This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on counseling to promote breastfeeding, a new topic for the USPSTF. Explanations of the ratings and of the strength of overall evidence are given in Appendix A and Appendix B, respectively. The complete information on which this statement is based, including evidence tables and references, is available in the systematic evidence review₁ on this topic, which can be obtained through the USPSTF web site (www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse™ (http://www.guideline.gov). The recommendation statement and the systematic evidence review are also available from the AHRQ Publications Clearinghouse in print or through subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates. To order, contact the Clearinghouse at 1-800-358-9295 or e-mail ahrqpubs@ahrq.gov.

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Agency for Healthcare Research and Quality

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US Department of Health and Human Services

Summary Of Recommendations

The USPSTF recommends structured breastfeeding education and behavioral counseling programs to promote breastfeeding. B recommendation.

The USPSTF found fair evidence that programs combining breastfeeding education with behaviorally-oriented counseling are associated with increased rates of breastfeeding initiation and its continuation for up to 3 months, although effects beyond 3 months are uncertain. Effective programs generally involved at least 1 extended session, followed structured protocols, and included practical, behavioral skills training and problem-solving in addition to didactic instruction.

The USPSTF found fair evidence that providing ongoing support for patients, through in-person visits or telephone contacts with providers or counselors, increased the proportion of women continuing breastfeeding for up to 6 months. Such support, however, had a much smaller effect than educational programs on the initiation of breastfeeding and its continuation for up to 3 months. Too few studies have been conducted to determine whether the combination of education and support is more effective than education alone.

The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and counseling by primary care providers; peer counseling used alone and initiated in the clinical setting; and written materials, used alone or in combination with other interventions. I recommendation.

The USPSTF found no evidence for the effectiveness of counseling by primary care providers during routine visits and generally poor evidence to assess the effectiveness of peer counseling initiated from the clinical setting when used alone to promote breastfeeding in industrialized countries. The evidence for the effectiveness of written materials suggests no significant benefit when written materials are used alone and mixed evidence of incremental benefit when written materials are used in combination with other interventions.

Clinical Considerations

• Effective breastfeeding education and behavioral counseling programs use individual or group sessions led by specially trained nurses or lactation specialists, usually lasting 30 to 90 minutes. Sessions generally begin during the prenatal period and cover the benefits of breastfeeding for infant and mother, basic physiology, equipment, technical training in positioning and latch-on techniques, and behavioral training in skills required to overcome common situational barriers to breastfeeding and to garner needed social support.

• Hospital practices that may help support breastfeeding include early maternal contact with the newborn, rooming-in, and avoidance of formula supplementation for breastfeeding infants.

• Commercial discharge packs provided by hospitals that include samples of infant formula and/or bottles and nipples are associated with reducing the rates of exclusive breastfeeding.

• Mothers who wish to continue breastfeeding after returning to work, especially those working full-time, may need to use an electric or mechanical pump to maintain a sufficient breast milk supply.

• Few contraindications to breastfeeding exist. In developed countries, infection with human immunodeficiency virus (HIV) in the mother is considered a contraindication to breastfeeding, as is the presence of current alcohol and drug use/dependence. Some medications (prescription and non-prescription) are contraindicated or advised for use “with caution” and appropriate clinical monitoring among lactating women.2 Clinicians should consult appropriate references for information on specific medications, including herbal remedies.

Scientific Evidence

Benefits of Breastfeeding

Effectiveness of Structured Breastfeeding Education and Behavioral Counseling Programs

Effectiveness of Support From Providers and Peers

Effectiveness of Other Breastfeeding Education and Support Measures

Discussion

In order to promote wider use of effective breastfeeding programs, research is needed to examine barriers to their use, the costs and cost-effectiveness of these programs and their individual components, and their effectiveness in more diverse populations and clinical settings.

The role of the primary obstetric, pediatric, or family medicine provider in promoting breastfeeding during clinical preventive visits has not received the attention it deserves. Because such visits are well-established elements of routine prenatal and postnatal care, they have rich but untested potential to yield effective and cost-effective approaches to breastfeeding promotion.

Recommendations Of Others

The Canadian Task Force on Preventive Health Care (CTFPHC) concludes that there is good evidence to counsel women to breastfeed and to implement peripartum interventions that promote breastfeeding.₂₂ The CTFPHC is in the process of updating its recommendation. The American Academy of Family Physicians recommends that physicians counsel pregnant women about breastfeeding and include behavioral supports, such as contact with lactation consultants, rooming-in, and early initiation of breastfeeding.₂₃ The World Health Organization, the United Nations Children's Fund, and the American Academy of Pediatrics (AAP) each recommend breastfeeding and include recommendations that clinicians promote breastfeeding, but none of these organizations include specific recommendations on the nature or extent of any counseling that should be undertaken by clinicians.₂₄,₂₅ The AAP also recommends that physicians work to promote support for breastfeeding at the department, hospital, and community level. Other organizations that support counseling to promote breastfeeding include the American College of Obstetricians and Gynecologists, the American Dietetic Association, and the International Lactation Consultants Association.₂₆,₂₇,₂₈

Members of the U.S. Preventive Services Task Force at the time this recommendation was voted on* were Alfred O.Berg, MD, MPH, Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, PhD, RN, CS, Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland-Baltimore, Baltimore, MD); Paul Frame, MD (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, MD, MPH (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, MD, MPH (Chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, MD, MPH (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, MD, MPH (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, MD, MSc (Clinical Professor and Director, Department of Medicine, University of Texas Health Science Center, and Director, National Program Office for Robert Wood Johnson Generalist Physician Faculty Scholars Program, San Antonio, TX); C. Tracy Orleans, PhD (Senior Scientist and Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, MD, MPH (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, PhD, RN, (Professor Emeritus, University of Michigan, Ann Arbor, MI); Albert L. Siu, MD, MSPH (Professor of Medicine, Chief of Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, MD, MPH (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, MD, MSc (Professor, Department of Obstetrics and Gynecology, Columbia University, New York, NY); and Steven H. Woolf, MD, MPH (Professor, Department of Family Practice and Department of Preventive and Community Medicine, Virginia Commonwealth University, Fairfax, VA).

*For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.

The USPSTF recommendations are independent of the U.S. Government. They do not represent the views of the Agency for Healthcare Research and Quality (AHRQ), the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

Corresponding author: Alfred O. Berg, MD, MPH, Chair, U.S. Preventive Services Task Force, c/o Project Director, USPSTF, Agency for Healthcare Research and Quality, 540 Gaither Rd., Rockville, MD 20850, E-mail: uspstf@ahrq.gov.

This recommendation and rationale statement was originally published in Ann Fam Med. 2003;1(2):79-80.

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U.S. Preventive Services Task Force Recommendations And Ratings

The Task Force grades its recommendations according to one of 5 classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms):

A. The USPSTF strongly recommends that clinicians routinely provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B. The USPSTF recommends that clinicians routinely provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

U.S. Preventive Services Task Force Strength Of Overall Evidence

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.