U.S. PREVENTIVE SERVICES TASK FORCE: RECOMMENDATIONS AND RATIONALE

Behavioral Interventions to Promote Breastfeeding: Recommendations and Rationale

U.S. PREVENTIVE SERVICES TASK FORCE

Summary of Recommendations

• The USPSTF recommends structured breastfeeding education and behavior counseling programs to promote breastfeeding. B recommendation.

TABLE 1 USPSTF Recommendations and Ratings The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, or I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms). A. The USPSTF strongly recommends that clinicians routinely provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms. B. The USPSTF recommends that clinicians routinely provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms. C. The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation. D. The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits. I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. USPSTF = U.S. Preventive Services Task Force.

The USPSTF found fair evidence that programs combining breastfeeding education with behaviorally oriented counseling are associated with increased rates of breastfeeding initiation and its continuation for up to three months, although effects beyond three months are uncertain. Effective programs generally involved at least one extended session, followed structured protocols, and included practical behavioral skills training and problem solving in addition to didactic instruction.

The USPSTF found fair evidence that providing ongoing support for patients, through in-person visits or telephone contacts with providers or counselors, increased the proportion of women continuing breastfeeding for up to six months. However, such support had a much smaller effect than educational programs on the initiation of breastfeeding and its continuation for up to three months. Too few studies have been conducted to determine whether the combination of education and support is more effective than education alone.

• The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and counseling by primary care providers; peer counseling used alone and initiated in the clinical setting; and written materials, used alone or in combination with other interventions. I recommendation.

The USPSTF found no evidence for the effectiveness of counseling by primary care providers during routine visits and generally poor evidence to assess the effectiveness of peer counseling initiated from the clinical setting when used alone to promote breastfeeding in industrialized countries. The evidence for the effectiveness of written materials suggests no significant benefit when written materials are used alone and mixed evidence of incremental benefit when written materials are used in combination with other interventions.

TABLE 2 USPSTF Strength of Overall Evidence The USPSTF grades the quality of the overall evidence for a service on a three-point scale (good, fair, or poor). Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes. Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes. Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes. USPSTF = U.S. Preventive Services Task Force.

Clinical Considerations

• Effective breastfeeding education and behavior counseling programs use individual or group sessions led by specially trained nurses or lactation specialists, usually lasting 30 to 90 minutes. Sessions generally begin during the prenatal period and cover the benefits of breastfeeding for infant and mother, basic physiology, equipment, technical training in positioning and latch-on techniques, and behavioral training in skills required to overcome common situational barriers to breastfeeding and to garner needed social support.

• Hospital practices that may help support breastfeeding include early maternal contact with the newborn, rooming-in, and avoidance of formula supplementation for breastfeeding infants.
• Commercial discharge packs provided by hospitals that include samples of infant formula or bottles and nipples are associated with reduced rates of exclusive breastfeeding.
• Mothers who wish to continue breastfeeding after returning to work, especially those working full-time, may need to use an electric or mechanical pump to maintain a sufficient breast milk supply.

• Few contraindications to breastfeeding exist. In developed countries, maternal infection with human immunodeficiency virus is considered a contraindication to breastfeeding, as is alcohol and drug use or dependence. Some medications (prescription and nonprescription) are contraindicated or advised for use with caution and appropriate clinical monitoring in lactating women.² Clinicians should consult appropriate references for information on specific medications, including herbal remedies.

Discussion

To promote wider use of effective breastfeeding programs, research is needed to examine barriers to their use, the costs and cost-effectiveness of these programs and their components, and their effectiveness in more diverse populations and clinical settings.

The role of the primary obstetric, pediatric, or family medicine clinician in promoting breastfeeding during clinical preventive visits has not received the attention it deserves. Because such visits are well-established elements of routine prenatal and postnatal care, they have rich but untested potential to yield effective and cost-effective approaches to breastfeeding promotion.

The Scientific Evidence and Recommendations of Others sections that usually are included in USPSTF recommendation statements are available in the complete Recommendation and Rationale statement on the USPSTF Web site (http://www.preventiveservices.ahrq.gov).

Address correspondence to Alfred O. Berg, M.D., M.P.H., Chair, U.S. Preventive Services Task Force, c/o Project Director, USPSTF, 540 Gaither Rd., Rockville, MD 20850 (e-mail: uspstf@ahrq.gov).

The U.S. Preventive Services Task Force recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available online at http://www.ahrq.gov/clinic/uspstf/uspsbrfd.htm.

REFERENCES

1. Guise JM, Palda V, Westhoff C, Chan BK, Helfand M, Lieu TA. Effectiveness of primary care-based interventions to promote breastfeeding: evidence review and meta-analysis. Accessed September 2003 at: http://www.ahrq.gov/clinic/3rduspstf/ brstfeed/brfeedsum.htm.
2. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 5th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; Washington: American College of Obstetricians and Gynecologists, 2002: 220-9.