Key Points for Practice
• Most women should breastfeed exclusively for six months and continue to breastfeed through the first year, combined with complementary foods.
• In birthing centers and hospitals, infants should be kept skin-to-skin with the mother until there has been at least one successful breastfeeding.
• When mothers and their infants present for follow-up care, family physicians should be prepared to discuss and encourage breastfeeding.
• Breastfeeding is contraindicated when the mother has HIV or human T-cell lymphotropic virus type I or type II, or the infant has type 1 galactosemia.
From the AFP Editors
Breastfeeding has a beneficial role in health outcomes for infants and women, and the evidence continues to grow. In developed countries, infants who are not breastfed may have a higher risk of getting certain conditions (e.g., acute otitis media, gastroenteritis, atopic dermatitis), some of which are life-threatening (e.g., lower respiratory infections, necrotizing enterocolitis, sudden infant death syndrome). Evidence indicates that exclusively breastfeeding for at least six months provides better protection against gastrointestinal and respiratory tract infections compared with exclusively breastfeeding for only four months. Additionally, the benefits of breastfeeding extend beyond the period of breastfeeding; for example, children who are not breastfed have been found to have a higher mean blood pressure, lower scores on intelligence tests, and increased risk of type 1 and 2 diabetes mellitus, obesity, asthma, and childhood leukemia.
In mothers, studies have suggested that exclusively breastfeeding for at least six months may help with weight loss, and that breastfeeding longer leads to greater sustained weight loss. Women who do not breastfeed may have a higher risk of post-partum depression, and those in developed countries may also have an increased risk of type 2 diabetes, breast cancer, ovarian cancer, hypertension, and cardiovascular disease.
Family physicians can have an important role in promoting breastfeeding, and are well positioned to provide support in the context of family-centered care. The position paper from the American Academy of Family Physicians (AAFP) provides key recommendations to assist family physicians in filling this role.
CURRICULUM, PRINCIPLES, AND ADVOCACY
To ensure adequate training, medical schools and family medicine residencies should provide courses in breastfeeding (e.g., lactation physiology). Additionally, support should be given to women in medical school or residencies who are breastfeeding, so that they can achieve their breastfeeding goals.
In birthing centers and hospitals, infants should be kept skin-to-skin with the mother until there is at least one successful breast-feeding. In the perinatal care setting, breast-feeding should be supported; ideally, this would occur by following the Ten Steps to Successful Breastfeeding. Health care professionals should be knowledgeable about breastfeeding to provide the best care to infants and mothers.
Even if the physician does not offer maternity care, the office should be breastfeeding friendly. Breastfeeding should be encouraged, and education should be provided to the patient and her family. For example, education and support can be incorporated into a variety of visits, such as those for preconception care, prenatal care, labor support, and postpartum care, among others. One key element in breastfeeding initiation is encouragement from a physician or other family members, particularly the father of the infant and the maternal grandmother. When a family physician also provides care for a mother's family, he or she should prompt them to encourage the mother to breastfeed. Infants should receive formula only when medically indicated, and family physicians should not provide samples of formula or coupons to mothers who are breastfeeding, so as not to undermine breastfeeding.
Family physicians should work to promote removing barriers to breastfeeding in their community by, for example, encouraging offices and workplaces to become more breastfeeding friendly and defending a woman's right to breastfeed in public.
Most women should breastfeed (or provide human milk to the infant) exclusively for about six months. Breastfeeding, combined with complementary foods (e.g., iron-rich foods), should continue until the infant is at least one year of age; however best outcomes can be achieved when breastfeeding continues until the child is two years of age. A mother can continue to breastfeed for as long as she and the child want.
Within several days of giving birth, mothers and their infants should present for follow-up care. Family physicians whose patient population includes mothers and infants should be able to help with breast-feeding and its possible challenges. However, if the challenges are outside the knowledge of the physician, referral to a health care professional with greater knowledge is indicated; for example, a lactation consultant who is board certified.
Although uncommon, medical contraindications to breastfeeding do exist. The Centers for Disease Control and Prevention discourages breastfeeding for women in the United States who are human immunodeficiency virus (HIV) positive. However, in areas where there is a high prevalence of diarrhea and respiratory illness resulting in infant mortality, exclusive breastfeeding for six months in patients with HIV may outweigh the risks. When adequate treatment with antiviral medications is provided, exclusive breastfeeding for six months, and continuing to breastfeed for 12 months, can be considered. Breastfeeding is discouraged if a woman with HIV is not being treated and other types of feeding are adequate and safe, and the woman can afford and keep up these feedings.
If a woman has human T-cell lymphotropic virus type I or type II, breastfeeding should not occur. Breastfeeding in type 1 galactosemia is contraindicated and adjustments in feeding may be needed with other types of inborn errors of metabolism. In women with herpes simplex virus who have active lesions on the breast, the infant should not feed from that breast until they are healed. During the newborn period, women with active tuberculosis not being treated or with active varicella virus should be separated from the infant; however the infant can still drink the mother's breast milk. Most conditions in the mother can be treated with breastfeeding-safe medications; however, illicit drugs, antimetabolites, chemotherapeutics, and radioisotopes may contraindicate breastfeeding.
Guideline source: American Academy of Family Physicians
Evidence rating system used? No
Literature search described? No
Guideline developed by participants without relevant financial ties to industry? Not reported