JPediatr(RioJ).2017;93(2):107---110
www.jped.com.br
EDITORIAL
Breastfeeding
in
Brazil:
major
progress,
but
still
a
long
way
to
go
夽
,
夽夽
Amamentac
¸ão
no
Brasil:
grande
progresso,
porém
ainda
há
um
longo
caminho
pela
frente
Rafael
Pérez-Escamilla
YaleSchoolofPublicHealth,DepartmentofChronicDiseaseEpidemiology,NewHaven,UnitedStates
The innovative and well-designed retrospective study by Oliveiraetal.featuredinthisissuedocumentsencouraging seculartrends in breastfeedingdurationin RiodeJaneiro duringthe1960---2009period.Studyparticipantswerestaff fromauniversityinthecityofRiodeJaneirointerviewed between 1999 and 2012 who were asked to recall the breastfeeding duration of their first-born child.1 Median
breastfeeding duration among women giving birth in the 2000---2009periodwas12months,comparedwithsixmonths amongchildrenborn between1960and1969, fivemonths amongthoseborn between1970---1979, six monthsamong those born between 1980---1989 and eight months among those born between 1990 and 1999. Given howstrikingly similar these findings areto secular breastfeeding trends previously reported for Brazil as a whole using repeated cross-sectional survey data,2,3 this commentary
extrapo-latesimplicationsfromOliveira’setal.studytothewhole country.3DatafromnationalsurveysandOliveiraetal.1on
onehandpointtothemajorprogressinbreastfeeding out-comesin Brazil over thepast four decades,asillustrated bydramatic nationalimprovements, includinganincrease
夽
Pleasecitethisarticleas:Pérez-EscamillaR.Breastfeedingin
Brazil:majorprogress,butstillalongwaytogo.JPediatr(RioJ).
2017;93:107---10.
夽夽SeepaperbyOliveiraetal.inpages130---5.
E-mail:rafael.perez-escamilla@yale.edu
inbreastfeedingdurationfrom2.5monthsin 1975to11.3 months in 2008 and a 14-fold increase in the prevalence ofexclusive breastfeeding, which currently stands at 41% amonginfantsunder6monthsofage.Theseimprovements correspondnicelywith thetiming of the launch of major breastfeeding protection, promotion, and support efforts andinvestmentsinthecountry.2Ontheotherhand,these
studiesindicatethatthecountrystillhasalongwaytogo tomeettheWorldHealthOrganization(WHO) recommenda-tionsthatcallforexclusivebreastfeedingforsixmonthsand totaldurationofanybreastfeedingofatleasttwoyears.
Aninnovative contributionfromOliveira’setal.article isthat it documents thatmodifiable risk factors for short breastfeedingdurations are not static,asthey doindeed changeovertime.Forexamplewhereasinthe1970s,higher levelsof incomewereassociatedwithshorter breastfeed-ingduration,bythe2000stheoppositebecametrue(i.e., lowermaternaleducationbecametheriskfactorfor short breastfeedingduration).Becauseshiftsinriskfactor direc-tionalitydonothappenovernight,itisimportanttoanalyze seculartrends in breastfeeding outcomeswithindifferent socio-economic and demographic groups.4,5 For example,
whereasbreastfeedingratesinMexicocontinuetobehigher inruralvs.urbanareas,lowervs.higherincomewomen,and indigenousvs.non-indigenouscommunities,itisclearthat therate of decline is significantly faster amongthe most socio-economicallyvulnerable,toapointwhereinthenear futurethe most vulnerablegroups willbe those withthe
http://dx.doi.org/10.1016/j.jped.2016.10.003
0021-7557/©2016SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND
108 Pérez-EscamillaR
worst breastfeeding outcomes, as it is now happening in Brazil.4,5Thisinequityisveryimportanttoaddress,asitcan
profoundlyaffectthehealthandwellbeingofthosealready leftbehind.Asaresult,akeyquestionthatpediatriciansand otherkeystakeholdersmayhaveisthis:Whatcanbedoneto protectbreastfeedingbehaviorsamongthemostvulnerable? Recent evidence strongly indicates that the answer to this question is quite complex, as multiple sectors and initiativesneed toworkin coordinationat multiple levels --- fromlocaltonational---tofurtherprotect,promote,and supporttherightofwomentobreastfeedtheirchildrenas longastheywant.6Actionsneededincludeimprovedpaid
parentalleavepolicies,strongerenforcementof theWHO InternationalCodeofMarketingofBreast-milkSubstitutes, hospitalandcommunitybasedprograms,andmanagement informationsystems that offer high qualitybreastfeeding supportserviceswithadequatecoverageacrossthe contin-uumofcare, behaviorchangecommunicationscampaigns, andfamilysupportincludingtheinvolvementoffathers.6,7
At the clinic andcommunity level, improved anticipa-toryguidanceduringpregnancyandlactationmanagement supportduring thefirstdaysandweeks afterbirthis cru-cialfor long-term breastfeeding success. Specific themes thatdeservefurtherconsiderationincludeperceived insuf-ficientmilk(PIM),8,9delayedonsetoflactation,10prelacteal
feeds(i.e.foods/liquidsofferedotherthanbreastmilk dur-ingthefirst72hoursafterbirth),11,12 thematernalobesity
epidemic,13andthehighprevalenceofC-sectionsinBrazil
andglobally.14
PIM has been documented as one of the main rea-sonsreportedbywomenfortheprematureinterruptionof breastfeeding.8,9,15AlthoughitwasinitiallythoughtthatPIM
wassimplyasociallyacceptableexcusegivenbywomenwho didnotwishtobreastfeedtheirinfantsandfeltashamedto admitso,thatexplanationisnowconsideredtobetoo sim-plisticandoften times inaccurate.PIMis indeed likelyto haveitsrootsinseriousbutpreventablelactationdifficulties establishingtheprocessoflactation.15Thecapacityofthe
mammaryglandtoproducebreastmilkevolvesthroughfour highly interconnectedstages: (1) preparationand further developmentof themammaryglandduringpregnancy,(2) birthtoonsetoflactation,i.e.,thebeginningofsecretion ofcopiousamountsofmilkfromthebreast,whichusually happens48---72hoursafterbirth,(3)establishmentof lacta-tion,and(4)maintenanceoflactation,thelattertwobased onamaternalsupply-infantdemandprocessdrivenbythe frequencyandintensityofsuckingbytheinfant.15 Ateach
ofthesestages,therearemodifiablerisk factorsthatcan preventhumanlactationfromsucceeding.
A highly sensitive human lactation period happens between birth andthe onset of lactation.If the onsetof lactationisdelayedbeyond72hours,maternalanxietyand stressincrease,whichinturncanfurtherpreventthe suc-cessful establishment of lactation as excessive levels of stresshormonesareveryharmfultothelactationprocess. Thisviciouscycleultimatelyleadstothepremature inter-ruptionofexclusivebreastfeedingandshortbreastfeeding durations independent of original maternal breastfeeding intentions.15 Modifiable risk factors for delayed onset of
lactation include maternal stress during labor and deliv-ery, C-sections, maternal obesity, and delaying the first
offeringof thebreasttothenewborn.15 Oncelactation is
established, factors that interfere withbreastfeeding on-demand (i.e., interfering with the natural development of the supply-demand human milk production process) ---includingpoorlatch,sorenipples,andbreastengorgement ---becomeriskfactorsfordiminishedmilkproduction.15
For-tunately,theserisk factorsarehighlypreventablethrough timelyandadequatelactationmanagementeducationand counseling.15
Toovercomethreatstobreastfeedingsuccess,aqualified workforceof health care professionaland paraprofession-als (i.e.,communityhealth workersor peercounselors) is requiredfortheofferingofhighqualityandtimely breast-feeding support services.6 Thus, pediatricians and other
health providers(includingobstetriciansand nurses)need tobeadequatelytrainedonnormalhumanlactation physi-ology,includingthefourphasesofhumanlactation,sudden changesininfanthungerandmilkproductionasaresultof infantgrowth spurts,thecorrectinterpretation ofhunger cues (as it cannot be assumed that crying is always an expressionofhungerbytheinfant),andtheneedtoaddress anyconcernsaboutinsufficientmilksupplythroughcareful monitoring of infant growth usingthe WHO growth refer-ence standards.15 Pediatricians should alsobe extensively
trainedonhowtoeffectivelyeducateandprovidesupport tobreastfeedingwomen. Theireffortscan benefitgreatly fromtheinclusionoflactationspecialistsandbreastfeeding peercounselorsintheirpractices.
Given the greatrelevance that the WHO Code hasfor protectingtherightsofwomentobreastfeediftheychoose to do so, schools of medicine and allied health profes-sions should considerincluding curriculum on conflicts of interest and their prevention, especially with regards to the interactions of health care professionals and health careinstitutionswithformulacompanyrepresentativesand products.6,15
Although little is still known about the actual cost of implementationofprogramsatscalethatincludeadequate workforcedevelopmentandotherkeyelementsthat breast-feeding programs need to succeed,16 we do know that
investing in improving breastfeeding outcomeshas a very high return on investment due to major benefits for the wellbeingofchildren, women,theenvironment,and soci-ety as a whole. Specifically, it has been estimated that improving exclusively breast feeding (EBF) rates can fos-ter national development by saving billions of dollars in preventable morbidities and premature deaths globally.17
This is why it is fully justified for breastfeeding protec-tion,promotion,andsupporttobecentraltotheattainment ofthe 2015---2030SustainableDevelopmentGoals.Indeed, Colcheroetal.18recentlyestimatedtheannualcostsof
BreastfeedinginBrazil 109
& Reinhold19 recentlyestimated thatif 90% offamiliesin
the United Stateswere to comply withthe recommenda-tionstobreastfeedexclusivelyforsixmonths,thecountry wouldsaveUS$13billionperyearandprevent911excess deaths,thevastmajoritybeinginfants.Theauthorsbased theircostestimatesonpreventionofnecrotizing enterocol-itis,otitismedia,gastroenteritis,hospitalizationfor lower respiratorytractinfections,atopicdermatitis,suddeninfant death syndrome, childhood asthma, childhood leukemia, type 1diabetes mellitus, andchildhood obesity.19 Bartick
et al.20 have also recently estimated the cost of
subop-timal breastfeeding in the United States with regards to suboptimal maternal health. Their analysis indicates that suboptimalbreastfeedingratesresultin4981excesscases ofbreastcancer,53,847casesofhypertension,and13,946 casesofmyocardial infarctioncomparedwithwomenwho optimallybreastfed.The resultingexcess morbidity trans-latesintoUS$17.4billioninannualcoststosocietyresulting fromprematuredeath, inadditiontoUS$ 733.7millionin directcosts,andUS$126.1millioninindirectillness-related costs.20
Inconclusion,theinnovativeandthought-provoking arti-cle by Oliveira et al.1 strongly supports previous findings
indicatingthatBrazilis amodelcountrywhenitcomesto investingineffectivebreastfeedingprotection,promotion, andsupportefforts,asillustratedbyaspectacularincrease in exclusive breastfeeding rates among infants under 6 monthsof agebetween 1975(3.1%)and 2008(41%).3 Itis
indeedquiteremarkablethatthishashappenedatatime whenalltheoddswereagainstthisoutcomeasaresultof accelerated urbanization, andespecially given the higher participationofwomeninthelaborforce.5Thefindingsof
Oliveiraetal.alsoshowthatthereissubstantialroomfor improvement inBrazil withregardsto both breastfeeding exclusivityandduration ofany breastfeeding.Brazilmust paycloseattentiontothebreastfeedinginequitiesthathave developedover timeandalsotostrengtheningtheroleof healthcare professionalsinensuringthattheroadto suc-cess continuesfor all. Healthcare professionals including pediatricians,obstetricians,andnurseshaveacentralrole to play in further protecting, promoting, and supporting optimalbreastfeedingpracticesinBrazil.Itisessentialthat the new generation of health providers operate within a supportiveenvironmentthatisfreefromconflictsof inter-est, especiallywithregardstotheir interactions withthe infant formula industry and baby food companies within andoutside theclinic environment.Healthcare providers shouldstronglyadvocateforfurtherstrengtheningthehighly effective BabyFriendlyHospitalInitiative,7paying special
attention to better integrating and coordinating facility-andcommunity-based protection, promotion, andsupport efforts.7 The attainability of these recommendations will
dependtoalargeextentonthequalityofpre-serviceand in-servicebreastfeedingandhumanlactationtrainingreceived by Brazil’s futureand present health care providers. The use of mobile communicationstechnology, including two-waytextmessagingandsocialmedia,toimprovethereach andtimelinessofbreastfeedingsupportshouldalsobe con-sideredaspartofanationalprogramdesignedtomeetthe needsofwomenbenefitingfromthetechnological opportu-nitiesofthe21stcentury.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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