Recommendation Statement
U.S. Preventive Services Task Force (USPSTF)
Date: October 2008
Summary of Recommendations
- The USPSTF recommends interventions during pregnancy
and after birth to promote and support breastfeeding.
Grade: B recommendation.
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Select for a Clinical Summary of this recommendation.
Contents
Rationale
Clinical Considerations
Other Considerations
Discussion
Recommendations of Other Groups
References
Members of the USPSTF
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 breastfeeding 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 bounded
the potential harms of interventions to promote and support
breastfeeding as no greater than small.
USPSTF Assessment
The USPSTF concludes that there is moderate certainty
that interventions to promote and support breastfeeding
have a moderate net benefit.
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Clinical Considerations
Patient Population Under Consideration
This recommendation applies to pregnant women,
new mothers, and young children. In rare circumstances
involving health issues in mothers or infants, such as HIV
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 breastfeeding 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 both prenatal and postnatal
components may be the most effective at increasing breastfeeding
duration. Many successful programs include peer
support, prenatal breastfeeding education, or both.
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Other Considerations
Implementation
Although the activities of individual clinicians 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 clinician and team member training and policy
development, and through senior leadership support and
institutionalization, these initiatives may be more likely to
be sustained over time. Although outside the scope of this
recommendation and evidence review, community-based
interventions to promote and support breastfeeding, such
as direct peer-to-peer support, social marketing initiatives,
workplace initiatives, and public policy actions, may offer
additional sizeable benefits.
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 multicomponent 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 individual 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.
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Discussion
Health Effects
In 2005, 73% of new mothers initiated breastfeeding,
nearly reaching the U.S. Healthy People 2010 goal of 75%.1,2 Thirty-nine percent breastfed their children for at
least 6 months and 20% did so for 12 months.1 Fourteen
percent of infants were exclusively breastfed for their
first 6 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 infections, lower
respiratory tract infections, and gastrointestinal infections.
6 Children who were not breastfed were more likely to
have asthma, type 2 diabetes, and obesity.
6 For women,
not breastfeeding is associated with higher rates of both
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 clinicians.
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 Counseling 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
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 breastfed and to have lower rates of gastrointestinal
infections and atopic dermatitis.9 This good-quality
study provides evidence of the potential effects of multifaceted
breastfeeding 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, there are potential harms, such as making
women feel guilty. Breastfeeding interventions, like all
other health care interventions designed to encourage
healthy behaviors, should aim to empower individuals 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.
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Recommendations
of Others
The AAP, AAFP, and the American College of Obstetricians
and Gynecologists all recommend that pregnant
women receive breastfeeding 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
breastfeeding support.3,10
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References
1. Breastfeeding Practices—Results from the National Immunization Survey,
2007. Atlanta: Centers for Disease Control and Prevention; 2007. Accessed at
http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm on 3 September 2008.
2. U.S. Department of Health and Human Services. Healthy People 2010:
Conference Edition. Washington, DC: U.S. Government Printing Office; 2000.
3. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D, Schanler RJ, et
al. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and
the use of human milk. Pediatrics 2005;115:496-506. [PMID: 15687461]
4. American Academy of Family Physicians. Breastfeeding (Policy Statement).
Leawood, KS: American Acad Family Physicians; 2007. Accessed at http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpolicy.html on 9 January
2008.
5. Breastfeeding—Best For Baby. Best For Mom. Washington, DC: Department
of Health and Human Services; 2007. Accessed at http://www.4women.gov/breastfeeding/index.cfm?page=home on 3 September 2008.
6. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding
and Maternal and Infant Health Outcomes in Developed Countries.
Evidence Report/Technology Assessment No. 153. (Prepared by Tufts-New England
Medical Center Evidence-based Practice Center, under contract no. 290-02-0022.) AHRQ Publication no. 07-E007. Rockville, MD: Agency for Healthcare
Research and Quality; 2007. Accessed at http://www.ahrq.gov/clinic/tp/brfouttp.htm on 3 September 2008.
7. Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care
to promote breastfeeding: an evidence review for the U.S. Preventive Services
Task Force. Ann Intern Med 2008;149:565-82.
8. Guise JM, Palda V, Westhoff C, Chan BK, Helfand M, Lieu TA. U.S.
Preventive Services Task Force. The effectiveness of primary care-based interventions
to promote breastfeeding: systematic evidence review and meta-analysis for
the US Preventive Services Task Force. Ann Fam Med 2003;1:70-8. Also available at http://www.ahrq.gov/clinic/3rduspstf/brstfeed/brfeedsum.htm [PMID:
15040435]
9. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro
S, et al. PROBIT Study Group (Promotion of Breastfeeding Intervention
Trial). Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized
trial in the Republic of Belarus. JAMA 2001;285:413-20. [PMID: 11242425]
10. American Academy of Family Physicians. Breastfeeding (Position Paper).
Leawood, KS: American Acad Family Physicians; 2007. Accessed at http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html on 9 January
2008.
11. American Academy of Pediatrics and American College of Obstetricians
and Gynecologists. Guidelines for Perinatal Care. 6th ed. Elk Grove, IL: American
Acad Pediatrics; 2007.
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Members of the U.S. Preventive Services Task Force
Members of the U.S. Preventive Services Task Force* are
Ned Calonge, MD, MPH, Chair (Colorado Department of
Public Health and Environment, Denver, Colorado); Diana
B. Petitti, MD, MPH, Vice Chair (Keck School of Medicine,
University of Southern California, Sierra Madre, California);
Thomas G. DeWitt, MD (Children’s Hospital Medical Center,
Cincinnati, Ohio); Allen Dietrich, MD (Dartmouth Medical
School, Lebanon, New Hampshire); Kimberly D. Gregory,
MD, MPH (Cedars-Sinai Medical Center, Los Angeles,
California); Russell Harris, MD, MPH (University of North
Carolina School of Medicine, Chapel Hill, North Carolina);
George Isham, MD, MS (HealthPartners, Minneapolis, Minnesota);
Michael L. LeFevre, MD, MSPH (University of Missouri
School of Medicine, Columbia, Missouri); Rosanne
Leipzig, MD, PhD (Mount Sinai School of Medicine, New
York, New York); Carol Loveland-Cherry, PhD, RN (University
of Michigan School of Nursing, Ann Arbor, Michigan);
Lucy N. Marion, PhD, RN (School of Nursing, Medical College
of Georgia, Augusta, Georgia); Virginia A. Moyer, MD,
MPH (University of Texas Health Science Center, Houston,
Texas); Judith K. Ockene, PhD (University of Massachusetts
Medical School, Worcester, Massachusetts); George F.
Sawaya, MD (University of California, San Francisco, San
Francisco, California); and Barbara P. Yawn, MD, MSPH,
MSc (Olmsted Medical Center, Rochester, Minnesota).
*This list includes members of the Task Force at the time
this recommendation was finalized. For a list of current Task
Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm
Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
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Copyright
This document is in the public domain within the United States. For
information on reprinting, contact Randie Siegel, Associate Director, Office of Communications and Knowledge Transfer, Agency for Healthcare Research and Quality,
540 Gaither Road, Rockville, MD 20850.
Requests for linking or to incorporate content in electronic resources
should be sent to: info@ahrq.gov.
Source: U.S. Preventive Services Task Force. Primary care interventions to promote breastfeeding: U.S. Preventive
Services Task Force Recommendation Statement. Ann Intern Med 2008;149:560-4.
AHRQ Publication No. 09-05126-EF-2
Current as of October 2008
Internet Citation:
U.S. Preventive Services Task Force. Primary Care Interventions to Promote Breastfeeding: U.S. Preventive Services Task Force Recommendation Statement. Originally published in Ann Intern Med 2008;149:560-4. AHRQ Publication No. 09-05126-EF-2, October 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf08/breastfeeding/brfeedrs.htm