USPSTF reaffirms use of primary care interventions to support breastfeeding

Primary care physicians should support women during pregnancy and after birth by providing breastfeeding interventions, according to the U.S. Preventive Services Task Force.

The agency issued its grade B recommendation in JAMA, concluding "with moderate certainty that interventions to support breastfeeding have a moderate net benefit" for both women and children.

"There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women," the USPSTF members wrote. "However, nearly half of all mothers in the United States who initially breastfeed stop doing so by 6 months, and there are significant disparities in breastfeeding rates among younger mothers and in disadvantaged communities."

On behalf of the USPSTF, Carrie D. Patnode, PhD, from Kaiser Permanente Research Affiliates Evidence-based Practice Center, and colleagues conducted a systematic evidence review of 52 studies that involved 66,757 participants.

They reported beneficial associations between breastfeeding interventions at the individual level and breastfeeding for up to 6 months. In addition, there was no significant association between interventions and breastfeeding initiation and limited, conflicting evidence of an association between interventions at the system level and breastfeeding rates.

“The updated evidence confirms that breastfeeding support interventions are associated with an increase in the rates of any and exclusive breastfeeding,” Patnode and colleagues concluded. “There are limited well-controlled studies examining the effectiveness of system-level policies and practices on rates of breastfeeding or child health and none for maternal health.”

The USPSTF noted that various intervention styles can help support women who are breastfeeding.

"Interventions can be categorized as professional support, peer support and formal education, although none of these categories are mutually exclusive, and interventions may be combined within and between categories," the USPSTF concluded. "Interventions may also involve a woman's partner, other family members, and friends."

The agency continued: "Not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values and preferences."

The recommendations are an update to recommendations issued in 2008. The USPSTF noted that other organizations, including the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics and the American Academy of Family Physicians, have issued recommendations regarding breastfeeding. Those recommendations include exclusive breastfeeding through 6 months, the development and maintenance of breastfeeding knowledge to help mothers make decisions and the including of WHO/UNICEF's '10 Steps to Successful Breastfeeding.'

"Primary care clinicians can support women before and after childbirth by providing interventions directly or by referral to help them make an informed choice about how to feed their infants and to be successful in their choice," USPSTF members wrote. "Interventions include promoting the benefits of breastfeeding, providing practical advice and direct support on how to breastfeed, and providing psychological support."

In an accompanying editorial, Valerie Flaherman, MD, MPH, from the University of California, San Francisco, and Isabelle Von Kohorn, MD, PhD, from Holy Cross Health, acknowledged that individual-level interventions were effective at improving breastfeeding, but system-level interventions were not.

"An approach to breastfeeding support with decisions tailored to the individual patient may be effective at promoting individual breastfeeding duration, whereas a single, uniform approach is ineffective at improving breastfeeding duration of the population," they wrote. "To improve breastfeeding rates in the United States, further implementation of system-level interventions such as the [Baby Friendly Hospital Initiative] for the general population should be reconsidered until good-quality evidence emerges that these interventions are safe and effective. Implementation of ineffective strategies, potentially those not based on evidence, may divert resources from effective interventions at the individual level and risk causing unnecessary harm."

In an editorial published in JAMA Pediatrics, Dimitri A. Christakis, MD, MPH, from Seattle Children's Research Institute, quoted a previous review that stated pediatricians were "drowning in a sea of advice." That review identified 192 guidelines that physicians were supposed to be following. Christakis wrote that the new USPSTF breastfeeding recommendations represent “another bucket of water.”

"Lest the USPSTF be accused of adding yet another bucket of water to the swirling sea of advisory directives, I contend that we should begin by draining the sea and then selectively refilling it, bucket by bucket, prioritizing those things for which there is sound evidence and proven value," he concluded. "If we were to take this approach, we might very well add breastfeeding support right after vaccinations." – by Chelsea Frajerman Pardes

Resources:

Christakis DA. JAMA Pediatr. 2016;doi:10.1001/jamapediatrics.2016.3390.
Flaherman V, Von Kohorn I. JAMA. 2016;doi:10.1001/jama.2016.15083.
Patnode CD, et al. JAMA. 2016;doi:10.1001/jama.2016.8882.
USPSTF. JAMA. 2016;doi:10.1001/jama.2016.14697.

Disclosures: The authors report no relevant financial disclosures.