US Public Health guildelines should reflect evidence, not anecdote

In 2008, the United States Preventive Services Task Force issued the following recommendation with Grade B Evidence: “The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.” Since that time, breastfeeding initiation, continuation, and exclusivity rates have continued to rise, and the number of hospitals designated as Baby Friendly has increased by almost 5-fold.  The ABM Position on Breastfeeding–Revised 2015 indicates that “breastfeeding is, and should be considered, normative infant and young child feeding” and “a human rights issue for both mother and child.”  ABM further states that “children have the right to the highest attainable standard of health,” and “as breastfeeding is both a woman’s and a child’s right, it is therefore the responsibility of the healthcare system . . . to inspire, prepare, and empower as well as support and enable each woman to fulfill her breastfeeding goals and to eliminate obstacles and constraints to initiating and sustaining optimal breastfeeding practices.” ABM calls for an improvement in breastfeeding promotion, protection and support and states that medical professionals have a responsibility to promote, protect, and support breastfeeding as a basic ethical principle.

The American Academy of Pediatrics, in its 2012 Policy Statement on Breastfeeding and the Use of Human Milk concludes that, “research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.”

Recently, the USPSTF proposed a new recommendation: “The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding.”  Note that this statement does not state “promote and support,” but just “support.” The task force made a deliberate decision to delete the “promote” from the previous “promote and support.” The evidence review, however, does not support the proposed change. In explanations about this change, a member of the Task Force, Dr. Alex Kemper, as quoted in MedPage Today, stated that “the reason the Task Force made this slight word change is to recognize the importance of a mother doing what she feels is best for her and her baby and not wanting to, for example, make mothers feel guilty or bad if they decide not to breastfeed,” he said. “It’s really a personal choice that needs to be made based on her own personal situation.”

In the 2016 USPSTF evidence report, the following statement is made:  “We systematically reviewed the literature for a variety of potential adverse events associated with breastfeeding interventions, including mothers reporting feeling criticized by the interventionist, guilt related to not breastfeeding, increased anxiety about breastfeeding, and increased postpartum depression. Only two of our included studies reported adverse events that mothers experienced related to the intervention and included reports of increased anxiety, feelings of inadequacy, and concerns regarding their family’s confidentiality. Although the goals of these interventions focused on initiating and continuing breastfeeding and empowering women to do so, it is important that interventionists respect family’s individual decisions.” The discussion further describes those two Canadian trials of “fair” quality, and goes on to note that: “Dennis and colleagues (CMAJ. 2002 Jan 8;166(1):21-8) compared a peer support intervention with usual care and reported that a few mothers in the intervention group expressed feelings of anxiety, decreased confidence, or concerns about confidentiality. For example, one mother requested to discontinue her participation in the intervention, stating that the peer volunteer frightened her about the potential hazards of not breastfeeding and diminished her feelings of confidence, despite the fact that breastfeeding was going well for her.”  The authors of the quoted study report that: “Of the 130 mothers who evaluated the peer support intervention, 81.6% were satisfied with their peer volunteer experience and 100% felt that all new breast-feeding mothers should be offered this peer support intervention.”  Therefore, it appears that one mother’s complaint about a peer counselor is enough to change a U.S. public health recommendation.  Is this change based on evidence or on personal opinion?

If breastfeeding is truly a public health issue with benefits that have been widely documented for both women and children, then health care providers should be promoting breastfeeding to empower women to make an informed decision about their infant feeding choice.  Physicians who have been taught counselling skills can provide such information without inducing guilt. We don’t seem to worry so much about guilt when counseling patients about smoking cessation, weight reduction, or need to increase exercise.  If we are advocating for each child and mother to achieve the highest attainable state of health, we must both promote and support breastfeeding, protecting each mother and child’s right to do so, and supporting each family in their infant feeding decision.  These are not mutually exclusive outcomes.

The DRAFT Recommendation Statement will be open for public comments until May 23, 2016 at 8:00 PM Eastern.

Joan Meek, MD, MS, FAAP, FABM, IBCLC is a Associate Dean for Graduate Medical Education and Professor of Clinical Sciences Florida State University College of Medicine. She has served as president of the Academy of Breastfeeding Medicine, Chair of the American Academy of Pediatrics Section on Breastfeeding, and Chair of the United States Breastfeeding Commitee. You can follow her on twitter @joanymeek