Interventions to promote breast-feeding: applying the evidence in clinical practice

In this document, the Canadian Task Force on Preventive Health Care (CTFPHC) updates its earlier breast-feeding recommendations¹ by presenting evidence on interventions that improve the initiation or duration of breast-feeding (or both). Breast-feeding has been shown in both developing and developed countries to improve the health of infants and their mothers, making it the optimal method of infant nutrition.^2,3 Although the prevalence of breast-feeding in Canada has risen, with over three-quarters of mothers now initiating breast-feeding, the duration of this practice remains short of the recommended World Health Organization (WHO) targets of exclusive breast-feeding for 6 months and partial breast-feeding for up to 2 years.^4,5 Recent Canadian data indicate that 22% of recent mothers aged 15–49 years breast-feed for less than 3 months, and 35% do so for at least 3 months.⁶ This premature discontinuation is more a result of difficulty with breast-feeding, including lack of information and support, than of women's choice.⁷ In fact, the number of Canadian hospitals that would qualify as “baby-friendly” according to WHO–UNICEF criteria⁸ was 5 of 523 hospitals responding to a 1993 survey,⁹ and according to UNICEF only a single hospital had that designation in 2002.¹⁰

In a joint endeavour, the CTFPHC and the US Preventive Services Task Force systematically reviewed the randomized trial evidence for the effectiveness of all counselling interventions originating in a clinician's practice (such as antepartum and postpartum support groups, education, telephone support or peer counsellors) to increase the rate of initiation or the duration of breast-feeding.^11,12 We present here the new CTFPHC recommendations, based on the joint systematic review as well as a key Canadian trial¹³ published after that review and tailored to the Canadian health care setting (Table 1). Definitions of the levels of evidence and grades of recommendations used in Table 1 are available in an online appendix to this article (www.cmaj.ca/cgi/content/full/170/6/976/DC1).

Table 1

Interventions consisting of antepartum structured breast-feeding education are effective at improving both initiation and continuation of breast-feeding during the first 2 months postpartum, compared with usual care.^{14,15,16,17,18,19,20,21,22,23,24,25,26,27,28}These interventions, consisting of individual or group instruction about breast-feeding knowledge, practical skills and problem-solving techniques, were effective when provided by lactation specialists or nurses, and both single sessions and multiple sessions were effective. Postpartum telephone or in-person support by lactation specialists, nurses or peer counsellors enhanced the effectiveness of these interventions. In addition, the use of peer counsellors improved breast-feeding rates and duration, and these types of programs may represent a cost-effective alternative to professionally delivered services, especially in locations or settings where professional services are scarce or not available.^{13,20,29,30,31,32} The CTFPHC recommends against the use of written materials (which have not been shown to be effective when used alone,^{16,19,22,26,33,34,35,36} although no harm was demonstrated) and commercial discharge packages (which have been shown to decrease breast-feeding rates).³⁷ Unfortunately, advice from a woman's primary clinician (such as family physician, obstetrician or midwife) has not been sufficiently evaluated, and a research gap remains in this area.

The recommendations presented here (Table 1) do not address the clinical benefits of breast-feeding, which the CTFPHC felt had been established by its earlier breast-feeding recommendations;¹ instead, we have concentrated on recommendations about interventions that change the initiation and duration of breast-feeding.

The Canadian Paediatric Society, Dieticians of Canada and Health Canada have recommended exclusive breast-feeding for at least the first 4 months of life, then continuation of breast-feeding along with complementary foods for up to 2 years and beyond.⁴³ The American Academy of Pediatrics has recommended exclusive breast-feeding for approximately the first 6 months after birth and continued breast-feeding for at least 12 months and thereafter for as long as mutually desired.⁴⁴ Provision of adequate individual and systems-based supports, such as recommended in the Baby-Friendly Hospital Initiative,⁸ are also recommended by most groups.