Summary of Recommendation and Evidence

The U.S. Preventive Services Task Force (USPSTF) recommends interventions during pregnancy and after birth to promote and support breastfeeding (Table 1). B recommendation.

Rationale

Importance. There is convincing evidence that breastfeeding provides substantial health benefits for children, and adequate evidence that breastfeeding provides moderate health benefits for women.

Effectiveness of interventions to change behavior. Adequate evidence indicates that interventions to promote and support breast-feeding increase the rates of initiation, duration, and exclusivity of breastfeeding.

Harms of interventions. No published studies focus on the potential direct harms from interventions to promote and support breastfeeding. The review did not include a search for potential harms of breastfeeding itself. The USPSTF has determined the potential harms of interventions to promote and support breastfeeding are no greater than small.

USPSTF assessment. The USPSTF concludes that there is moderate certainty that interventions to promote and support breast-feeding have a moderate net benefit.

Clinical Considerations

• Patient population. This recommendation applies to pregnant women, new mothers, and young children. In rare circumstances involving health issues in mothers or infants, such as human immunodeficiency virus infection or galactosemia, breastfeeding may be contraindicated and interventions to promote breastfeeding may not be appropriate. Interventions to promote and support breastfeeding may also involve a woman's partner, other family members, and friends.

• Interventions. The current literature does not allow assessment of the individual aspects of multicomponent interventions or comparative effectiveness assessments of single-component interventions. The promotion and support of breastfeeding may be accomplished through interventions over the course of pregnancy; around the time of delivery; and after birth, while breast-feeding is under way. Interventions may include multiple strategies, such as formal breastfeeding education for mothers and families, direct support of mothers during breastfeeding observations, and the training of health professional staff about breastfeeding and techniques for breastfeeding support. Evidence suggests that interventions that include prenatal and postnatal components may be the most effective at increasing breastfeeding duration. Many successful programs include peer support, prenatal breastfeeding education, or both.

Other Considerations

• Implementation. Although the activities of individual physicians to promote and support breastfeeding are likely to be positive, additional benefit may result from efforts that are integrated into systems of care. System-level interventions can incorporate physician and team member training and policy development. Through senior leadership support and institutionalization, these initiatives may be more likely to be sustained over time. Although they are outside the scope of this recommendation and evidence review, community-based interventions to promote and support breastfeeding may offer additional sizeable benefits. These interventions may include direct peer-to-peer support, social marketing initiatives, workplace initiatives, and public policy actions.

• Research needs and gaps. Additional research is needed to better understand the effects of health care–based interventions to promote and support breastfeeding in the United States. Future research should include data collection on exclusive breastfeeding rates in addition to partial breastfeeding rates. Studies will be more useful if they are designed to allow some assessment of the relative contributions of individual components of multi-component breastfeeding support programs. Research on the costs and cost-benefits of interventions is also needed. Additional research is needed to allow the tailoring of interventions to the needs of women and families. Good-quality prospective studies are needed to understand the effectiveness of compliance with the World Health Organization's Baby-Friendly Hospital Initiative in the United States, the contributions of individual components, and the interactive effect of the components with particular focus on postdischarge breastfeeding support.

Discussion

• Health effects. In 2005, 73 percent of new mothers initiated breastfeeding, nearly reaching the U.S. Healthy People 2010 goal of 75 percent.^1,2 Thirty-nine percent breastfed their children for at least six months and 20 percent did so for 12 months.¹ Fourteen percent of infants were exclusively breastfed for their first six months, as recommended by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the U.S. Surgeon General.^3–5

  Not breastfeeding is associated with health risks for mothers and children. For infants, not being breastfed is associated with increased numbers of ear, lower respiratory tract, and gastrointestinal infections.⁶ Children who were not breastfed are more likely to have asthma, type 2 diabetes, and obesity.⁶ For women, not breast-feeding is associated with higher rates of breast and ovarian cancer.⁶

• Scope of review. This recommendation is supported by a systematic evidence review conducted for the USPSTF by the Tufts-New England Medical Center Evidence-based Practice Center.⁷ The review updates the USPSTF's 2003 evidence report⁸ and includes literature published between January 2001 and January 2007. Although the investigators included multiple study designs in their search strategies, the final report focused on randomized controlled trials. The investigators limited studies to those with a focus on healthy term and near-term infants, their mothers, and members of the mother-child support team. As directed by the USPSTF, they used a broad conception of primary care interventions that encompassed activities initiated, conducted, or referable by primary care physicians. Settings included primary care offices; labor, delivery, and postpartum inpatient settings; and patient homes. The review did not address community-based interventions, such as media campaigns, worksite lactation programs, and peer-to-peer support programs that do not interact with the health system.

• Effectiveness of interventions to change behavior. In evaluating more than 25 randomized trials of interventions conducted in the United States and in developed countries around the world, the USPSTF concluded that adequate evidence indicates that coordinated interventions throughout pregnancy, birth, and infancy can increase breastfeeding initiation, duration, and exclusivity. A large, cluster randomized study of an intervention conducted in the Republic of Belarus and modeled on the Baby-Friendly Hospital Initiative found that infants in the intervention group were significantly more likely than those in the control group to be exclusively breast-fed and to have lower rates of gastrointestinal infections and atopic dermatitis.⁹ This good-quality study provides evidence of the potential effects of multifaceted breast-feeding interventions to improve health outcomes.

• Potential harms of interventions. No studies identified for the USPSTF reported harms from interventions to promote and support breastfeeding. Nonetheless, potential harms exist, such as making women feel guilty. Breastfeeding interventions, like all other health care interventions designed to encourage healthy behaviors, should aim to empower women to make informed choices supported by the best available evidence. As with interventions to achieve a healthy weight or to quit smoking, 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.

• Estimate of magnitude of net benefit. The USPSTF found that the benefits of breastfeeding are substantial and that the benefits of multimodal interventions to promote and support breastfeeding are moderate. Although the evidence was inadequate to determine the potential harms of these interventions, the USPSTF estimated these potential harms to be no greater than small. The USPSTF concluded with moderate certainty that the net benefits are moderate for multifaceted interventions to promote and support breastfeeding.

• Recommendations of others. The AAP, AAFP, and the American College of Obstetricians and Gynecologists recommend that pregnant women receive breast-feeding education and counseling.^3,10,11 The AAFP and AAP also recommend that peripartum policies and practices support breastfeeding mothers and infants, and that breastfeeding families receive ongoing breast-feeding support.^3,10