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Complete Summary

GUIDELINE TITLE

Breastfeeding friendly physician's office, part 1: optimizing care for infants and children.

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

This is the current release of the guideline.

COMPLETE SUMMARY CONTENT

 SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 QUALIFYING STATEMENTS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Infant health/nutrition

GUIDELINE CATEGORY

Counseling
Evaluation
Management
Prevention

CLINICAL SPECIALTY

Family Practice
Gastroenterology
Nursing
Nutrition
Obstetrics and Gynecology
Pediatrics
Preventive Medicine
Radiology
Surgery

INTENDED USERS

Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Hospitals
Nurses
Physician Assistants
Physicians
Public Health Departments

GUIDELINE OBJECTIVE(S)

To optimize care for infants and children by promoting a physician's practice that enthusiastically promotes, supports, and protects breastfeeding through a warm office environment and education of health care professionals and families

TARGET POPULATION

Mothers and their breastfeeding infants

INTERVENTIONS AND PRACTICES CONSIDERED

Evaluation/Counseling

  1. Prenatal and postnatal encouragement of breastfeeding
  2. Assessment of successful and adequate breastfeeding at first and subsequent office visits

Management/Treatment

  1. Provide an office environment supportive of breastfeeding
    • Provide written breastfeeding-friendly office policy to patients, hospitals, physicians
    • Encourage breastfeeding in office
    • Provide a private lactation room
    • Display images of breastfeeding in office
  2. Offer prenatal visit to office
  3. Offer culturally and ethnically competent care
  4. Collaborate with local hospitals and maternity care professionals in the community
  5. First postpartum follow-up visit
    • Ensure access to a lactation consultant
    • Answer questions and concerns
  6. Provide appropriate (noncommercial) educational resources for patients (ethnically diverse materials e.g., handouts, visual aids, books, videos)
  7. Establish telephone triage protocols to address breastfeeding concerns
  8. Provide positive feedback to breastfeeding mothers
  9. Encourage community employers and day care providers to support breastfeeding
  10. Help patients receive reimbursement from insurance companies for breast pumps and lactation services
  11. Physician education regarding breastfeeding
    • Medical student and medical resident education: benefits of breastfeeding, physiology of lactation, management of common breastfeeding problems, contraindications to breastfeeding
    • Offer medical student and resident clinic practice rotations
  12. Track breastfeeding initiation and duration rates

MAJOR OUTCOMES CONSIDERED

Breastfeeding initiation and duration rates

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METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

An initial search of relevant published articles written in English in the past 20 years in the fields of medicine, psychiatry, psychology, and basic biological science is undertaken for a particular topic. Once the articles are gathered, the papers are evaluated for scientific accuracy and significance.

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Levels of Evidence

I Evidence obtained from at least one properly randomized controlled trial

II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies and case reports; or reports of expert committees

METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

An expert panel is identified and appointed to develop a draft protocol using evidence based methodology. An annotated bibliography (literature review), including salient gaps in the literature, are submitted by the expert panel to the Protocol Committee.

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

External Peer Review
Internal Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft protocol is peer reviewed by individuals outside of lead author/expert panel, including specific review for international applicability. Protocol Committee's sub-group of international experts recommends appropriate international reviewers. Chair (co-chairs) institutes and facilitates process. Reviews submitted to committee Chair (co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. Chair (co-chairs) and protocol author(s) amends protocol as needed.

Following all revisions, protocol has final review by original author(s) to make final suggestions and ascertain whether to maintain lead authorship.

Final protocol is submitted to the Board of Directors of ABM for approval.

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RECOMMENDATIONS

MAJOR RECOMMENDATIONS

  1. Establish a written breastfeeding-friendly office policy (UNICEF, 2005). Collaborate with colleagues and office staff during development. Inform all new staff about policy. Provide copies of your practice's policy to hospitals and physicians covering for you.
  2. Encourage breastfeeding mothers to feed newborns only breast milk and avoid offering supplemental formula or glucose water unless medically indicated (Gartner et al., 2005). Instruct mother to not offer bottles or a pacifier until breastfeeding is well established (Howard et al., 2003).
  3. Offer culturally and ethnically competent care (Gartner et al., 2005). Understand that families may follow cultural practices regarding infant colostrum consumption and maternal diet during lactation. Provide access to a multilingual staff, translators, and ethnically diverse educational material.
  4. Offer a prenatal visit and show your commitment to breastfeeding during this visit (American Academy of Pediatrics Section on Breastfeeding, 2003). If providing antenatal care to the mother, broach the subject of infant feeding in the first trimester and continue to express your support of breastfeeding throughout the course of the pregnancy. Inquire about a feeding plan and previous breastfeeding experience. Provide educational material that highlights the many ways in which breastfeeding is superior to formula feeding. Direct education and educational material to all family members involved in child care (father, grandparents, etc.) (Bentley et al., 1999; Gartner et al., 2005; Ingram & Johnson, 2004). Encourage attendance of both parents at prenatal breastfeeding classes before parents decide about feeding plan. Identify patients with lactation risk factors (e.g., flat or inverted nipples, history of breast surgery, no increase in breast size during pregnancy, previous unsuccessful breastfeeding experience).
  5. Collaborate with local hospitals and maternity care professionals in the community (Gartner et al., 2005). Convey to delivery rooms and newborn units your office policies on breastfeeding initiation. Leave orders in the hospital not to give formula/sterile water/glucose water to baby without orders and not to dispense commercial discharge bags containing infant formula and/or feeding bottles to mothers (Donnelly et al., 2000; Snell et al., 1992). Show support for breastfeeding during hospital rounds. Facilitate breastfeeding within 1 hour of infant's birth. Help mothers initiate and continue breastfeeding. Counsel mothers to follow infant's hunger and satiety cues and ensure that the infant breastfeeds 8 to 12 times in 24 hours. Encourage rooming-in and breastfeeding on demand.
  6. Schedule a first follow-up visit for the infant 48 to 72 hours after hospital discharge* or earlier if breastfeeding related problems, such as excessive weight loss (>7%) or jaundice are present at the time of hospital discharge (Gartner et al., 2005; American Academy of Pediatrics Section on Breastfeeding, 2003; "Management," 2004). Ensure access to a lactation consultant/educator or other health care professional trained to address breastfeeding questions or concerns during this visit. Provide comfortable seating and a nursing pillow for the breastfeeding dyad to facilitate adequate evaluation. Assess latch and successful and adequate breastfeeding at the early follow-up visit. Identify lactation risk factors and assess infant's weight, hydration, jaundice, feeding activity, and output. Provide medical help for women with sore nipples or other maternal health problems that impact breastfeeding. Begin by asking parents open-ended questions and then focus on their concerns. Take the time to address the many questions that a mother may have, especially if it is her first nursing experience. Provide close follow-up until the infant is doing well with adequate weight gain and parents feel confident.

    *In cultures or medical situations in which the dyad has remained hospitalized for long enough that weight gain and parental confidence are established prior to hospital discharge, follow-up may be deferred until the initial well child care visit at 1 to 2 weeks of age if otherwise appropriate.

  7. Ensure availability of appropriate educational resources for parents. Educational material should not be commercial and not advertise breast milk substitutes, bottles, or nipples (Howard et al., 2000). Educational resources may be in the form of handouts, visual aids, books, and videotapes. Recommended topics for educational material are growth patterns, feeding, and sleep patterns of breastfed babies; management of growth spurts; recognition of hunger and satiety cues; latch-on and positioning; management of sore nipples; mastitis; low supply; blocked ducts; engorgement; reflux; normal stooling and voiding patterns; maintaining lactation when separated from the infant (e.g., during illness, prematurity, return to work); postpartum depression; maternal medication use; and maternal illness during breastfeeding.
  8. Do not interrupt or discourage breastfeeding in the office. Allow and encourage breastfeeding in the waiting room. Display signs in waiting area encouraging mothers to breastfeed. Provide a comfortable private area to breastfeed for those mothers who prefer privacy (American Academy of Pediatrics Section on Breastfeeding, 2003).
  9. Ensure an office environment that demonstrates breastfeeding promotion and support. Eliminate the practice of distribution of free formula and baby items from formula companies to parents (Howard et al., 2000). Store formula supplies out of view of parents. Display posters, pamphlets, pictures, and photographs of breastfeeding mothers in your office (American Academy of Pediatrics Section on Breastfeeding, 2003). Do not display images of infants bottle feeding. Do not accept gifts (including writing pads, pens, or calendars) or personal samples from companies manufacturing infant formula, feeding bottles, or pacifiers. Specifically target material to populations with low breastfeeding rates.
  10. Develop and follow telephone triage protocols to address breastfeeding concerns and problems (American Academy of Pediatrics Section on Breastfeeding, 2003). Conduct follow-up phone calls to assist breastfeeding mothers. Provide readily accessible resources such as books and protocols to triage nurses.
  11. Commend breastfeeding mothers during each visit for choosing and continuing breastfeeding. Provide breastfeeding anticipatory guidance in routine periodic health maintenance visits. Encourage fathers of infants to accompany mother and baby to office visits (Ingram & Johnson, 2004; Wolfberg et al., 2004).
  12. Encourage mothers to exclusively breastfeed for 6 months and continue breastfeeding with complementary foods until at least 24 months and thereafter as long as mutually desired (World Health Assembly, 2003). Discuss introduction of solid food at 6 months of age, emphasizing the need for high-iron solids, and assess need for vitamin D supplementation (Gartner et al., 2005).
  13. Set an example for your patients and community. Have a written breastfeeding policy and provide a lactation room with supplies for your employees who breastfeed or express breast milk at work.
  14. Acquire or maintain a list of community resources (e.g., breast pump rental locations) and be knowledgeable about referral procedures. Refer expectant and new parents to community support and resource groups. Identify local breastfeeding specialists, know their background and training, and develop working relationships for additional assistance. Support local breastfeeding support groups (Grummer-Strawn et al., 1997).
  15. Work with insurance companies to encourage coverage of breast pump costs and lactation support services (Gartner et al., 2005). Bill lactation support codes (American Academy of Pediatrics Section on Breastfeeding and Committee on Coding and Nomenclature, 2006).
  16. Encourage community employers and daycare providers to support breastfeeding (Gartner et al., 2005; Ortiz, McGilligan, & Kelly, 2004) The following website provides material to help motivate and guide employers in providing lactation support in the workplace: http://www.breastfeedingwa.org/working_packet (Breastfeeding Coalition of Washington State, 2005).
  17. All clinical physicians should receive education regarding breastfeeding (American Academy of Pediatrics Section on Breastfeeding, 2003; Freed et al., 1995). Areas of suggested education include the benefits of breastfeeding, physiology of lactation, management of common breastfeeding problems, and medical contraindications to breastfeeding. Make educational resources available for quick reference by health care professionals in your practice (books, protocols, etc.). Staff education and training should be provided to the front office staff, nurses, and medical assistants. Identify one or more breastfeeding resource personnel on staff. Consider employing a lactation consultant or nurse trained in lactation (Lawlor-Smith, McIntyre, & Bruce, 1997; Jones & West, 1986).
  18. Volunteer to let medical students and residents rotate in your practice. Participate in medical student and resident physician education (Freed et al., 1995; Hillenbrand & Larsen, 2002). Encourage establishment of formal training programs in lactation for future and current healthcare providers (Gartner et al., 2005).
  19. Track breastfeeding initiation and duration rates in your practice and learn about breastfeeding rates in your community.

CLINICAL ALGORITHM(S)

None provided

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EVIDENCE SUPPORTING THE RECOMMENDATIONS

REFERENCES SUPPORTING THE RECOMMENDATIONS

References open in a new window

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically stated.

The recommendations were based primarily on a comprehensive review of the existing literature. In cases where the literature does not appear conclusive, recommendations were based on the consensus opinion of the group of experts.

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BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Improved breastfeeding outcomes for mothers and infants

POTENTIAL HARMS

Not stated

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QUALIFYING STATEMENTS

QUALIFYING STATEMENTS

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

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IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

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INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Staying Healthy

IOM DOMAIN

Effectiveness
Patient-centeredness

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2006

GUIDELINE DEVELOPER(S)

Academy of Breastfeeding Medicine - Professional Association

SOURCE(S) OF FUNDING

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau, US Department of Health and Human Services

GUIDELINE COMMITTEE

Academy of Breastfeeding Medicine Protocol Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Committee Members: Caroline J. Chantry, MD, Co-Chairperson; Cynthia R. Howard, MD, MPH, Co-Chairperson; Ruth A. Lawrence, MD; Nancy G. Powers, MD

Contributor: Ulfat Shaikh, MD, MPH, University of California Davis Medical Center, Sacramento, CA (Lead author)

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None to report

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the Academy of Breastfeeding Medicine Web site.

Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd floor, New Rochelle, New York 10801.

AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

  • Procedure for protocol development and approval. Academy of Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd floor, New Rochelle, New York 10801.

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on November 14, 2007. The information was verified by the guideline developer on October 31, 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Single copies may be downloaded for personal use. Copyright permission to be requested for use of multiple copies by e-mailing requests to abm@bfmed.org. An official request form will be sent electronically to person requesting multiple copy use.

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DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
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