Promotion and support of breastfeeding

MEDLINE
Counseling Interventions Recommended to Promote and Support Breast-Feeding
News Author: Laurie Barclay, MDCME Author: Charles Vega, MD
Release Date: October 23, 2008;
Authors and Disclosures
Laurie Barclay, MDDisclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Charles Vega, MDDisclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.

Laurie Scudder, MS, NP-CDisclosure: Laurie Scudder, MS, NP-C, has disclosed no relevant financial information.

Brande Nicole MartinDisclosure: Brande Nicole Martin has disclosed no relevant financial information.


October 23, 2008 — The US Preventive Services Task Force (USPSTF) has issued an updated statement recommending counseling interventions during pregnancy and after birth to promote and support breast-feeding. The updated guidelines and evidence review are published in the October 21 issue of the Annals of Internal Medicine.
"In children, breastfeeding has been associated with a reduction in the risk for acute otitis media, nonspecific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, childhood leukemia, and the sudden infant death syndrome," write Mei Chung, MPH, from Tufts-New England Medical Center Evidence-Based Practice Center in Boston, Massachusetts, and coauthors of the accompanying evidence review. "In mothers, a history of lactation has been associated with a reduced risk for type 2 diabetes and breast and ovarian cancer. According to the American Academy of Pediatrics, some of the obstacles to initiation and continuation of breastfeeding include insufficient prenatal education about breastfeeding, disruptive maternity care practices, and lack of family and broad societal support."
The goal of the evidence review was to evaluate the efficacy of primary care–based interventions to promote breast-feeding in breast-feeding rates and child and maternal health outcomes.
The reviewers performed electronic searches of MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL from September 2001 to February 2008 as well as references of selected articles. Inclusion criteria for the review were English-language publications describing randomized controlled trials of interventions initiated in primary care to promote breast-feeding, primarily in developed countries.
Pertinent data reviewed by the authors included characteristics of interventions and comparators, study setting and design, clinical and demographic characteristics of the study sample, the proportion of infants continuing to be breast-fed for various durations, and health outcomes in infant and mother.
Of 38 randomized controlled trials identified that met inclusion criteria, 36 took place in developed countries. Breast-feeding promotion interventions in developed countries were associated with significantly increased rates of short-term (1 - 3 months) and long-term (6 - 8 months) exclusive breast-feeding, based on random-effects meta-analyses. Rate ratios were 1.28 for short-term rates (95% confidence interval [CI], 1.11 - 1.48) and 1.44 for long-term rates (95% CI, 1.13 - 1.84).
Compared with either prenatal or postnatal interventions alone, combining prenatal and postnatal breast-feeding interventions had a greater effect on increasing breast-feeding durations, according to the results of subgroup analyses. In increasing the short-term breast-feeding rate, interventions associated with a component of lay support, such as peer support or peer counseling, were more effective than usual care.
Limitations of this review included clinical and methodologic heterogeneity, precluding extensive meta-analyses; and inability to obtain reliable estimates for the isolated effects of each component of multicomponent interventions.
"Evidence suggests that breastfeeding interventions are more effective than usual care in increasing short- and long-term breastfeeding rates," the review authors write. "Combined pre- and postnatal interventions and inclusion of lay support in a multicomponent intervention may be beneficial."
On the basis of the above-described systematic evidence review, the USPSTF evaluated the efficacy of interventions to promote and support breast-feeding that were initiated in, conducted in, or referred to primary care. The resulting guidelines are an update of the 2003 USPSTF recommendation on counseling to promote breast-feeding.
Because the USPSTF concluded that there was moderate certainty that interventions to promote and support breast-feeding have a moderate net benefit, the updated statement recommends interventions during pregnancy and after birth to promote and support breast-feeding (grade B level recommendation).
"There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women," write Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment in Denver, and colleagues. "Adequate evidence indicates that interventions to promote and support breastfeeding increase the rates of initiation, duration, and exclusivity of breastfeeding. No published studies focus on the potential direct harms from interventions to promote and support breastfeeding."
Although the review did not include a search for possible harms associated with breast-feeding itself, the USPSTF concluded that the potential harms of interventions to promote and support breast-feeding were no greater than small.
The task force noted that interventions including both prenatal and postnatal components may be most effective at increasing duration of breast-feeding, and they also recommended considering multiple intervention strategies. These may include formal breast-feeding education for mothers and their families, direct support of mothers during breast-feeding, training primary care staff regarding breast-feeding and various techniques for breast-feeding support, and peer support.
"Although the activities of individual clinicians to promote and support breastfeeding are likely to be positive, additional benefit may result from efforts that are integrated into systems of care," the statement authors conclude. "System-level interventions can incorporate clinician and team member training and policy development, and through senior leadership support and institutionalization, these initiatives may be more likely to be sustained over time. Although outside the scope of this recommendation and evidence review, community-based interventions to promote and support breastfeeding, such as direct peer-to-peer support, social marketing initiatives, workplace initiatives, and public policy actions, may offer additional sizeable benefits."
The Agency for Healthcare Research and Quality, US Department of Health and Human Services, supported this evidence review and statement. The authors of the statement have disclosed no relevant financial relationships.
Ann Intern Med. 2008;149:560-564, 565-582.
Clinical Context
The American Academy of Pediatrics recommends breast milk as the preferred choice for feeding infants, and the goals of the Healthy People 2010 initiative includes a target of 75% of mothers initiating breast-feeding their infants. In the United States, the rate of new mothers initiating breast-feeding was 73% in 2005, and 20% of mothers breast-fed their infants exclusively for 12 months. These rates in 2005 were higher vs 2002.
In its last recommendation in 2003, the USPSTF recommended counseling to promote higher rates of breast-feeding. The current recommendation uses the results of a systematic review of data available from January 2007 to update this recommendation. The results of this review and new recommendation are described in the "Study Highlights."
Study Highlights
Breast-feeding has been associated with numerous health benefits for both mother and infant. Breast-feeding during infancy has been associated with lower rates of otitis media, respiratory tract infection, and gastrointestinal tract infection. Later in childhood, breast-fed children have a lower risk for asthma, obesity, and type 2 diabetes vs children who were not breast-fed. Finally, breast-feeding is associated with lower risks for breast and ovarian cancer in the mother.
The systematic review included 38 randomized controlled trials of primary care–initiated interventions to promote breast-feeding. Study settings included primary care offices, hospital settings, and patient homes. The majority of these studies were located in developed countries.
Overall, breast-feeding promotion increased the odds ratio of breast-feeding during 1 to 3 months by a factor of 1.28. These programs increased the odds ratio of breast-feeding during 6 to 8 months by 1.44.
One study from Belarus, a developing country, demonstrated that a program to promote breast-feeding not only improved rates of breast-feeding but also reduced rates of gastrointestinal tract infection and atopic dermatitis in children.
Many interventions used multiple modalities to promote breast-feeding, so it was difficult to identify the most effective individual tool to increase the rate of breast-feeding. However, interventions built into health systems seemed to be the most effective, and combining prenatal and postnatal interventions was more effective than either type of intervention alone.
Interventions involving lay workers appeared more effective than usual care in promoting higher rates of breast-feeding.
No harms were reported in research studying interventions to support breast-feeding.
Overall, the USPSTF gives a grade B recommendation to interventions to promote and support breast-feeding. This level means that there is a high certainty of a moderate degree of benefit for these interventions or that a moderate certainty that the benefit is moderate to substantial.
The authors of the current recommendation call for further research into the individual components of breast-feeding promotion programs as well as cost-benefit analyses of these programs.
Pearls for Practice
Breast-feeding during infancy has been associated with lower rates of otitis media, respiratory tract infection, and gastrointestinal tract infection. Later in childhood, breast-fed children have a lower risk for asthma, obesity, and type 2 diabetes vs children who were not breast-fed. Finally, breast-feeding is associated with lower risks for breast and ovarian cancer in the mother.
The USPSTF recommends measures to promote and support breast-feeding in the prenatal and postnatal periods (a grade B recommendation).