Congenital tongue-tie and its impact on breastfeeding

Full text

For the second time in U.S.
history, a national breastfeed-
ing campaign has been
launched.
The goal of the National
Breastfeeding Awareness
Campaign is to encourage
mothers to commit to exclu-
sive breastfeeding for the first
6 months of their child’s life in
order to reduce morbidity and
mortality.
Contemporary science has
demonstrated unequivocally
an increased disease burden
in children who were not
breastfed, with maximal bene-
fit occurring in those who were
exclusively breastfed for the
first 6 months of life. Epidemi-
ological data, however, dem-
onstrate that exclusive breast-
feeding rates have remained
very low, despite the rise in
overall breastfeeding
CONGENTIAL TONGUE-TIE AND ITS IMPACT ON BREASTFEEDING
By Elizabeth Coryllos, MD, MSs, FAAP, FACS, FRCSc, IBCLC
Catherine Watson Genna, BS, IBCLC
Alexander C. Salloum, MD, MA
PEDIATRICIANS NEEDED TO MAKE NATIONAL BREASTFEEDING AWARENESS
CAMPAIGN SUCCESSFUL
By Lori Feldman-Winter, MD, FAAP
Introduction
Many of today’s practicing physi-
cians were taught that treatment
of tongue-tie, (ankyloglossia) is
an outdated concept – a relic of
times past. Among breastfeeding
specialists tongue-tie has
emerged as a recognized cause
of breastfeeding difficulties - and
a very easily corrected one.7,8,10,12,
14, 19
During the last several decades
of predominant bottle-feeding,
tongue-tie was relegated to the
status of a “non-problem” be-
cause of the lack of significant
impact upon bottle feeding be-
haviors. The goal of this article is
to alert pediatricians to the po-
tential link between tongue-tie
and breastfeeding problems in
order to expedite intervention in
symptomatic cases.
Background Information
Tongue-tie (ankyloglossia, tight
frenulum) is a condition in which
the bottom of the tongue is teth-
ered to the floor of the mouth
by a membrane (frenulum) so
that the tongue’s range of mo-
tion is unduly restricted. This
may result in various oral devel-
opment, feeding, speech, swal-
lowing, and associated problems.
Genetic factors are suspected, as
tongue-tie is frequently familial.
Tongue-ties can be divided into
four types, according to how
close to the tip of the tongue
the leading edge of the frenulum
is attached:
Type 1 is the attachment of the
frenulum to the tip of the
tongue, usually in front of the
alveolar ridge in the lower lip
sulcus.
Type 2 is two to four mm be-
hind the tongue tip and attaches
on or just behind the alveolar
ridge.
Type 3 tongue-tie is the attach-
ment to the mid-tongue and the
[continued on p 2]
Summer 2004
INSIDE THIS ISSUE:
Congenital Tongue-Tie and Its
Impact on Breastfeeding
Pediatricians Needed to Make
National Breastfeeding
Awareness Campaign Successful
The California Perinatal Quality
Care Collaborative
Chapter Breastfeeding
Coordinator Reports from
California, Florida and Indiana
Join the Section on
Breastfeeding
Breastfeeding: Best
for Baby and Mother
Section on Breastfeeding
(combination of breastfeed-
ing plus formula feeding).
Thus, while almost 70% of
American mothers initiated
breastfeeding in 2001, less
than half initiated exclusive
breastfeeding, and only
17.42% were exclusively
breastfeeding at 6 months.1
[continued on p 7]
CHECK OUT THE AAP BREAST-
FEEDING WEB PAGES FOR:
*VIDEO ON TONGUE-TIE
*MORE INFORMATION ABOUT THE
NATIONAL BREASTFEEDING
AWARENESS CAMPAIGN
*VIDEO ON INFANT POSITIONING AND
ATTACHMENT AT BREAST

Breastfeeding: Best for Baby and Mother Page 2
CONGENTIAL TONGUE-TIE [CONTINUED FROM P 1]
middle of the floor of the mouth and is usually
tighter and less elastic.
Type 4 is essentially against the base of the tongue,
and is thick, shiny and very inelastic.
Types 1 and 2, considered “classical” tongue-tie,
are the most common and obvious tongue-ties, and
probably account for 75% of incidence. Types 3 and
4 are less common, and since they are more difficult
to visualize are the most likely to go untreated.
Type 4 is most likely to cause difficulty with bolus handling and swallowing, resulting in more
significant symptoms for mother and infant (see section on Diagnostic Assessment).
Oral-motor Movements That Differ Between Bottle and Breastfeeding
An infant can obtain milk from a bottle without the wide gape and consistent suction needed for
a good breast latch. If the tongue-tied infant cannot maintain the tongue over the lower gum
during sucking, the “phasic bite reflex” (chewing) is triggered.24 This chewing motion is sufficient
to transfer milk from the bottle, but is clearly problematic at breast. Bottle feeding allows milk
to drip into the mouth without effort, thus requiring less tongue muscle effort (such as tongue
grooving, cupping and depression) than needed for breastfeeding (Hartman, P, oral communica-
tion, 2003). Breastfeeding requires well-defined peristalsis from the front to the back of the
tongue as well as tongue–palate synchronization. Some tongue-tied infants cannot even manage
a bottle.
Diagnostic Assessment
Physical examination and observation of breastfeeding should be conducted, with particular
attention to the following items:
• Assessment of range of motion of the tongue should include the degree of extension of the
tongue beyond the lower dental ridge and lip,13 elevation to palate with mouth wide
open,10,13 and transverse movement from one corner of the lips to the other without
twisting the tongue. Elevation seems to be the most important tongue movement for
breastfeeding and should be weighted most heavily in the assessment.8,20,25
• Thorough evaluation of adequacy of latch and effectiveness of milk transfer are important.
The amount and rate of milk transfer from the breast can be determined by test-weighing
[continued on p 3]
The American Academy of Pediatrics (AAP)
offers the Breastfeeding: Best for Baby and Mother
newsletter as a member benefit of the AAP
Section on Breastfeeding. Information about the
AAP Breastfeeding Promotion in Physicians’
Office Practices (BPPOP-Phase II) program also
is included. The newsletter is intended as a fo-
rum for sharing information about breastfeeding
and AAP breastfeeding initiatives to facilitate
networking among AAP members. The AAP
provides this newsletter through its Department
of Community Pediatrics Division of Community
Health Services.
Comments and questions are welcome and can
be directed to:
American Academy of Pediatrics
Division of Community Health Services
141 Northwest Point Blvd
Elk Grove Village, IL 60007-1098
Phone: 800/433-9016, ext 7821
Fax: 847/434-8000
E-mail: lactation@aap.org
Web site: www.aap.org
AAP Staff
Betty Crase, IBCLC, RLC, Manager
Cyndy Rouse, Division Assistant
Thomas F. Tonniges, MD, Director, Department
of Community Pediatrics
Newsletter Editor
Nancy Powers, MD
Chairperson, Communications Committee
AAP Section on Breastfeeding
AAP Chapter Breastfeeding Coordinator, Kansas
Electronic mailing lists are available for AAP Chap-
ter Breastfeeding Coordinators, members of the
BPPOP-Phase II program, and members of the AAP
Section on Breastfeeding. Contact program staff for
information regarding participation.
The recommendations listed in this newsletter and
in the mentioned publications do no indicate an
exclusive course of treatment or serve as a stan-
dard of medical care. Variations, taking into account
individual circumstances, may be appropriate. This
newsletter and the materials mentioned within this
newsletter discuss titles published by organizations
other than the American Academy of Pediatrics.
Statements and opinions expressed in these publica-
tions are those of the authors and not necessarily
those of the American Academy of Pediatrics.
Any part of this newsletter may be reproduced for
noncommercial educational purposes.
© 2004 American Academy of Pediatrics
Classic heart shaped tongue caused by restricted central tongue tip elevation. This presentation is actually
sometimes less symptomatic than the tighter, shorter frenula that present as flattened (simple) or bunched
tongue .
Classic Simple
Types 3 and 4 may require a digital exam
© 2004 Catherine W Genna © 2004 Catherine W Genna

Breastfeeding: Best for Baby and Mother Page 3
the infant with an appropriate digital
scale and standardized protocol. (See
Box B.)
• Evaluate the efficiency of bolus handling
(ability to hold milk on the grooved
tongue for a controlled swallow that is
well coordinated with breathing).1,2,8
Cineradiography and close observation
have been the primary tools. Signs of
imperfect coordination between swal
lowing and breathing include increasing
nasal congestion over the course of a
feed, gulping sounds, decreasing respire
tion rate during sucking, sucking in un
usually short bursts (fewer than 10-15
sucks per burst) and even short bouts of
apnea.24 If the infant nurses, transfers
milk, and breathes well over a three to
five minute period, this is good clinical
evidence of normal suck-swallow-
breathing coordination.
• Observe the degree of fatigue and irrita
bility shown by the infant (especially
important in posterior tongue tie, which
is less apparent to the examiner), during
and after feeding, often expressed as jaw
and tongue tremor, fussiness and arching
away during feeding or needing to feed
again and again after short periods of
rest).
• Document the degree of nipple pain and
nipple skin erosion of the mother.
• Examine for any other contributing or
confounding issues including occult clefts
of the palate, facial deformity, muscular
or neurological deficit, thrush, etc.
Tongue-tie is seen relatively frequently in
association with other birth defects.2,6,14
The Surgical Treatment of Tongue-tie
Frenotomy is a simple, safe and effective sur-
gical procedure. It improves comfort, effec-
tiveness and ease of feeding for the mother
and infant, thereby increasing the exclusivity
and duration of breastfeeding for affected
dyads. (Benefits/outcomes other than for
improved breastfeeding are beyond the scope
of this article).
A simple “snip” with a blunt ended scissors is
usually all that is needed and bleeding is mini-
mal. It is less traumatic than ear piercing, and
much less invasive and painful than circumci-
sion. The author usually prefers to use topical
benzocaine on a small cotton swab to each
side of the frenulum and has used this in in-
fants and young children from 0-5 years with
good results and without side effects. Immedi-
ately after the frenotomy is done, the infant is
placed back on the breast, and the latch ad-
justed. There is usually immediate improve-
ment in milk transfer and maternal com-
fort.10,12-16,20,21
Fortunately, complications are minimal.
Rarely, the release does not help breastfeed-
ing but does help with speech later on. It is
not harmful to the baby. Occasionally there
might be enough bleeding to stain half of a
2 x 2 gauze pad instead of the more usual few
drops.
Usually there seems to be no pain and breast-
feeding in the immediate post operative pe-
riod is sufficient analgesia for the nursling.
[continued on p 4]
CONGENTIAL TONGUE-TIE [CONTINUED FROM P 2]
Rollunder tongue-tie
Bunched tongue-tie
Box A
Presentation of
Tongue-tie
++++++++++++++++++++++
The presentation of symptomatic tongue-
tie may vary widely, including symptoms
and signs in both infant and mother.
Maternal presentation is commonly char-
acterized by:
• nipple pain and/or erosions
• painful breasts
• low milk supply
• plugged ducts
• mastitis
• frustration, disappointment, and
discouragement with breastfeeding
• untimely weaning
Infant symptoms and signs include:
• poor latch and suck
• clicking sound while nursing (poor
suction)
• ineffective milk transfer
• inadequate weight gain or weight loss
• irritability or colic
• fussiness and frequent arching away
from the breast
• fatigue within one to two minutes of
beginning to nurse
• difficulty establishing suction to
maintain a deep grasp on the breast
• gradual sliding off the breast
• “chewing” of the nipple
• falling asleep at the breast having
taken less than an optimal feed, as
proven by “test weight” on a digital
scale (experience of authors)

However, the author suggests infant ace-
tominophen drops 10mg/kg q4h for 24
hours as needed. A drop of topical benzo-
caine on the clean small finger, may be used
if the frenotomy site seems sore during the
first 24 hours. It can be placed under the
tongue where the snip was performed.
Fortunately, complications are minimal.
Only rarely is a general anesthetic needed,
when a frenuloplasty (transverse cutting
and vertical repair) is needed rather than a
simple anterior to posterior snip
(frenotomy).15
Medical management of tongue-tie
surgical intervention may not be an option
because of religious, cultural, or personal
reasons or because the parents are unable
to find a medical professional willing to
provide surgical treatment. In these cases
the lactation consultant usually plays a criti-
cal role. Multiple latch modifications may
be employed to find one that is adequate.
Mothers may need to express milk to help
maintain an adequate milk supply and opti-
mal infant growth. As the child grows and
the mother perseveres, successful breast-
feeding may be possible, though some de-
gree of discomfort may continue. Contin-
ued breastfeeding in this situation typically
requires much time, patience, emotional
and professional support, and a dedicated
mother.
Other Oral Frenula
In addition to the lingual frenulum, there
are several other oral frenula (Genna,
Weissinger): a buccal frenulum connects
cheek to gum; a labial frenulum connects
the upper or lower lip to the gum, espe-
cially the superior labial frenulum which
runs from the center of the upper lip to
the gum line. These may interfere with lip
“flanging”.
A baby who cannot flange his /her upper lip
because of a tight upper labial frenulum
may need to alter his/her nursing position
or have it surgically released in order to
permit effective nursing. A mother with a
short nipple and inelastic breast tissue may
have trouble even achieving latch-on with
such a baby. It may be that a short or tight
lower labial frenulum can cause similar prob-
lems by preventing the lower lip from flang-
ing.
Conclusion
Tongue-tie is a significant clinical entity,
which, when symptomatic, should be treated
as early as possible to minimize this breast-
feeding problem. Surgical treatment is safe
and effective. Complications are rare and
general anesthesia is not required.
About the Author
Dr Coryllos is a pediatric surgeon, and is
emeritus director of pediatric surgery at
Winthrop University Medical Center, a
teaching hospital in New York. She has per-
formed over 500 frenotomies since 1953,
and has found the results to be satisfactory
in all cases, and excellent in most, with few
complications. [continued on p 5]
References:
1. Ardran G, Kemp F, Lind J. A Cinera-
diographic study of breastfeeding. Br J
of Radiol. 1958;31(363):156-162
2. Ardran G, Kemp F. Some important
factors in the assessment of oropharyn-
geal function. Dev Med Child Neurol.
1970;12:158-166
3. Ballard, JL et al. Ankyloglossia: as-
sessment, incidence, and dffect of fre-
nuloplasty on the breastfeeding dyad.
Pediatrics. 2002;110(5):e63-e68
4. Bosma J, Hepburn L, Josell S, et al.
Ultrasound demonstration of tongue
motions during suckle feeding. Dev
Med Child Neurol. 1990;32:223-229
5. Bullock F, Woolridge M, Baum, J.
Development of coordination of suck-
ing, swallowing and breathing: ultra-
sound study of term and preterm in-
fants. Dev Med Child Neurol.
1990;32:669-678 [Continued on p 6]
Breastfeeding: Best for Baby and Mother Page 4
CONGENTIAL TONGUE-TIE [CONTINUED FROM P 3]
Untreated tongue-tie in an 11 year old child.
Mis-shapen palate and dental ridge
in the same child
BOX B TEST-WEIGHING
Test-weighing is defined as “weighing the
infant before and after breastfeeding to
determine intake.”
Test-weighing requires an appropriate
digital scale with the following features
1. Digital read-out
2. Integration function that allows for
movement of the infant
3. Accurate to 2 grams
Test-Weighing Procedure:
1. Before breastfeeding, place baby on the
scale and weigh him. No need to undress
the baby. This is the "before" weight.
2. Mother breastfeeds the infant. DO
NOT CHANGE DIAPER YET.
3. Reweigh the infant, WITH THE EXACT
SAME CLOTHES, DIAPER, BLANKET,
etc). This is the "after" weight.
4. Subtract the first (before) weight from
the second (after) weight. The difference
in grams is considered the "intake" in
milliliters.
5. Some scales automatically store the
values and compute the difference for
you. Refer to manufacturers instructions.

Breastfeeding: Best for Baby and Mother Page 5
CONGENTIAL TONGUE-TIE [CONTINUED FROM P 4]
Schema of frenotomy procedure in infants
(0-12 mos) and in carefully selected cases, >12 mos., and up to 3-4 years.16
Instruments:
I. Tongue-tie grooved director (Pilling and Co.- Philadelphia). (Can use fingers in some infants.)
II. Stevens Tenotomy (blunt-ends) scissors or small blunt ended Metzenbaums
III. Topical Anesthesia to each side of Frenulum on cotton swab
a. oil of clove, or
b. dental flavored benzocaine gel In the case of an older child, greater than 10-12 months,
use either a or b plus inject to frenulum with 1cc syringe and #25-26 needle ¼- ½ cc 1%
xylocaine with 1/10,000 epinephrine.
IV. Head lamp or surgical focused floor lamp. If needed may use #7 magnifying opti-visor.
V. Immobilization—Swaddle in receiving blanket, baby papoose immobilizer (baby may need to
be held and comforted for 2-3 minutes after local anesthesia is applied and then repositioned before clipping.) A person is
needed (often parent) to hold head. Then the physician (or a helper) presses down gently on the chin. Physician places
groove director under the tongue straddling the frenulum, holds frenulum in place with visualization of tongue base and
frenulum, and the frenulum is then snipped along the underside of the tongue to its base. The area is checked to insure
complete release.
VI. Post frenotomy
a. Small amount of bleeding – control with pressure from a 2x2 gauze pad under the tongue. There is occasionally a
visible small vein down the anterior edge of the frenulum. Ligation may be considered though usually pressure is enough.
b. Mother holds and comforts, and almost immediately puts the infant to the breast.
c. Latch, milk transfer, swallowing, and especially mother’s comfort are immediately evaluated.
d. Child is then re-evaluated for wider mouth opening and improved tongue protrusion, elevation and a deeper latch.
There will be improved maternal comfort, often immediately.
e. Follow-up: recheck at 1 week, 2 months, and as needed, which can be entrusted to an International Board Certified
Lactation Consultant. Mother is given an emergency phone number and is instructed to call anytime for anything and as
often as she requires.
f. Nursing on demand.
g. Weight checks.
h. In the infant, it may be necessary to engage in tongue stroking, from the base of the tongue to the tip, in the days
immediately after tongue-tie release in order to help extension of the tongue, particularly if the infant is more than five
days of age. (Authors’ experience.) A pacifier “tug of war” may also help. This may be required for seven to fourteen
days for optimal results. The assistance of a lactation consultant will be most helpful. In the older infant or child, tongue
exercises are more frequently required in order to help the patient learn the use of a mobilized tongue. Lolly pops and
ice cream cones work very well, especially for encouraging tongue protrusion.
VII. Cautions
a. Orifices of submandibular and lingual salivary glands open under the tongue on the floor of the mouth. Therefore the
snip must be closer to the base of the tongue than the floor of the mouth.
b. The earlier frenotomy is performed, the faster the infant will adapt to the increased tongue mobility and assume normal
oral motor function. If frenotomy is delayed, mothers should be counseled to expect several days to weeks before
breastfeeding is optimal. Because the late correction of tongue-tie takes time to become fully effective, (the child has to
learn how to use a tongue with normal mobility), the mother should be in contact with a lactation consultant or her
pediatrician for consistent professional assistance and emotional support.
Grooved director and blunt
Metzenbaum scissors.
© 2004 Catherine W Genna

Breastfeeding: Best for Baby and Mother Page 6
CONGENTIAL TONGUE-TIE [CONTINUED FROM P 4]
References: (Continued)
6. Emmanouil-Nikoloussi E, Kerameos-Foroglou C. Congenital syndromes connected with tongue malformations.
Bull Assoc Anat (Nancy). 1992;76:67-72
7. Fletcher SG, Meldrum JR. Lingual function and relative length of the lingual frenulum. J Speech Hearing Res 2.
1968;382-390
8. Genna CW. Breastfeeding and tongue-tie. Leaven. 2002;38(2):27-29
9. Glass RP, Wolf LS. Incoordination of sucking, swallowing and breathing as an etiology for breastfeeding difficulty.
J Hum Lact. 1992;10(3):185-189
10. Hazelbaker AK. Assessment Tool for Lingual Frenulum Function. Columbus, OH: Privately printed;1992.
11. Hingley G. Ankyloglossia clipping and breastfeeding. J Hum Lact. 1990;6:103
12. Jain E. Video: Tongue-tie: Impact on Breastfeeding [videotape]. Calgary, Alberta, Canada: Lakeview Breastfeeding Clinic;
1996
13. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int. 1999;30(4): 259-262
14. Lalakea ML, Messner AH. Ankyloglossia: does it matter? Pediatr Clin North Am. 2003;50:381-397
15. Lalakea ML, Messner AH. Frenotomy and frenuloplasty: if, when, and how. Otolaryngol Head Neck Surg. 2002;3:93-97
16. Marmet C, Shell E, Marmet R: Neonatal frenotomy may be necessary to correct breastfeeding problems. J Hum Lact.
1990;6(3):117-121
17. Messner AH, Lalakea ML, Aby J, MacMahon J, Bair E. Ankyloglossia: incidence and associated feeding difficulties. Arch
Otolayngol Head Neck Surg. 2000;126:36-39
18. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54:123-131
19. Mukai S, et al. Ankyloglossia with deviation of the epiglottis and larynx. Ann Otol Rhinol Laryngol Suppl 1991;153,3-20
20. Palmer B. The Influence of breastfeeding on the development of the oral cavity: a commentary. J Hum Lact.
1981;14(2):93-98
21. Ross MW. Back to the breast: retraining infant suckling patterns. Lactation Consultant Series; Wayne, NJ; Avery
Publishing Group;1987
22. Salloum, AC, MD, MA. Student IV paper for “Medicine in Contemporary Society.” Stonybrook Medical School, SUNY; 2003
23. Wiessinger D, Miller M. Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. J Hum Lact
1995;11(4):313-316
24. Wolf LS, Glass RP. Feeding and Swallowing Disorders in Infancy: Assessment and Management. Tucson, AZ; Academic
Press, Inc; 1992
25. Woolridge M. The anatomy of infant sucking. Midwifery. 1986;2:164-171

Breastfeeding: Best for Baby and Mother Page 7
Breastfeeding promotion efforts have
been successful in getting women to
breastfeed, but the payoffs of better
health remain less than optimal without
the commitment to exclusive breastfeed-
ing for 6 months.2
The U.S. Department of Health and Hu-
man Services through the Office on
Women’s Health (OWH) worked with the
Advertising Council to create public ser-
vice announcements for television and
radio on the importance of exclusive
breastfeeding for the first 6 months of life.
In addition, print advertisements were
created for newspapers, magazines and
billboards.
Specific requirements were established
for the selection of information used in the
advertising campaign: well-designed stud-
ies published after 1990, studies from
developed countries, breastfeeding dura-
tion of at least six months and sample
sizes of 100 children or more. The studies
looked at the effects of breastfeeding on
the incidence of diarrhea, hospitalization
for respiratory illness, obesity/overweight
and otitis media. For a reference list, see
page 8.
Public health experts are hopeful the cam-
paign will go far to shift the American
norm from formula feeding with and with-
out breastfeeding to breastfeeding without
the need for supplementing with formula.
A campaign dealing with any aspect of
child health and welfare requires the co-
operative support of pediatricians to make
it a success. This campaign is no differ-
ent. The U.S. public health system is
counting on pediatricians to provide the
necessary support for women who re-
spond to the campaign and choose to
breastfeed, as well as women who have
questions, problems or want the cam-
paign’s message validated.
Members of the AAP Section on Breastfeed-
ing Leadership Team worked with the OWH
to provide scientific expertise for the cam-
paign. In addition, several pediatricians are
involved in 18 community demonstration
projects (CDP) funded by the OWH to en-
hance the campaign’s impact. The following
cities have a CDP:
• Atlanta, Georgia
• Birmingham, Alabama
• Boston, Massachusetts
• Camden, New Jersey
• Chicago, Illinois
• Kansas City, Missouri
• Knoxville, Tennessee
• Los Angeles, California
• New Orleans, Louisiana
• Philadelphia, Pennsylvania
• Portland, Oregon
• Providence, Rhode Island
• Pueblo, Colorado
• San Juan, Puerto Rico
• Rosebud, South Dakota
• San Francisco, California
• St. Paul, Minnesota, and
• Washington, D.C.
To find a CDP near you, call 1-800-994-
WOMAN (9662).
There are a number of steps pediatricians
can take to get involved. The first is to be
prepared to validate the campaign. Moth-
ers should feel the messages they hear or
read are shared by all of the professionals
who care for them and their babies. Pe-
diatricians also can support the campaign
by:
• Affirming to mothers that the
AAP supports breastfeeding as
the optimal nutrition for infants.
• Explaining why a campaign is
needed in the United States at
this time. For instance, tell moth-
ers that that despite high initia-
tion rates of breastfeeding, low
duration rates persist. Also, ex-
plain the importance of exclusive
breastfeeding.
• Encouraging all mothers, with
rare exceptions, to breastfeed
exclusively for about six months,
which means delaying other
foods or fluids, and to continue
breastfeeding thereafter for as
long as mother and child desire
it.
• Coordinating community re-
sources to support mothers,
such as the CDPs, or referring
them to the OWH-funded free
Breastfeeding Helpline (1- 800-
994-WOMAN) or Web site
(www.4woman.gov), which has
extensive information and help
for breastfeeding mothers.
• Working collaboratively with
members of your health care
team to assess and manage
breastfeeding support.
• Scheduling the first ambulatory
visit by a qualified observer for
all breastfed newborns at 3 to 5
days of life.
• Enhancing your knowledge
about breastfeeding and skills for
assessment of breastfeeding by
attending continuing medical
[continued on p 8]
NATIONAL BREASTFEEDING AWARENESS CAMPAIGN [CONTINUED FROM P 1]

education (CME) courses dedicated to breastfeeding topics, joining the AAP Section on Breastfeeding and
hosting CME in your community.
• Giving Grand Rounds on breastfeeding promotion and management at your community hospital.
The Academy has always promoted breastfeeding as the best way to nourish and nurture infants. Pediatricians were an integral
part of the first U.S. public health campaign at the turn of the century to promote breastfeeding, but at the same time they were
campaigning to purify cow’s milk. There is no need to launch a public health campaign to improve infant formula.
For those who cannot breastfeed, infant formula is an acceptable solution. But the solution to improved health status for the major-
ity can be achieved by promoting and supporting exclusive breastfeeding for the first 6 months of life and continued breastfeeding
for at least 12 months and thereafter for as long as mutually desired.
It is time to embrace exclusive breastfeeding as ideal behavior and find ways to eliminate unnecessary use of infant formula. The
National Breastfeeding Awareness Campaign may create the catalyst for change, and pediatricians are an essential link to the
campaign’s success.
References for Diarrhea:
1. Scariati P, Grummer-Strawn L, Beck Fein S. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the
United States. Pediatrics. 1997;99(6):e5-e9
2. Raisler J, Alexander C, O’Campo P. Breast-feeding and infant illness: a dose-response relationship? Am J Public Health.
1999;89(1):25-30
3. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first 6 months of life. J Pediatr.
1995;126:191-197
4. Howie PW, Forsyth JS, Ogston SA, Clark A, du V Florey C. Protective effect of breast feeding against infection. BMJ. 1990;
300:11-16
References for Otitis Media:
5. Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM. Relation of infant feeding practices, cigarette smoke
exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life. J Pediatr.
1993;123:702-11
6. Scariati P, Grummer-Strawn L, Beck Fein S. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the
United States. Pediatrics. 1997;99(6):e5-e9
7. Raisler J, Alexander C, O’Campo P. Breast-feeding and infant illness: a dose-response relationship? Am J Public Health.
1999;89(1):25-30
8. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first 6 months of life. J Pediatr.
1995;126:191-197.
9. Duffy LC, Faden H, Wasielewski R, Wolf J, Krystofik D, Tonawanda/Williamsville Pediatrics. Exclusive breastfeeding protects
against bacterial colonization and day care exposure to otitis media. Pediatrics. 1997;100(4):e7
NATIONAL BREASTFEEDING AWARENESS CAMPAIGN [CONTINUED FROM P 7]
Page 8 Breastfeeding: Best for Baby and Mother

10. Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM. Exclusive breast-feeding for at least 4 months protects
against otitis media. Pediatrics. 1993;91(5):867-872
References for Hospitalization for Respiratory Illness
11. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J Pediatr.
1995;126:191-197
12. Howie PW, Forsyth JS, Ogston SA, Clark A, du V Florey C. Protective effect of breast feeding against infection. BMJ. 1990;
300:11-16
13. Nafstad P, Jaakkola JJ, Hagen JA, Botten G, Kongrud J. Breastfeeding, Maternal Smoking, and Lower Respiratory
Tract Infections. Eur Respir J. 1996;9:2623-2629
14. Oddy WH, Holt PG, Sly PD, Read AW, Landau LI, Stanley FJ, Kendall GE, Burton PR. Association Between Breast
Feeding and Asthma in 6-Year-Old Children: Findings of a Prospective Birth Cohort Study. BMJ. 1999;319:815-819
15. Oddy WH, Sly PD, de Klerk NH, Landau LI, Kendall GE, Holt PG, Stanley FJ. Breast feeding and respiratory morbidity in
infancy: a birth cohort study. Archives of Disease in Childhood. 2003;88:224-228
16. Cushing AH, Samet JM, Lambert WE, Skipper BJ, Hunt WC, Young SA, McLaren LC. Breastfeeding reduces risk of
respiratory illness in infants. Am J Epidemiol 1998;147:863–870
References for Obesity
17. Gillman MW, Rifas-Shiman SL, Camargo CA, Berkey CS, Frazier AL, Rockett HR, Field AE, Colditz GA. Risk of overweight
among adolescents who were breastfed as infants. JAMA. 2001;285:2461 –2467
18. Grummer-Strawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the
Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics. 2004;113(2):e81-86
19. Hediger ML, Overpeck MD, Kuczmarski RI, Ruan WJ. Association between infant breastfeeding and overweight in young
children. JAMA. 2001;285:2453 –2460
20. Toschke AM, Vignerova J, Lhotska L, Osancova K, Koletzko B, von Kries R. Overweight and obesity in 6- to 14-year old
Czech children in 1991: protective effect of breast-feeding. J Pediatr. 2002;141:764 –769
21. Von Kries R, Koletzko B, Sauerwald T, von Mutius E. Does breast-feeding protect against childhood obesity? Adv Exp Med
Biol. 2000;478:29-39
22. Strbak V, Skultetyova M, Hromadova M, Randuskova A, Macho L. Late effects of breast-feeding and early weaning:
seven-year prospective study in children. Endocr Regul. 1991;25(1-2):53-57
Dr. Feldman-Winter chairs the AAP Section on Breastfeeding Education Committee.
(Note: This article is being published as a commentary in the August 2004 issue of AAP News. The online edition
(http://www.aapnews.aappublications.org) will contain links to the abstracts of the citations in the commentary.)
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Page 10 Breastfeeding: Best for Baby and Mother
CHAPTER BREASTFEEDING ACTIVITIES
The California Perinatal Quality Care Collaborative (CPQCC)
By Nancy E Wight MD, IBCLC, FABM, FAAP
The concept of collaboration among institutions for the purpose of improving overall quality of care is a key component of successful and
efficient change in health care. Dialogue between clinical units, as well as visits by a multidisciplinary team from one unit to another, can
provide an exchange of ideas and solutions to clinical problems. Where evidence is inconclusive, sharing ideas and approaches to practice can
offer incentives to seek answers to important questions through collaborative clinical research.1
Building on the existing VON (Vermont-Oxford Network) framework, the California Association of Neonatologists (CAN), in association
with multiple public and private partners (Kaiser Permanente Health Care Plan, the David and Lucille Packard Foundation, Pacific Business
Group on Health, CA Dept. Health and Human Services, CA Perinatal Section AAP, CA ACOG) developed the California Perinatal Quality
Care Collaborative (CPQCC) to foster benchmark performance by all of the NICUs in California. The three arms if the CPQCC are the
Data Center, The Perinatal Quality Improvement Panel (PQIP) and the research unit. 1
PQIP regional opinion leaders identify NICU care practices that have the potential for improvement, using as criteria the availability of indica-
tor data, demonstrated variability in current practice, and research evidence of the validity and impact on outcome of the recommended prac-
tices. Practice recommendations in a selected area of care are presented in a stand-alone quality improvement “toolkit” and a multidiscipli-
nary quality improvement workshop designed to “jump-start” unit teams. Participants are sent exercises before the workshop that are de-
signed to assess current practice and create “cognitive dissonance” as a force for change.
Quality improvement (QI) initiatives have targeted antenatal steroid use, surfactant use, consistent mechanical ventilation, abandonment of
postnatal steroid use, and prevention of nosocomial infection. In 2004, the QI initiatives are nutrition support of the VLBW infant (specifically
supporting breastfeeding) and prevention of early-onset sepsis.
I had the privilege of working on “Nutritional Support of the Very Low Birth Weight Infant: Part I, which encompasses 19 best practice rec-
ommendations in 3 sections, with an extensive reference list and multiple, practical appendices. 2 The entire toolkit was designed to help the
NICU care team assess current nutritional practices and outcomes, and to promote and support breastmilk for VLBW infants as part of opti-
mal nutritional management. Part 2 (2005) will include best practices in parenteral and enteral nutrition, plus additional attention to contin-
ued support for breastfeeding in the NICU and post-discharge. The Toolkit, Part 1 is currently available as a free download (~150 pages).2
1. Wirtschafter DD, Powers RJ. Organizing regional perinatal quality improvement: global considerations and local implementation.
NeoReviews. 2004; 5(2):e50-59
2. CPQCC/PQIP: nutritional support of the very low birth weight infant: part 1, http://www.cpqcc.org/NutritionToolkit.html
Florida
Florida Chapter Activities
By Joan Meek, MD, FAAP, IBCLC
Arnold “Bud” Tanis, MD, and Joan Meek, MD, FAAP, IBCLC, continue to serve as the Florida Chapter Breastfeeding Coordinators. They
work closely with all of the Chapter Breastfeeding Coordinators and with the AAP Section on Breastfeeding, within the AAP Department of
Community Pediatrics, to support breastfeeding. [continued on p 11]
California

The 9th annual International Academy of Breastfeeding Medicine meeting, “Hot Topics in Breastfeeding: Celebrating the Year of the Family,”
will be held in Orlando, Florida, October 21-25, 2004. Several chapter members will be participating in that meeting, including Dr. Rob Law-
rence from the University of Florida. Information about the meeting can be found at www.bfmed.org. Application has been made for AAP
co-sponsorship of the meeting.
Goals for the future include continued education of pediatric practitioners and ancillary health care personnel across the state and
development of a multidisciplinary statewide breastfeeding coalition.
Breastfeeding: Best for Baby and Mother Page 11
CHAPTER BREASTFEEDING ACTIVITIES [CONTINUED FROM P 10]
Florida [continued]
Indiana Chapter Activities
By Kinga A Szucs, MD, FAAP
The Indiana Breastfeeding Task Force is currently working on the Indiana State Breastfeeding Plan following a training conference by Best
Start Social Marketing last year, which enabled a state-wide breastfeeding needs assessment and helped evaluate rates by county and barriers
to breastfeeding. The Task Force includes representatives from the Indiana WIC Program, Indiana State Department of Health Maternal and
Child Health Services, Indiana Perinatal Network, Healthy Mothers, Healthy Babies, Healthy Start, LLLI, as well as a breastfeeding mother
representative and myself from the AAP.
With the launch of the National Breastfeeding Campaign, we are organizing a subcommittee, within the Task Force, to deal with involving the
media as much as possible. There will also be various health fairs coming up at our Community Health Centers, along with the Indiana Black
Expo Summer Celebration Black and Minority Health Fair which will give us a chance to reach more people in the community.
For World Breastfeeding Week in August 2004, events included an Indianapolis Area Family Walk For Breastfeeding and the Midwest Breast
Fest in South Bend with the goal of trying to break the Guinness Book of World Records with the largest number of breastfeeding mothers
and babies in one place at one time.
Previous activities have included the Indiana Perinatal Network putting together the Breastfeeding Promotion Consensus Statement, followed
by the Governor of Indiana issuing a Breastfeeding Proclamation, in 2002, supporting breastfeeding for World Breastfeeding Week. In Decem-
ber 2002, Methodist Hospital in Indianapolis became the first in the state with the Baby Friendly Hospital (BFHI) designation, and continues to
be the largest BFHI in the US. This has been followed by another hospital having an active Certificate of Intent and many others working to-
wards policies and procedures that foster the BFHI principles. In July 2003, a law was enacted to remove legal barriers to breastfeeding in
public: ”A woman may breastfeed her child anywhere the woman has a right to be.” Also in 2003, the Indiana Breastfeeding Resource Hand-
book updated 4th edition was published and sent to physicians.
Our future efforts will include legislative issues, such as providing health insurance coverage for breast pump rental, lactation consultant ser-
vices, and possibly for donor human milk and a tax rebate for employers providing breastfeeding support to their employees. A few model
employee lactation programs have been identified that can be publicized and replicated in other workplace, hospital and clinic settings.
Indiana

Benefits of section membership include
Join the Section on
Breastfeeding!
The Section on Breastfeeding seeks to enhance educational efforts
in the area of breastfeeding and develop collaborative relationships
with other AAP sections, committees, and outside organizations.
• Participate in annual section
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Conference & Exhibition
• Have your programs and
activities recognized in the
Breastfeeding: Best for Baby and
Mother newsletter
• Network through electronic
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and section meetings
• Participate in educational
program development,
consultation, and technical
assistance efforts
American Academy of
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