Environment

day one project

Transforming Infant Nutrition to Give Every Baby a Strong, Healthy Foundation

07.21.20 | 6 min read | Text by Andrea Ippolito

Breastfeeding can provide important health and financial benefits for new families. But insufficient healthcare coverage, underlying medical conditions, and economic obstacles can make breastfeeding difficult or impossible for many parents. In this memo, a three-pronged approach is proposed—facilitated by an interagency collaboration through the National Advisory Council on Maternal, Infant, and Fetal Nutrition—to transform infant nutrition. First, to increase breastfeeding rates in the United States, the Centers for Medicare & Medicaid Services (CMS) should alter reimbursement policy by reimbursing tele-lactation and nutrition support for all babies covered under Medicaid. Second, the government should partner with the private sector to launch a “Synthesizing Human Milk Grand Innovation Challenge” to catalyze new extramural R&D and innovation efforts to accelerate commercialization of breast-milk alternatives for those that cannot breastfeed. And finally, the government should enact paid parental leave policies to give parents financial flexibility and dedicated time after birth to breastfeed.

Challenge and Opportunity

To ensure that all babies begin their lives on equal footing, swift action should be taken to give as many babies as possible access to breastmilk and high-quality breastmilk alternatives. Though breastfeeding and breastmilk represent only 0.04% of the National Institute of Health (NIH) budget, access to breastmilk and infant nutrition are issues that affect the health and finances of all American families with very young children. For babies, access to breastmilk has been shown to protect against respiratory illnesses, ear infections, gastrointestinal diseases, eczema, and sudden infant death syndrome. For mothers, breastfeeding may help reduce postpartum blood loss and may lower risk of post-partum depression, Type 2 diabetes, rheumatoid arthritis, cardiovascular disease, breast cancer, and ovarian cancer. The U.S. Department of Agriculture (USDA) Economic Research Service has estimated that Medicaid would save at least $172.6 million every year if breastfeeding rates among women, infants, and children increased to medically recommended levels.¹ More broadly, one study highlighted by the American College of Obstetricians and Gynecologists (ACOG) estimated that increasing breastfeeding rates could save $3.6 billion annually in the costs of treating some childhood illnesses.²

While breastfeeding can provide important health and financial benefits for new families, not all babies can breastfeed. 1 in 8 mothers in the United States face lactation dysfunction, which means that they cannot produce enough breastmilk to provide sufficient infant nutrition.³ Medical conditions such as Insufficient Glandular Tissue (IGT), mastitis, postpartum depression and anxiety (PPD/A), and infant birth defects—to name just a few—present challenges to breastfeeding. Adoptive parents can only breastfeed in certain circumstances, and birth mothers may be confused about whether they can breastfeed while on certain medications, may dislike the process of breastfeeding, or face difficulty breastfeeding while transitioning back to work.

For these and other reasons, 75% of babies use infant formula instead of breastmilk to some extent by the time they are 6 months old. A 2007 report from the Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ) found that existing formula-feeding solutions are associated with higher risks for chronic diseases including Type 2 diabetes, asthma, and childhood obesity.⁴ Formula feeding is also linked with higher rates of necrotizing enterocolitis (NEC) for premature infants. More research is needed to understand the underlying biochemical mechanisms of human breastmilk to develop infant formulas that better mimic breastmilk. In addition, infant formula is a major expense for the federal government. Infant formula is the single most expensive item that the federal Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) provides, and the program spends more on formula than any other food—a total of $927 million in FY 2010.

It is also important to note that paid parental leave is a critical part of the postnatal experience for mothers and babies. Increases in paid parental leave are consistently associated with better infant and child health, particularly in terms of lower infant mortality rates.⁵ Paid parental leave also gives parents the opportunity and flexibility to focus on breastfeeding, which can be extremely time-consuming. The children of educated, well-off mothers are more likely to breastfeed because they have access to paid parental leave, careers with access to breaks for breast pumping, and disposable income to hire support such as night nurses. However, according to a national survey of employers conducted by the Bureau of Labor Statistics (BLS), only 18% of private industry U.S. employees had access to paid family leave through their employers. Paid parental leave in the private sector is voluntary and more prevalent among managerial and professional occupations.

Plan of Action 

CMS, USDA, NIH, state WIC agencies, and the private sector should work together through the National Advisory Council on Maternal, Infant, and Fetal Nutrition to transform U.S. infant nutrition for the better. The following specific actions are recommended:

First, to increase breastfeeding rates in the United States, CMS should alter its reimbursement policy to reimburse bi-weekly tele-lactation and nutrition support appointments for any baby covered under Medicaid during the baby’s first three months of life. Currently, the Affordable Care Act requires private insurance plans and Medicaid expansion programs to cover maternity care—including prenatal screenings and lactation consultations—without cost sharing by the patient. But there is no federal requirement to reimburse for telemedicine. Advocates should encourage the Center for Consumer Information and Insurance Oversight (CCIIO) at CMS to expand mandatory maternal-health coverage to include telehealth and for CMS to implement this policy change. This can be done in collaboration with WIC, which already provides breastfeeding support through state agencies.

Second, the federal government should catalyze new R&D and innovation efforts to accelerate commercialization of high-quality breastmilk alternatives such as

• Organizing a national “Synthesizing Human Milk R&D Summit.” This Summit would bring together formula makers, academic researchers, clinicians, parent and infant advocacy groups, representatives of the public-health community, and government stakeholders. Government stakeholders include NIH, CMS, the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration [FDA], the U.S. Surgeon General, and the U.S. Preventive Services Task Force (USPSTF). The goals for the event include (i) gathering input and commitments from stakeholders to lay the groundwork for a “Synthesizing Human Milk Grand Challenge” (see next bullet); (ii) identifying barriers to developing an infant formula that more closely mimics breast milk; and (iii) generating a white paper to summarize the current understanding of the underlying biochemical mechanisms of human milk.
• Launching a “Synthesizing Human Milk Grand Challenge.” Based on the insights gained by the Synthesizing Human Milk R&D Summit, NIH should launch a “Synthesizing Human Milk Grand Challenge” that awards cash prizes for innovations in development of human breastmilk alternatives. Industry stakeholders should be recruited to match NIH investments in the prize amounts.
• Dedicating extramural academic research funds from NIH as well as funds from the Small Business Innovation Research (SBIR) program to stimulate commercialization of high-quality breastmilk alternatives. These funds would help scale up innovations from the “Synthesizing Human Milk Grand Challenge” and would motivate additional R&D in academic settings to bring infant formula closer to human milk. In addition, a “synthesizing human milk” budget set-aside subpriority should be established as part of the SBIR NIH/NICHD program.
• Only purchasing validated infant formulas with federal funds. WIC should only buy infant formula solutions that demonstrate specific outcomes as outlined by an interagency committee convened by the USDA through the National Advisory Council on Maternal, Infant, and Fetal Nutrition. The committee should include representatives from NIH, CMS, CDC, USDA, FDA, USPSTF, and the American Academy of Pediatrics (AAP).

Third, in the longer term, the federal government should enact paid parental-leave policies that give parents financial flexibility and dedicated time after birth to breastfeed.