This article was published for Crib Conversations, a bimonthly digest of news, resources and updates about infant safe sleep.

August is National Breastfeeding Month, which means that the end of August is a great time to think about how we can support new parents, help them reach their breastfeeding goals, and empower them with consistent information from trusted sources throughout the year.

Pediatrician Marianne Neifert, MD, is a member of the Infant Safe Sleep Partnership. Below, she provides information about the relationship between breastfeeding and safe sleep, and she encourages us all to be a part of the conversation to increase breastfeeding and infant safe sleep practices.

Q & A with Pediatrician Marianne Neifert, MD

Q: This year’s National Breastfeeding Month theme is “Together We Do Great Things,” a message that celebrates the power and impact of our collective efforts. How can safe sleep champions and breastfeeding advocates do great things together?

Neifert:  It’s fitting that last month, the American Academy of Pediatrics (AAP) released updated policy statements on both “Breastfeeding and the Use of Human Milk” and “Sleep-Related Infant Deaths,” two key issues that impact new families. Infant feeding and sleeping are the two most daunting challenges that new parents face, and these fundamental infant activities impact one another.

Breastfeeding is a protective factor against sleep-related deaths and is important for the overall health and well-being of infants throughout their life. Yet, mothers who choose to nurse their babies do not always achieve their breastfeeding goals, and breastfeeding parents do not always apply what they know about infant safe sleep. Both breastfeeding and safe infant sleep practices are impacted by cultural values, unrealistic expectations, personal barriers, support systems, and variable daily circumstances. Furthermore, racial and ethnic disparities persist in both breastfeeding and safe infant sleep routines.

Marianne Neifert, MD

Marianne Neifert, MD

Marianne Neifert, MD, MTS, FAAP, aka Dr. Mom®, is a well-known pediatrician and nationally recognized expert in lactation management, who is among the most experienced and dynamic speakers who provide breastfeeding education for diverse health professionals. Dr. Neifert graduated with honors from University of Colorado School of Medicine and completed her residency training at University of Colorado Medical Center and Affiliated Hospitals. She is the Managing Member of Dr. Mom Presentations LLC and a clinical professor of pediatrics at University of Colorado Denver School of Medicine.

Q: What were some of the key takeaways from the updated 2022 AAP Breastfeeding Policy?

Neifert: Traditionally the AAP has recommended exclusive breastfeeding for about six months, with continued breastfeeding through 12 months and beyond, as mutually desired by mother and baby, and as solid foods are added. In the 2022 policy, the AAP, consistent with the World Health Organization (WHO), supports continued breastfeeding for two years or beyond, acknowledging that mothers who decide to breastfeed beyond the first year often feel alienated and unsupported in their choice. Yet, human milk during the second year of life continues to be an important source of nutrients and immunologic factors for toddlers. Research emphasizes the importance of nutrition during “the first 1000 days” (conception to two years of age) on neurodevelopment and lifelong health. Breastfeeding beyond 12 months also continues to have a positive impact on maternal health, decreasing the risk of diabetes mellitus, hypertension, and breast and ovarian cancer.

A major emphasis of the 2022 AAP Breastfeeding Policy Statement and accompanying Technical Report was an extensive review of the documented improved infant and maternal health outcomes linked with breastfeeding, including breastfeeding beyond one year. The 2022 policy statement also repeated past recommendations that birthing facilities implement maternity care practices that promote and support breastfeeding, such as WHO’s Ten Steps to Successful Breastfeeding, including early skin-to-skin contact, frequent breastfeeding, and skilled lactation support. 

The AAP again acknowledged the importance of supporting breastfeeding and the use of human milk in reducing short- and long-term morbidities among very low birth weight infants. When a mother’s own milk is not available for these vulnerable infants, the AAP recommends pasteurized donor human milk.

The updated breastfeeding policy also re-emphasized that pediatricians need to be knowledgeable about breastfeeding benefits, management, and the provision of culturally congruent breastfeeding care; partner with community resources to improve breastfeeding support; and address inequities in the delivery of care to eliminate breastfeeding disparities. The AAP addressed the significant breastfeeding inequity issue that predominantly impacts the non-Hispanic Black population and acknowledged that breastfeeding-supportive hospital practices and peer support interventions for women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) have been shown to reduce breastfeeding disparities. The full policy statement and technical report can be downloaded below.

Q: Why do lactation care providers make ideal partners in promoting safe infant sleep?

Neifert: I view breastfeeding and safe infant sleep as dual aligned public health priorities and consider safe sleep proponents and breastfeeding advocates as ideal partners in safeguarding infant wellbeing. Lactation consultants and other lactation care providers are deeply committed to the welfare of infants and mothers and to reducing health disparities. They recognize the importance of breastfeeding in improving maternal-child health, including reducing sleep-related infant deaths. Lactation care providers develop quality client relationships within which empowering health information can be shared, and they work in maternity, pediatric, and public health settings. In addition, lactation care professionals are committed to lifelong learning and the use of evidence-based practices. 

Lactation care providers who work with expectant and new mothers have the opportunity and ethical responsibility to help prevent sleep-related infant deaths. The postpartum hospital stay provides a convenient early opportunity for hospital-based lactation consultants to teach and model safe infant sleep practices as part of their education about safe skin-to-skin care. 

Q: Can collaboration between safe sleep proponents and breastfeeding advocates more effectively promote safe infant sleep?

Neifert: In 2015, the National Action Partnership to Promote Safe Sleep and Breastfeeding Improvement and Innovation Network (NAPPSS-IIN) was launched to create a national coordinated strategy to engage the full set of partners to make safe infant sleep and breastfeeding the national norm. 

Some of us may have only one-time or limited contact with expectant or new parents—such as at a prenatal class—where we can offer conversation starters concerning the topic of safe infant sleep and elicit questions and concerns. Others will have ongoing interactions over a limited time period—such as during the postpartum hospital stay—where nurses and lactation consultants can facilitate safe sleep conversation deepeners. Still others—such as visiting nurses, WIC staff, or primary care providers–will engage with families through continuing interactions that permit ongoing dialogues. What’s important to remember is that compliance with safe infant sleep recommendations is increased when clients hear consistent information from multiple trusted sources and multiple times! 

Q: What if parents won’t commit to implementing the AAP recommendations?

Neifert: Despite our passion about safe infant sleep practices, we have to recognize that parents and other caretakers are the ultimate decision-makers about where and how their babies sleep. We must begin by meeting families where they are and conducting individualized, open, culturally appropriate, and non-judgmental conversations about their infant sleep practices. We can seek to understand personal, cultural, and community values and families’ life realities. And, we can learn to shift our attitude about our role as “experts” who make recommendations to being “resources” who support families to make their own decisions.

In our safe sleep conversations, we can:

  1. Ask open-ended questions. (“Have you thought about where and how your baby will sleep?”) 
  2. Practice reflective listening to confirm caretakers’ opinions, ambivalence, feelings, and concerns. (“So, you’ve heard that bedsharing makes nighttime breastfeeding easier.”)
  3. Use affirmations/validations and a strengths-based perspective. (“It sounds like you already have a great deal of information about safe infant sleep.”)
  4. Ask permission to share information. (“May I share some information/education you may not have heard about creating a safe infant sleep environment?”)

Other strategies to increase compliance with safe sleep recommendations include:

  1. provide families who do not have a safe sleep space for their infant with information about low-cost or free cribs/play yards;
  2. integrate safe sleep messaging with other health messaging, such as prevention of infant falls; and
  3. introduce safe sleep recommendations in school curricula to educate older siblings and teen babysitters about safe infant sleep practices.

Together we can do great things and save infant lives!

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