Establishing a County Health Department Lactation Program: Filling the Gaps through Policy and Action

By Daniel J. Stapleton, Public Health Director, Niagara County
The Niagara County Department of Health is taking a multipronged approach to building a lactation program and breastfeeding friendly community initiative in Niagara County. We have established a comprehensive lactation program serving the Niagara County workforce and the outside community. Program components include qualified lactation consultant and counselors, a Breastfeeding Friendly Workplace and Daycare Initiative, public outreach and education, medical resident training initiative, and lactation mobile clinic services.

Feed and Protect: Health Security is “Fluid”
Increasing rates of breastfeeding initiation and sustainment is critical to public health. Eliminating barriers and securing sustainability of breastfeeding is consistent with our mission to reduce chronic diseases and infant morbidity in Niagara County. Breastfeeding is a matter of health equity for infants and children, requiring minimum changes in public health system infrastructure and low cost workplace modifications to achieve positive long-term health and economic outcomes. Furthermore, health risks of suboptimal or never breastfeeding are significant. The lack of human milk (HM) early in life can serve as a powerful antecedent to chronic conditions later, creating personal and economic burdens on families, employers, communities and the public health system. Exclusive breastfeeding for the first six months of life, with continued breastfeeding for one year and beyond, is the definitive standard for infant feeding. Human milk (HM) contains the exact amount of water and nutrients human infants need to grow and flourish. The immunologic significance of human milk and long-term implications for reducing disease and the economic burden on public health cannot be overstated. HM provides a remarkably wide spectrum of protection against disease organisms and is linked to lowered risk of Sudden Infant Death Syndrome (SIDS). Nineteen gastrointestinal hormones regulate metabolism and other pathways to reduce risks of obesity and Type 2 diabetes later in life. Growth factors and other substances promote infant bone and nervous system development influencing attainment of developmental milestones. Bioactive agents and immune cells in HM form a protective lining in the digestive tract, reducing risk of inflammatory bowel diseases, allergies and pathogen invasion.

Exclusive breastfeeding from the beginning of life affords immune protection against diseases until babies receive their first lifesaving vaccines.

Public Health Impact and Cost Benefit
We are in the midst of an obesity crisis in the US, affecting 17.2% of children 2 to 19 years old. According to a report of The American Academy of Pediatrics (AAP), medical costs associated with childhood obesity tops $14 billion/year. The Agency for Healthcare Research and Quality (AHRQ) links exclusive breastfeeding with a potential risk reduction of up to 4% for each month of breastfeeding. Overall, research data associate a history of breastfeeding with a reduction in obesity risk later in life. Asthma, heart disease, cancer, diabetes, immune mediated disorders of gut, and infant morbidity from respiratory, diarrheal infections and infant hospitalization rates remain formidable challenges. Over the past three years, health indicators in our communities show only modest improvements, necessitating a closer look at how we can promote additional behaviors to improve health. Given the burden of disease on human health and the economy in Niagara County, prioritizing a comprehensive breastfeeding program addressing nutrition and immune system development from birth aligns with the needs of our community. It also supports the Public Health Director's stewardship of public resources and health cost containment. Breastfeeding promotion and support is a smart investment, according to the September 2014 Report of the National Conference of State Legislatures. The positive economic impact of breastfeeding includes reduction in Medicaid and other insurance costs, lower employee costs and a reduction in family expenses. According to a 2010 pediatric cost analysis published in AAP, if 80% of US families could comply with medical recommendations to breastfeed exclusively for six months (Healthy People 2020 target 60.6%), the US would save $10.5 billion and prevent 741 infant deaths. At 90% compliance with recommendations, the savings would be $13 billion per year, with over 911 infant deaths prevented. In terms of indirect costs, over $1.2 billion can be saved in personal expenses and reduced time missed from work in breastfeeding families.

Potential to Reduce Early Intervention Program (EIP) Costs
Breastfeeding can potentially relieve the EIP cost burden to counties. Findings in a study published by The American Academy of Pediatrics showed infants who never breastfed were 50% more likely to have gross motor coordination delays than infants that breastfed exclusively for at least four months (10.7% vs 7.3%). Additionally, never breastfed infants had at a 40% greater likelihood of fine motor delay than those given breast milk for a prolonged period. This evidence was attributed solely to breastfeeding factors; not advantaged social position, education, or parenting style.

Community Engagement and Annual Lactation Services at Niagara County Fair
For the last three years in the first week of August, NCDOH has provided a safe, environmentally controlled lactation and baby care station for nursing mothers at the Niagara County Fair. Niagara County provides a fully-equipped trailer on space donated for free through a partnership with the Cornell Cooperative Extension. Numerous qualified volunteers support this effort, while we provide Certified Lactation Counselors (CLC), an Internationally Board Certified Lactation Consultant (IBCLC), Advanced Nurse Lactation Consultant (ANLC) and Medical Doctors from the State Universityof New York at Buffalo (SUNYAB) Residency Program to assess and assist women with breastfeeding issues.

Breastfeeding Friendly Worksite and Daycare Initiatives
In support of women returning to work after childbirth, the NCDOH is a Breastfeeding Friendly Workplace. Over 70% of working women with children under three years old work full time. Unlike most countries in Europe and Central Asia, which provide 26 weeks or more of paid leave for new mothers, others in the United States return to work much earlier after giving birth, usually after six to 12 weeks of unpaid leave. This is often disruptive to the mother's breastfeeding routine and her ability to sustain production of an adequate milk supply for her baby. In surveys conducted by our department, return to work was the most frequent reason for ending breastfeeding earlier than recommendations. Federal and state laws support breastfeeding as essential to infant and family health. The U.S. Fair Labor Standards Act (FLSA), and Section 206-c of the New York State (NYS) Labor Law require employers to provide reasonable time for employees to express milk during the work period in a private space, free from intrusion by co-workers and the public. NYS law requires workplaces to accommodate a mother's need to express milk for up to three years. Ample evidence shows women are more likely to continue breastfeeding when employers have supportive policies and practices in place. Supporting employees helps mitigate health care costs, lost productivity and absenteeism.

Our Workplace Lactation Program, managed by our ANLC, provides a 24/7 support line and a safe, clean, private and well-equipped lactation room. Prior to establishing this room, we gained the full support of our county leadership and Board of Health in development of county employee lactation policies. We also sent surveys and invitations to other major employers to join NCDOH in providing accommodations for their breastfeeding employees. When employers provide accommodations for breastfeeding employees to express milk, the health and economic benefits to infants, families, employers and the community are innumerable and far-reaching. With an immediate return on investment of three dollars for every one dollar spent for employees, it is a smart practice to create a breastfeeding friendly environment for working mothers.

Daycares have complex issues; they are employers, as well as childcare providers. Children in daycare have higher rates of infectious diseases, especially infant respiratory and diarrheal illnesses. Moreover, daycare staff caring for breastfed babies may not recognize breastfed infants' needs for more frequent feedings of bottled HM. NCDOH educates daycare staff on HM benefits, and to recognize feeding cues rather than applying rigid formula feeding schedules. Breastfeeding makes good business sense for daycares, as breastmilk also qualifies for milk reimbursement.

Medical Resident Internship
NCDOH includes Medical Residents in our Lactation Initiative. A recently published study supports our experience with medical residents; most lack knowledge of human lactation and interventions for resolving basic lactation problems. Training medical residents in the science behind breastfeeding in a public health setting is a priority for NCDOH, as research demonstrates timing of provider support for initiation and sustainment of breastfeeding is critical. Engaging physicians early before they embark on their careers is important for continuity of breastfeeding benefits, as Public Health lactation programs can serve to augment support between routine provider visits, especially during the crucial return to work adjustment.

The Call for Public Health Leadership 
Leadership and partnerships are key to the success of any breastfeeding initiative. Partnerships with healthcare providers public officials, academia, communities, and businesses can help achieve health equity for children across the spectra of the socioeconomic landscape. There is a call for a nucleus of public health leaders to advocate and promote breastfeeding as the most basic and cost-effective remedy for reducing health disparities in our communities, beginning with each precious new life. Fellow Public Health Directors and Commissioners, I invite you to please join me in supporting this important initiative.