Putting Prevention into Practice

An Evidence-Based Approach

Primary Care Interventions to Promote Breastfeeding



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Am Fam Physician. 2010 May 15;81(10):1273-1274.

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This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 1195.

Case Study

L.M. is a 19-year-old woman who is pregnant for the first time. During her first prenatal visit, you ask what she has heard about breastfeeding. L.M. explains that her grandmother has told her that formula is just as good as breast milk, but that her friends have said breastfeeding is best. L.M. is unsure which option would be better for her baby.

Case Study Questions

  1. Which one of the following is the most accurate evidence-based response to L.M.'s comments?

    • A. There is strong evidence that breastfeeding increases the IQ of infants.

    • B. In addition to immediate benefits, breastfeeding has long-term health effects for children, including decreased risk of serious medical conditions, such as heart disease.

    • C. Breastfeeding has health benefits for children and mothers, including reducing the long-term risk of diabetes.

    • D. Not being breastfed increases an infant's risk of common problems, such as ear infections, lower respiratory tract infections, gastrointestinal infections, and eczema.

    • E. Breastfeeding has many health advantages for infants, but the evidence does not demonstrate health benefits for women.

  2. L.M. asks how common breastfeeding is in America. According to studies, which one of the following statistics about breastfeeding in the United States is correct?

    • A. Nearly 75 percent of new mothers initiated breastfeeding in 2005.

    • B. More than 50 percent of mothers breastfed for at least six months in 2005.

    • C. In 2005, almost 50 percent of infants were exclusively breastfed for their first six months.

    • D. In 2005, fewer than 5 percent of infants were exclusively breastfed for their first 12 months.

    • E. The American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the U.S. Surgeon General recommend breastfeeding exclusively for the first 12 months.

  3. L.M. asks what you can do to help her succeed if she chooses to breastfeed. According to the U.S. Preventive Services Task Force (USPSTF), which of the following options are part of successful breastfeeding interventions?

    • A. Referring pregnant women and their supporters to prenatal classes, which include breastfeeding education.

    • B. Direct support of mothers during breastfeeding observations.

    • C. Emphasizing the negative impacts of bottle feeding on the health of babies.

    • D. Training primary care staff about breastfeeding and techniques for providing breastfeeding support.

Answers

  1. The correct answer is D. A systematic evidence review on the maternal and child health outcomes of breastfeeding found an association between not being breastfed and an increased risk of common infantile illnesses, including ear, lower respiratory tract, and gastrointestinal infections. Not being breastfed was also associated with longer-term illnesses, including asthma, obesity, and type 2 diabetes. Current evidence does not demonstrate a strong association between breastfeeding and IQ for term infants when controlled for appropriate confounders. The review found no clear relationship between breastfeeding and heart disease. For women, not breastfeeding increases the risk of breast and ovarian cancers. Breastfeeding has not been shown to reduce the long-term risk of diabetes in women.

  2. The correct answer is A. In 2005, 73 percent of new mothers in the United States initiated breastfeeding, nearly reaching the U.S. Healthy People 2010 goal of 75 percent. Thirty-nine percent of new mothers breastfed their children for at least six months, and 20 percent did so for 12 months. Fourteen percent of infants were exclusively breastfed for their first six months, as recommended by the AAP, the AAFP, and the U.S. Surgeon General.

  3. The correct answers are A, B, and D. In its 2008 recommendation, the USPSTF concluded that the evidence was sufficient to encourage primary care practices to conduct interventions during pregnancy and after birth to promote and support breastfeeding. The USPSTF noted that the evidence was insufficient to determine the relative contributions of specific aspects of multicomponent interventions or the comparative effectiveness of single-component interventions.

    Family physicians can implement multicomponent interventions in their offices that may include offering formal breastfeeding education programs for mothers and families; referring pregnant women and new mothers to peer support organizations; and providing direct support of mothers during breastfeeding, including observing feedings during office visits. Physicians also can ensure that office staff are trained regarding the benefits of breastfeeding and are encouraged to share positive support messages with patients and families. Clinical staff should be trained to provide breastfeeding support to lactating women.

    Breastfeeding promotion, like other interventions designed to encourage healthy behaviors, should provide evidence-based information and aim to empower patients to make informed choices. Breastfeeding interventions should be designed and implemented in ways that do not make women feel guilty when they make an informed choice not to breastfeed.

SOURCES

U. S. Preventive Services Task Force. Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(8):560–564.

Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(8):565–582.

The case study and answers to the following questions on primary care interventions to promote breastfeeding are based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. More detailed information on this subject is available in the USPSTF Recommendation Statement and the evidence synthesis on the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm). The practice recommendations in this activity are available at http://www.ahrq.gov/clinic/uspstf/uspsbrfd.htm.



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