From the Journals

USPSTF gives breastfeeding support a ‘B’ grade

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Breastfeeding support should be prioritized

The key to successful office-based health promotion and prevention programs is to prioritize evidence-based practices and recommendations that parents already have a predilection to follow. That is, of the myriad of topics one might discuss, why not start with the ones that caregivers are most interested in. Breastfeeding is surely one of those.

The USPSTF estimates the number needed to treat when offering breastfeeding support is 30. That is, if 30 women are offered it, 1 additional woman will breastfeed for 6 full months. This compares favorably with the NNT for antibiotics for otitis media for fever and pain reduction at 48 hours in children older than 2 years, (NNT, 20) especially when one considers the comparable benefits of each. And the breastfeeding NNT could be reduced even further if there were structural changes to workplaces and communities that helped support breastfeeding mothers.

Dimitri A. Christakis, MD, MPH , of Seattle Children’s Research Institute, is an associate editor for JAMA Pediatrics. His comments are adapted from an editorial published in JAMA Pediatrics (2016 Oct 25. doi: 10.1001/jamapediatrics.2016.3390). He reported having no relevant financial disclosures.


The U.S. Preventive Services Task Force (USPSTF) has issued a B-level recommendation for interventions given during pregnancy and after birth to support breastfeeding.

The Task Force cites “adequate” evidence that breastfeeding provides substantial health benefits for children and moderate health benefits for women. While they found evidence to support individual-level interventions, such as education and psychosocial support, system-level interventions were not shown to be effective. The recommendation appears online in JAMA (2016 Oct 25;316[16]:1688-93).

The recommendation updates a previous one issued in 2008, in which the USPSTF also recommended breastfeeding support interventions with a grade of B. The new recommendation is based on a review of 43 studies of individual-level primary care interventions in support of breastfeeding, and nine system-level interventions. The authors evaluated the available evidence on breastfeeding initiation, duration, and exclusivity, as well as breastfeeding’s effects on child and maternal health outcomes. They determined that support from a professional lactation consultant or a peer group was effective in producing any or exclusive breastfeeding, while systemwide interventions, such as the World Health Organization’s Baby-Friendly Hospital Initiative offered inconsistent benefits. The evidence review was also published in JAMA (2016;316[16]:1694-1705).

Mother breastfeeding her child. Thinkstock
This could prove controversial since high levels of public resources are devoted to systemwide breastfeeding support initiatives, Valerie Flaherman, MD, MPH, of the University of California, San Francisco, and Isabelle Von Kohorn, MD, PhD, of Holy Cross Health in Silver Spring, Md., wrote in an accompanying editorial in JAMA (2016 Oct 25;316[16]:1685-7).

The Initiative’s “Ten Steps to Successful Breastfeeding” program, in particular, presents a potential risk, they noted. The program recommends counseling parents to avoid use of pacifiers in the newborn period to support breastfeeding, but evidence is growing that avoiding pacifiers is not associated with any breastfeeding outcomes and pacifier use may be protective against sudden infant death syndrome.

“U.S. institutions will need to disengage from the Ten Steps if they conclude that the scientific evidence that conflicts with them is valid,” Dr. Flaherman and Dr. Von Kohorn wrote.

The practice of recommending that mothers do not supplement breast-milk feedings with formula is also of concern, based on mixed evidence. Since not all mothers produce adequate milk supplies during the first week postpartum, not supplementing with formula could run the risk that the infant suffers dehydration, hyperbilirubinemia, or other complications. With up to 2% of all newborns in the United States requiring hospital readmission – the risk is doubled for breastfed infants – Dr. Flaherman and Dr. Von Kohorn suggest that strict adherence to a “breast-milk only” policy has the potential to be harmful, especially given that current evidence doesn’t show that exclusive breastfeeding in the newborn period improves breastfeeding duration.

“Individual clinical judgment may be more valuable than a single rigid rule for exclusive breastfeeding for the first 6 months,” Dr. Flaherman and Dr. Von Kohorn wrote.

Based on the evidence, the USPSTF advised clinicians that they can support women before and after childbirth by promoting the benefits of breastfeeding during monthly visits, providing practical guidance on how to breastfeed, and offering psychosocial support.

“Although there is moderate certainty that breastfeeding is of moderate net benefit to women and their infants and children, not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values, and preferences,” the USPSTF members wrote.

The USPSTF members reported receiving travel reimbursement and honorarium for participating in USPSTF meetings. Dr. Flaherman and Dr. Von Kohorn reported having no relevant financial disclosures.

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