Ina May's Guide to Breastfeeding

APPENDIX A: MEDICATIONS YOU MAY NEED
W
HILE PREGNANT OR NURSING

Surveys in several countries have shown that ninety to ninety-nine percent of mothers will take some form of medication during the first postpartum week. Anecdotal evidence and surveys have shown that many women decide or are told not to breastfeed because of fear that medications they take might reach their babies through their milk. What these people don’t know is that many medications that are transferred into mother’s milk are destroyed in the baby’s gut or are never absorbed into the baby’s system. Unfortunately, though, a pediatrician who relies only on package inserts to evaluate possible negative effects of drugs on lactation may be unaware that these inserts usually contain statements designed more to provide legal protection for the pharmaceutical manufacturer than to protect babies who need their mothers’ milk. The same goes for a pediatrician who uses the Physicians’ Desk Reference (PDR) to evaluate drug safety, since this well-known reference is based upon manufacturers’ package inserts—making it essentially worthless. If you live in Canada, your pediatrician is likely to refer to the Compendium of Pharmaceuticals and Specialties (CPS), which is essentially worthless with respect to breastfeeding information for the same reason.

Key Facts to Consider

·      Most mothers can continue breastfeeding while taking a medication, without harming their babies. It’s actually quite rare for women to have to completely stop nursing because of potential harm to their babies from a medication they must take.

·      If a medication the mother needs is considered unsafe, there is usually another medication she could substitute that would pose no risk to her baby.

·      Drug manufacturers have rarely funded studies of the effects of their drugs on breast milk, which explains the statements in package inserts that recommend cessation of breastfeeding.

·      Amounts of medication reaching your baby through your milk on the first four to five days are extremely small because of the tiny amount of milk ingested during that time.

·      The protective benefits of colostrum and milk during the first weeks of life almost always outweigh possible risks to babies posed by transfer of medications into your milk.

·      It’s best to avoid the newest medications on the market, as their effects are less likely to have been studied yet.

·      Drugs with shorter half-lives are preferable to those with longer half-lives, such as some of the anticancer drugs.

·      Herbal medications should also be used with caution, as some contain chemical substances that could be risky for your baby.

Our best authority on drugs and human milk is Dr. Thomas Hale’s paperback book, Medications and Mothers’ Milk. Dr. Hale, a clinical pharmacologist, recognizes the health benefits of breastfeeding for both mothers and babies and keeps his valuable book up to date by issuing new editions every few years. Many nursing mothers carry his book with them whenever they see a physician for their baby’s or their own care. If your baby is born prematurely or ill, you might be wise to invest in a copy for yourself. Dr. Hale’s book includes advice based upon published research regarding herbal medications that could affect your breastfed baby. Your lactation consultant almost certainly will own a copy.

Most medications that you might need to take at some point while nursing will result in only a tiny amount (around one percent) getting into your milk. Several factors are good to take into account in your decision-making. These include your medical needs, the age and maturity of your baby, the length of your treatment, the route of administration, whether or not the medication is absorbed by your baby’s gut, and how much time passes after taking the medication before you nurse him. (Hint: If there is a drug that you must take during lactation, try to take your dose immediately after a feeding session, as this will minimize the amount of drug reaching your baby.)

Here are guidelines concerning the use of some commonly taken drugs:

Anti-allergy agents: People who are highly allergic to bee or wasp stings often carry epinephrine in case of a life-threatening allergic reaction. After epinephrine is given to a woman by injection, it is considered safe for her to continue nursing her baby.

Anti-allergy medications such as fexofenadine (Allegra) and diphen-hydramine (Benadryl, Allerdryl, Insomnal, Nytol, Delixir, and Paedamin) are considered safe. There have been anecdotal reports of these medications suppressing milk production, but these haven’t been substantiated. In general, though, a medication that produces a feeling of dryness in the nose and mouth may also have the effect of suppressing milk production.

Antibiotics: If, for any reason, it becomes necessary for you to take antibiotics during pregnancy, ask your midwife or doctor to make sure that any yeast infection that follows is resolved before you give birth. This precaution can prevent an oral thrush (yeast) infection from being transmitted to your baby during birth. Aviva Jill Romm’s The Natural Pregnancy Book includes several good remedies, internal and external, for preventing and treating vaginal yeast infections. Sexual contact is another mode of transmission, so husbands need to be included in treatment as well as the mother and baby to break the cycle.

Most antibiotics that are commonly used are generally safe to take while breastfeeding. Small amounts do enter breast milk, and it is possible for some babies to show an allergic reaction, but most won’t.

Ampicillin, amikacin, amoxicillin, gentamicin, methicillin, penicillin, tobramycin, and vancomycin (which is used for methicillin-resistant staph A, or MRSA, infections) are all considered safe for lactating mothers to take. Erythromycin and azithromycin are also considered safe, except when taken during the early postpartum period (when some new-borns whose lactating mothers are taking erythromycin develop pyloric stenosis). Tetracyclines are considered safe, despite their bad reputation for causing discoloration and weakness of enamel of your child’s second set of teeth. These effects happen only when a child is given large doses for more than three weeks. The same goes for doxycycline, a long half-life tetracycline antibiotic.

Furazolidone, a treatment for giardia lamblia, is considered safe in babies more than a month of age and is a good alternative to metronidazole (sometimes known as Flagyl, which is controversial: Some pharmacists advise mothers to stop nursing until twenty-four hours after the last dose, but guidelines in Canada’s CPS state that discontinuing nursing while taking metronidazole is “overly conservative”).

For most nursing mothers and babies, furazolidone and metronidazole pose no problem, and there is no need to stop nursing. If your baby is less than one month old and you are diagnosed with giardia, it would be advisable to wait.

Chinese herbalists use herbs such as garlic, licorice, pulsatilla (bai tou weng), scutellaria (huang qin), portulaca (ma chi xian), stemona (bai bu), and coptis (huang lian) for treating amoebic dysentery in pregnant and lactating mothers. All of these are considered safe within the tradition of Chinese herbal medicine; of these medications, Dr. Hale comments only on garlic, which he puts in his “moderately safe” risk category of medications that lack a foundation of published data regardless of how safe they may actually be.

Antidepressants and tranquilizers: These medications should be used with great caution. Some drugs in this category do produce noticeable effects in babies’ behavior, particularly drowsiness. Many have not been on the market long enough for studies of their long-term effects to be carried out. For these reasons, counseling and lower-impact therapies are preferable, as long as they are effective. It’s important to realize as well that too-sudden weaning can aggravate symptoms of depression because of shifts in hormone levels. Decisions about these medications should be made with a physician who has had experience working with breastfeeding mothers.

The herb St. John’s wort, according to a study published recently by the British Medical Journal, is effective at suppressing anxiety and is virtually devoid of side effects.

Paroxetine (Paxil) is a much-prescribed serotonin reuptake inhibitor (SSRI). Very little of it gets into breast milk.

Sertraline (Zoloft) is another SSRI that is similar to Paxil and Prozac. Dr. Hale puts it in the category of medications for mother that pose only a remote risk for breastfed babies. Very small amounts of the drug get into breast milk.

Fluoxetine (Prozac, Apo-Fluoxetine, Novo-Fluoxetine, Lovan, and Zactin) is a third SSRI that is often prescribed for depression. Some side effects, such as fussiness, colic, and seizures, have been reported in babies of mothers taking these drugs. Dr. Hale remarks that he has received reports of several such cases himself, but he recommends that if a mother taking fluoxetine isn’t able to tolerate a substitute medication, she should continue with the fluoxetine. (The reported problems were seen in babies less than six months old.)

Antifungals: Gentian violet and simple household remedies including vinegar or bicarbonate of soda compresses are good to try first in cases of overgrowth of thrush. Another remedy that many women swear by is grapefruit extract (one pill, or fifteen drops three times a day). If these don’t do the job… clotrimazole and miconazole can be used topically for yeast infections, whether in a baby’s mouth or for vaginal infections. Fluconazole is cleared for direct use in babies older than six months. The FDA has not given this clearance for babies younger than six months, but many pediatricians prescribe it anyway. Rarely, some negative effects to the liver have been reported, mostly in AIDS-infected babies taking other medications. Some of these babies had diarrhea, skin rashes, vomiting, and abdominal pain.

Antiparasitic medications: Avoid Lindane to treat scabies, as it stays in the body for a long time and is quite toxic. Permethrin is a better choice, and it can also be used in case of lice.

Mebendazole can be used for pinworms, roundworms, and hookworms, although it may inhibit milk production in some women.

Asthma medications: Asthma inhalers using ipratropium (DuoNeb) or albuterol (Proventil, Ventolin, Novo-Salmol, Asmavent, Respax, Respolin, Asmol, Salbulin, Salbuvent, and Salamol) are considered safe. Try not to swallow leftover medication after inhaler use.

Theophylline (aminophylline) may be used, but babies sometimes become jittery after its use.

Zafirlukast is considered safe.

Birth-control preparations: Avoid those products that contain estrogen, as they do inhibit milk production. The progestin-only pill (also called the mini-pill) is less likely to negatively affect lactation than those containing estrogen. If the progestin-only pill does reduce your milk supply, it would be good to switch to a hormone-free intrauterine device or barrier methods. Depo-Provera is somewhat controversial during nursing because of reports that it may cause lowered milk production, but these charges haven’t been proven. Look in Resources for books on fertility awareness if you want to avoid any sort of medicated birth-control device.

Blood-pressure-control medications: These drugs haven’t been well studied, since most women of breastfeeding age don’t suffer from hypertension.

Esmolol and nisoldipine are considered safe.

Chemotherapy for cancer: Because of the toxicity of these drugs, it is better not to breastfeed.

Cold and cough medications: These drugs can be taken without prescription, but it’s still advisable to use them cautiously while breastfeeding, as they can affect babies. For example, decongestants can cause babies to become irritable, and antihistamines can make them drowsy.

Be aware that medications containing pseudoephedrine may suppress milk supply.

Medications containing chlorpheniramine and phenylephrine may cause sedation in some babies.

Stay away from cough syrups containing codeine, such as Prometh VC with codeine cough syrup and promethazine HCL with codeine cough syrup. Another cold remedy to avoid is Rynatuss tablets (which contain chlorpheniramine and ephedrine).

In general, nasal sprays are safer for you to take than oral medications while breastfeeding. Such medications are best taken just after a feeding session to minimize the amount that is reaching the baby, and it’s a good idea to limit their use to a day or two at a time. Using a saline nasal wash on a regular basis can prevent nasal, sinus, and ear problems caused by colds, allergies, infections, and exposure to pollution. See Resources.

Diuretics: These medications stimulate the kidneys to increase the amount of urine output. Sometimes they are prescribed to people with hypertension, but they are also sold as weight-loss drugs or antidotes for premenstrual fluid retention. They are best avoided during pregnancy and should be shunned during lactation (when you want more fluid, not less of it).

Migraine medications: Sumatriptan is considered safe. Little is known about other migraine medications.

Pain relievers: Avoid the use of fentanyl during labor, as it can inhibit milk production. The same goes for meperidine (Demerol or Pethidine), which makes the initiation of breastfeeding more difficult. Acetaminophen is considered the safest analgesic while breastfeeding. Narcotics (codeine, hydrocodone, and morphine) are generally safe but shouldn’t be overused, as they may make the baby sleepy. According to the American Academy of Pediatrics (AAP), aspirin is generally safe if used with caution. However, continuous use could possibly cause bleeding in a breastfed baby. Low concentrations of aspirin do come into milk, and although no instances of Reye’s syndrome or aspirin-related bleeding have been reported in breastfed babies, these side effects are considered possible, given sufficient exposure. For these reasons, acetaminophen or ibuprofen would be better choices. Pain relievers for dental work are safe. Nonsteroidal anti-inflammatory medications such as naproxen and piroxicam are considered safe if used for just a few days when a baby is more than a month of age.

Medications Not to Worry About While Breastfeeding

These include antacids, anticonvulsants, cortisone, insulin, laxatives, and thyroid medications. If you should need an MRI scan, you’ll be given an injection of gadopentetate. Even though your radiologist may tell you to stop breastfeeding for twenty-four hours after this injection, only a tiny amount of this drug will get into your milk. The same goes for radiopaque iodine-containing agents. Continue nursing your baby.

Medications Not to Use While Breastfeeding

These include cancer chemotherapy drugs, radioactive drugs, long-term use of sedatives, pseudoephedrine (a decongestant), and ergot alkaloids such as migraine preps, ergotamine, and cabergoline (a relatively new drug used to treat pituitary tumors and other disorders you almost certainly don’t have). Stay away from amphetamines, weight-loss products, and Parlodel (bromocriptine), a medication that was sometimes, and still is, prescribed to women who want to dry up their milk; several maternal deaths from stroke have occurred because of it.

Nonmedical Drugs

Alcohol: Alcohol does enter milk quickly after consumption, and large amounts taken over a short time can get your baby drunk. An occasional glass of wine or beer is not forbidden, but it’s best to wait for an hour or two after a drink before you nurse. Drinking nearly every day is not a good idea, as heavy use may interfere with your ability to let down your milk.

Tobacco: Secondhand smoke is harmful to babies. If you are unable to stop smoking, do it outside to protect your baby.

Cocaine and heroin: Both of these drugs are highly addictive and should therefore be avoided.

Cannabis: Although this controversial herb is listed as contraindicated by the American Academy of Pediatrics, Dr. Hale puts it in a low-risk category, with the dose received being “insufficient to produce significant side effects in the infant.”

Do You Have an Illness That Precludes Breastfeeding?

Women may find themselves diagnosed with illnesses during pregnancy that prompt questions regarding the safety of breastfeeding during the course of the illness or its treatment.

Cancer

The disease itself, in whatever part of the body it resides, is not contagious to others and is not transmitted via milk or bodily fluids. In general, the diagnostic tests that might be used when cancer is suspected need not interrupt breastfeeding. However, the use of radioactive compounds for diagnosis is incompatible with breastfeeding. If this is necessary, a mother should not continue breastfeeding for the duration of exposure and some time beyond (because it takes time for radioactivity to decline). If such a mother decides to express her milk to keep up her supply, her milk can be tested over time to determine its levels of radioactivity.

Chicken pox

Medical experts differ on whether women having chicken pox around the time of birth should be separated from their babies or not. (Some but not all babies get a severe case within the first ten days after birth if their mothers have chicken pox around the time of birth.) The period of contagion is about seven days. If the decision is for separation, milk should be expressed as often as possible and given to the baby. But the separation period in such a case can be shortened if the baby is given a varicella-zoster immune globulin injection, as these antibodies can prevent transmission and reduce the severity of infection.

Hepatitis A

Continue breastfeeding, but make sure that you wash your hands well with soap and water before handling your breasts or your baby’s face, mouth, and hands.

Hepatitis B

If you have this form of hepatitis, the American Academy of Pediatrics Committee on Infectious Diseases recommends that your baby be given the hepatitis B immune globulin and hepatitis B virus vaccine soon after birth. Continue breastfeeding; this should be safe even before any immunization is given.

Hepatitis C

In general, research has not implicated breast milk as a transmitter for the hepatitis C virus, even though the milk may contain the virus. The reason for this may be that milk contains factors that prevent infectious agents from gaining entrance to the baby. Some pediatricians may advise against breastfeeding with cracked or bleeding nipples until the nipples are healed.

Herpes simplex I and II

Herpes simplex I (cold sores) and II (genital lesions) need not affect breastfeeding, as long as the baby does not touch the sores.

HIV (AIDS)

No conclusive evidence has been produced yet regarding which infant feeding method is preferable for the infants of HIV-positive mothers. In poor countries, many experts lean toward breastfeeding, given the many other dangers and challenges surrounding the use of artificial formulas. Many wealthy countries (where milk banks are available) discourage breastfeeding for HIV-positive mothers. In the end, each woman in this situation needs to come to her own best decision, with the help of her physician.

Human T-cell leukemia virus type 1

This type of virus is spread by sexual contact, sharing syringes, blood transfusions, and from mother to child during birth or breastfeeding. Those infected with the virus should not breastfeed, as such infection can cause leukemia and lymphoma.

Toxoplasmosis

This protozoal infection can be contracted through eating infected meat that is raw or undercooked or through contact with infected cat poop. Continue breastfeeding if you are being treated for it.

Tuberculosis

This infectious disease is compatible with breastfeeding, as long as it is considered safe for the mother to be with her baby. If temporary separation is necessary, milk should be expressed and discarded until the period of separation is over.

Herbs to Avoid While Breastfeeding

·      Aloe

·      Buckthorn bark and berry

·      Cascara sagrada bark

·      Coltsfoot leaf

·      Extract of senna leaf, peppermint, and caraway oil

·      Kava kava

·      Indian snakeroot

·      Rhubarb root

·      Senna leaf

·      Sage

·      Uva ursi

·      Jin bu huan

·      Germander

·      Mistletoe

·      Skullcap

·      Mate tea

·      Pennyroyal oil

Breastfeeding is so good for your baby that there is almost never a good reason to stop doing it. Even if your baby gets some of a medication that has been prescribed for you, it would almost always be better for you to continue nursing than to start giving infant formula instead.

 

APPENDIX B: RECENT FORMULA RECALLS

June 2, 2008: Recall of about 13,000 cans of Abbott Laboratories’ Calcilo XD Low-Calcium/Vitamin D-Free infant formula with iron powder in 14.1-oz. cans (400g). Reason: air contamination that causes spoilage of the food and foul smell.

May 28, 2007: Recall of Abbott’s Ross Products’ Similac Special Care 24cal./fl. oz. ready-to-feed premature infant formula with iron (5,000 cases). Reason: insufficient iron; using more than one month could result in anemia (not at all good for at-risk preemies).

December 14, 2006: The FDA told Nestlé that it might have to recall the group’s Good Start Supreme infant formula with iron because tests showed it did not contain the minimum levels of calcium and phosphorus required under U.S. law. Nestlé disputed these findings, claiming that its tests were better than the FDA’s. I could find no further information about how many cans of formula were involved, but none seem to have been recalled.

September 15, 2006: Recall of 200,000 bottles of Ross Products’ Similac Advance with Iron liquid ready-to-feed formula (labeled to be used by May 1, 2007) and 100,000 bottles of Similac Alimentum Advance (also for use by May 1, 2007). The FDA also had to warn that a lot of Similac Advance hospital-discharge gifts may have included some of the recalled products. Reason: not as much vitamin C as indicated on the label and dark, discolored liquid. Vitamin C deficiency could result from more than two to four weeks’ use.

February 22, 2006: Recall of Mead Johnson’s Gentlease powdered infant formula in 24-oz. cans (lot numbers BMJ19). Amount: 41,000 cans. Reason: metal splinters in cans. No one knows how many babies were fed formula with bits of metal before the manufacturer warned retailers to sell no more cans in that lot.

2005: Recall of Similac Advance with iron formula powder. Almost 83,000 cans contained rigid polyvinyl chloride (PVC) particles and were distributed throughout the United States.

2005: Recall of Enfamil LactoFree with Lipil, 76,896 13-oz. concentrated-liquid cans. Reason: The formula had an “off odor, clumping, and product separation.”

2003: Recall of Mead Johnson’s EnfaCare Lipil, 12.9-oz. powdered formula for premature infants, 3,030 cans. Reason: contamination with Enterobacter sakazakii, which can cause sepsis, meningitis, and necrotizing enterocolitis, especially in premature or immunocompromised babies. In December 2002, 505 cases were shipped to hospitals, retail stores, and WIC clinics nationwide.

November 12, 2002: Recall of 1.5 million cans of Wyeth’s powdered formula products. The tainted formula was sold under several names, including Baby Basics (Albertson’s), Kozy Kids (Amway), CVS Soy Infant Formula, Hill Country Fare (HEB Grocery Stores), American Fare Little Ones (K-Mart), HEB Baby Formula, HomeBest, Safeway Select, Healthy Best (Target), Walgreens, Parent’s Choice (Wal-Mart), Healthy Baby, and Perfect Choice. Reason: contamination with a food-borne pathogen that can cause blood infection, meningitis, or necrotizing enterocolitis (severe intestinal infection) in newborn infants.

2002: Recall of Portagen formula, 16-oz. powder; 17,358 cans were shipped nationwide in 2001 by Mead Johnson. Reason: A premature baby died in April 2001 from being given Portagen formula contaminated with Enterobacter sakazakii. Portagen is used for babies having trouble digesting fats.

2001: Recall of Carnation Follow-Up formula, 32-oz. liquid, 120 cans. Reason: excessive magnesium content, which can cause low blood pressure and irregular heartbeat. Wal-Mart stores in nineteen Texas cities sold this stuff.

2001: Recall of Mead Johnson’s LactoFree and Enfamil AR sample packs, distributed by physicians to their patients. Reason: Ingredients weren’t listed on bottles. Babies allergic to milk protein ran the risk of serious or life-threatening allergic reaction if they drank this product.

2001: Recall of Mead Johnson’s Nutramigen powder (3.7 million 16-oz. cans) and Nutramigen ready-to-feed (930,000 32-oz. cans). Reason: incorrect preparation directions in Spanish that could lead to seizures, irregular heartbeat, or death if the formula was used over several days. Babies who were already ill or who lived in hot climates were at greater risk for potentially fatal complications. The formula was distributed nationwide, as well as in Guam, the Dominican Republic, and Puerto Rico. According to lactation consultant Marsha Walker, the product was allowed to remain in stores, with parents being expected to notice the correct preparation instructions in Spanish as tear-off sheets.

2000: Recall of repackaged infant formula: Isomil powder and concentrate; Similac with iron, low-iron powder, and concentrate; Neosure powder; Enfamil low-iron and with-iron powder; Enfamil LactoFree powder; Prosobee soy powder. Reason: misbranded packaging.

2000: Recall of Nestlé Carnation Good Start, Alsoy, and Follow-Up in 13-oz. concentrate (2.5 million cans). Reason: processing screwup, with temperatures not high enough to ensure sterility. Maybe not such a good start after all.

On March 12, 2008, Reuters news agency reported that Nestlé, the world’s largest food company, was recalling a batch of infant formula that had been contaminated with excessive levels of copper, iron, and zinc, causing an unknown number of babies to suffer from vomiting and diarrhea. The Swiss parent company told Reuters that the recalled cans of formula were so foul-smelling that no baby would have swallowed them. Nevertheless, at least fifteen customer complaints followed the news report in certain African countries, so some babies did swallow the stuff. There have been no reports of Nestlé and the other artificial-milk companies paying restitution for the illnesses their products have caused.

Are you surprised by the length of this list? Were any of these recalls publicized well enough for you to have heard about them? I won’t be surprised if your answer is no. FDA’s website does not archive recall information. This means that FDA’s recall notices are posted for only a few weeks before being removed. How many U.S. babies have been made sick or died from drinking some of the “recalled” products mentioned above is unknown, because we currently have no reliable way of gathering this information.

China’s Melamine Scandal and Some
Lessons to Be Learned from It

Following the first official revelations in September 2008, of the melamine-tainted infant-formula scandal in China that killed at least six babies, put another 300,000 in the hospital and permanently damaged the kidneys of an unknown number of those who were hospitalized, the FDA was quick to reassure the U.S. public that there was nothing to fear about contaminated formula in the United States. Dr. Stephen Sundlof, director of the FDA’s Center for Food Safety and Applied Nutrition, told reporters on October 3, 2008, that none of the five manufacturers that supply infant formula to the United States uses any milk or milk products from China.1

Sundlof went on to say that the FDA had determined that for all foods except infant formula, only those with amounts of melamine less than 2.5 parts per million were acceptable. As for levels in infant formula, the Associated Press quoted Sundlof: “FDA is currently unable to establish any level of melamine and melamine-related compounds in infant formula that does not raise public health concerns.” This statement was widely taken to mean there was a policy of zero tolerance of mela mine in U.S. infant formula. According to a statement by the Grocery Manufacturers Association to its members: “FDA could not identify a safe level for melamine and related compounds in infant formula; thus it can be concluded they will not accept any detectable melamine in infant formula.”2

Less than two months later, the FDA reported that it had found trace amounts of melamine in the U.S. formulas produced by the big three companies: Nestlé, Mead Johnson, and Abbott (their infant formula constitutes ninety percent of that sold in the United States). At the same time, the agency stated a new standard for melamine in baby formula that would consider products with less than 1 part per million of melamine acceptable, provided that cyanuric acid (a melamine byproduct) was not also present.

Consumers Union called the FDA decision “seriously flawed” and medically risky because parents may feed their babies more than one product. Author James E. McWilliams, in an article forSlate.com, called the FDA decision “the arbitrary adjustment of allowable levels of a contaminant.”3 According to Urvashi Rangan, a senior scientist with the Consumers Union, “The FDA needs to step up and expand melamine testing. The failure to properly inform people about these findings undermines consumer confidence in a fundamental product that millions of parents depend on.”4

Remarkably, the new U.S. standard for melamine allows for twenty times as much of the chemical in infant formula as Taiwan’s standard of 0.5 part per million. Why is this standard not possible in the United States?

APPENDIX C: THE TEN STEPS
TO
 SUCCESSFUL BREASTFEEDING

A Joint WHO/UNICEF Statement, Geneva, Switzerland, 1989

Every facility or agency providing maternity services and care of newborn infants should:

·      Have a written breastfeeding policy that is routinely communicated to all health-care staff.

·      Train all health-care staff in skills necessary to implement this policy.

·      Inform all pregnant women about the benefits and management of breastfeeding.

·      Help mothers initiate breastfeeding within one half-hour of birth.

·      Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.

·      Give newborn infants no food or drink other than breast milk, unless medically indicated.

·      Practice rooming-in—that is, allow mothers and infants to remain together twenty-four hours a day.

·      Encourage breastfeeding on demand.

·      Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

·      Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.