U.S. Preventive Services Task Force (USPSTF)
Discussion
This systematic review summarizes the effects of primary
care–initiated interventions to promote and support
breastfeeding with respect to maternal and child health
outcomes and breastfeeding outcomes. Although a large
number of RCTs have been published since 2001, fewer
than one third of them fulfilled most of our quality criteria
and another one third had substantial methodological flaws
(Appendix Table). We also
found great heterogeneity among the actual interventions
as well as the background social support and health care
systems that constituted usual or routine care across studies.
Nonetheless, the RCTs reviewed in this report showed
consistent findings. The evidence suggests that breastfeeding
interventions can be more effective than usual care in
increasing short- and long-term breastfeeding rates. Combined
pre- and postnatal interventions and inclusion of
layperson support in a multicomponent intervention may
be beneficial. Observational data from our previous report4 showed a relationship between breastfeeding and many
beneficial child and maternal health outcomes (Table 1).
In summary, only a few RCTs directly examined the effectiveness
of breastfeeding interventions on child and maternal
health outcomes. Thus, our conclusions about the
value of breastfeeding interventions on health outcomes are
largely based on an indirect chain of evidence.
Our review has several limitations, which stem mainly
from methodological shortcomings of the primary studies
and the multitude of possible breastfeeding promotion interventions.
First, we found substantial clinical and methodological
heterogeneity across studies, which make our
summary effects difficult to interpret. This variability in
interventions, definitions, and outcomes is not surprising.
Breastfeeding schedules and habits are determined by cultural
norms, personal desires, and a plethora of socioeconomic
factors. To the extent possible, we performed subgroup
and sensitivity analyses on factors that may explain
the observed heterogeneity. Second, trials of breastfeeding
interventions included several individual components. It is
impossible to reliably distinguish "independent" effects for
these components without performing head-to-head comparisons
between them because the effects of individual
components cannot be considered independent or additive.
Finally, we did not use strict criteria to categorize "primary
care–initiated" interventions. Whether a study was classified
as primary care–initiated was entirely dependent on
the clarity of reporting of the individual studies.
We did not find interventions with formal breastfeeding
education or individual-level professional support to be
effective in increasing the rates of breastfeeding initiation
or duration. However, some evidence suggests that interventions
with lay support may be effective in increasing the
rates of short- and long-term breastfeeding. This conclusion,
however, is based on findings from indirect comparisons
of different studies. To further understand the role of
lay versus professional support in breastfeeding promotion,
future studies should directly compare them in the same
population.
Only 2 fair-quality RCTs in developed countries directly
examined the effects of breastfeeding interventions
on child health outcomes. In both trials, the effects of
interventions on rates of exclusive breastfeeding matched
the corresponding effects on child outcomes. Specifically, 1
RCT reported an increased exclusive breastfeeding rate at 3
months and a lower risk for diarrheal diseases in the breastfeeding
intervention group than in the control group.93 The other RCT did not detect a significant difference in the exclusive breastfeeding rate at 3 months and also did
not detect a difference in certain infant health outcomes
between the intervention and control groups.94,95 One
may surmise from the above findings that the rate of exclusive
breastfeeding may be an important determinant of
certain health outcomes in infants. It is unclear whether
differences in definitions of exclusive breastfeeding, health
outcomes, and unknown factors that could interact with
the intervention could also explain some of the different
findings. However, these findings stressed the need to further
examine the role of postnatal home support for breastfeeding
from trained professionals or peer counselors.
Two good-quality RCTs conducted in developing
countries98,126 provided good evidence that the BFHI
is effective in increasing exclusive breastfeeding rates, at
least up to 6 months after delivery. The PROBIT126 also compared infants in the breastfeeding intervention group with those in the control group and showed a significant
reduction in the risk for 1 or more gastrointestinal
infections and atopic dermatitis. It is conceivable that a
cluster randomized study similar to PROBIT in Belarus
could be done in the United States, as the BFHI is not yet
widely adopted; only 1.3% of the maternity units in this
country are designated as baby-friendly (according to www
.babyfriendly.org). Such a study is important to estimate
the public health effect in a sociocultural environment that
is not as breastfeeding-friendly as the one in Belarus. To
assess the effectiveness of the complete BFHI, it is important
to implement all 10 steps (Table 2); none of the
studies conducted in developed countries did that.
More cluster RCTs with greater methodological rigor
are needed to provide an understanding of the effectiveness
of various breastfeeding interventions. Cluster RCTs allow
random assignment of groups (such as families or primary
care practices) rather than individuals. Cluster studies preempt
exposures of intended interventions to nontargeted
individuals, thus minimizing cross-contamination of interventions
between groups. However, cluster RCTs are more
complex to design, require more participants to obtain
equivalent statistical power, and demand more complex
analyses.133 In addition to proper randomization, the
quality of the RCTs can be improved with clear and unbiased
patient selection criteria, a common definition of exclusive
breastfeeding, reliable collection of feeding data,
definition of specific and quantifiable clinical outcomes of
interest, and blinded assessments of the outcome. Any substantial
differences in the degree of breastfeeding between
the intervention and control groups as a result of the
breastfeeding intervention will provide further opportunity
to investigate any disparity in health outcomes between the
2 groups.
Return to Contents
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AHRQ Publication No. 09-05126-EF-4
Current as of October 2008
Internet Citation:
Chung M, Raman G, Trikalinos T, Lau J, Ip S. Primary Care Interventions to Promote Breastfeeding: An Evidence Review for the U.S. Preventive Services Task Force. Originally published in Ann Intern Med 2008;149:565-82. AHRQ Publication No. 09-05126-EF-4, October 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf08/breastfeeding/brfeedart.htm
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