Final Recommendation Statement
October 15, 2008
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.
Effectiveness of Interventions to Change Behavior
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.
The USPSTF concludes that there is moderate certainty that interventions to promote and support breastfeeding have a moderate net benefit.
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.
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.
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.
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.
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
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 https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/current-members
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.
This document is in the public domain within the United States.
Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.
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.
- American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 6th ed. Elk Grove, IL: American Acad Pediatrics; 2007.
- Breastfeeding Practices—Results from the National Immunization Survey, 2007. Atlanta: Centers for Disease Control and Prevention; 2007. Accessed at https://www.cdc.gov/breastfeeding/data/NIS_data/index.htm on 3 September 2008.
- U.S. Department of Health and Human Services. Healthy People 2010: Conference Edition. Washington, DC: U.S. Government Printing Office; 2000.
- 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]
- American Academy of Family Physicians. Breastfeeding (Policy Statement). Leawood, KS: American Acad Family Physicians; 2007.
- Breastfeeding—Best For Baby. Best For Mom. Washington, DC: Department of Health and Human Services; 2007.
- 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 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781366/ on May 8, 2019.
- 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.
- 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. [PMID: 15040435]
- 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]
- 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.