Breastfeeding: Primary Care Preventions --Pregnant women, new mothers, and their children


General

Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding.

Frequency of Service

During pregnancy and after birth

Risk Factor Information

This recommendation applies to pregnant women, new mothers, and their infants and children. Interventions to support breastfeeding may also involve a woman's partner, other family members, and friends. This recommendation does not apply in circumstances where there are contraindications to breastfeeding (e.g., certain maternal medical conditions or infant metabolic disorders, such as galactosemia). The USPSTF did not review evidence on interventions directed at breastfeeding of preterm infants.


Clinical

Patient Population Under Consideration

This recommendation applies to pregnant women, new mothers, and their infants and children. Interventions to support breastfeeding may also involve a woman's partner, other family members, and friends. This recommendation does not apply in circumstances where there are contraindications to breastfeeding (e.g., certain maternal medical conditions or infant metabolic disorders, such as galactosemia). The USPSTF did not review evidence on interventions directed at breastfeeding of preterm infants.

Interventions

Breastfeeding support can begin during pregnancy and continue through the early life of the child. Primary care clinicians can support women before and after childbirth by providing interventions directly or through referral to help them make an informed choice about how to feed their infants and to be successful in their choice. Interventions include promoting the benefits of breastfeeding, providing practical advice and direct support on how to breastfeed, and providing psychological support. Interventions can be categorized as professional support, peer support, and formal education, although none of these categories are mutually exclusive, and interventions may be combined within and between categories.

Professional Support

Professional support is 1-on-1 counseling about breastfeeding provided by a health professional (medical, nursing, or allied professionals, including those providing lactation care). Some interventions include the provision of supplies, such as educational materials, nursing bras, and breast pumps. Professional support can include providing information about the benefits of breastfeeding, psychological support (encouraging the mother, providing reassurance, and discussing the mother’s questions and problems), and direct support during breastfeeding observations (helping with the positioning of the infant and observing latching). Professional support may be delivered during pregnancy, the hospital stay, the postpartum period, or at multiple stages. It may be conducted in an office setting, in the hospital, through home visits, through telephone support, or any combination of these. Sessions generally last from 15 to 45 minutes, although some programs have used shorter or longer sessions. Most successful interventions include multiple sessions and are delivered at more than 1 point in time.

Peer Support

Similar to professional support, peer support provides women with 1-on-1 counseling about breastfeeding but is delivered by a layperson (generally a mother with successful breastfeeding experience and a background similar to that of the patient) who has received training in how to provide support. Like professional support, peer support may be delivered through a variety of stages, settings, methods, and durations.

Formal Education

Formal education interventions typically include a formalized program to convey general breastfeeding knowledge, most often in the prenatal period, although some may span time periods. Education is usually offered in group sessions and may include telephone support, electronic interventions, videos, and print materials. They are directed at mothers but may include other family members. Content generally focuses on the benefits of breastfeeding, practical breastfeeding skills (e.g., latching), and the management of common breastfeeding complications; these programs may also offer family members encouragement and advice on how to support the mother.

Useful Resources

The Centers for Disease Control and Prevention provides information on different breastfeeding intervention strategies, including program examples and resources.2 Another resource is the Surgeon General’s "Call to Action to Support Breastfeeding".3

Rationale

Importance

There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women. However, nearly half of all mothers in the United States who initially breastfeed stop doing so by 6 months, and there are significant disparities in breastfeeding rates among younger mothers and in disadvantaged communities.1

Effectiveness of Interventions to Change Behavior

Adequate evidence indicates that interventions to support breastfeeding increase the duration and rates of breastfeeding, including exclusive breastfeeding.

Harms of Interventions to Change Behavior

There is adequate evidence to bound the potential harms of interventions to support breastfeeding as no greater than small, based on the nature of the intervention, the low likelihood of serious harms, and the available information from studies reporting few harms.

USPSTF Assessment

The USPSTF concludes with moderate certainty that interventions to support breastfeeding have a moderate net benefit for women and their children.


Others

Other Considerations Implementation Although there is moderate certainty that breastfeeding is of moderate net benefit to women and their infants and children, not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values, and preferences.In addition to clinicians’ direct activities to support breastfeeding, there are system-level interventions intended to promote breastfeeding. System-level interventions include policies, programs, and staff training, usually implemented within hospitals or health care systems. The Baby Friendly Hospital Initiative is the most widely implemented system-level intervention and is based on the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) "10 Steps to Successful Breastfeeding for Hospitals".4 Other system-level interventions include maternity care practices such as encouraging skin-to-skin contact, rooming-in, restricted pacifier use, and distributing breast pumps. Community-based interventions include social marketing initiatives, workplace initiatives, and public policy actions. A comprehensive review of the evidence on the effectiveness of these types of system-level interventions for the purposes of making a recommendation is beyond the scope of the USPSTF. A focused review of system-level interventions is included in the full evidence report,5and the Centers for Disease Control and Prevention also provides information about individual, system-level, and community-based interventions.6 Research Needs and Gaps To better assess how population-level interventions would affect breastfeeding rates, future studies should include women who have not already declared their intention to breastfeed. To better understand the effects of different interventions and patient populations, future research should include adequate sample sizes, clear descriptions of the included populations and comparators, and standardized reporting of outcomes. Studies would be more useful if they are designed to allow assessment of the relative contributions of individual components of multicomponent breastfeeding support programs. Trials should include reliable and valid measures of infant and maternal health outcomes and be powered to detect potential effects on these outcomes. Studies also should explore maternal satisfaction with the intervention and any potential negative feelings or feelings of inadequacy that could result if mothers choose not to or are unable to breastfeed. Studies in populations with low breastfeeding rates are especially needed, and more research is needed to better understand the root causes of breastfeeding disparities and how they can be addressed through health care and community interventions. Other areas for research include the potential benefits and harms of supporting indirect breastfeeding (e.g., use of breast pumps), the role of breastfeeding support for adoptive or surrogate families, the role of systems to distribute donor breast milk, and the effect of new technologies to support breastfeeding (e.g., web- or computer-based interventions). Update of USPSTF Recommendations This recommendation updates the 2008 USPSTF recommendation on primary care interventions to promote and support breastfeeding. The scope of the review and type of interventions recommended did not change. The grade of the recommendation remains a B. Recommendations of Others Several national and international organizations, including the American Academy of Pediatrics (AAP),15 the American College of Obstetricians and Gynecologists (ACOG),16 and WHO/UNICEF,17 recommend exclusive breastfeeding up to around 6 months, followed by continued breastfeeding for at least 1 year, as mutually desired by mother and infant, while complementary foods are introduced. ACOG also recommends that all obstetrician-gynecologists and other providers of obstetric care develop and maintain knowledge and skills in anticipatory guidance and support each woman’s informed decision about whether to initiate or continue breastfeeding. ACOG endorses the integration of the WHO/UNICEF "10 Steps to Successful Breastfeeding" into maternity care to increase the likelihood that women achieve their personal breastfeeding goals.16 AAP recommends that pediatricians serve as breastfeeding advocates and educators, provides resources that pediatricians can use in their practices, and endorses the WHO/UNICEF "10 Steps to Successful Breastfeeding".15 The American Academy of Family Physicians recommends providing interventions during pregnancy and after birth to support breastfeeding.18 The National Association of Pediatric Nurse Practitioners endorses the optimization of infant breastfeeding and breastfeeding promotion as part of pediatric care.19 In 2011, the US Surgeon General issued a call to action that clinicians, health systems, community programs, and government policy support women who choose to breastfeed.3


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