Case Scenario

I enjoy a busy practice where I care for a diverse population with many prenatal patients that I follow to term and delivery. I also see new mothers referred to me from a local maternal health clinic. One of my frustrations is getting women to exclusively breastfeed their babies. I often hear comments such as “I don't have enough milk.” This perception results in babies receiving formula in the hospital as a supplement or turning to formula exclusively. I have noticed hospital nurses giving formula to the babies “so the mother can rest.” I am convinced that these formula supplements have interfered with the establishment of effective lactation. I try my best to promote breastfeeding during prenatal visits, but formula always seems to become part of the infants' diets. Is there anything I can do to improve the number of women who exclusively breastfeed their babies?

Commentary

A recent report from the Agency for Health-care Research and Quality has confirmed the numerous benefits of breastfeeding to mothers and their babies.¹ Healthy People 2010 has set goals for initiation and continuation of breastfeeding, with additional goals for exclusive breastfeeding without artificial formula supplementation.² Data from 2004 show that we are close to achieving the initiation and continuation rates, but are well short of the exclusive breastfeeding rates (see accompanying table).² Family physicians should be working hard to help their patients achieve all of these goals. To address the above case scenario, we need to answer two questions: (1) What are the obstacles faced?; and (2) What are the strategies that have been proven effective in achieving these goals?

Risks for early discontinuation of breast-feeding include the mother's lack of confidence in breastfeeding, the presence of early breastfeeding problems, and lower maternal education.³ Another study found that risks for discontinuation at 12 weeks were maternal depression and the need of the mother to return to work or school.⁴

Another study showed that maternal anxiety was a factor leading to formula supplementation and that being born on the hospital night shift led to greater use of formula in breastfed babies.⁴ The highest rates of formula supplementation occurred from 7 pm to 9 am, regardless of the time of birth.⁴ Therefore, the physician in the case scenario is not alone in hearing from nurses on morning rounds that newborns received formula to allow the mother to get some rest. A survey of 151 nurses found that some believe there are no nutritional differences between human milk and artificial formula.⁵ We have all probably heard that “one bottle can't hurt,” but results of one study show that hospital supplementation of one or more formula feedings can adversely affect breastfeeding duration.⁶

Another obstacle for many mothers is their concern about breastfeeding in public. Factors that influence a mother's decision to breastfeed in public include: the mother's body image, her previous experience and level of confidence in breastfeeding, the attitudes of her partner, and the potential audience and location of breastfeeding.⁷

Prenatal breastfeeding education has been proven effective in improving breastfeeding initiation and continuation. The U.S. Preventive Services Task Force recommends structured breastfeeding education and behavior counseling programs as a type-B recommendation.⁸ One study showed that women who received prenatal encouragement from family physicians and pediatricians who attended a five-hour breastfeeding course had higher exclusive breastfeeding rates and continuation rates compared with women who received prenatal encouragement from a group of control physicians.⁹ Therefore, family physicians should take the extra time to educate themselves about breastfeeding to more effectively counsel and support their patients who are breastfeeding.

In the delivery room, early skin-to-skin contact between mother and infant leads to higher breastfeeding continuation rates, according to a recent Cochrane Review.¹⁰ Early skin-to-skin contact has other benefits for the mother and infant, including improved maternal affectionate behavior, improved maternal attachment behavior, shorter infant crying times, and better cardio-respiratory stability among preterm infants.¹⁰

Another effective strategy is to become a Baby-Friendly hospital through the Baby-Friendly Hospital Initiative (from the World Health Organization and the United Nations Children's Fund). One study examined the breastfeeding rates at 28 Baby-Friendly hospitals in 2001 and found in them a mean breastfeeding initiation rate of 83.8 percent compared with a national mean of 69.5 percent (with exclusive breastfeeding rates of 78.4 vs. 46.3 percent, respectively).¹¹ Becoming a Baby-Friendly hospital involves educating all physicians and maternity nurses who admit to the unit. A particular challenge to becoming a Baby-Friendly hospital is the requirement to accept no free formula samples. Convincing hospital administrators to pay for something they can get for free can be difficult, but this has the potential for maintaining breastfeeding initiation rates above 80 percent.¹¹

It is important to arrange for early follow-up of the breastfeeding mother and her infant following their discharge from the hospital. The American Academy of Pediatrics has recommended an initial office visit at three to five days of life for all breastfed babies.¹² This allows the family physician an opportunity to make an early assessment of how breastfeeding is going and to intervene quickly if there are any problems. Physicians should be encouraged to watch the new mother breastfeed her infant to assess for proper latch-on technique. It is important for a breastfeeding infant to be held directly facing the mother's breast, and the entire nipple and most of the areola must be in the infant's mouth. The physician can easily learn to recognize the desired pattern for the breastfeeding infant of two to three sucks followed by a pause to swallow. As an alternative, physicians could train a member of their office staff to assist in lactation support.

The issue of breastfeeding in public is problematic, despite the fact that 39 states have legislation protecting a woman's right to breastfeed in any public or private location.¹³ Physicians may learn more about their own state's breastfeeding laws at http://www.ncsl.org/programs/health/breast50.htm. Strategies to help women breastfeed in public include encouraging her to: practice breastfeeding in front of supportive friends or family to gain confidence; practice breastfeeding discreetly using a scarf or blanket; attend supportive mothers' groups or play groups to learn from peers⁷; and receive help and advice from a board certified lactation consultant or a volunteer counselor from La Leche League International (http://www.llli.org).