Breast-feeding Guidelines Updated by USPSTF

Diana Swift

October 25, 2016

Updated breast-feeding guidelines from the US Preventive Services Task Force (USPSTF) continue to recommend providing supportive interventions during pregnancy and postpartum for mothers intending to breast-feed. "Adequate evidence indicates that interventions to support breastfeeding increase the duration and rates of breastfeeding, including exclusive breastfeeding," the recommendations state.

"There is adequate evidence to bound the potential harms of interventions to support breastfeeding as no greater than small, based on the nature of the intervention, the low likelihood of serious harms, and the available information from studies reporting few harms," the recommendations continue. However, editorialists say two common recommendations — counseling mothers to avoid pacifiers and feedings other than breast milk — "could present potential risk associated with primary care interventions to support breastfeeding."

Kirsten Bibbins-Domingo, PhD, MD, USPSTF chair and a professor of medicine and epidemiology at the University of California, San Francisco, and colleagues published the recommendation statement in the October 25 issue of JAMA. The new "B" level recommendation updates the previous recommendations published in 2008.

Individual-level interventional strategies include one-on-one professional support from medical, nursing, and lactation workers; one-on-one peer support; and formal education programs, no one of which mutually excludes the others. In some cases, interventions may include the supply of educational materials, nursing bras, and breast pumps.

Medical and nursing professionals and lactation professionals can provide psychological support as well as practical breast-feeding help, such as assisting the mother with positioning and latching the baby on.

Carrie D. Patnode, PhD, a research associate at Kaiser Permanente Research Affiliates Evidence-based Practice Center in Portland, Oregon, and colleagues conducted an evidence review that included 52 primary care studies, 43 of which studied individual-level interventions. They report their findings in the same issue of the journal.

Overall, they found varying results, but conclude that breast-feeding support and education were associated with a higher likelihood of any and exclusive breast-feeding at younger than 3 months and at 3 to 6 months compared with usual care.

Pooled estimates found a beneficial association for any breast-feeding at younger than 3 months (risk ratio [RR], 1.07; 95% confidence interval [CI], 1.03 - 1.11; 26 studies) and at 3 to less than 6 months (RR, 1.11; 95% CI, 1.04 - 1.18; 23 studies), as well as for exclusive breast-feeding at younger than 3 months (RR, 1.21; 95% CI, 1.11 - 1.33; 22 studies) and 3 to younger than 6 months (RR, 1.20; 95% CI, 1.05 - 1.38; 18 studies). At 6 months, individual-level interventions correlated with a 16% higher probability of exclusive breast-feeding (RR, 1.16; 95% CI, 1.02 - 1.32; 17 studies), but not any breast-feeding.

Multiple interventions during the prenatal, peripartum, or postpartum periods appeared to be more effective than those during a single period.

Evidence was sparse and inconsistent, however, for associations between system-level interventions and rates of breast-feeding. The most widely used system-level intervention is the Baby-Friendly Hospital Initiative, which outlines 10 steps hospitals should use to promote breast-feeding, such as helping the mother breast-feed within the first hour after birth and keeping the baby with the mother 24 hours a day.

Low Risk for Potential Harms

Although data on the potential harms of breast-feeding interventions are sparse, the potential for serious harm appears small, the recommendation authors note. Potential harms could theoretically include guilt about not breast-feeding, increased anxiety about breast-feeding, and increased postpartum depression. Thus, clinicians should respect women's autonomy regarding breast-feeding decisions.

One of just two trials addressing intervention-related adverse events found no significant differences in maternal anxiety between intervention and usual-care groups at 14 days. The other reported that a few mothers experienced anxiety and decreased confidence despite good progress with breast-feeding and discontinued their participation in a peer counseling intervention.

Routine advice to restrict the use of pacifiers and any feedings other than breast milk could have a negative effect on primary care interventions, and may even pose ethical problems, Valerie Flaherman, MD, MPH, from the University of California, San Francisco, and Isabelle Von Kohorn, MD, PhD, from Holy Cross Health in Silver Spring, Maryland, write in an accompanying editorial. Both measures are advised in the Baby-Friendly Hospital Initiative.

"Counseling to avoid the use of pacifiers in the newborn period is an intervention commonly used to support breastfeeding," they write. "However, evidence has been building that infant use of a pacifier may be associated with a reduced risk of sudden infant death syndrome, the most common cause of postneonatal death in the United States."

Advising women to avoid feeding anything other than breast milk can also be problematic, they explain. "[T]he onset of copious breast milk production varies. For women who have scant colostrum and no copious milk production for 4 to 7 days, exclusive breastfeeding in the first few days after birth is associated with increased risk of hyperbilirubinemia, dehydration, and readmission."

The editorialists emphasize the need to report data on adverse events related to breast-feeding promotion.

Individualized Approach Needed

Evidence of breast-feeding's benefit aside, healthcare professionals should always tailor decision making to patients and their circumstances. "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," Dr Bibbins-Domingo and colleagues write.

Dr Flaherman and Dr Von Kohorn agree that an individualized approach is needed. "Using clinical judgment individualized for each mother and infant may result in better outcomes than following a rigid system of practices," they write. "Because so many public health and medical resources are being directed to system-level interventions to support breastfeeding, this area is of high importance for future research."

System-Level Interventions May Need Rethinking

The editorialists note that the USPSTF findings may spark controversy because only individual-level interventions were effective at promoting breast-feeding, whereas their systemic-level counterparts, including the Baby-Friendly Hospital Initiative, were not. The authors of the evidence review found "no consistent association with the rate of any or exclusive breastfeeding from 9 studies of system-level policy or maternity care practices."

Further implementation of system-level interventions needs to be rethought pending good-quality evidence that systemic interventions are safe and effective, the editorialists write. "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."

Much Room for Improvement

Of the eight in 10 new US mothers who start out breast-feeding, nearly half quit by 6 months, the statement authors note. In addition, significant disparities in nursing rates exist among younger mothers and those in low-income communities.

The editorialists write that at the societal level, the demands of extended breast-feeding can put women at a disadvantage compared with men in the contemporary workplace. "Therefore, when primary care interventions are successful in encouraging breastfeeding, a disproportionate burden will continue to be placed on women until and perhaps even when progressive policies become commonplace," they write. "Workplace accommodations are needed for lactating mothers, and the importance of social factors should be considered when making policy decisions."

The USPSTF is an independent, voluntary body supported by the Agency for Healthcare Research and Quality, which assisted in the development and writing, but not the final approval, of the statement. The authors of the statement, the evidence review, and the editorial have disclosed no relevant financial relationships.

JAMA. 2016;316:1685-1705. Recommendation statement full text, Evidence review full text, Flaherman and Von Kohorn editorial full text

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