Breastfeeding Medicine

Physicians blogging about breastfeeding

US Public Health guildelines should reflect evidence, not anecdote

with 8 comments

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?

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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 

Written by jymeek

May 11, 2016 at 8:21 am

8 Responses

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  1. The mollycoddling, paternalistic, patronizing and condescending nature of treating women when it comes to informing them about the feeding of their children is becoming increasingly problematic. It is not a choice to walk, to breathe, to eat. Neither is it a choice to breastfeed. I understand their are those that cannot provide enough or have other obstacles of course, but for the majority of women the milk is there. This is what our offspring need. It is what nature intends for all mammals.

    Cheryl Marian

    May 11, 2016 at 10:51 am

  2. Why don’t you trust women to make the right choice for them and their babies? Why do you feel that pressuring women is necessary or even helpful?

    The breastfeeding rate has tripled since 1973; can you show us any population data that indicates that the increased breastfeeding rates has had any impact on the health of term babies?

    Amy Tuteur, MD

    May 11, 2016 at 2:43 pm

  3. How about reporting on the risk of starvation jaundice, hypoglycemia, hypotensive dehydration, hypernatremia and brain injury from undergoing the Baby-Friendly protocol? How about the 1 in 10 risk of needing phototherapy? Or the risk of developmental disabilities? Why don’t any of you ever discuss those common complications? Or the risk of B12, vitamin D, and iron deficiency anemia among babies who are exclusively breastfed past 4 months? The ABM once again ignores and sweeps under the rug the harms of their recommendations in order to promote breastfeeding.

    Christie del Castillo-Hegyi

    May 11, 2016 at 6:58 pm

    • Why then are top physicians (e.g. Dr Jane Morton from Stanford University) promoting breastfeeding and baby friendly if your statements are true? Do you read the evidence and research based guidelines which is baby friendly practices? OR do you listen with a biased ear of isolated cases of a family possibly not following the physicians recommendations on when to follow up? Did you research that formula causes asthma, leukemia, ear infections, diabetes, obesity…..?? Infants are primarily at risk for hypoglycemia because their mother’s are diabetics….

      Roxanne Flynn

      May 21, 2016 at 6:26 pm

  4. Those involved in the task force may have realized that the ‘evidence’ was a bit thin.
    They stated that there were associations with a ‘reduced risk of some negative outcomes” but did not say that the relationship was causal.
    The report also stated that “the majority of studies are observational and the definitions and comparisons vary widely “ and there was:
    “Insufficient evidence to determine the direct effects of interventions to support breastfeeding on child and maternal health outcomes”.

    Anne Risch

    May 11, 2016 at 7:32 pm

  5. Can you please show me hard evidence that the increase in breastfeeding rates has increased public heath? Because I am a pediatrician and have not seen any evidence that breastfeeding does anything health-wise over the long term. I have been practicing for over 10 years, so you would have thought I’d have less patients coming in less often but I have seen no change in the average time a patient comes in, and they come in equally whether breastmilk or formula fed. Over 50% of my patients are either breastfed or fed breastmilk through a bottle, up from 15% 10 years ago.

    Amaya Smith

    May 12, 2016 at 1:57 pm

  6. It’s a pity that there is any controversy at all. You have to come to a developing country or a resource poor setting to see the difference between breast fed and bottle fed. It’s like saying we won’t stop people from smoking cigarettes just tell them the dangers.Both stopping smoking and breastfeeding have to be promoted. We are talking about lives of children!!!!

    Sunita Katyayan

    May 16, 2016 at 8:10 am

  7. […] Breastfeeding Medicine US Public Health Guidelines Should Reflect Evidence, not anecdoteUS Public Health guildelines should reflect evidence, not anecdote […]


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