Editorials - September 15, 2001 - American Family Physician

Editorials

Promoting and Supporting Breastfeeding

DAVID MEYERS, M.D.
Georgetown University School of Medicine Washington, D.C.

See article on page 981.

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 breastfeeding 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 curbside 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 breastfeeding 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 breastfeeding 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 breastfeedingsupportive 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

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

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

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

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

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.

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

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

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

The ABCs of Treating Congestive Heart Failure

JAY SIWEK, M.D.
Georgetown University Medical Center, Washington, D.C.

See article on page 1045.

In a two-part article published in this issue and the previous issue of American Family Physician, Chavey and associates^1,2 summarize current guidelines for the treatment of congestive heart failure caused by systolic dysfunction. As with guidelines in general, putting this one into practice is, by way of paraphrase, easier "read" than done. Studies repeatedly show the poor track record physicians have in implementing clinical guidelines--even ones with which they agree.^3,4 This is probably more true in cardiovascular medicine than in most other fields. Physicians, cardiologists and primary care physicians alike, often fail to prescribe aspirin and beta blockers after myocardial infarction, or fail to use angiotensin-converting enzyme inhibitors in patients with congestive heart failure, despite the proven benefits of these medications.

TABLE 1
ABC Mnemonic for the Treatment of Coronary Artery Disease

A Aspirin* and antianginal agents*

B Beta blockers* and blood pressure control*

C Cholesterol lowering* and cigarette cessation*

D Diet (low fat)Ý and diabetes controlÝ

E EducationÝ and exerciseÝ

*--Shown to improve survival.
Ý--Shown to improve symptoms and function.

Adapted with permission from Gibbon RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angine). J Am Coll Cardiol 1999;33:2092-197; retrieved July 2001, from: http://www.americanheart. org/Scientific/statements/1999/stable_angina.

TABLE 2
ABC Mnemonic for the Treatment of Congestive Heart Failure

A Angiotensin-converting enzyme inhibitors,* aldosterone antagonist (spironolactone [Aldactone] for moderate to severe congestive heart failure)*

B Beta blockers (e.g., carvedilol [Coreg])*

C Cigarette cessationÝ

D Diet (low salt),Ý diuretics,Ý digoxin (Lanoxin)Ý

E Education,Ý exerciseÝ

*--Shown to improve survival.
Ý--Shown to improve symptoms and function.

The American College of Cardiology and the American Heart Association have developed a simple mnemonic to help physicians remember the ABCs of cardiovascular therapy (Table 1).⁵ Because of the overlap in treatment between coronary heart disease and congestive heart failure, these ABCs could readily be adapted to the latter condition (Table 2). Not all of the listed interventions will apply to every patient, and not all have been shown to reduce morbidity and mortality. However, the mnemonic is useful for reminding physicians about key considerations in treating congestive heart failure. So, when treating patients with congestive heart failure, remember your ABCs!

Jay Siwek is professor and chair of the Department of Family Medicine at Georgetown University School of Medicine. He is also the editor of American Family Physician.

Address correspondence to Jay Siwek, M.D., Department of Family Medicine, 212 Kober-Cogan Hall, Georgetown University Medical Center, 3800 Reservoir Rd. NW, Washington, D.C. 20007 (e-mail: siwekj@georgetown.edu).

REFERENCES

Chavey WE II, Blaum CS, Bleske BE, Harrison RV, Kesterson S, Nicklas JM. Guideline for the management of heart failure caused by systolic dysfunction: Part II. Treatment. Am Fam Physician 2001;64:1045-54.

Chavey WE II, Blaum CS, Bleske BE, Harrison RV, Kesterson S, Nicklas JM. Guideline for the management of heart failure caused by systolic dysfunction: Part I. Guideline development, etiology and diagnosis. Am Fam Physician 2001;64:769-74.

Cohen JD. ABCs of secondary prevention of CHD: easier said than done. Lancet 2001;357:972-3.

Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. EUROASPIRE I and II Group. European Action on Secondary Prevention by Intervention to Reduce Events. Lancet 2001;357:995-1001.

Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). J Am Coll Cardiol 1999;33:2092-197. Retrieved July 2001, from: http://www.americanheart.org/Scientific/statements/1999/stable_angina.

Concussion in Sports

THEODORE G. GANIATS, M.D.
University of California, San Diego, School of Medicine
La Jolla, California

See article on page 1007.

Evidence-based medicine offers the promise of improved health outcomes for our patients. The problem is that the evidence is often difficult to find, conflicting or insufficient to guide our practice. Sometimes, it is just impossible to keep up with the latest changes. For physicians who are interested in evidence-based medicine, clinical practice guidelines offer a solution. Guidelines can synthesize a comprehensive review, letting us know what the bulk of the evidence says. When the evidence does not exist or is insufficient, a good guideline, explicit in its limitations and methods and written by consensus, can still offer direction.

In this issue of American Family Physician, Kushner¹ reviews concussion in sports, relying on a guideline for the management of minor closed head injury in children that was jointly developed by the American Academy of Pediatrics and the American Academy of Family Physicians (AAFP) and published in 1999.² As one of AAFP's representatives on the panel that developed this guideline, I take special interest in seeing how others apply it. There are three key issues for the family physician to consider in reading Kushner's article. First, what are the limitations of the original guideline? Second, how do these limitations affect Kushner's view? Finally, does the article exhibit a subspecialist bias?

The panel members who developed the guideline were disappointed by the paucity of evidence on the subject. Our literature search identified 542 articles, and 64 articles were included in the review. Despite all this "evidence," we never found some key data, such as a description of the natural history of minor head trauma (e.g., a person with minimal symptoms and a mild abnormality or small bleed demonstrated on computed tomographic scanning). Without this information, it is not possible to determine the true benefit of any intervention, nor is it possible to ascertain the risks of watchful waiting. In the end, we had to make a decision, and the decision was made by consensus. While not evidence-based, this decision and the process behind it are explicitly stated in the guideline. The bottom line is that the guideline Kushner used to support his article lacks some of the critical evidence we would like, but it is the best document available.

The question of how to manage a child with mild head trauma has been controversial, and the guideline, written as a collaborative product of the two major specialties caring for children, clearly sets the parameters for good care. However, the guideline refers to a specific patient group: ". . . previously neurologically healthy children of either sex two through 20 years of age, with isolated minor closed head injury . . . who have normal mental status at the initial examination, who have no abnormal or focal findings on neurological (including funduscopic) examination, and who have no physical evidence of skull fracture . . . who may have experienced temporary loss of consciousness (duration <1 minute) . . . evaluated by a health care professional . . . within 24 hours [of the] injury."^2(p.1407-8) In other words, this is a fairly specific patient group, and the guideline does not address all children with head trauma. Any attempt to apply the guideline to other types of patients should be interpreted with caution.

An important point to emphasize when considering whether a child can be observed at home is the definition of an "observer." While Kushner's article refers to a "reliable observer," the original guideline describes a "competent observer" who is able to comply with instructions for home observation. A key component of these instructions is the ability to return for care if the child's condition deteriorates. The ability to travel (e.g., living relatively close to medical care and being able to return at any hour) is an important part of the clinical assessment.

Finally, there is the question of how Kushner as a subspecialist--not only a neurologist but the medical director of a brain injury program--is able to relate to the needs of the practicing family physician. From my perspective, he did an excellent job.

Dr. Ganiats is professor and vice chair in the Department of Family and Preventive Medicine at the University of California, San Diego, School of Medicine, La Jolla, Calif. He also serves as chair of AAFP's Commission on Clinical Policies and Research.

Address correspondence to Theodore G. Ganiats, M.D., Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, La Jolla, CA 92093-0622 (e-mail: tganiats@ucsd.edu).

REFERENCES

Kushner DS. Concussion in sports: minimizing the risk of complications. Am Fam Physician 2001;64: 1007-14.

The management of minor closed head injury in children. Committee on Quality Improvement, American Academy of Pediatrics. Commission on Clinical Policies and Research, American Academy of Family Physicians. Pediatrics 1999;104:1407-15.

Copyright © 2001 by the American Academy of Family Physicians.
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