Interventions in Primary Care to Promote Breastfeeding: An Evidence Review for the U.S. Preventive Services Task Force

Human milk is the natural nutrition for all infants. According to the American Academy of Pediatrics, it is the preferred choice of feeding for all infants (1). The goals of Healthy People 2010 for breastfeeding are an initiation rate of 75% and cont... show more

Human milk is the natural nutrition for all infants. According to the American Academy of Pediatrics, it is the preferred choice of feeding for all infants (1). The goals of Healthy People 2010 for breastfeeding are an initiation rate of 75% and continuation rate of 50% at 6 months and 25% at 12 months after delivery (2). A survey of U.S. children in 2002 indicated that only 71% had ever been breastfed, and the percentage of infants who continue to be breastfed to some extent is 35% at 6 months and 16% at 12 months (3). Although the breastfeeding initiation rate is close to the goal set by Healthy People 2010, according to this survey, the breastfeeding continuation rates at 6 and 12 months fall short. Evidence suggests that breastfeeding decreases risks for many diseases in infants and mothers. In children, breastfeeding has been associated with a reduction in the risk for acute otitis media, nonspecific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, childhood leukemia, and the sudden infant death syndrome. In mothers, a history of lactation has been associated with a reduced risk for type 2 diabetes and breast and ovarian cancer (4). According to the American Academy of Pediatrics, some of the obstacles to initiation and continuation of breastfeeding include insufficient prenatal education about breastfeeding, disruptive maternity care practices, and lack of family and broad societal support (5). Effective interventions reported to date include changes in maternity care practices, such as those implemented in pursuit of the Baby-Friendly Hospital Initiative (BFHI) designation (6, 7), and worksite lactation programs (8). Some of the other interventions implemented include peer-to-peer support, maternal education, and media marketing (9). Our review is based on an evidence report (10) that was requested by the Center on Primary Care, Prevention, and Clinical Partnerships at the Agency for Healthcare Research and Quality, on behalf of the U.S. Preventive Services Task Force, to support the Task Force's update of its 2003 recommendations on counseling to promote breastfeeding (11). Together with the Tufts Evidence-based Practice Center, these agencies jointly developed an analytic framework for study questions to evaluate the available evidence to promote and support breastfeeding (Figure 1). Five linked key questions were proposed in the analytic framework: Figure 1. Analytic framework and study questions. 1. What are the effects of breastfeeding interventions on child and maternal health outcomes? 2. What are the effects of breastfeeding interventions on breastfeeding initiation, duration, and exclusivity? 3. Are there harms from interventions to promote and support breastfeeding? 4. What are the benefits and harms of breastfeeding on infant or child health outcomes? 5. What are the benefits and harms of breastfeeding on maternal health outcomes? The contextual questions regarding the effectiveness of health care system influences on interventions to promote breastfeeding and the potential benefits and harms related to such interventions can be answered by synthesizing the available scientific evidence for each key question. To avoid redundant work, a joint decision was made to adopt results from our earlier Agency for Healthcare Research and Quality evidence report (4) to address questions 4 and 5 on the benefits and harms of breastfeeding for infants and mothers. Table 1 (1284) presents a synopsis of that report's findings on questions 4 and 5. We address only questions 1 to 3 in this article. Specifically, we examine the effects of primary careinitiated interventions to support or promote breastfeeding on child and maternal health outcomes and breastfeeding rates, as reported in randomized, controlled trials (RCTs) from developed countries. We also document reported harms from interventions to promote and support breastfeeding. Table 1. Findings from the Previous Systematic Review Methods Data Sources This systematic review focuses on recent evidence (September 2001 to February 2008) and updates a previous systematic review (85) conducted for the U.S. Preventive Services Task Force to support its 2003 recommendation on counseling to promote breastfeeding (available at www.ahrq.gov/clinic/uspstf/uspsbrfd.htm). We searched for English-language articles in MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL from September 2001 to February 2008 by using such Medical Subject Heading terms and keywords as breastfeeding, breast milk feeding, breast milk, human milk, nursing, breastfed, infant nutrition, lactating, and lactation. We also reviewed reference lists of a related systematic review (86) for additional studies. Study Selection We included RCTs published from September 2001 to February 2008 that included any counseling or behavioral intervention initiated from a clinician's practice (office or hospital) to improve the breastfeeding initiation rate or duration of breastfeeding among healthy mothers or members of the motherchild support system (such as partners, grandparents, or friends) and their healthy term or near-term infants (35 weeks' gestation or 2500 g). We focused our review on studies conducted in developed countries; however, because of the widespread interest in the BFHI, we also included RCTs of the BFHI that were conducted in Brazil and Belarus. We considered interventions conducted by various providers (lactation consultants, nurses, peer counselors, midwives, and physicians) in various settings (hospital, home, clinic, or elsewhere) to be eligible as long as they originated from a health care setting. We considered maternity services to be primary care for this review. We also included such health care system interventions as staff training. We excluded community- or peer-initiated interventions. Control comparisons were any usual prenatal, peripartum, or postpartum care, as defined in each study. Studies needed to re show less