Draft Recommendation Statement
Breastfeeding: Primary Care Interventions
This opportunity for public comment expired on May 23, 2016 at 8:00 PM EST
Note: This is a Draft Recommendation Statement. This draft is distributed solely for the purpose of receiving public input. It has not been disseminated otherwise by the USPSTF. The final Recommendation Statement will be developed after careful consideration of the feedback received and will include both the Research Plan and Evidence Review as a basis.
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.
There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women. However, nearly one half of all mothers in the United States stop breastfeeding by 6 months, and there are significant disparities in breastfeeding rates among younger mothers and disadvantaged communities.1
Effectiveness of Interventions to Change Behavior
Adequate evidence indicates that interventions to support breastfeeding increase the duration and rates of breastfeeding, including exclusive breastfeeding.
Harms of Interventions to Change Behavior
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 USPSTF concludes with moderate certainty that interventions to support breastfeeding have a moderate net benefit for women and their children.
Draft: Clinical Considerations
Patient Population Under Consideration
This recommendation applies to pregnant women, new mothers, and their children. Interventions to support breastfeeding may also involve a woman's partner, other family members, and friends. This recommendation does not apply to women with contraindications to breastfeeding (e.g., maternal HIV infection or infant metabolic disorders, such as galactosemia). The USPSTF did not review evidence on interventions directed at breastfeeding of preterm infants.
Primary care clinicians can support women who intend to breastfeed through interventions, such as professional support, peer support, and formal education, providing these services either directly or through referral. None of these interventions are mutually exclusive, and they may be combined within and between categories.
Professional support includes one-to-one counseling about breastfeeding provided by a health professional (medical, nursing, or allied professionals, including lactation care providers). Adjunctive interventions include the provision of supplies, such as educational materials, nursing bras, and breast pumps. Support can include psychological support (encouraging the mother, providing reassurance, and discussing the mother’s questions and problems) and direct support during breastfeeding observations (helping with the positioning of the infant and observing latching). Professional support may be delivered during pregnancy, the hospital stay, or the postpartum period or at multiple stages. It may be conducted in an office setting, in the hospital, through home visits, through telephone support, or through any combination of these. Sessions generally last from 15 to 45 minutes, although some programs have used shorter or longer sessions. Most successful interventions include multiple sessions and are delivered at more than one point in time.
Similarly to professional support, peer support provides women with one-to-one counseling about breastfeeding, but it is delivered by a layperson (generally mothers with successful breastfeeding experience and a similar background as the patient) who has received training in how to provide support. As with professional support, peer support may be delivered through a variety of time periods, settings, modalities, and durations.
Formal education interventions typically include a formalized program to convey nontailored breastfeeding knowledge and most often occur in the prenatal period, although some may span time periods. Education is usually offered in group sessions and may include telephone support, electronic interventions, videos, and print materials. They are directed at mothers but may include other family members. Content generally focuses on the benefits of breastfeeding, practical breastfeeding skills (e.g., latching), and the management of common breastfeeding complications; it may also offer family members encouragement and advice on how to support the mother.
The Centers for Disease Control and Prevention provides information on different breastfeeding intervention strategies, including program examples and resources, at www.cdc.gov/breastfeeding/resources/guide.htm. Another resource is the Surgeon General’s Call to Action to Support Breastfeeding, available at www.surgeongeneral.gov/library/calls/breastfeeding/index.html.
Draft: Other Considerations
Although there is moderate certainty of net benefit to women and their children, 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.
In addition to clinicians’ direct activities to support breastfeeding, systems of care may be adopted that promote breastfeeding. System-level interventions include policies, programs, and staff training, usually implemented within hospitals or health care systems. The Baby Friendly Hospital Initiative is the most widely adopted system-level intervention and is based on the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) “10 Steps to Successful Breastfeeding for Hospitals”.2 Other system-level interventions include maternity care practices such as encouraging skin-to-skin contact, rooming-in, restricted pacifier use, and distributing breast pumps. Community-based interventions include social marketing initiatives, workplace initiatives, and public policy actions. A comprehensive review of the evidence on the effectiveness of these other types of interventions is beyond the scope of the USPSTF. However, a focused review of system-level interventions is included in the full evidence report,3 and the Centers for Disease Control and Prevention provides examples of individual, system-level, and community-based interventions at www.cdc.gov/breastfeeding/promotion/index.htm.
Research Needs and Gaps
To better assess how population-level interventions would affect breastfeeding rates, future studies should include women who have not already declared their intention to breastfeed. To better understand the effects of different interventions and patient populations, future research should include adequate sample sizes, clear descriptions of the included populations and comparators, and standardized reporting of outcomes. 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. Trials should include reliable and valid measures of infant and maternal health outcomes and be powered to detect potential effects on these outcomes. Studies should also explore maternal satisfaction with the intervention and any potential negative feelings or feelings of inadequacy that could result if mothers choose not to or are unable to breastfeed. More research is needed to better understand the root causes of breastfeeding disparities and how they can be addressed through health care and community interventions. Other areas for research include assessment of the potential benefits and harms of supporting indirect breastfeeding (e.g., use of breast pumps), the role of breastfeeding support for adoptive or surrogate families, the role of systems to distribute donor breast milk, and the impact of new technologies to support breastfeeding (e.g., Internet- or computer-based interventions).
Burden of Disease
A history of being breastfed has been found to be associated with a reduced risk of a variety of negative health outcomes in infancy and childhood, including illnesses such as acute otitis media, asthma, atopic dermatitis, and gastrointestinal infection, and chronic conditions such as obesity, diabetes, and high blood pressure.3 Although the majority of studies are observational and the definitions and comparisons vary widely, any breastfeeding appears to be more beneficial than no breastfeeding and longer durations confers greater benefits than shorter durations. Breastfeeding is also associated with positive maternal health outcomes, such as a reduced risk of maternal breast and ovarian cancer and type 2 diabetes.
Estimates for any breastfeeding of infants born in 2012 in the United States were 80.0 percent for initiation, 51.4 percent at 6 months, and 29.2 percent at 12 months. Rates of exclusive breastfeeding through 3 and 6 months were 43.3 and 21.9 percent, respectively.1 These rates have been rising over the past few decades but are still short of the Healthy People 2020 targets for initiating breastfeeding (81.9%), breastfeeding to 6 months (66.6%), and breastfeeding to 12 months (34.1%). Targets for exclusive breastfeeding at 3 months are 46 percent and 25 percent at 6 months.4
Scope of Review
The USPSTF commissioned a systematic evidence review to update its 2008 recommendation on primary care interventions to promote breastfeeding. This update focused on the effectiveness of breastfeeding support interventions on breastfeeding initiation, duration, and exclusivity. The USPSTF briefly reviewed the literature on child and maternal health outcomes published since the previous review to ensure that there have been no major changes in the direction of the evidence. The population of interest included mothers of full- or near-term infants as well as members of the mother-infant support system (e.g., partners, grandparents, or friends). The review used a broad conception of primary care interventions that encompassed activities initiated, conducted, or referred by primary care clinicians.
Effectiveness of Interventions to Change Behavior and Outcomes
The USPSTF found insufficient evidence to determine the direct effects of interventions to support breastfeeding on child and maternal health outcomes. Six trials reported inconsistent effects of counseling interventions on a range of infant health outcomes, such as gastrointestinal illness, otitis media, respiratory tract illness, and health care use. None of the studies reported maternal health outcomes.3, 5-10
However, the USPSTF found evidence that interventions to support breastfeeding can increase the rate and duration of breastfeeding. An analysis of 43 trials found that breastfeeding support and education interventions targeting women were associated with a statistically significant higher likelihood of any and exclusive breastfeeding at less than 3 months and at 3 to 6 months compared to usual care. Pooled estimates indicated beneficial associations for any breastfeeding at less than 3 months (risk ratio [RR], 1.07 [95% confidence interval (CI), 1.03 to 1.11]; k=26) and at 3 to 6 months (RR, 1.11 [95% CI, 1.04 to 1.18]; k=23) and for exclusive breastfeeding at less than 3 months (RR, 1.21 [95% CI, 1.11 to 1.33]; k=22) and at 3 to 6 months (RR, 1.20 [95% CI, 1.05 to 1.38]; k=18). At 6 months, interventions to support breastfeeding were associated with a 16 percent higher likelihood of exclusive breastfeeding (RR, 1.16 [95% CI, 1.02 to 1.32]; k=17) but not any breastfeeding. The association between interventions to support breastfeeding and breastfeeding initiation was not statistically significant based on the pooled point estimate (RR, 1.00 [95% CI, 0.99 to 1.02]; k=14).3 Based on these data, for every 30 women offered support, one more woman will breastfeed for up to 6 months.
Despite great variation in intervention and study design, there was little evidence that the effects of interventions varied across different populations or intervention characteristics, although the variability itself may have masked relationships. There was some suggestion that interventions taking place during a combination of prenatal, peripartum, or postpartum time periods were more effective than those taking place only during one time period. There was also some data suggesting that interventions are effective among adolescents as well as adults. All four trials of interventions to support breastfeeding among adolescents or young adults reported higher rates of breastfeeding among intervention versus control group participants.
Potential Harms of Interventions to Support Breastfeeding
There are very little data on the potential harms of interventions to support breastfeeding, which in theory could include guilt related to not breastfeeding, increased anxiety about breastfeeding, and increased postpartum depression. Only two trials among adults reported on adverse events related to a breastfeeding support intervention. One trial found no significant differences in maternal anxiety between groups at 2 weeks. The other trial reported that a few mothers expressed feelings of anxiety and decreased confidence in their breastfeeding ability despite breastfeeding going well and discontinued their participation in the peer counseling intervention.
Estimate of Magnitude of Net Benefit
There is adequate evidence that interventions to support breastfeeding change behavior and that the harms of these interventions are no greater than small. Therefore, the USPSTF concludes that there is moderate certainty that interventions to support breastfeeding have a moderate net benefit.
Draft: Recommendations of Others
Several national and international organizations, including the American Academy of Pediatrics,11 the American College of Obstetricians and Gynecologists,12 and WHO/UNICEF,13 recommend exclusive breastfeeding up to or around 6 months, followed by continued breastfeeding for at least 1 year, as mutually desired by mother and infant, while complementary foods are introduced. The American College of Obstetricians and Gynecologists also recommends that obstetrician-gynecologists and other obstetric care providers support each woman’s informed decision about whether to initiate or continue breastfeeding through education and counseling in the prenatal, perinatal, and postnatal periods.12 It endorses the WHO/UNICEF “10 Steps to Successful Breastfeeding” and policy efforts to enable women to breastfeed, whether through individual patient education, change in hospital practices, community efforts, or supportive legislation. The American Academy of Pediatrics recommends that pediatricians serve as breastfeeding advocates and educators, provides resources that pediatricians can use in their practices, and endorses the WHO/UNICEF “10 Steps to Successful Breastfeeding”11 The American Academy of Family Physicians recommends interventions during pregnancy and after birth to promote and support breastfeeding.14 In 2011, the U.S. Surgeon General issued a “Call to Action to Support Breastfeeding,” calling for clinicians, health systems, community programs, and government policy to support women who choose to breastfeed.15
1. Centers for Disease Control and Prevention. Breastfeeding among U.S. children born 2002–2012, CDC National Immunization Surveys. 2015. http://www.cdc.gov/breastfeeding/data/nis_data/index.htm
2. World Health Organization, United Nations Children’s Fund. Protecting, promoting and supporting breast-feeding: the special role of maternity services. Geneva: World Health Organization; 1989.
3. Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary Care Interventions to Support Breastfeeding: An Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 143. AHRQ Publication No. 15-05218-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
4. U.S. Department of Health and Human Services. Healthy People 2020: maternal, infant, and child health. 2016. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health
5. Anderson AK, Damio G, Young S, Chapman DJ, Pérez-Escamilla R. A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. Arch Pediatr Adolesc Med. 2005;159(9):836-41.
6. Bonuck KA, Freeman K, Trombley M. Randomized controlled trial of a prenatal and postnatal lactation consultant intervention on infant health care use. Arch Pediatr Adolesc Med. 2006;160(9):953-60.
7. Bunik M, Shobe P, O’Connor ME, Beaty B, Langendoerfer S, Crane L, Kempe A. Are 2 weeks of daily breastfeeding support insufficient to overcome the influences of formula? Acad Pediatr. 2010;10(1):21-8.
8. Chapman DJ, Morel K, Bermúdez-Millán A, Young S, Damio G, Pérez-Escamilla R. Breastfeeding education and support trial for overweight and obese women: a randomized trial. Pediatrics. 2013;131(1):e162-70.
9. Gagnon AJ, Dougherty G, Jimenez V, Leduc N. Randomized trial of postpartum care after hospital discharge. Pediatrics. 2002;109(6):1074-80.
10. Hopkinson J, Konefal Gallagher M. Assignment to a hospital-based breastfeeding clinic and exclusive breastfeeding among immigrant Hispanic mothers: a randomized, controlled trial. J Hum Lact. 2009;25(3):287-96.
11. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-41.
12. American College of Obstetricians and Gynecologists. Committee Opinion No. 658: optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol. 2016;127(2):e86-92.
13. World Health Organization, United Nations Children’s Fund. Global strategy for infant and young child feeding. Geneva: World Health Organization; 2003.
14. American Academy of Family Physicians. Breastfeeding, structured education and counseling. 2008. http://www.aafp.org/patient-care/clinical-recommendations/all/breastfeeding.html
15. Office of the Surgeon General. The Surgeon General’s call to action to support breastfeeding. Rockville, MD: Office of the Surgeon General; 2011.
Internet Citation: Draft Recommendation Statement: Breastfeeding: Primary Care Interventions. U.S. Preventive Services Task Force. April 2016.