Editorials

Promoting and Supporting Breastfeeding

Am Fam Physician. 2001 Sep 15;64(6):931-932.

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Family physicians, as doctors of women and children, are in the ideal position to promote and support breastfeeding. The American Academy of Family Physicians' (AAFP) policy “Breastfeeding and infant nutrition“ states, “Human milk is the optimal form of nutrition for infants.”1 With input from AAFP, the U.S. Department of Health and Human Services has published “Breastfeeding: HHS blueprint for action on breastfeeding,” an up-to-date, comprehensive review of the evidence of the medical and economic benefits of breastfeeding for women, children, families and employers.2

Despite recent increases, rates of breastfeeding initiation and continuation fall far short of national public health goals.3 Results of studies evaluating why American women choose not to breastfeed reveal a variety of barriers that include a lack of broad social support, insufficient prenatal breastfeeding education and media portrayal of formula feeding as normative.4 Another obstacle—a surprising one, given the extensive research detailing the benefits of breastfeeding and the concomitant risks associated with breastmilk substitutes—is the degree of physician misinformation about and apathy toward breastfeeding.5,6

Because most women have made important decisions about infant feeding by the beginning of the third trimester, prenatal education about breastfeeding should begin at the first prenatal visit and continue throughout the pregnancy. Physicians should be prepared to address common barriers to breastfeeding, such as unsupportive partners and family members, concerns about returning to work and breastfeeding in public, attitudes about body image and the sexualization of the female breast. As with most patient education, breastfeeding support will be more successful if conducted in a culturally responsive way. Culturally appropriate breast-feeding education may be one of the keys to reaching out to the black community, which has significantly lower rates of breastfeeding initiation and continuation.7

Disruptive hospital policies have been identified as one obstacle to the initiation and continuation of breastfeeding in the United States.4 In this issue of American Family Physician, Sinusas and Gagliardi8 provide evidence-based recommendations to reevaluate labor and delivery practices to provide an environment for mothers and infants that is safe and conducive to breastfeeding.

Recent efforts in prenatal breastfeeding education and the movement among hospitals to become more “baby friendly” have resulted in an increasing number of American women initiating breastfeeding. Nonetheless, family physician and Surgeon General David Satcher states, “The rates of breastfeeding in the United States are [still] low, especially at 6 months postpartum,” and suggests that, in addition to continuing our efforts to initiate breastfeeding, strategies to support the continuation of breastfeeding must be developed.2

Supporting the continuation of breastfeeding begins with anticipatory guidance while women and infants are still in the hospital. In addition to teaching new parents how to know if their child is getting enough milk and how to manage engorgement, important concepts such as the supply and demand nature of breastmilk production can be reviewed. Before discharge, we should ensure that women who breastfeed know how to obtain additional help—and feel comfortable in doing so.

Physicians, as well, must feel comfortable asking for assistance. We should establish relationships with knowledgeable professionals, including lactation consultants, so curb-side consultations can be obtained and appropriate referrals arranged when necessary. We can recognize that factors such as an inverted nipple or a cesarean section are indications for providing a new mother with additional breastfeeding support. By ensuring timely post-hospital follow-up for all breast-feeding mothers, we are in the position to provide lactation support and to identify potential problems before they lead to premature weaning.

In efforts to improve the quality of care we provide, we must make sure that physician misinformation is no longer a barrier to continued breastfeeding. While recognizing the very few medical contraindications to breast-feeding that exist, physicians can support women and children through most medical situations. For example, breastfeeding should not be discontinued for physiologic jaundice or mastitis. When lactating women require medications, appropriate treatments can be found by using up-to-date resources including texts, online information and knowledgeable consultants. As medical school and residency curricula begin to include breastfeeding and additional CME opportunities assist those of us in practice, physicians will advocate for extended breastfeeding as we recognize its benefits for women and children.

To dispel the perception of physician apathy, there are many ways a family physician's office can encourage breastfeeding. In addition to displaying photographs or posters of breastfeeding women, we can post a sign stating, “You are welcome to breastfeed here.” As partners with the physicians, the entire staff can be recruited to provide a consistent pro-breastfeeding message. Both directly and indirectly, the routine distribution of free formula samples undermines the promotion and support of lactation. We can also make our offices into models of breastfeeding–supportive workplaces by creating lactation rooms, providing lactation breaks and allowing flexible scheduling for employees and partners who are breastfeeding.

The AAFP's Advisory Committee on Breastfeeding has developed an evidence-based position paper that will be presented at the 2001 AAFP Congress of Delegates. The AAFP recognizes the importance of breastfeeding and the central role family physicians must play in promoting and supporting it.1

David Meyers, M.D., recently completed a fellowship in health policy and research in the Georgetown University School of Medicine Department of Family Medicine and is a member of the American Academy of Family Physician's Advisory Committee on Breastfeeding.

Address correspondence to David Meyers, M.D., Department of Family Medicine, 212 Kober-Cogan Hall, Georgetown University School of Medicine, 3800 Reservoir Road, NW, Washington, D.C. 20007 (e-mail: davidmeyersmd@hotmail.com). Reprints are not available from the author.

REFERENCES

1. AAFP reference manual: selected policies on health issues. American Academy of Family Physicians. Kansas City, Mo.: The Academy, 1999–2000:59.

2. Breastfeeding: HHS blueprint for action on breastfeeding. Washington, D.C.: U.S. Dept. of Health and Human Services, Office on Women's Health, 2000.

3. Healthy People 2010. Washington D.C.: U.S. Dept. of Health and Human Services, Public Health Services, November 2000.

4. Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group on Breastfeeding. Pediatrics. 1997;100:1035–9.

5. Freed GL, Clark SJ, Sorenson J, Lohr JA, Cefalo R, Curtis P. National assessment of physicians' breastfeeding knowledge, attitudes, training, and experience. JAMA. 1995;273:472–6.

6. Schanler RJ, O'Connor KG, Lawrence RA. Pediatricians' practices and attitudes regarding breastfeeding promotion. Pediatrics. 1999;103:E35.

7. Forste R, Weiss J, Lippincott E. The decision to breastfeed in the United States: does race matter? Pediatrics. 2001;108:291–6.

8. Sinusas K, Gagliardi A. Initial Management of Breastfeeding. Am Fam Physician. 2001;64:981–90,991–2.


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