The main takeaway from a recent US Preventive Services Task Force (USPSTF) update on breastfeeding interventions is that a lack of support at the primary care level, compounded by societal barriers, can interfere with a family’s desire to breastfeed their child and even make them feel badly about their circumstances, according to experts.
An updated evidence review of the original 2016 USPSTF recommendation affirmed that breastfeeding interventions have the potential to increase breastfeeding in newborns and infants for up to 6 months, with no reported harms. The recommendations kept their B grade, deemed to have moderate benefit, and are published online in JAMA.
The Data
For the update, outcomes from 90 randomly controlled trials were included for a systematic review of the timing, delivery, and duration of a range of breastfeeding support interventions across diverse populations (N = 49,597).
As for infant health outcomes, the researchers found evidence of the effectiveness of these interventions to be limited and mixed (10 trials, n = 6592). The same was true in maternal symptoms of anxiety, depression, and well-being (nine trials, n = 2334).
A beneficial association was observed between lactation support intervention and any breastfeeding (risk ratio [RR], 1.13; 95% CI, 1.05-1.22; 37 trials [n = 13,579]) or exclusive breastfeeding (RR, 1.46; 95% CI, 1.20-1.78; 37 trials [n = 14,398]) for up to and at 6 months. However, no relationship was observed between interventions and breastfeeding initiation or breastfeeding at 12 months.
The analyses used for the recommendations were conducted by researchers led by Carrie D. Patnode, PhD, MPH, a behavioral epidemiologist at Kaiser Permanente Center for Health Research in Portland, Oregon.
Calls for Policy Changes
The update triggered some to call for more physician training and for expanded support for breastfeeding mothers.
“This updated recommendation provides an important, evidence-based directive for delivering lactation support — an area that remains under researched and poorly integrated into health systems,” wrote Jill R. Demirci, PhD, RN, IBCLC, and her coauthors in an editorial accompanying the update.
Demirci is a lactation researcher at the University of Pittsburgh, Pittsburgh, where she is an associate professor of nursing and vice chair of the Department of Administration Health Promotion & Development.
Potential Harms Elucidated
Demirci and her colleagues decried that since there have been only 37 randomized controlled trials (RCTs) on optimal breastfeeding interventions since the 2016 recommendations, there is not enough evidence to offer clinicians much guidance on the matter.
“It remains unclear what breastfeeding education topics are most critical, the most effective mediums and formats for delivery, and how often support should be provided,” Demirci and her coauthors wrote.
What’s more, they said, regardless of RCT outcomes, it’s hard to standardize breastfeeding interventions in community settings where there are many variables. And current RCT data on the subject neither address nor delineate potential harms from families being offered no or limited breastfeeding interventions, they wrote.
Need for Systemic Change
Even with more attention paid to breastfeeding support in the primary care setting, change is necessary at multiple levels, according to Demirci and her coauthors. “Beyond primary care, structural-level changes — requiring increased advocacy, funding, and research — are necessary to eliminate breastfeeding disparities,” they wrote.
A physician specializing in lactation agreed.
“Ultimately, we need better maternity and family leave policies and better working conditions once people do go back to work. The fact is, the system is not helping people who are lactating,” Cindy Rubin, MD, a medical lactation specialist and pediatrician in Chicago, told Medscape Medical News in an interview.
Currently in the United States, only 27.2% of infants aged 6 months are exclusively breastfed, according to the recommendations. The national goal per the Healthy People 2030 federal initiative is to reach 42.4% of all US babies exclusively breastfed by 2030.
“There are some public health initiatives to provide boots-on-the-ground lactation support and education, but these cannot function in isolation,” Rubin said. “In particular, home visits are invaluable as a form of early postpartum support and education for lactation.”
Rubin, who is a founding board member of the North American Board of Breastfeeding and Lactation Medicine, a professional organization for the nascent lactation medicine subspecialty, said that were perinatal home visits from lactation experts more widely available, “I am sure we would do better at reaching our nation’s breastfeeding goals.”
Rubin also said that insurance-driven quarter-hour appointment schedules leave little time for the provider to “help with latching or go over the warning signs for breastfeeding challenges that may arise.”
Without advocacy, Rubin said, there will be no drive for insurance to expand coverage.
Inadvertent Harms
Breastfeeding has been linked to multiple positive natal health outcomes. Among them, according to the updated recommendation, are lower rates of asthma, respiratory and gastrointestinal tract infections, and infant mortality. The maternal health benefits of breastfeeding listed in the recommendations are lower rates of ovarian cancer, hypertension, and type 2 diabetes.
Often, socioeconomic factors such as race and income play a role in a family’s decision to breastfeed, according to the updated recommendations.
Members of Hispanic and Latin communities, as well as individuals with lower socioeconomic status, according to studies cited in the update by the USPSTF, may hold jobs not conducive to breastfeeding (pumping) while working. Additionally, the authors of the update wrote that, “Black women often report returning to work early, at 6-8 weeks postpartum, which may make it more difficult to breastfeed their infants.”
“There is harm when we’re telling everybody that breastfeeding is the best thing, that breast milk is optimal, but then we don’t provide enough resources to help people do that,” Rubin said. “They feel bad because they want to do it, but they can’t access the support, or their lives don’t support it.”
Not Enough Education and Referrals
Demirci and her coauthors also called out a lack of basic lactation education across primary care providers as a fundamental reason for there being a lack of breastfeeding interventions; there is a federal program, the Physician Education and Training on Breastfeeding Project, available.
“It’s like with menopause,” said Rubin. “People didn’t learn about it in med school because it isn’t studied there. But now it’s the latest thing. That’s the same thing with breastfeeding. They don’t teach it in med school.”
Even if physicians are familiar with the basics of breastfeeding, Whitney Kathryn Kaefring, MD, a family medicine physician and lactation specialist, told Medscape Medical News that if further consultation on a medical condition is required to help ensure breastfeeding success, there need to be specialists able to take the case.
The recommendation says that primary care physicians should be providing support and referrals. “Well, my question is, what are we putting in the referral?” Kaefring said.
She added that more specialized education is necessary to fully meet the family’s needs. “Is this a first-time mom who wants to learn how to breastfeed before they have to do it, or is this somebody who’s had a history of breast reduction or has a metabolic condition that could put them at risk for breastfeeding problems? They need to see a lactation medicine specialist.”
Kaefring works in the Mercy Health System in Ferguson, Missouri.
“Ancillary lactation services should be a part of any primary care setting that serves people having babies,” Rubin agreed.
To that end, Demirci and her coauthors pointed to the future, writing that, “Primary research and systematic reviews should include implementation science, qualitative research, and community-based participatory research to assess how interventions work in real-world settings.”
Patnode, Nicholson, Demirci, Rubin, and Kaefring had no relevant financial conflicts to disclose.