality rate, especially among non-breastfed babies, and the vast majority of babies were breastfed. So the cure for mothers and babies was largely within the realm of midwives. But during this time of science emerging, especially if any of you have read Erik Larson's book about Devil in the White City he talks all about the world fair in the 1890s, I thought that was an incredible book. He talks about how science really revved up in so many different ways. And of course, we all learned about Industrial Revolution in school. And Dr. Rotch is one physician who Dr. Apple focused on in her book, a physician who was very interested in infant mortality rates and really thought that infant feeding had a lot to do with infant mortality. So his quote reads, a quote from him, "The preventive medicine of early life is preeminently the intelligent management of the nutriment which enables young human beings to breathe and grow and live. In fact, it is a proper or an improper nutriment which makes or mars the profession of the perfection of the coming race. Infant feeding, then, is the subject of all others which should interest and incite to research all who are working in the preventive medicine of early life." So he's basically saying that feeding is of utmost importance, especially as they were looking at infant mortality. 

And at that point, in 1890s, one-third of infants died before the age of five. And the majority of these babies were being breastfed. However, he focused on the possibility that some breast milk wasn't as good as others. And when researchers started to look at breast milk they realized that some women's milk has more protein than others and some has more calories than others and some has more fat. So there must be something about women and their qualities and their behaviors that influences their breast milk. Well, now we know that that variation in women is very normal, and we see variations at different times of the lactation period from newborn on and throughout the day we see those variations. But back then they thought that that was a major reason why some breast milk may be bad. In addition, people like Nestle, he was a researcher back in the late 1800s, he would dabble in chemistry and came up with some ideas of things that babies could be given if they didn't have access to breast milk. So there was this emergence of breast milk substitutes which really wasn't within the scientific realm. And Dr. Rotch said, look, we really need to bring this whole science of breast milk substitutes into the scientific realm to understand the best way to make substitutes for breast milk when breast milk is not available. 

So basically breast milk was questioned. They thought that the mammary gland was vulnerable, that the mother's state of health affected her breast milk. So if she was mentally ill, stressed, nervous, over-tired, didn't eat well, that her breast milk may be poor. So women were given these specific ways of living and of eating, ways to go about their lives in order to have ideal breast milk. And Dr. Rotch thought, gee, I bet we can figure out what babies are missing and then take cows' milk and design it just like human milk so that they can have a substitute, especially when mom's milk is not good anymore. So what happened is that, so initially when the field of pediatrics emerged the whole idea with pediatrics was really to get babies to survive and it really focused on infant feeding. But as formula manufacturing sort of evolved, it ended up more in the hands of manufacturers. The manufacturers were very excited that physicians got interested in breast milk substitutes and so sort of the ball got rolling, and over time it ended up more in the realm of the commercial manufacturers of the formula as opposed to the physicians. And physicians really started to step back and look at other things regarding pediatrics, things that they could do like immunizations and taking care of infections and other sorts of illnesses that infants had. And I just wanted to show the relationship between an old ad and a relatively new ad. 

If you can see this is from like the early 1900s for Benger's Food, and here it says mother's milk or Benger's Food. It's nature's intention that the baby should be fed by the milk of its own mother. When this is injudicious or impossible the next and nearest thing is cows' milk modified by Benger's Food. So here we have Enfamil Lipil, which is a relatively recent, in the last 10 years, formula. And here it says our closest formula to breast milk. And it's hard to see but manufactured, or I can't see what that says, but basically nutrients found in breast milk, the added lipids. So basically infant formula continued to become popular, and there are certain scientific methods that became very important and made formula safer, particularly pasteurization of cows' milk. And what happened is that, so in a way this formula was a good thing because there was a reduction in infant mortality because babies did have something that was better than unpasteurized cows' milk in order to survive if they didn't have access to mother's milk. So people thought, gee, this is great, this formula saved, we're seeing a reduction in infant mortality rate. However, there were other things happening at that time, and this was an association and not a cause. 

There was also clean water, indoor plumbing, the start of immunizations as well. And so there was a great deal of advertising of this formula to families as perfect food for infants in mothering magazines and also in medical journals. So this was the beginning. Even in the early 1900s physicians were being flooded with this information about what formulas would be appropriate for their patients. And physicians were not, in medical school physicians, there never has been emphasis on infant nutrition in medical school. And so physicians learned their information on infant nutrition, particularly formulas, from formula companies. So at the same time, so there are other forces that are happening at the same time. We have the down fall of the wet nurse. And again because there is this interest in making sure that the woman was perfect in various attributes to make perfect milk, the idea was that finding a perfect wet nurse was probably pretty difficult. And it may be wiser and easier just to use a bottle, especially with the advent of these rubber teats or nipples. 

And there were also social issues that always were the case with wet nurses, having to hire them, dealing with their personalities, perhaps jealousy, perhaps getting involved with their husbands. Who knows what was going on. So it was felt to be a very difficult situation to have a wet nurse with them. So bottles just seemed to make sense with formula. Science continued to become very important and also, so not just in the manufacturing of things and newer technologies for roads and other things that you could see and feel, but also in terms of behavior, and if was felt that science could explain some of our sexual behavior, racial issues, the difference between races, and also how women should mother. And so there was this idea that women need to learn how to mother, that it's not instinctual. And this was a quote from Good Housekeeping in 1911, from A Trained Mother. "Maternal instinct is not knowledge. It's love, patience, and unselfishness... But maternal instinct left alone succeeds in killing a large proportion of the babies born into this world." So it's the idea that you can't trust your instinct, that you need to learn how to care for your baby properly. 

And so many of you probably have heard of Attic Angels which is currently an extended care facility for people. But Attic Angels was originally, in Madison, founded by Dr. Dorothy Reed Mendenhall back in the early 1900s, around 1920s. And this was actually a summertime child health center where women would come and they would get pasteurized cows' milk for their children, but they also learn how to mother and their children would be checked to make sure they were healthy. And it made more sense to do it in the summer because, number one, the pasteurized milk is more important in the summertime because of the heat, but also because it would be difficult for them to get to a well-child center in the wintertime. So another huge, huge thing which has had ramifications around the world are hospital practices. And birthing in hospitals really gained popularity in the 1920s. In fact, our first president who was born in the hospital, I think many of you people know, was Jimmy Carter. So prior to that people were largely born at home. And so the hospitals would use scientific practices to keep babies safe. And so one of their big things was to make sure that the babies were in sterile environments because that would be safer for them so they didn't die or get sick. 

And so they separated the babies right away from the moms. And then infant feeding was schedule. So all the infants were in the nursery, they were brought out to moms and they would have X amount of time to feed the babies, and then the babies would go back to the nursery. And those of you who are out there nursing and who have experience with breastfeeding understand that's not how you establish breastfeeding. The baby needs to be with you. The baby needs to nurse quite often. And mom needs to watch for those early feeding cues which also promotes bonding and brings the milk in faster. And so by having these babies separated, moms are not establishing the breast milk supply well. Babies sometimes are not even figuring out how to nurse. At the time there was documentation that nurses were cleaning breasts and also wearing masks and telling moms to wear masks, and so it was considered very much scientific. 

But this was how mothers were learning how to nurse their babies. And they were encouraged to go home and do the same thing, to keep them on a schedule. And this was just one picture of one hospital in the 1920s where you can see the babies are lined up in their cribs. You can see the scale and the table where the baby's getting bathed and changed and things like that. And here again, this small room with the babies all lined up and essentially not being held and just brought out for tasks and then put back into their cribs. So pretty much by the 1950s we reach our lowest point of breastfeeding and formula seemed ideal at that point. Breastfeeding was pretty problematic. There was a thought that we don't really know what's in breast milk. We have no understanding of it, but we do know what's in formula. And so nutritional deficiencies were identified and thought that maybe this would be a problem for infant feeding, and if an infant didn't grow well or whatever was wrong with the infant, breastfeeding was probably the problem. 

People, again, were concerned about the psychosocial issues that a woman had so that if she was depressed, anxious, stressed that her breast milk would not be good. And there was this loss of understanding about breastfeeding so even the thought that colostrum was not sufficient the first couple days and that babies needed to be supplemented just showed how there is this loss of knowledge regarding breastfeeding. There was a very heavy advertising by formula companies. And I understand how hospitals can decide that breastfeeding is just too much work. It's too difficult. You have to be there, you have to spend too much time with the patients and with the babies. You have to worry about making sure the babies take enough. You can't measure how much the babies are taking. And this became just too much for staff who are busy. They have a lot of babies to take care of, a lot of moms to take care. 

And physicians lacked the breastfeeding education. And guess what? Physicians wrote a lot of the policies in the hospital. So then comes in the natural childbirth movement. So for every action there's an equal but opposite reaction. Fortunately, that was the natural childbirth movement which encouraged women to not accept as much anesthesia during childbirth. And there was some influence by this childbirth movement to encourage hospitals to allow babies to room-in in mothers' rooms. And probably the most important thing was the childbirth education that women underwent before they gave birth. So they knew what was going to happen to their bodies, and then they also learned about breastfeeding. We also saw the rise of the La Leche League in the early '40s and 1950S. And this was a hugely important grassroots movement to provide that mother-to-mother support for breastfeeding. 

And for a lot of women, La Leche League would be the only group that women had available to learn and to have support in terms of breastfeeding. There's no evidence that physician knowledge or any increase in evidence regarding the benefits of breastfeeding had any impact in the gradual return of breastfeeding rates in the 1970s and 1980s. So here you can see that the breastfeeding rates were quite low back down to the '20s in the 1970s. And then there was a rise into the 1980s for breastfeeding. And much of that probably was in middle-class Caucasian population. And the rates, and probably in the immigrant population, too, continued to nurse. But then it sort of dropped off in the 1980s, and the thought was that many of these women went back to work and so that decreased the breastfeeding rates. And then you can see another rise in the 1990s and that probably had to do with WIC, with the Women, Infant and children program, having breastfeeding programs available to help women nurse. Yes. >> Can you explain, do you have any indication that the rise of the birth control pill had any influence on breastfeeding rates? >> Did the rise of the birth control pill have an affect on breastfeeding rates. 

Well, it probably would have decreased breastfeeding rates because the birth control pill probably would have been given very early to women postpartum, and the estrogen in the birth control pills would decrease the milk supply until physicians figured out that women should only have progesterone only birth control pills. So I would think that it would be unrelated actually. Because the common knowledge is that women would continue to nurse in order to stave off pregnancy. So I think it's unrelated. So again, we saw a gradual increase in breastfeeding rates, not only from the natural childbirth movement, with less medication, more knowledge about what's going to happen to one's bodies, but also there were some other movements happening. One was called the baby-friendly hospital movement in the 1980s. And this was started by the World Health Organization and the World Health Assembly. They recognized around the world that hospitals were the biggest barriers to preventing women from being successful with breastfeeding. If women leave hospitals and are not breastfeeding, they are very unlikely to breastfeed. Now this movement back in the '80s was probably not important in the United States because we didn't really start revving up with our baby-friendly hospital movement in the United States until the mid-2000s. 

But in other countries that was very important. But it gave hospitals ideas on things that they could do to improve their breastfeeding rates, especially in the 1990s. Again, we had the WIC programs which have done wonderful things in terms of peer counselors and education for families who are WIC eligible to increase breastfeeding rates. And then one of the other things that was important in the mid-1990s that increased breastfeeding rates was the FMLA act. So women knew that they could stay home and breastfeed and not have to go back to work for 12 weeks because their job would be safe. And this is just an article showing that there was a gradual increase in the amount of literature and research being done in breastfeeding medicine. Between 1960 and 1969 there were about 408 breastfeeding citations on MEDLINE. And then by the 1990s we saw 6,269. So we saw this huge increase in research. So does breastfeeding really matter now in this country? We have pretty low infant mortality rates. 

And when babies become ill we can fix them. We can treat their infections and their illnesses with modern medicine. We also have immunizations, clean water, indoor plumbing. So babies are fairly safe. Well, let's talk a little bit about the difference between breast milk and formula. If you look at this slide, this is formula. It basically is a bunch of chemicals put and dissolved in water and has no organic matter in it. When you look at breast milk, you have lots of organic matter. You have lots of enzymes, you have hormones, you have fats and proteins that all, not only provide nutrition, but have living qualities about them that alter one's health. And this is something, this is a reason why formula will never be like breast milk unless they start to engineer all these different factors, all these cellular factors that are in breast milk. 

So what's important to understand simply is that babies are immature when they are born. And the immaturity is in all areas. It's neurologic, it's musculoskeletal, it's gut, it's kidney, it's brain, it's every organ system, and breast milk is designed to complement that immaturity. And the best, probably the most obvious way that we see that is that breastfed babies are much less likely to become infected the first three months as compared to a formula-fed baby because there are all kinds of antibodies in breast milk. But there's so much more in breast milk that's important for gut maturity, for brain and retinal maturity, for prevention of infection, for immunomodulation, which we'll talk a little bit more about, for emotional growth. So all of these are important to complement. And the analogy I make is let's say that you decide that you're going to just not eat food anymore but just go on a strict diet of something like Boost or Ensure. You know that if you eat your five fruits and vegetables a day you're getting antioxidants, you're getting vitamins and minerals that are natural. With enzymes, you're getting anticancer factors. You're getting so much more than just your vitamins and your protein, and your carbs, and your fats. 

And so the difference is that these nutrients do a lot more than just provide nutrition. So all of these factors, like oligosaccharides, glycoprotein, human milk fats, antibodies, all of these not only, again, provide nutrition, but they're actually actively, they all have several, several roles in how they actually fight pathogens, modulate the immune system so that babies are not as likely to react and have bad asthma or allergies or dermatitis. They're going to grow differently too, and I'll show you a slide later about the difference in growth in babies who are breastfed versus formula-fed. So is breastfeeding just a benefit or can we also say that because breastfeeding is beneficial, formula is risky? And I think this is one of the biggest barriers that we have to increasing breastfeeding rates in this country is that we are always talking about breastfeeding benefits. And breastfeeding, if we just talk about breastfeeding benefits, we're making this assumption that formula is good. Formula is fine, formula is good, but breastfeeding is better. But we can change this conversation by saying, look, if you don't have these benefits from breastfeeding, you're taking a risk with formula-feeding. And that's really the message that has to come out. And I realize that that can play a role with guilt issues and fretting by parents who are not able to breastfeed. But it's informed consent. 

And as a physician I'm always telling my patients about the risk of smoking and the risk of having a trampoline in their backyard, the risk of not wearing a seat belt. They need to understand the risk of using formula. It's only good medicine to make sure that people understand that. So what's interesting is that this concept sometimes is difficult to grasp. There was a survey in 2003 where US residents were asked, is infant formula as good as breast milk? And 74% of residents said no, they didn't agree. However, when the same group of people were asked, is feeding a baby formula instead of breast milk, does that increase the chance that the baby will get sick? Only 24% agreed with that. So, again, many people don't understand that concept that flipping the risks of breastfeeding can translate into the, I'm sorry the benefits of breastfeeding can translate into the risk of formula. So let's talk a little bit about risks. The maternal risks of artificial feeding, there are several because breastfeeding is so important for women's health, as it is for the baby's health. So probably the most astounding thing is the increased rate of breast cancer among women who don't breastfeed. 

And we find that for every year that a woman breastfeeds, she reduces her risk of breast cancer by 4.3%. So if she has three kids, each is nursed for a couple years, she is reducing her risk of breast cancer by 25%. Women who have children and decide not to breastfeed have a 1.5-fold increased risk of ovarian cancer. And they also have a higher risk of high blood pressure, high cholesterol, diabetes, and a greater risk of heart attacks. There's also a higher risk of something called a metabolic syndrome which is kind of a pre-diabetic pattern with increased waist to hip ratio, higher blood pressure, higher triglycerides, and a higher blood sugar. For infants we see a higher risk of just any sort of infection in the first year of life. Particularly what's oftentimes measured are ear infections. We see two times the risk of ear infections and 3.6 times increased of hospitalizations for lower respiratory infections such as RSV, pneumonias, or bad asthma. There's actually an increased risk of dying for an infant who is never breastfed, 1.3 times increased risk. And what's been interesting is more research coming out showing the increased risk of sudden infant death syndrome or sudden unexplained infant death syndrome. 

About two times the risk. We see a marked increased risk of obesity in children. And we'll talk more about that in a little bit because that's one of the main drives for really increasing breastfeeding rates by a number of organizations. We see a higher IQ in the first decade in infants who are breastfed and that's controlling for things like maternal education status and smoking, and all sorts of other issues. And we know that babies who are breastfed, babies who are formula fed have a higher risk of neglect and abandonment, there's just not the bonding. I wanted to show this slide because I think this has to do with the obesity issue. And again we'll talk more about that. But there are two growth curves going on here. And a growth curve is basically how an infant grows. The World Health Organization decided that they were going to measure how infants really grow based on making sure that the infants are fed in a very ideal way. 

Meaning that they're breastfed for at least a year and they don't start solids until the babies are six months. And compared that to data that we've been using in the United States for a long time which is data for the Center for Disease Control on how infants grow. And that data is a mixture of growth data like from the 1970s, 1980s, even the 1960s, and most of those infants were not breastfed. And so what's interesting is that in the first six months you can see that the dotted line is oftentimes under the solid line which means that the breastfed kids actually weigh more than the formula-fed kids. But when you get past six months and you get towards two years, you can see this huge difference. You can see how much thinner the solid line is, the solid line weighs less than the dotted line. So the breastfed kids weigh substantially less than the formula-fed kids. And this is something that, again, people are very interested in, especially as we see these incredibly high rates of childhood obesity. This seems to be something that could be changed in order to decrease that rate. So we also see disparity in health between formula-fed and exclusively breastfed babies with suboptimal immune regulation in babies who are formula-fed. 

They have more pathogenic bacteria in their gut, meaning they have more E. coli, which is more infection-producing, and less bifidobacteria, which is healthy gut flora. We see a smaller thymus gland and the thymus gland sits in your chest and it produces antibodies for infants. It's quite big in infants when they are born, and it gradually shrinks down as they become adults. And it's much smaller in formula-fed kids than in breastfed kids because we know that there are factors in breast milk that stimulate that thymus gland to continue to make antibodies and work on that immune system. We see more dermatitis. Many of you may know someone who has atopic dermatitis as a child, that itchy red rash that happens in the elbows and behind the knees. We see much more of that in babies who are formula-fed. And we see more type 1 diabetes and a higher risk of leukemia in babies who are formula-fed. So let's talk about what our goals are for breastfeeding in this country. Well, the healthy people movement is a movement by the federal government to establish goals where we want to take our country. 

And so they had the healthy people 2010 goals for all kinds of different things, but I'm just going to focus on breastfeeding goals. And so now we're beyond that and we're looking at the 2020 breastfeeding goals. And so the breastfeeding rates that we hope to see at birth, meaning a mother gives birth to a child and puts that baby to the breast, we're hoping that about 81.9% or 82% of moms will put their babies to the breast. We're hoping at three months that at least 46.2% of mothers are just nursing and not giving their babies anything else such as solids or formula. We hope at six months that 25.5% of moms are still just nursing, not giving any solids or any formula, and that at least 60% are at least breastfeeding to some degree. And we hope that at a year that 34% of moms are still nursing their babies. And here we are, just wanted to show how we compare to the rest of the country here in Wisconsin. We have about a 40% to 49% breastfeeding rate at six months. And you can see where we kind of sit with our other shades of similar color. And you can see out west and in Alaska they have much higher breastfeeding rates, more than 50% of babies are being nursed at six months. 

And then there are some areas in the south that are actually extremely low with breastfeeding. Less than 30% are being breastfed at six months. If we look at our report card, there are a number of different surveys, and, in fact, I just got an email today or yesterday about the report card for 2011 which I didn't open up yet for Wisconsin. But basically if you look at these rates, this is sort of, in 2009, hoping to meet those 2010 goals, which we pretty much did, we had a 75% initiation rate in Wisconsin and the goal was 75%. At six months we were hoping for 50%, we got to 48.6%. At 12 months we got to 25.9%, and we were hoping for 25%. So that's actually not too bad in Wisconsin, but we can do much better. The big issue is the disparity in breastfeeding rates in the United States and that's still very significant. You can see that non-Hispanic blacks have a much lower rate. Although, that has risen pretty quickly. 

And in fact, for a long time it was the increased rates of breastfeeding were largely among African Americans in this country. But they still lag significantly below the Hispanic population and Caucasian population. And I think what's most important for us to remember is that we have a very high infant mortality rate among African Americans in this particular state. Particularly in the southeast portion of our state. And if you look at these numbers, they're actually pretty astounding and they necessitate a call to action. If you look at the infant mortality rate in Kenosha County, I keep losing my cursor, among whites, we have about a 4.83 infants per thousand who have died. And these are rates averaging between 2004 and 2008. And for African Americans it's 15.14. In Milwaukee County, 6.56 Caucasian, 15.93 for African Americans. So about 16 per thousand black infants are dying in Milwaukee County each year. 

So if we look at Wisconsin overall and we look at the black to white ratio, black babies die at three times the rate as white babies do. And so the question is what does this have to do with breastfeeding? Well, in reality breastfeeding probably plays a pretty important role, not the main role because the number one cause of infant mortality among African Americans in this state is prematurity. So there's a lot of work that has to be done to make sure that these moms are getting to term with their babies. But once the babies are born we know that they have low breastfeeding rates, and some of these babies could survive if we saw higher breastfeeding rates. We would see lower sudden infant death syndrome, we'd see less neglect and abandonment. We'd see fewer hospitalizations for respiratory and GI illnesses, and we would see less in something called necrotizing enterocolitis, which is one of the main reasons why premature babies die. They die from gut inflammation from not having the right food, which is breast milk. So what are our barriers in this country and in this state to successful breastfeeding? Well, first of all, we still have a lot of difficulty with hospital practices. Many of the practices that we talked about back in the 1920s through the 1950s have persisted in this country. We still have a lack of staff education. 

We have staff values that trumped evidence. We have routines that interfere with breastfeeding. And we'll talk a little bit more about that, but basically the government recently reported on the quality of hospital practice to promote breastfeeding, and less than 5% of hospitals actually have ideal practices in terms of their guidelines and the routines throughout the day to encourage breastfeeding, to promote breastfeeding. We have medical interventions. Many physicians know nothing about breastfeeding. I teach students all the time. I teach residents who come from medical schools where they say they have received no lectures on breastfeeding. And so we have physicians out there who have never been trained in breastfeeding. And so they're making recommendations to women who perhaps have, let's say, high thyroid function telling them that they need to stop breastfeeding so they can receive radioactive iodine. Well, that's not necessary. 

There are other options there. So usually there are very few reasons why a woman medically needs to stop breastfeeding. So I tell my patients before someone tells you that, call me. Lack of social support is still very important in our country. We'll talk a little bit more about that. Lack of education within the lower socioeconomic groups. Employment is still a barrier and formula advertising forces persist. So the baby-friendly hospital initiative, I spoke a little bit about that before, but these are steps a hospital can take to reduce barriers to breastfeeding success. And these are things like having the baby room-in with mom in the hospital, making sure that babies are not automatically being given pacifiers or supplements, educating the staff and family about breastfeeding and making sure that moms have a place to go for really close follow-up after they leave the hospital to make sure things are going well. And so there's actually a certificate that hospitals can get to be established as baby-friendly. 

And there are 114 hospitals in this country that are certified, which is very, very few. And seven of those hospitals are actually in Wisconsin. So we have more than your average and especially for the size of our state, we're doing really well with our baby-friendly hospitals. But the medical system is not doing so well. We still have a lot of difficulty getting insurances to cover lactation consultations and covering pumps and other paraphernalia that's sometimes needed for moms to be successful with breastfeeding. We have little to no breastfeeding education training in schools of nursing, medicine, PA schools and other health professional schools. And physicians still unintentionally will thwart breastfeeding such as giving gift packs. And many physicians and hospitals have become sort of agents for these formula companies giving these gifts. And these are not gifts. These are plagues that we're giving to women giving them mixed messages that yes we want you to breastfeed but here, maybe you need that formula. 

There's also still a strong lack of social support. I think it's so engrained in us that we don't recognize that. Recently in last couple years Wisconsin finally passed a law that outlaws harassment of breastfeeding women which basically implies that breastfeeding is not normative because who would think that you need a law to tell someone to stop bothering a breastfeeding woman. And even with many states having those laws, it still happens on a regular basis. And family, even though family and friends may think that they are encouraging breastfeeding, sometimes they give really mixed messages so that if a woman's nursing and her friends or family say, hey, have a couple drinks. No, I'm nursing. Oh, can't you just pump and dump? Whereas, the woman really can have one drink and she can just sort of have that drink over the course of an hour, but why is drinking so important? I think the biggest thing is infant sleep. When people start talking about your baby's not sleeping through the night yet? And your baby's three months old? You shouldn't have to get up and do that, you shouldn't have to feed. And physicians are just as guilty about that. Your baby's six months? No your baby doesn't need to feed at six months, you need to just let that baby cry. 

And sleep is a work in progress that first year. If a woman allows a baby to sleep throughout the night at four to five months, she is going to lose her milk supply or diminish that greatly. She'll get her period back. Her prolactin levels will drop quite a bit. She's also at risk for infection. So it's normal for these babies to wake up in the middle of the night. They can nurse a baby, get back to sleep, still function the next day. That's why women in their 20s and 30s have babies and women in their 70s and 80s don't have babies. Just these messages that we give women really tell women well, gosh, maybe I'm doing something wrong, maybe the baby's winning and I'm not, and that actually has a real negative effect on breastfeeding. Employment is an issue. 

Unpaid maternity leaves. Women want to get back to work earlier because they need the income. Oftentimes there's not a good place for women to express their milk. And this is especially true for women who are on the move such as mail women and police officers. And so communities could do a better job in providing places for these women to pump or to meet their babies to nurse. In our Healthcare Recovery Act there actually is a clause in there and a law that companies need to provide the space and time for women to either nurse or pump their milk. And I think that many companies don't realize this and many women are not empowered to confront their Human Resources department to say, hey, you know, this is a law, you're supposed to help me with this. But on the other hand, it's a huge benefit to corporations to support breastfeeding. There is so much literature now and there's so much evidence that corporations that support breastfeeding women actually have a decreased rate of absenteeism because their babies are healthier so the women are missing less work. There's improved production because women are so proud that not only can they continue to provide breast milk for the babies but they're also productive at work and they're bringing home a paycheck. 

There's decreased healthcare expenditures not only for the women but also for the babies because they're healthier. And there's improved employee satisfaction. If a mother has had a baby and she can pump and she knows she may have a few more babies and she knows that the employer is going to make accommodations for her, she'll stick around. So that's quite important. And we save as a nation. One estimate is that there's $13 billion saved each year if 90% of infants exclusively breastfed for at least six months. I like The Lorax, that was one of my favorite books when my kids were little. "Unless someone like you cares a whole awful lot, nothing is going to get better, it's not." So let's talk a little, just for the last few minutes, what are we doing, where are the messages? Well, our new Surgeon General, Dr. Benjamin, put out a call to breastfeeding action in January, 2011. And her call was to remove obstacles to breastfeeding success and also to decrease disparities among races in breastfeeding. And she encourages mother-to-mother support in communities. 

She encourages hospitals to become designated as baby-friendly and that healthcare providers should become knowledgeable to properly care for breastfeeding couples, mothers and babies. Families should give mothers support and employers should provide paid maternity leave and high quality lactation support. And if anyone's interested, if you just Google the Surgeon General's call to action, you'll find this information. Just in June, the Institute of Medicine came out and said we need to be breastfeeding, we need to breastfeed babies in order to prevent obesity in children birth to five. And they strongly advocated that breastfeeding, that babies needed to be breastfed exclusively for six months, meaning no formula or solids, and at least for one year. They encouraged the baby-friendly hospital initiative again, just like Dr. Benjamin, and encourages the hospitals to enforce the World Health Organization code of marketing of breast milk substitutes, which I mentioned before, which is to not allow companies in this country to market directly to patients, or allow hospitals or doctors to give away free gift packs of formula. And just in the last couple days, the CDC puts out something called the morbidity and mortality review every week which is about a public health topic and their most recent public health topic this past week was about breastfeeding. And they also strongly recommended breastfeeding, stating that breastfeeding for nine months reduces a child's odds for becoming overweight by more than 30%. Although 75% of US women begin breastfeeding, only 31% are still breastfeeding at nine months. And suboptimal breastfeeding in the United States results in an estimated $2.2 billion annually in additional direct medical costs to our country. 

Hospital policies and practices to support breastfeeding are crucial for improving breastfeeding rates. However, as we talked a little bit about this before, only 3.5% of hospitals, so it's probably those 114 hospitals that are baby-friendly, actually have adequate policies in place to support women to make sure that they are leaving the hospital and breastfeeding successfully. Facilities that provide maternity care need to adopt these evidence-based practices, such as baby-friendly, to support breastfeeding. So this is also quite exciting. And the focus seems to be recognizing how breastfeeding is that right start in life to reduce obesity, but we know, at least I know, that obesity is just a huge issue for chronic disease. If we can reduce obesity, we can reduce the number of knee replacements, hip replacements, the amount of hypertension, diabetes, strokes, heart attacks, blood clots, atrial fibrillation. These are all the things I'm going to the hospital for on a regular basis to care for, and I would say at least 50% of what I'm caring for in the hospital now is obesity related. So this is a very important issue, and I'm so glad that our government has recognized this. So we've come a long way in the last 50 years. Not breastfeeding is associated with chronic illness in the United States. 

But breastfeeding is not normative yet. We still have a lot of barriers to breastfeeding success, and it's important to further research and discuss the risks of infant formula-feeding. My final slide: drink human milk. Thank you very much for having me. It was a pleasure to speak to you tonight about breastfeeding. [APPLAUSE]