In Support of Breastfeeding Support in Primary Care

In an important article published in 2006, Belamarich and colleagues¹ rightly point out that general pediatricians are “drowning in a sea of advice.” Reviewing 10 years of American Academy of Pediatrics policy recommendations, they identified 192 discrete health advice directives that pediatricians were being tasked with dispensing. Into that sea, another bucket of water is now poured. In this week’s JAMA, the US Preventive Services Task Force (USPSTF)² gives primary care breastfeeding support a “B” recommendation, meaning that the evidence is strong enough that it should be part of routine care.³ No doubt many other “buckets” have been added in the 10 years since Belamarich et al¹ published their report, but it is worth noting how and why this one² is different.

First, as Belamarich and colleagues¹ rightly note, many of the directives have weak or nonexistent evidence bases. In contrast, breastfeeding has demonstrable and well-established benefits to both mother and child, including reduction of gastroenteritis, otitis media, eczema, and obesity for infants and breast cancer and type 2 diabetes mellitus for mothers.⁴ It is not surprising then that the World Health Organization⁵ and the American Academy of Pediatrics⁶ both recommend exclusive breastfeeding until approximately age 6 months. Despite these recommendations, the United States (like most countries) falls far short of any reasonable metric. Rates of exclusive breastfeeding through 3 and 6 months are 43% and 22%, respectively, and are even lower among low-income and minority populations.⁷ Nonetheless, the Baby Friendly Hospital Initiative⁸ has been very successful at increasing initiation rates where it has been implemented. In fact, 2014 national estimates indicate that 80% of US infants begin life breastfeeding.⁹ Initiation is a necessary if not sufficient step toward reaching the Healthy People 2020 goal of 60% breastfeeding at 6 months.¹⁰ But initiation tells us something: it tells us that 4 of 5 new mothers not only intend to breastfeed, they have actively begun to do so. It demonstrates what economists call a revealed preference. 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.

Second, there is the question of just how effective office-based support is. The USPSTF estimates the number needed to treat (NNT) 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.¹¹ And the breastfeeding NNT could be reduced even further if there were structural changes to workplaces and communities that helped support breastfeeding mothers.¹²

Finally, there is the question of reimbursement, a thorny reality that often scuttles efforts to introduce new practices. The Affordable Care Act mandates coverage for 23 preventive visits related to breastfeeding education with no copay or deductible. That number of visits seems more than adequate. I could not find the amount reimbursed per visit, which surely varies by plan. Lobbying for supporting the actual cost of this service may be necessary.

Lest the USPSTF be accused of adding yet another bucket of water to the swirling sea of advisory directives, I contend that we should begin by draining the sea and then selectively refilling it, bucket by bucket, prioritizing those things for which there is sound evidence and proven value. If we were to take this approach, we might very well add breastfeeding support right after vaccinations.

Corresponding Author: Dimitri A. Christakis, MD, MPH, Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, 2001 Eighth Ave, Ste 400, Seattle, WA 98121 (dimitri.christakis@seattlechildrens.org).

Published Online: October 25, 2016. doi:10.1001/jamapediatrics.2016.3390

Conflict of Interest Disclosures: None reported.