Case Study

BS, a 26-year-old woman in her second trimester of pregnancy, comes to your office for routine prenatal care. She expresses concern because one of her relatives has told her that she should not breastfeed. You want to recommend breastfeeding and wonder how to counsel her.

Case Study Questions

• 1. Which one of the following statements about the U.S. Preventive Services Task Force (USPSTF) recommendations for counseling to promote breastfeeding is correct?

  A. Structured breastfeeding education and behavioral counseling programs are associated with increased rates of breastfeeding initiation and continuation.

  B. There is insufficient evidence to recommend for or against structured breastfeeding education and behavioral counseling programs.

  C. Brief education and counseling by primary care clinicians are recommended.

  D. Structured breastfeeding education and behavioral counseling programs are not effective for increasing breastfeeding initiation rates.

  E. Written materials, alone or in combination with other interventions, are effective in promoting breastfeeding.

• 2. In deciding how best to counsel BS, you review the evidence for effective breastfeeding counseling interventions. Which of the following statements is/are correct?

  A. Effective breastfeeding education and behavioral counseling programs use individual or group sessions led by physicians, usually lasting five to 10 minutes.

  B. Effective breastfeeding education and behavioral counseling programs generally begin during the prenatal period.

  C. Effective programs generally include practical behavioral skills training and problem-solving in addition to didactic instruction.

  D. Providing ongoing support for patients increases the proportion of women who breastfeed for up to six months.

• 3. BS has concerns about breastfeeding safety. Which one of the following responses is correct?

  A. There are few contraindications to breastfeeding.

  B. She does not need to discuss any new nonprescription medications with you before starting them.

  C. Human immunodeficiency virus (HIV) cannot be transmitted to infants through breast milk.

  D. Mothers who use alcohol or drugs should not worry about transmitting these substances to their infants through breast milk.

Answers

1. The correct answer is A. The USPSTF recommends structured breastfeeding education and behavioral counseling programs to promote breast-feeding. The USPSTF found fair evidence that programs combining breastfeeding education with behavior-oriented counseling are associated with increased rates of breastfeeding initiation and continuation for up to three months. Effects beyond three months are uncertain.

The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and counseling by primary care professionals; peer counseling used alone and initiated in the clinical setting; and written materials, used alone or in combination with other interventions. For example, no studies have evaluated whether advice given by a woman’s maternity care provider or an infant’s healthcare provider is by itself effective for increasing breastfeeding.

Potential barriers to breastfeeding in the healthcare setting include commercial infant discharge packages that include formula samples. One systematic review found that these sample packets are associated with decreased rates of exclusive breastfeeding.

2. The correct answer is B, C, and D. Effective breastfeeding education and behavioral counseling programs use individual or group sessions led by specially trained nurses or lactation specialists. Sessions generally begin during the prenatal period and cover the benefits of breastfeeding for infant and mother, basic physiology, equipment, and technical training in positioning and latch-on techniques. Behavioral training includes skills in overcoming common situational barriers to breast-feeding (e.g., returning to work) and garnering needed social support. Effective programs generally involve at least one extended session and follow structured protocols.

The USPSTF found fair evidence that providing ongoing support for patients, through in-person visits or telephone contacts with health care providers or counselors, increased the proportion of women who breastfed for up to six months. Such support, however, had a much smaller effect than educational programs on the initiation of breastfeeding and its continuation for up to three months.

3. The correct answer is A. Few contraindications to breastfeeding exist. In developed countries, maternal infection with HIV is considered a contraindication to breastfeeding, as is current alcohol and drug use and/or dependence. Some medications (prescription and nonprescription) are contraindicated or advised for use with caution and appropriate clinical monitoring in lactating women. Clinicians should consult appropriate references for information about specific medications, including herbal remedies.