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12 Commercial Aspects of Breastfeeding: Products and Services

Published onJul 01, 2018
12 Commercial Aspects of Breastfeeding: Products and Services
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12 Commercial Aspects of Breastfeeding: Products and Services


Rebecca Mannel, MPH, IBCLC, FILCA

Expected Key Learning Outcomes

  • The importance of access to safe pumping facilities

  • Guidelines to ensure safe supplementation

  • Importance of donor milk

  • Importance of access to skilled breastfeeding support and who should provide it

12.1 Introduction

Any discussion of a public health topic has a commercial aspect to it and breastfeeding is no exception. Similar to childbirth and parenting, the natural, biologically normal process of breastfeeding has been over-commercialised. Healthcare providers who focus specifically on providing lactation care recognise that for most breastfeeding couplets, all that is needed is a baby and lactating breast(s). Yet, any visit to a retail store or Internet search for maternity/baby products will reveal an astonishing array of items that the breastfeeding mother “needs”. The audience for these markets usually is the middle-to-upper socio-economic segments of a society with excess income to spare for non-essentials. Lower socio-economic families are less likely to spend scarce resources on breastfeeding products and this lack of ability to purchase “needed” items may influence the mother’s perception of how successful she will be at breastfeeding [1], [2].

A proportion of breastfeeding couplets encounter difficulties requiring professional lactation care and specialty products to help overcome those issues. In these situations, it is more likely that the higher-income mother can access services and products to help her sustain breastfeeding, while the lower-income mother cannot, leading to premature weaning. Global statistics on breastfeeding initiation and duration highlight the disparity in breastfeeding rates in many countries [3]. In some countries, this disparity is even reflected in the hospital of delivery. Hospitals that deliver a higher percentage of upper-income families are more likely to implement best practices to establish successful breastfeeding, while hospitals that deliver a higher percentage of lower-income families are more likely to maintain outdated practices that decrease breastfeeding initiation and duration rates [4].

This chapter describes commonly used products (breastfeeding and human milk products) and commonly available breastfeeding services (lactation service providers). Mothers may purchase accessories or items they perceive helpful for breastfeeding or they may be provided a breastfeeding tool needed as part of a plan of care to resolve a problem. Breastfeeding infants may need some type of human milk product, in addition to or in lieu of their own mothers’ milk. Virtually every breastfeeding mother and child benefits from the services of a healthcare provider specifically trained to provide some level of lactation care, ranging from the preventive/educational level of care to the more complex/clinical level of care. Policymakers and healthcare authorities can benefit from a clear understanding of essential products and services, and barriers to their access.

12.2 Breastfeeding Products

12.2.1 Milk Expression

One of the most frequently purchased breastfeeding products is some type of mechanical breast pump used for milk expression [5]. Breast pumps can be very useful for mothers who need to express milk on a regular basis, while manual/hand expression is a more effective and efficient method for many women worldwide. Globally, 54% of mothers are in the workforce while in the United States (USA) 64% of mothers of infants return to work, thus necessitating daily, regular milk expression to maintain milk production and provide milk for their infants [6], [7] (see Chapter 9). Mothers who give birth to a preterm or critically ill infant that cannot yet feed at the breast must initiate and maintain lactation through some form of milk expression (see Chapter 16). Preterm birth rates range from 5% to 18%, with a global average of 11% [8]. These vulnerable infants are more likely to survive and thrive if fed their own mothers’ milk. Increasing frequency of milk expression is also recommended for mothers who have experienced a decrease in milk production for various reasons (e.g., difficulty latching the newborn, early formula supplementation).

Manual or hand expression is an option for most mothers that does not require special equipment, electricity or battery power, and is free. For a mother who is separated from her baby, use of a double electric multi-user breast pump is often considered an absolute necessity for initiating and maintaining milk production in the early weeks. However, newer evidence indicates that even the most expensive, quality pumps are less effective at milk removal than hand expression [9], [10], [11]. Combining hand expression with use of an electric breast pump is very effective and can reduce the time it takes a mother to express her milk [10]. Specifically, use of a breast pump may be more comfortable for a mother who has severely engorged breasts or some type of physical impairment, and may be psychologically more acceptable to a mother with a history of sexual abuse [12], [13].

Mechanical breast pumps range from low-cost manual pumps for occasional milk expression to various types of electric pumps. More expensive electric breast pumps will have more automated features, such as automatic cycling of vacuum and speed. Lower cost electric pumps require manual cycling of vacuum and speed and can cause nipple damage if the vacuum is not released appropriately. Any breast pump can cause pain and trauma if not used correctly. When mothers are not instructed in effective milk expression, they may inadvertently cause pain or damage by pumping for too long or with too high a vacuum, neither of which will help them remove more milk [14]. The section of the pump kit that fits over the nipple area (the pump flange) must be fit to the individual mother. A flange that is too tight can cause nipple pain and damage, and obstruct the flow of milk, reducing the volume removed and eventually reducing overall milk production [15].

Access to quality, safe breast pumps is a public health and economic issue. Some countries define breast pumps as consumer goods rather than medical devices [16]. Most countries do not regulate the quality of breast pumps though some may monitor and report safety concerns [17]. Upper socio-economic families are more likely to afford the higher quality breast pumps, while lower socioeconomic families may purchase a lower cost pump only to find that it does not function effectively, or worse, causes breast/nipple trauma. Resource-poor countries may not have quality breast pumps or access to replacement parts, different size pump flanges, batteries, or consistent electricity. Ultimately, if pumping is painful, too time consuming at work, or leads to a drop in maternal milk production, it is easier for many mothers to discontinue breastfeeding and turn to the ever present, highly marketed formula products.

Mothers who deliver in a Baby-Friendly designated hospital are more likely to receive timely breastfeeding support from trained hospital staff, including instruction in hand expression. They must also be taught early effective milk expression if separated from their newborn for medical reasons [3]. A mother who gives birth in a hospital that is not Baby-Friendly designated is less likely to receive either skilled breastfeeding support or instruction in milk expression. If the hospital has breast pumps, staff is less likely to be trained in their use, and mothers are more likely to receive formula for routine supplementation of their newborns and leave the hospital with breastfeeding problems.

12.2.2 Alternative Methods of Feeding

When infants are not nursed directly at breast, they must be fed milk by some other means. Once breastfeeding and milk production are well established, the breastfed baby can typically be fed by bottle in the absence of the mother (e.g., when she is at work). In the early postpartum period, when lactation is critically dependent on effective infant latch and milk transfer, introduction of bottle-feeding or use of artificial nipples (bottle nipples or pacifiers) can cause many breastfeeding difficulties [18]. Mothers are encouraged to breastfeed exclusively and to avoid supplementation with formula or use of artificial nipples [19], [20]. Feeding of formula to the newborn decreases the frequency of breastfeeding and stimulation of milk production, in addition to increasing risk of acute and chronic diseases in the infant. Use of artificial nipples or pacifiers also decreases suckling time at breast and can lead to painful breastfeeding due to changes in how the infant attaches at breast.

The Baby-Friendly Hospital Initiative guidelines require informed decision-making by the mother before a breastfed baby is supplemented with any type of milk or fed by any other method. If there is a medical necessity to supplement, the baby should be fed by an alternative method, not bottle, and the mother should be instructed immediately in milk expression [3]. Research on alternative methods of oral feeding that support continued breastfeeding is limited. Commonly described methods include feeding by cup or paladai, with a tube supplementing device at breast or by finger, or by dropper or spoon (▶Fig. 12.1, ▶Fig. 12.2). Babies who are completely unable to feed by mouth are likely to be fed by intra-gastric tube, an invasive method which is not discussed here. The largest body of evidence supports cup feeding, which is simple, non-invasive, easy to learn, easy to clean, and low cost in that it requires only a small cup, such as the 30 ml plastic medicine cups that are widely available in many hospitals. In India, the paladai is a small cup with a spout that channels the milk so the baby can sip easily

The Academy of Breastfeeding Medicine’s Model Hospital Policy recommends supplementation by cup when there is a medical reason to supplement a breastfed newborn [21]. Their 2009 protocol #3 on Supplementary Feedings provides a concise summary of the risks and benefits of various methods, ultimately stating that ‘an optimal supplemental feeding device has not yet been identified’ [22].

▶Fig. 12.1

Cup feeding an infant.

▶Fig. 12.2

Feeding with a paladai.

A tube-supplementing device delivers the supplement at breast for the infant that can latch and suckle to some degree. These devices are expensive, not readily available, can be complex to use, and are difficult to clean. Certain highly motivated mothers may prefer using a tube supplementer at breast to enable them to directly breastfeed their babies, e.g., adoptive mothers or mothers who are physically unable to produce milk [23]. Finger feeding is use of a tube supplementer attached to the caregiver’s finger that the infant sucks on. Research on feeding with any kind of tube supplementer is very limited [22].

12.2.3 Breastfeeding Challenges

Nipple shields were initially developed for use by mothers with inverted or retracted nipples to help the infant grasp the breast and maintain their latch during feeding. Most current models are made of very thin silicone and designed to be placed directly over the mother’s nipple (▶Fig. 12.3). If the infant can attain a deep, areolar latch, the mother’s nipple and breast tissue will be drawn well into the infant’s mouth and rhythmically compressed during suckling. Nipple shields can be very helpful in certain circumstances and have been over-utilised in many cases [24], [25]. The strongest evidence for their use is with preterm babies in the neonatal intensive care unit (NICU) [26], yet they may often be given to mothers in the hospital who have no nipple anomaly but have a baby who is not consistently latching or is sleepy in the first few hours of life. Nipple shields have been helpful in cases where the infant has sucked on artificial bottle nipples or pacifiers and will no longer maintain a latch at breast. Nipple shields may also help sustain direct breastfeeding in cases of severe nipple trauma.

Early use of nipple shields should be accompanied by regular milk expression to protect maternal milk supply [27]. Nipple shields come in different sizes, and must be fit to the mother’s nipple and baby’s oral cavity. Early use of nipple shields can also lead to a baby who will not nurse without it, leaving the mother in a stressful situation if the nipple shield is lost. Nipple shields are easily purchased in many retail outlets, and may be obtained by mothers attempting to resolve a breastfeeding problem without professional help. Improper use of a nipple shield may compromise maternal milk production and lead to an ineffective infant latch. Use of a nipple shield requires follow up with an International Board Certified Lactation Consultant (IBCLC) to monitor infant intake, weight gain, and maternal milk production, and assess if the original problem has been resolved. Mothers need help in weaning their babies from the nipple shield and teaching them to latch without one [27].

Nipple everters are devices developed more recently to aid in correcting inverted nipples without having to utilise a nipple shield. They are designed to apply concentrated suction directly to the nipple immediately prior to latching the baby. Nipple everters are usually some type of syringe or bulb-syringe device, and there is no research on their efficacy. In lieu of evidence-based options, some lactation consultants recommend use of a mechanical breast pump to help draw the nipple out and protect the milk supply.

Gel dressings are glycerine or water-based gel pads that are placed over the nipple area to promote moist wound healing in cases of moderateto-severe nipple trauma. Gel dressings are oxygen permeable, speed tissue healing, protect damaged skin from further trauma, and reduce nipple pain. While gel pads can be costly, one set (pair) can be reused for several days, which in many cases is the length of time they are needed. Gel pads should not be used when there is a known wound infection. They also have the potential to contribute to growth of yeast or bacteria if not used appropriately. Research on their efficacy is conflicting [28].

▶Fig. 12.3

Nipple shields. (Family Larsson-Rosenquist Foundation, Switzerland)

Pacifiers or dummies are a ubiquitous baby product worldwide. While designed for use by any infant caregiver, they are often considered a necessity for breastfeeding mothers due to the common misconception that babies who nurse frequently are “using her as a pacifier”. Cultures that value early independence of children are more likely to perceive frequent nursing as a needy, demanding baby instead of normal physiological breastfeeding and mother-child bonding [29], [30]. Pacifiers can lead to breastfeeding problems if they are utilised because of an underlying breastfeeding problem [31], [32]. Early pacifier use before establishment of effective latch and maternal milk production can lead to missed feedings at breast, decreased milk production, decreased infant intake, difficulty latching, and increased nipple pain [33], [34]. Long-term use of pacifiers can increase risk of ear infections, change the shape of the oral cavity structure, and cause shorter breastfeeding duration [35].

Pacifiers can be useful for infants having painful procedures, who are not able to feed orally to help them associate sucking with milk intake, and who need calming when their mother is not immediately available. Pacifiers have also been recommended once breastfeeding is well-established, when infants are laid down to sleep to reduce risk of sudden unexpected infant death [36], [18]. The Baby-Friendly Hospital Initiative requires hospitals to educate mothers on risks of pacifier use and eliminate their routine use in newborns.

Nursing bras, nursing clothing, baby wraps/ slings, and breastfeeding pillows are other commonly available products marketed heavily to breastfeeding mothers. These types of products can be nice to have for the mother that can afford them, but are not necessary for successful breastfeeding. Mothers do not need special clothing for breastfeeding, although a well-fitting bra that she can comfortably nurse in is helpful. Baby wraps for carrying the baby and allowing easy breastfeeding when out in public or managing other responsibilities are very useful. They keep the baby close, calm, and can be easily and inexpensively made with a large piece of cloth. In Bolivia and other Andean countries, the colourful aguayos are standard equipment for mothers with babies and young children (▶Fig. 12.4). Specialty breastfeeding pillows that wrap around the mother and support the baby during feedings are popular and may facilitate easier breastfeeding for a first-time mother or a mother with twins. Some type of pillow support can be achieved with common household items, such as bed pillows or rolled up blankets.

▶Fig. 12.4

Bolivian aguayo.

12.3 Human Milk Products

12.3.1 Banked Donor Milk

The practice of giving a baby milk from another mother has existed throughout human history. The Code of Hammurabi from 2250 BC is the first known written information on breastfeeding and it described the qualities of a good wet nurse [37]. In past centuries, breastfeeding and human milk were commodities that could be sold by low-income women through the practice of wet nursing [38]. The concept of milk banking developed in more recent history when artificial formula milk products began to compete with breastfeeding and it became difficult to locate wet nurses when needed. The first milk bank opened in Vienna, Austria in 1909, while the first milk bank prototype in the US was opened by a physician in Boston, Massachusetts in 1910 [39]. The Boston Directory for Wet Nurses intended to address the sudden decline in breastfeeding rates by making it easier and more respectable to find a wet nurse. It gave ‘destitute girls with babies an opportunity to earn an honest living’ and sold expressed milk that had been purchased from the wet nurses [40]. The development of refrigeration allowed for safer storage of expressed milk in milk banks and hospitals, enabling more low-income mothers to have honourable employment by selling their milk to a milk bank while they cared for their own child at home.

In Australia, milk banking began on an informal volunteer basis in the 1970s, with some hospitals partnering with the Nursing Mothers Association of Australia to recruit members to donate expressed milk for certain sick infants [41]. The Human Milk Banking Association of North America (HMBANA) was formed in 1985 to establish standards for milk banks in Canada, Mexico, and the US, and it also promoted milk donation instead of payment for milk. As with most milk banks prior to the identification of the HIV virus, the milk was not pasteurised, although donor mothers were screened for infectious diseases. It is now common practice throughout the non-profit milk banking consortium to require milk donation in an effort to reduce the risk that a mother would be financially tempted to sell her milk instead of providing for her own baby or to adulterate the milk to increase the volume provided. Most banked donor milk is pasteurised by an evidence-based method specific for human milk known as Holder pasteurisation [42], [39]. Though active research is ongoing, current processes have a strong safety record. HMBANA reports no proven adverse outcome in infants receiving milk from a HMBANA milk bank in thirty years of operation.

A full description of milk banking is covered in Chapter 14. This section describes the increased demand for safe, pasteurised donor milk for use in hospitals and the current controversy between non-profit and for-profit milk banking. Milk banks have increased greatly in number as the evidence in support of donor milk feedings for preterm and critically ill infants has grown [43], [44]. There are milk banks in at least 37 countries worldwide with Brazil the leader in milk bank development at 215 banks [45]. Brazil cites its extensive milk bank network as instrumental in the dramatic decrease of infant mortality by 73% in less than 30 years [46]. The Brazilian model demonstrates the powerful impact of federal funding to build an adequate nationwide milk bank infrastructure rapidly (▶Fig. 12.5). HMBANA, with no federal funding, reports an increase in distribution of pasteurised donor milk from 1.4 million ounces in 2008 to 3.7 million ounces in 2014. This volume is a significant increase yet still well below the 2011 estimate of 9 million ounces needed just to serve the preterm infants born weighing less than 1500 grams in the US [39], [44].

The vast majority of milk banks around the world are non-profits with similar standards for donor screening and the processing and distribution of donated milk. The International Milk Banking Initiative is an alliance of many of these milk banks formed to ‘promote safe, ethical and accountable human milk banking around the globe’ [45]. Non-profit milk banks in many countries belong to a national organisation that provides standards for best practice, such as the European Milk Banking Association, and promote international cooperation on research and milk bank processes, such as joint statements of EMBA and HMBANA [47].

▶Fig. 12.5

Brazilian preterm Infant in kangaroo care and receiving breast milk.

While healthy breastfeeding mothers freely donate their milk, milk banks charge a service fee for any pasteurised milk dispensed to cover some of the costs of screening, testing, and processing. This practice is similar to the blood banking industry. Many milk banks also rely on government funding, grants, and financial donations to support their operations. Target populations served with pasteurised donor milk primarily include preterm or critically ill hospitalised infants. Some milk banks may provide milk on an outpatient basis to babies in the community with a medical need, while the lowest priority for most banks, due to current supply, are healthy term infants whose own mother cannot produce enough milk. Ideally all babies that do not have access to their own mothers’ milk would be provided donor milk as the next best option. Worldwide current milk banking capacity needs to be greatly expanded and the Brazilian model is worth exploring, especially for resource-poor countries.

In recognition of the need for human milk products, lack of regulation in some countries, and the potential for financial profit has led to development of various for-profit models of milk banking. Prolacta Bioscience is a for-profit company based in the US which primarily produces human milk-based fortifier, designed to be added to own mother’s milk or donor milk for very low birth weight babies in NICUs. Producing human milk-based fortifier requires about ten times the volume of donated milk to be concentrated into fortifier. Prolacta partners with other organisations to recruit donor mothers and offers US$1 per ounce of donated milk up to 300 ounces per donor mother [48]. All milk is sent to Prolacta’s main facility in California for processing and dispensing. Partner organisations receive priority in the use of Prolacta products. Prolacta has sponsored and published its own research as well as some clinical trials that have been published in peer-reviewed medical journals [49].

Two other companies are Medolac and the International Milk Bank [50], [51]. Medolac lists itself as a “public benefit corporation”, which in the US is defined as a for-profit corporation that can include some type of public benefit in its charter in addition to maximising profit. Medolac produces a donor-milk product that it advertises as ‘commercially sterile’ and stable at room temperature for three years but has not been independently tested for composition or health outcomes. The International Milk Bank (IMB) is in development and describes itself as a privately held company that will also produce ‘commercially sterile’ milk. It is partnered with an online-only organisation, Only The Breast, that provides an Internet platform for mothers to sell their breast milk to anyone in the country, for adult or child use (See Chapter 12.3.4).

The commercialisation of human milk raises concerns over allocation of a uniquely scarce and vulnerable resource. Human milk donation, as opposed to blood or organ donation, is unique in that the giving or selling of a mother’s milk potentially impacts not just a single donor but the mother and her infant. The non-profit milk banks have a long history of checking the health status of both the donor mother and her baby as part of their donor screening [39]. Most non-profit milk banks worldwide belong to a national or regional network of banks that support each other and ensure the supply of pasteurised donor milk is available to the most critically ill infants, regardless of family income. Many HMBANA milk banks also provide charity care in their communities.

In the US, the Food and Drug Administration (FDA) does not currently regulate human milk banks, although they have begun reviewing HMBANA milk banks through onsite inspections. Medolac and IMB both state they follow the FDA’s pasteurised milk ordinance, which applies to the dairy industry. Prolacta states that it is registered with the FDA as a food manufacturer and that its products are regulated as infant formulas.

12.3.2 Other Milk Products

The most common additional milk product is human milk fortifier. This product is typically used to provide additional nutrients to expressed human milk for the very low birth weight infant, weighing less than 1,500g. With modern neonatal care increasing the survival rate of these tiny infants, research on optimal nutrition for a baby born months too early is ongoing. Human milk feedings, particularly the baby’s own mother’s milk, are the current standard of care in NICUs worldwide [52]. Fortification for very low birth weight infants is also commonly recommended to address the gap in protein, calcium, and phosphorus. While optimum growth rates may still be debatable (weight versus length), fortification is strongly recommended [43]. Until the recent development of the first human milk-based fortifier by Prolacta, the only fortifiers available were made by the formula industry from bovine-based products. These products are suspected of contributing to the development of necrotising enterocolitis even when the infant was otherwise exclusively fed human milk. For more detailed information on fortifiers in the NICU, see Chapter 13.

Due to the very high cost of human milk-based fortifier, both in monetary terms and usage of human milk resources, some neonatologists have proposed individualised fortification of human milk. Some research has looked at separate fortification with calcium and phosphorus instead of a packaged ‘one size fits all’ approach. Other research has looked at protein supplementation using hydrolysed bovine-based proteins. Individualising an infant’s feedings would also benefit from pre-supplementation analysis of the mother’s milk to increase accuracy of nutritional fortification. Most NICUs are not currently able to analyse human milk, although some have partnered with local milk banks to explore this option [53].

12.3.3 Other Human Milk Uses

Colostrum capsules and powders made from bovine products have been available for over 20 years and are advertised as potent immune system boosters. Social media and the Internet have now allowed the promotion of human colostrum and breast milk sold by individuals. Cancer patients have tried regular doses of donated human milk as a cancer treatment and to relieve the side effects of chemotherapy. While there is laboratory research indicating certain proteins in human milk can destroy cancer cells [54], [55], there is no published research that adult consumption can treat or prevent cancer. Human milk has also been touted as a nutritional therapy for transplant patients, and as a topical treatment for burn patients and acute infections of various types. Human milk is advertised by some sellers as 100% organic, dairy free, nicotine free, gluten free, etc. A newer trend is the purchase of human milk at even higher prices by athletes to increase stamina and boost energy [56]. There is no evidence to date to support any benefit of human milk for an adult diet or as a therapeutic topical treatment. Women selling their milk for unproven benefit raise concerns that some may sell their milk to generate income rather than feed it to their own baby, or that this action will discourage them from donating to a milk bank to help preterm infants.

12.3.4 Milk From Other Mothers

A more common historical practice has been the informal provision of human milk to family members or close friends or neighbours in one’s community. This practice is now known as informal milk sharing to distinguish it from donating milk to a milk bank. Sharing or giving milk to someone that is known personally reduces the risk of receiving milk that is contaminated or adulterated in some way, or that the mother uses tobacco or other substances that could be transmitted through her milk. Giving milk or wet nursing historically was most often due to maternal illness or death, leaving the family with no safe alternatives for feeding the newborn.

In more modern times, the strong public health messaging about the importance of breast milk and breastfeeding has led to an increase in percentage of women wanting to breastfeed but not succeeding due to the multiple societal barriers that now exist (e.g., hospital practices, workplace obstacles, lack of maternity leave). In many countries, the vast majority of women initiate breastfeeding but less than half are doing any breastfeeding by six months and certainly not the recommended exclusive breastfeeding for the first six months [57], [58]. Mothers who want their babies to have the best nutrition and are unable to provide it themselves now turn to friends and family members for help in providing milk. EMBA and HMBANA have issued a joint statement concerning the topic of informal milk sharing (available online at www.europeanmilkbanking.com). When mothers and their babies are known to each other, the concept of beneficence is more likely to apply and the gift of milk is unlikely to carry any serious risk for the recipient baby, unless the mothers live in a region where breastfeeding with HIV is not contraindicated [39], [59].

12.3.5 Internet Purchasing of Milk

The new development in milk “sharing” is the donating or selling of human milk via social media and the Internet. Several websites and Facebook sites now help connect mothers with surplus milk to mothers or others seeking milk to feed an infant or for other uses as mentioned previously. This practice is currently not regulated and, similar to the sale of prescription medications online, would be difficult to do so. Some recent studies examining the content of human milk purchased over the Internet indicate possible bacterial contamination, lack of appropriate storage of the milk during transport, and adulteration with bovine products. Keim et al. found that 10% of 102 samples of milk purchased over the Internet contained at least 10% cow’s milk, indicating a cow-milk product was purposefully added [60]. The same authors analysed the milk for bacterial contamination and found the majority of samples had significant bacterial growth when compared to unpasteurised milk donated by screened donors to a non-profit milk bank [61]. They concluded that mothers want to breastfeed due to the tremendous health advantages and have limited options when they encounter breastfeeding difficulties or struggle with milk supply issues. More access to lactation support is needed to help women successfully feed their own babies.

12.4 Lactation Service Providers

12.4.1 International Board Certified Lactation Consultants

The International Board of Lactation Consultant Examiners (IBLCE) is an independent, non-profit organisation whose mission is to establish the ‘highest standards in lactation and breastfeeding care worldwide’, and to certify ‘individuals who meet these standards’ (www.iblce.org [62]). IBLCE is accredited through the National Commission for Certifying Agencies of the Institute for Credentialing Excellence and has maintained that designation as a high quality certification program for over 30 years. IBLCE administers the global certification program for International Board Certified Lactation Consultants (IBCLCs), which currently includes over 28,000 IBCLCs in 102 countries.

IBCLCs are skilled healthcare professionals trained in all aspects of breastfeeding and lactation care. Candidates must meet the eligibility requirements of college-level health science courses, 90 hours of lactation-specific education, clinical practice hours, and pass IBLCE’s rigorous, independent exam (http://iblce.org/certify/eligibilitycriteria/). The psychometrically evaluated exam is administered worldwide and translated into 15– 17 languages from year to year. IBCLCs must maintain certification through a recertification process every five years including re-examination every ten years. Recertification every five years through continuing education encourages continued professional development and lifelong learning. Recertification by exam every ten years assesses current knowledge and cognitive skills and is based on a global practice analysis that captures new developments in the profession.

IBCLCs practice within the Scope of Practice for IBCLCs, must comply with the Code of Professional Conduct for IBCLCs and are subject to IBLCE’s disciplinary process. The Clinical Competencies for the Practice of IBCLCs provides a detailed description of the knowledge and expertise expected of currently certified IBCLCs, while the Standards of Practice published by the International Lactation Consultant Association provide guidance on a minimum expectation for clinical practice and professional behaviour (www.ilca.org). Current certification status of any IBCLC can be verified at IBLCE’s online registry at https://iblce.org/publicregistry/. While the IBCLC credential is recognised worldwide, IBCLCs must comply with any legal requirements in the country or jurisdiction in which they practice.

As the only healthcare team members independently certified as specialists in breastfeeding and lactation care, IBCLCs can provide preventive and diagnostic care, advocate for policy changes to support breastfeeding families, and educate healthcare professionals, policy makers, and families about the importance and management of breastfeeding. IBCLCs work in many healthcare settings, such as hospitals, birth centres, physicians’ offices, and public health clinics, and as home-visiting providers. IBCLCs are key members of not only the clinical healthcare team but the public health team. Access to IBCLC care is a public health issue and can increase breastfeeding initiation and duration rates. A 2013 study in Pediatrics showed that 60% of breastfeeding mothers in the US stopped breastfeeding before they intended to, many due to breastfeeding problems [1]. A 2006 study demonstrated a four-fold increase in breastfeeding at hospital discharge for low income women enrolled in the US Medicaid program when the hospitals employed IBCLCs [63]. Bonuck et al. found that mothers who spent an average of three hours total with an IBCLC were almost three times more likely to initiate breastfeeding and continue breastfeeding to three months [64]. An earlier study by these authors published in Pediatrics found that IBCLC contact also increased breastfeeding intensity and duration in low-income minority women [65]

12.4.2 Other Lactation Training and Certification

While IBCLCs are important healthcare team members, valuable breastfeeding support can and should be provided by others. Lactation and breastfeeding are impacted by many factors, including physiological, psychological, sociological, and cultural factors. At a minimum, any professional working in maternal-child health should have a basic knowledge of the importance of breastfeeding and how to access skilled support for families. Depending on their level of contact with families of breastfeeding infants or young children, health professionals need further training in basic breastfeeding management, particularly preventive care. The World Health Organization and UNICEF developed a 40-hour course in breastfeeding appropriate for any health professional [66]. The US Breastfeeding Committee identified core competencies in breastfeeding for all health professionals [67]. The Baby-Friendly Hospital Initiative requires a minimum of 20 hours of training, including skills verification for nurses working in maternal/newborn units [3].

There are numerous lactation courses worldwide, many readily available online. Courses that are at least 45 hours in length and meet quality standards established by the Lactation Education Approval and Accreditation Review Committee can be found at www.leaarc.org. Some courses may provide a title after attending or completing the course. These education courses are often proprietary and only confer a title if their specific course is completed such as Lactation Educator (LE), Certified Breastfeeding Educator (CBE), Certified Lactation Educator (CLE), or Certified Lactation Specialist (CLS). Some courses may offer attendees a test at the end, such as the CBE or the Certified Lactation Counselor (CLC). The CLC course was initially based on the WHO 40-hour course though it has been increased to 45 hours. Typically, there are no prerequisites for these types of courses and they are targeted to professionals and para-professionals.

In many countries, para-professionals or community health workers increase access to care and may provide basic breastfeeding support in the community or in the home setting. These health workers also need breastfeeding training. In India, every village selects a local woman who is trained as an Accredited Social Health Activist (ASHA) [68]. ASHAs provide education and information on a number of public health issues such as hygiene, nutrition, healthy living, and sanitation. ASHAs receive training in reproductive issues including safe delivery and breastfeeding, and may be the first contact for women and children with limited access to healthcare services. Latino communities in the US and many Latin American countries may employ a similar type worker known as a promotora [69]. The advantage of these types of community health workers in breastfeeding support is that they are more likely to represent the culture and background of the families in the community. Disparities in breastfeeding rates that are often seen in minority populations can be reduced when culturally and ethnically supportive breastfeeding care is available in the community [70].

12.4.3 Mother-to-Mother/Peer Support

Historically, before the advent of artificial milk substitutes that were and continue to be heavily marketed to replace breastfeeding, mothers received support from other breastfeeding mothers. Often defined as mother-to-mother support (MTM) or peer support, perhaps the best known organised version of this type of support is La Leche League International (LLLI). LLLI was launched in 1956 by a small group of mothers in the Chicago, Illinois area when breastfeeding initiation rates in the US were hitting their nadir of 20% (http://www.llli.org/lllihistory.html). LLLI is now 60 years old with chapters in close to 70 countries. LLLI leaders are volunteers trained in breastfeeding counselling and must have breastfed at least one child. The Australian Breastfeeding Association (ABA) also trains breastfeeding mothers to provide MTM support (https://www.breastfeeding.asn.au/).

In 1985, the ABA (then known as Nursing Mothers Association of Australia) and LLLI recognised the need for a healthcare professional specifically trained in lactation care and, with initial funding from LLLI, advocated for the launch of the IBCLC profession. In the US, the Women, Infants and Children Supplemental Nutrition Service (WIC), adapted the MTM or peer support model to the WIC population by training WIC Breastfeeding Peer Counselors (BFPC). These paid counsellors are required to have been a WIC client and also successfully breastfed a child. WIC BFPCs have been shown to have a significant positive impact on breastfeeding initiation, exclusivity, and duration [71]. In Oklahoma, US, counties with WIC BFPCs have breastfeeding initiation rates higher than the state and national averages when WIC populations typically have some of the lowest breastfeeding rates [70], [72], [73].

12.4.4 Levels of Lactation Care

All breastfeeding families need access to timely, adequate lactation and breastfeeding care. The level of care needed can vary significantly and can be influenced by the level of knowledge and training of the available lactation-support provider. Some countries may define breastfeeding care as a preventive-type service, with education of the family about breastfeeding as an option for infant feeding. The expectation is that breastfeeding is ‘natural’ and therefore the family can manage without further healthcare support. If the infant requires a higher level of care, for example if the level of bilirubin is elevated and requires re-admittance to the hospital, then diagnostic care is implemented. This situation can lead to a “diagnosis” of breastfeeding failure and recommendation to change to formula feeding. This type of suboptimal breastfeeding care can occur in systems where healthcare professionals have not had any breastfeeding training and IBCLCs are not available. A more optimal application of a preventive/diagnostic model of care would involve the following:

  • Trained healthcare staff that provide effective prenatal breastfeeding education

  • Delivery in a Baby-Friendly hospital that provides optimal breastfeeding care

  • Access to trained community support after discharge for low risk breastfeeding families

  • Access to IBCLC care in hospital and in the community for high risk or complicated breastfeeding situations

Another model defines breastfeeding care based on acuity [74]. Defining different breastfeeding situations as low acuity versus high acuity helps to allocate appropriate resources in a timely fashion. Patient acuity is a concept that is used widely in healthcare and is applicable to lactation and breastfeeding care. In Mannel’s 2011 article [74], Defining Lactation Acuity to Improve Patient Safety and Outcomes, lactation acuity levels were defined based on the potential risk of poor maternal/infant health outcomes, including premature cessation of breastfeeding. Couplets with low acuity or level I acuity have minimal risk factors and effective breastfeeding occurring at the time of assessment. Low-acuity couplets can be managed by trained healthcare professionals or para-professionals, such as bedside nurses, CLCs, or community health workers. Higher-acuity couplets have multiple risk factors or complications and require referral to IBCLC care. When inadequately trained staff or volunteers try to manage high-acuity breastfeeding problems, care is less efficient and less effective, and risk of poor outcomes increases, which ultimately leads to higher costs to the healthcare system [75]. Matching lactation acuity to appropriate resources, including appropriate lactation-support providers, makes better use of staff, provides timely, effective care to breastfeeding families, and improves breastfeeding and maternal-infant outcomes [76].

12.4.5 Insurance Coverage

Any discussion of insurance coverage or payment for lactation support services is challenging due to the wide variety of healthcare systems around the world. In countries that have some level of national healthcare available, perinatal services are usually covered, including childbirth and postpartum/newborn care. Skilled breastfeeding care may not necessarily be available depending on the knowledge of policymakers in defining what care and services should be provided [77]. A common assumption of policymakers is that perinatal care providers are adequately trained in breastfeeding management when that may not be the case. Even in countries where midwifery care is common for low-risk births, midwives are unlikely to be trained to manage high-acuity lactation cases that require IBCLC care [78]. In a system with universal healthcare, the return on investment for providing timely, effective lactation care is clear, with increased breastfeeding duration rates and long term improvement in maternal and child health. In the complicated US healthcare system, there is great discrepancy in access to adequate lactation care [79], [80]. Middle-to-upper income families are more likely to be able to afford lactation care if it is not covered by their health insurance. Low-income families must rely on Medicaid benefits that may not include IBCLC services or any type of skilled breastfeeding support. The Affordable Care Act requires coverage of breastfeeding equipment, such as breast pumps and lactation consults, although it did not define who should provide the lactation care [81]. Thus, many insurance payers consider lactation consults a service already provided by clinicians in their network, such as physicians and advanced practice nurses who may not be trained to provide basic breastfeeding care, much less care for high-acuity lactation situations.

12.4.6 Licensure/Regulation

Licensure or government recognition of IBCLCs as healthcare team members could help to increase access to lactation care. In some countries, the majority of IBCLCs hold another healthcare credential such as physician, midwife or nurse, although this is not required by IBLCE. Requiring the IBCLC to be a secondary credential limits access to the profession, especially by younger generations and minority populations, increases cost of acquiring IBCLC certification, and does not guarantee payment for IBCLC services separate from the care provided by the initial credential. Ideally, IBCLCs should be recognised as healthcare providers independent of any other credential. Licensure efforts are ongoing in the US, with Rhode Island and Georgia the first states to officially license IBCLCs. Licensure currently is achieved on a state-by-state basis with another thirty states actively engaged in some level of effort.

12.5 Conclusion

Ultimately providing access to timely, effective breastfeeding care and products has a cost as does any other aspect of healthcare. The cost of not providing this care is even greater, with the increased occurrence of poor health outcomes for both mothers and children [82], [83]. A provocative 2013 article reporting the potential loss of economic value from not protecting women’s lactation and milk, estimated the value of human milk production at $3 billion per year in Australia and $110 billion per year in the US [84]. The author concluded that ‘failure to account for mothers’ milk production in GDP and other economic data has important consequences for public policy’. This devaluing or ignoring the cost of human milk allows for the continued lack of prioritisation and funding of programmes and regulations to protect, promote, and support breastfeeding.

Key Points

  • Breast pumps can be very useful for mothers who need to express milk on a regular basis. Access to quality, safe breast pumps is a public health and economic issue

  • The Baby Friendly Hospital Initiative guidelines require informed decision making by the mother before a breastfed baby is supplemented with any type of milk or fed by any other method. More research is needed to identify optimal methods of supplementing breastfed babies when medically-indicated supplementation is needed

  • Mothers need access to skilled lactation support providers when any kind of commercial breastfeeding device is used to address a breastfeeding problem

  • Safe, pasteurised donor milk should be available any time a baby does not have access to his/her own mother’s milk

  • Non-profit milk banks follow well established evidence-based guidelines and network with each other to meet the demand for donor milk to their maximum capacity. Milk banking could be expanded rapidly with more governmental support

  • IBCLCs are skilled healthcare professionals trained in all aspects of breastfeeding and lactation care. Access to IBCLC care is a public health issue and can increase breastfeeding initiation and duration rates

  • Licensure or government recognition of IBCLCs as healthcare team members could help to increase access to lactation care

  • The cost of not providing access to timely, effective breastfeeding care and products is even greater with the increased occurrence of poor health outcomes for both mothers and children

Rebecca Mannel, MPH, IBCLC, FILCA, is Director of the Oklahoma Breastfeeding Resource Center at the University of Oklahoma Health Sciences Centre. She previously managed the lactation service at a tertiary care hospital for 15 years. She provides professional lactation education, has published several peer-reviewed articles, and was Lead Editor for the International Lactation Consultant Association textbook, Core Curriculum for Lactation Consultant Practice. She works closely with health departments, national and international organisations, and is a member of the US Breastfeeding Committee.

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