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More cluster RCTs with greater methodological rigor are needed to provide an understanding of the effectiveness of various breastfeeding interventions. State and local area integrated telephone survey: Effect of breast feeding in infancy on blood pressure in later life:
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Am J Public Health. View inline View popup. One plus one mobile price in india and features However, intervention effects on short - and long-term exclusive breastfeeding were significant rate ratios, 1. Table 4 describes subgroup analyses performed according to the timing of breastfeeding promoting interventions prenatal, postnatal, and combinations thereof.
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The views expressed are the authors' and do not necessarily reflect those of the Health Resources and Services Administration or the Centers for Disease Control and Prevention. Intensive weight management in primary care improved weight loss and remission of type 2 diabetes Annals of Internal Medicine; 6: VLBW children were more likely than children born with normal or above-normal weights to have been breastfed adjusted OR:
References
A Systematic Evidence Review for the U. Studies needed to report rates of breastfeeding initiation, duration of breastfeeding, or exclusivity of breastfeeding to be included. The NSCH, which was conducted in all 50 states and the District of Columbia, was designed to produce national and state-level prevalence estimates of various aspects of children's physical, emotional, and mental health, as well as to provide data on children's family structure and demographic characteristics. Furthermore, our study was limited in that the data were collected by using a landline-based telephone survey. Factors associated with breastfeeding exclusively for 6 months differ from those associated with breastfeeding initiation. Seven of the 10 RCTs did not show a significant difference in absolute breastfeeding duration between the intervention and control groups.
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08.03.2018 - Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: Home breastfeeding support by health professionals: According to the American Academy of Pediatrics, it is the preferred choice of feeding for all infants 1. The effects of breastfeeding interventions on child health outcomes were reported in 3 RCTs published in 4 articles 93—95,
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23.01.2018 - Dads as breastfeeding advocates: The association between duration of breastfeeding and adult intelligence. Again, multiple components were often combined into a single, multifaceted breastfeeding intervention. These 2 RCTs were graded poor quality because of incomplete reporting of trial protocol for example, randomization and blinding and nonrigorous definitions of breastfeeding outcomes.
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Observational data from our previous report 4 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. 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 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, 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 countries 98, provided good evidence that the BFHI is effective in increasing exclusive breastfeeding rates, at least up to 6 months after delivery.
The PROBIT 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.
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 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.
Department of Health and Human Services. Breastfeeding rates in the United States by characteristics of the child, mother, or family: Agency for Healthcare Research and Quality; World Health Organization; Baby-friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting.
The impact of two corporate lactation programs on the incidence and duration of breast-feeding by employed mothers. Centers for Disease Control and Prevention; Agency for Healthcare Research and Quality; October How should relative risk estimates for acute otitis media in children aged less than 2 years be perceived?
Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. Exclusive breast-feeding for at least 4 months protects against otitis media. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States.
Epidemiology of otitis media during the first seven years of life in children in greater Boston: Breast-feeding and the onset of atopic dermatitis in childhood: Breast milk and the risk of opportunistic infection in infancy in industrialized and non-industrialized settings.
Breastfeeding and the risk of hospitalization for respiratory disease in infancy: Breast-feeding and the risk of bronchial asthma in childhood: Breast-feeding reduces the risk of asthma during the first 4 years of life.
Factors influencing the relation of infant feeding to asthma and recurrent wheeze in childhood. Prolonged breast-feeding six months or more and milk fat content at six months are associated with higher developmental scores at one year of age within a breast-fed population.
Effect of breast feeding on intelligence in children: Does breastfeeding protect against pediatric overweight? Early life predictors of childhood intelligence: The association between duration of breastfeeding and adult intelligence.
Breast feeding and cognitive development in childhood: The effect of breastfeeding on child development at 5 years: Breastfeeding in infancy and blood pressure in later life: Effect of breast feeding in infancy on blood pressure in later life: Breastfeeding and cardiovascular mortality: A meta-analysis of infant diet and insulin-dependent diabetes mellitus: Cow's milk exposure and type I diabetes mellitus.
A critical overview of the clinical literature. Rapid early growth is associated with increased risk of childhood type 1 diabetes in various European populations. Pre-natal and early life risk factors for childhood onset diabetes mellitus: Perinatal and neonatal determinants of childhood type 1 diabetes.
A case—control study in Yorkshire, U. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Environment of infants during sleep and risk of the sudden infant death syndrome: Risk factors for sudden infant death syndrome following the prevention campaign in New Zealand: Four modifiable and other major risk factors for cot death: Prospective assessment of exclusive breastfeeding in relation to weight change in women.
Gestational weight gain and postpartum behaviors associated with weight change from early pregnancy to 1 y postpartum. Reproductive history and postmenopausal risk of hip and forearm fracture.
Dietary calcium intake, physical activity and the risk of vertebral fracture in Chinese. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women.
Demographic and obstetric risk factors for postnatal psychiatric morbidity. Psychosocial factors associated with the early termination of breast-feeding. In the shadow of maternal depressed mood: Breastfeeding and risk of breast cancer: Breast cancer and breastfeeding: Effect of lifetime lactation on breast cancer risk: Breastfeeding and the risk of epithelial ovarian cancer in an Italian population.
Factors related to inflammation of the ovarian epithelium and risk of ovarian cancer. Reproductive risk factors for epithelial ovarian cancer according to histologic type and invasiveness.
Risk factors for invasive epithelial ovarian cancer: Reproductive factors and epithelial ovarian cancer risk by histologic type: Risk factors for ovarian cancer in Taiwan: The effectiveness of primary care-based interventions to promote breastfeeding: Current methods of the U.
Preventive Services Task Force: Improved tests for a random effects meta-regression with a single covariate. A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community.
Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months.
Randomized controlled trial of a prenatal and postnatal lactation consultant intervention on infant health care use. A randomised controlled trial in the north of England examining the effects of skin-to-skin care on breast feeding.
Comparison of the effect of two systems for the promotion of exclusive breastfeeding. Breastfeeding education program with incentives increases exclusive breastfeeding among urban WIC participants.
Two mid-pregnancy interventions to increase the initiation and duration of breastfeeding: Postpartum positioning and attachment education for increasing breastfeeding: Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding.
Assessment of a structured in-hospital educational intervention addressing breastfeeding: Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: Home versus hospital breastfeeding support for newborns: Mother-infant skin-to-skin contact after delivery results in early recognition of own mother's milk odour.
The effect of a programme of organised and supervised peer support on the initiation and duration of breastfeeding: Breastfeeding attitudes, intention, and initiation in low-income women: Development and testing of a prenatal breastfeeding education intervention for Hispanic women.
A randomised-controlled trial in England of a postnatal midwifery intervention on breast-feeding duration. Dads as breastfeeding advocates: Simple antenatal preparation to improve breastfeeding practice: Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status.
Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: Association of degree and timing of exposure to breastfeeding peer counseling services with breastfeeding duration.
The effect of peer support on breast-feeding duration among primiparous women: Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women. Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding.
Home breastfeeding support by health professionals: Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration.
Breastfeeding expectations versus reality: Effect of early postnatal breastfeeding support: A breast-feeding promotion and support program. A randomized trial in The Netherlands.
A mother's feelings for her infant are strengthened by excellent breastfeeding counseling and continuity of care. Does continuity of care by well-trained breastfeeding counselors improve a mother's perception of support?
Can support and education for smoking cessation and reduction be provided effectively by midwives within primary maternity care? Health Care Strategies to Promote Breastfeeding: Preventive Services Task Force Recommendations.
Primary Care Interventions to Promote Breastfeeding: View More View Less. A Systematic Evidence Review for the U. Is There a Personal Doctor in the House? Annals of Internal Medicine; 5: Intensive weight management in primary care improved weight loss and remission of type 2 diabetes Annals of Internal Medicine; 6: In long-term benzodiazepine users, primary care—based, structured, tapering interventions reduced use Annals of Internal Medicine; 6: Adverse health effects of ferronickel manufacturing factory on local residents: An interrupted time series analysis.
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Buy This Article Subscribe. You will be redirected to acponline. Our adjusted findings showing that the mother's age was strongly associated with the likelihood of breastfeeding exclusively for 6 months is of particular relevance to pediatricians.
Improvements in this area can be made, as Feldman-Winter et al 34 found that rates of 6-month exclusive breastfeeding increased significantly at institutions that implemented the AAP breastfeeding residency curriculum.
A main study limitation was our reliance on parental reports of breastfeeding behaviors. Although mothers' recall of breastfeeding initiation and duration has been found to be reliable and valid when investigated within 3 years after the practice, 35 our study included children through 5 years of age.
Measuring breastfeeding exclusivity presents unique challenges, as Li et al 35 found that the validity and reliability of mothers' recall of introducing foods and fluids other than breast milk were less satisfactory than those for other breastfeeding behaviors.
Furthermore, our study was limited in that the data were collected by using a landline-based telephone survey. Noncoverage of households without landlines might have biased our results by excluding families who use cell phones exclusively.
However, sampling weights provided by the NCHS are adjusted to match sociodemographic population estimates from the Census Bureau. This adjustment reduces the likelihood of coverage bias.
It is important to note that some factors, such as mother's education level, mother's mental and emotional health status, and household income at the time of the survey, might not reflect accurately the conditions of the child's infancy.
Other limitations included our use of breastfeeding data collected from survey respondents other than the biological mothers of the study subjects and the lack of detailed data on maternal employment.
Early breastfeeding cessation has been associated with decreased maternity leave, 37 and employment-related challenges to breastfeeding may be more pronounced among younger mothers who lack job control, paid maternity leave, and the financial resources necessary to make use of the Family Medical Leave Act, which does not provide for paid leave.
Despite a substantial increase in the national rate of breastfeeding initiation over the past 25 years, we found that few US children are breastfed exclusively for the first 6 months of their lives.
The determinants of exclusive breastfeeding for 6 months differ somewhat from those of breastfeeding initiation; therefore, significant differences in breastfeeding initiation rates according to sociodemographic factors do not necessarily result in differences in rates of exclusive breastfeeding.
Younger mothers, mothers with poor mental or emotional health, and mothers of VLBW infants are the least likely to breastfed exclusively; however, population-wide promotion of exclusive breastfeeding will be necessary to achieve national Healthy People targets.
The views expressed are the authors' and do not necessarily reflect those of the Health Resources and Services Administration or the Centers for Disease Control and Prevention. The authors have indicated they have no financial relationships relevant to this article to disclose.
We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.
We do not capture any email address. Skip to main content. Search for this keyword. Jones, Michael D. Kogan, Gopal K. Singh, Deborah L. Dee, Laurence M. FIGURE 1 Flow diagram of study populations for analyses of breastfeeding initiation and exclusive breastfeeding for 6 months.
View inline View popup. Footnotes Accepted August 10, Address correspondence to Jessica R. Breastfeeding and the use of human milk. World Health Organization ; ACOG committee opinion No.
James DC, Lessen R. Position of the American Dietetic Association: J Am Diet Assoc. Breastfeeding and maternal and infant health outcomes in developed countries. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding.
Cochrane Database Syst Rev. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: Healthy People Midcourse Review. US Government Printing Office ; Centers for Disease Control and Prevention.
Accessed October 10, Accessed December 10, Prevalence of exclusive breastfeeding among US infants: Am J Public Health. Breastfeeding rates in the United States by characteristics of the child, mother, or family: Multivariate analysis of state variation in breastfeeding rates in the United States.
Design and operation of the National Survey of Children's Health, Vital Health Stat 1. National Center for Health Statistics. Accessed November 1, State and local area integrated telephone survey: National Survey of Children's Health.
Racial and socioeconomic disparities in breastfeeding: The Rush Mothers' Milk Club: J Obstet Gynecol Neonatal Nurs. Breast-feeding and infant illness: Progress in protecting, promoting, and supporting breastfeeding.
Comfort with the idea of formula feeding helps explain ethnic disparity in breastfeeding intentions among expectant first-time mothers. Nutritional practices in the neonatal intensive care unit: The use of human milk for premature infants.
Pediatr Clin North Am. Lactation counseling for mothers of very low birth weight infants: Effect of maternal confidence on breastfeeding duration: Cholesterol-related counseling by registered dietitians in northern California.
Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. The effect of peer support on breast-feeding duration among primiparous women: A randomized controlled trial of telephone peer support's influence on breastfeeding duration in adolescent mothers.
Pediatricians and the promotion and support of breastfeeding.
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PC Exclusive breast milk feeding. The United States Breastfeeding Committee (USBC) states that. TJC defines exclusive breast milk feeding as ‘newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, mineral, or medicines.’ Breast milk feeding includes expressed mother’s milk. The African Union | Economy of Africa.
21.02.2018 - Is There a Personal Doctor in the House? This disparity in breastfeeding initiation may result in part from increased comfort with formula feeding among black women, compared with nonblack women, 23 and this initial acceptance of formula feeding is an important consideration for the promotion of both breastfeeding initiation and exclusive breastfeeding for 6 months. Ccleaner free download for google chrome - Free cc... Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. However, intervention effects on short - and long-term exclusive breastfeeding were significant rate ratios, 1.
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31.01.2018 - The evidence suggests that breastfeeding interventions can be more effective than usual care in increasing short - and long-term breastfeeding rates. The determinants of exclusive breastfeeding for 6 months differ somewhat from those of breastfeeding initiation; therefore, significant differences in breastfeeding initiation rates according to sociodemographic factors do not necessarily result in differences in rates of exclusive breastfeeding. View More View Less. Ccleaner free download for windows 8 1 64 bit file... We also reviewed reference lists of a related systematic review 86 for additional studies. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women.
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21.02.2018 - However, cluster RCTs are more complex to design, require more participants to obtain equivalent statistical power, and demand more complex analyses Observational data from our previous report 4 showed a relationship between breastfeeding and many beneficial child and maternal health outcomes Table 1. Ccleaner free download 2011 for windows 7 - 902 22... Bartick MReinhold A. Table 4 describes subgroup analyses performed according to the timing of breastfeeding promoting interventions prenatal, postnatal, and combinations thereof. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice.
PC Exclusive Breast Milk Feeding STK Discharged on Antithrombotic Therapy reported eCQM included among their QRDA I file submissions will be excluded. o Any EH selected for chart-abstracted IQR measure validation will be excluded o Any hospital that granted a Hospital IQR Program Extraordinary. Circumstances. Guess when mise a jour ccleaner gratuit en francais Mise A Jour Ccleaner Télécharger. Télécharger des logiciels fichers gratuit à comportement conformé en ce qui concerne des systèmes de fichiers de. Online shopping at 11street Malaysia. All Categories. Feeding & Nursing; Formula Milk & Baby Food; NEW Exclusive Mamypoko Limited Edition Extra DrySkin Boys.
A third investigator reviewed studies for which the first 2 investigators gave discordant quality ratings. We reached final grades for those studies via consensus.
We performed subgroup analyses to examine the effects of study quality on the meta-analysis results. We also based our qualitative conclusions on good - or fair-quality studies.
We calculated the rates of breastfeeding initiation and short-term, intermediate-term, long-term, and prolonged breastfeeding for both the intervention and control groups in each study. We recorded the exclusivity of breastfeeding and did the same calculations for the exclusive breastfeeding rates.
We used the rate ratio relative risk as the metric of choice to quantify the effectiveness of each breastfeeding promotion intervention. We used the DerSimonian and Laird model for random-effects meta-analysis 88 to obtain summary estimates across studies.
We used random-effects meta-regression fitted with restricted maximum likelihood to explore whether the effectiveness of breastfeeding interventions depends on breastfeeding duration, provided that at least 6 studies with relevant information were available 91, We performed subgroup analyses according to various study factors, such as study quality, timing of intervention prenatal, postpartum, or combined prenatal and postpartum, and different components of breastfeeding interventions.
We used a Z test to compare summary estimates between the subgroups. We used Intercooled Stata, version 8. All P values are 2-tailed and considered significant when less than 0.
Preventive Services Task Force helped formulate the initial study questions but did not participate in the literature search, determination of study eligibility criteria, data analysis or interpretation, or preparation of the manuscript.
We identified abstracts in our search and evaluated a total of full-text articles. Thirty-eight RCTs met our eligibility criteria: The interventions included system-level breastfeeding support such as BFHI and training of health professionals, formal breastfeeding education, professional support such as from lactation consultants, midwives, nurses, physicians, or other health professionals, lay support such as peer support or counseling, motivational interviews, delayed or discouraged pacifier use, and skin-to-skin contact.
Several components were often combined into a single, multifaceted breastfeeding intervention. The Appendix Table describes the criteria of quality assessment used to reach the overall quality rating for each RCT.
Table 3 summarizes the study characteristics. The effects of breastfeeding interventions on child health outcomes were reported in 3 RCTs published in 4 articles 93—95, One of these RCTs also reported maternal health outcomes.
We could not combine the results from these RCTs in a meta-analysis because the interventions were dissimilar. Infants in the intervention group a modeled BFHI had a significant reduction in the risk for 1 or more gastrointestinal infections adjusted odds ratio, 0.
The 2 fair-quality RCTs, involving a total of mother—infant pairs in low-income families in the United States, reported discordant results. The major drawbacks of these 2 RCTs were high rates of loss to follow-up or missing breastfeeding data.
One study showed no significant differences between the 2 groups hospital and home visits by 2 study lactation consultants vs. The latter study also reported that mothers in the intervention group were less likely than those in the control group to have menses return at 3 months Cessation of menstrual periods for the first few postpartum months during exclusive breastfeeding is a normal physiologic process.
The sociodemographic characteristics of the study populations also varied. As shown in Figure 3 , breastfeeding promotion interventions resulted in an increased rate of breastfeeding initiation rate ratio, 1.
It is questionable whether these trivial effects have any real-world effect. For short-term exclusive breastfeeding, the relative risk was 1. When we excluded the 2 RCTs from developing countries 98, , the results for any breastfeeding initiation and short-term breastfeeding were no longer significant.
However, intervention effects on short - and long-term exclusive breastfeeding were significant rate ratios, 1. Effectiveness of breastfeeding promotion on any breastfeeding initiation or durations, compared with usual care.
Effectiveness of breastfeeding promotion on exclusive breastfeeding initiation or durations, compared with usual care. Table 4 describes subgroup analyses performed according to the timing of breastfeeding promoting interventions prenatal, postnatal, and combinations thereof.
Overall, the direction of the effects favors breastfeeding promotion interventions over usual care and was statistically significant for some subgroups Table 4. We found no clear pattern for the outcome of any breastfeeding with respect to intervention timing.
We performed subgroup analyses on the effects of different components of breastfeeding interventions on breastfeeding initiation, duration, and exclusivity compared with usual care. Again, multiple components were often combined into a single, multifaceted breastfeeding intervention.
Our analyses compared only a specific component within a multifaceted intervention with usual care. Indirect comparison of the pooled effect sizes between different intervention components could be misleading, because other components in the intervention and control groups may not be the same across the different subgroups.
Overall, we did not find that formal or structured breastfeeding education or individual-level professional support significantly affected the breastfeeding outcomes.
Finally, the summary rate ratios of breastfeeding initiation and duration did not statistically significantly differ across RCTs of different quality grades data not shown.
Ten RCTs in 11 publications, , , , , , , , , , reported the differences in the absolute breastfeeding duration between breastfeeding intervention and usual care groups. The follow-up durations ranged from 2 weeks to 1 year.
We did not perform meta-analyses because the intervention components and units of analysis for the breastfeeding outcomes varied greatly across these trials. Seven of the 10 RCTs did not show a significant difference in absolute breastfeeding duration between the intervention and control groups.
We identified 2 poor-quality RCTs involving family members in breastfeeding intervention. These 2 RCTs were graded poor quality because of incomplete reporting of trial protocol for example, randomization and blinding and nonrigorous definitions of breastfeeding outcomes.
One study compared the effects of breastfeeding classes for expectant fathers to control group classes of baby care and safety on rates of any breastfeeding initiation and any breastfeeding at 2 months However, the rate of any breastfeeding at 2 months did not significantly differ between the intervention and control groups.
The other study examined the role of a grandmother maternal mother or a close female confidante sister or friend of the mother's own choice in supporting breastfeeding This study found no significant difference in breastfeeding initiation or duration between the breastfeeding promotion with a female confidante and the routine prenatal care without a female confidante.
We did not identify any study specifically designed to examine harms from interventions to promote and support breastfeeding regardless of design. None of the eligible RCTs reported harms from the breastfeeding interventions.
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, 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 report 4 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. 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 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, 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 countries 98, provided good evidence that the BFHI is effective in increasing exclusive breastfeeding rates, at least up to 6 months after delivery.
The PROBIT 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.
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 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.
Department of Health and Human Services. Breastfeeding rates in the United States by characteristics of the child, mother, or family: Agency for Healthcare Research and Quality; World Health Organization; Baby-friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting.
The impact of two corporate lactation programs on the incidence and duration of breast-feeding by employed mothers. Centers for Disease Control and Prevention; Agency for Healthcare Research and Quality; October How should relative risk estimates for acute otitis media in children aged less than 2 years be perceived?
Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. Exclusive breast-feeding for at least 4 months protects against otitis media. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States.
Epidemiology of otitis media during the first seven years of life in children in greater Boston: Breast-feeding and the onset of atopic dermatitis in childhood: Breast milk and the risk of opportunistic infection in infancy in industrialized and non-industrialized settings.
Breastfeeding and the risk of hospitalization for respiratory disease in infancy: Breast-feeding and the risk of bronchial asthma in childhood: Breast-feeding reduces the risk of asthma during the first 4 years of life.
Factors influencing the relation of infant feeding to asthma and recurrent wheeze in childhood. Prolonged breast-feeding six months or more and milk fat content at six months are associated with higher developmental scores at one year of age within a breast-fed population.
Effect of breast feeding on intelligence in children: Does breastfeeding protect against pediatric overweight? Early life predictors of childhood intelligence: The association between duration of breastfeeding and adult intelligence.
Breast feeding and cognitive development in childhood: The effect of breastfeeding on child development at 5 years: Breastfeeding in infancy and blood pressure in later life: Effect of breast feeding in infancy on blood pressure in later life: Breastfeeding and cardiovascular mortality: A meta-analysis of infant diet and insulin-dependent diabetes mellitus: Cow's milk exposure and type I diabetes mellitus.
A critical overview of the clinical literature. Rapid early growth is associated with increased risk of childhood type 1 diabetes in various European populations.
Pre-natal and early life risk factors for childhood onset diabetes mellitus: Perinatal and neonatal determinants of childhood type 1 diabetes. A case—control study in Yorkshire, U.
Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Environment of infants during sleep and risk of the sudden infant death syndrome: Risk factors for sudden infant death syndrome following the prevention campaign in New Zealand: Four modifiable and other major risk factors for cot death: Prospective assessment of exclusive breastfeeding in relation to weight change in women.
Gestational weight gain and postpartum behaviors associated with weight change from early pregnancy to 1 y postpartum. Reproductive history and postmenopausal risk of hip and forearm fracture.
Dietary calcium intake, physical activity and the risk of vertebral fracture in Chinese. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women.
Demographic and obstetric risk factors for postnatal psychiatric morbidity. Psychosocial factors associated with the early termination of breast-feeding.
In the shadow of maternal depressed mood: Breastfeeding and risk of breast cancer: In the United States, the prevalence of exclusive breastfeeding for 6 months remains low among those who initiate breastfeeding.
Factors associated with breastfeeding exclusively for 6 months differ from those associated with breastfeeding initiation. Exclusive breastfeeding has been established as the optimal feeding practice for infants younger than 6 months; however, the overall prevalence of exclusive breastfeeding remains low in the United States.
This study examined differences between the factors associated with exclusive breastfeeding and those associated with breastfeeding initiation. The value of promoting exclusive breastfeeding has been recognized by the US Department of Health and Human Services and has been incorporated into national health policy.
Previous estimates of the prevalence of exclusive breastfeeding for 6 months, derived from national survey data, showed disparities according to race, family income, population density of the area of residence, and the mother's age, education level, marital status, and BMI.
The National Survey of Children's Health NSCH allows for analyses of the prevalence of exclusive breastfeeding according to these previously unexplored characteristics. In this study, we assessed the extent to which these characteristics were associated with exclusive breastfeeding for 6 months and investigated how these associations differed from associations between the same characteristics and breastfeeding initiation.
Data for this cross-sectional study were obtained from the NSCH. The NSCH, which was conducted in all 50 states and the District of Columbia, was designed to produce national and state-level prevalence estimates of various aspects of children's physical, emotional, and mental health, as well as to provide data on children's family structure and demographic characteristics.
The survey respondent for each interview was a parent or guardian familiar with the child's health. For homes in which multiple children resided, 1 child was selected randomly to be the subject of the interview.
Informed consent was obtained from all respondents. A total of 91 interviews were conducted between April and July interview completion rate: More details of the survey's methods and response rates can be found elsewhere.
The selection of this study population is shown in Fig 1. Because we wanted to assess associations with exclusive breastfeeding for 6 months, independent of associations with breastfeeding initiation, we limited our analyses of exclusive breastfeeding to children who had been breastfed initially.
Flow diagram of study populations for analyses of breastfeeding initiation and exclusive breastfeeding for 6 months. Of all interviews concerning children in this age range, The specific wording of these questions is identical to that of the questions used in the National Immunization Survey 16 , 17 and can be found in Table 1.
We classified a child as being exclusively breastfed for 6 months if the parent or guardian reported that the child was breastfed for the first days of life and was introduced to no other foods or liquids, including water, during that period.
These questions were asked only when the mother currently resided in the home; therefore, exclusion of missing or unknown responses for these variables in the regression models would have reduced the effective sample size for analyses significantly and would have decreased the generalizability of the results.
We imputed the household poverty level by using a multiple-imputation technique designed by the NCHS to account for missing data on household income and household size.
This technique involves 5 imputed data sets, which are used in 5 separate analyses, combined by following standard multiple-imputation rules, and then merged with the public use analysis files by using an unique household identifier.
Demographic characteristics of the study population are presented in Table 2. We found that approximately three-fourths of children aged 6 months through 5 years were breastfed or fed breast milk at least once Table 3.
Rates of breastfeeding initiation were significantly higher among Hispanic children In addition, a higher prevalence of breastfeeding initiation was observed among subjects who reported positive maternal mental and emotional health.
A significantly smaller proportion Children living in 2-parent biological or adoptive families were more likely to have been breastfed Higher rates of exclusivity were observed among children whose mothers were 30 years of age or older, reported positive maternal emotional and mental health, and lived in a home where a tobacco smoker was not present.
Children in 2-parent families biological or adoptive were most likely to have been exclusively breastfed, compared with children in any other family structure.
Adjusted analyses indicated that the mother's education level and nativity status were significantly associated with breastfeeding initiation with adjustment for all other covariates of interest Table 4.
In addition, they showed that the likelihood of being breastfed was significantly lower among non-Hispanic black children than among non-Hispanic white children adjusted odds ratio [OR]: VLBW children were more likely than children born with normal or above-normal weights to have been breastfed adjusted OR: Children who lived in a home with a smoker were significantly less likely to have been breastfed, compared with children who did not adjusted OR: Exclusive breastfeeding was significantly associated with maternal age in the adjusted analysis.
Children born to mothers 20 years of age or younger were approximately one-half as likely to have been exclusively breastfed, compared with children born to mothers 30 years of age or older adjusted OR: The association of VLBW with exclusive breastfeeding differed from its association with breastfeeding initiation.
Children born to mothers who reported fair or poor mental and emotional health were significantly less likely to have been exclusively breastfed than were children whose mothers who reported excellent mental and emotional health adjusted OR: Some differences in the likelihood of exclusive breastfeeding according to family structure were observed.
Children living in families with a stepparent were less likely to have been exclusively breastfed, compared with children living in other 2-parent families adjusted OR: Consistent with previous research on racial disparities in breastfeeding outcomes, 13 , 14 , 22 we found that non-Hispanic black women were less likely than non-Hispanic white women to initiate breastfeeding.
This disparity in breastfeeding initiation may result in part from increased comfort with formula feeding among black women, compared with nonblack women, 23 and this initial acceptance of formula feeding is an important consideration for the promotion of both breastfeeding initiation and exclusive breastfeeding for 6 months.
However, the results of our analyses among children who had ever been breastfed, which showed no significant association between race and the likelihood of having been breastfed exclusively for 6 months, suggested that the difference in rates of exclusive breastfeeding between black and white infants was primarily the result of lower rates of breastfeeding initiation among black infants.
Our results also indicated that although VLBW was associated with an increased likelihood of being breastfed, it also was associated with a decreased likelihood of being breastfed exclusively, compared with normal or above-normal birth weight.
We speculate that the greater likelihood of breastfeeding initiation among VLBW children may be attributable in part to their spending time in a NICU, because, with adjustment for gestational age, preterm infants who were admitted to a NICU were found to be more likely to have been breastfed than were preterm infants who were not admitted.
Despite high rates of breastfeeding initiation, unique challenges in achieving exclusive breastfeeding exist for VLBW infants. Fortification of expressed breast milk with vitamins and minerals is indicated for some VLBW infants 1 , 26 and is not a violation of exclusive breastfeeding.
However, it is not known how parents might report this fortification. In addition, prolonged hospitalizations, medical complications, and the mothers' potential for stress-induced insufficiency of milk production might reduce the likelihood that VLBW infants would be breastfed exclusively for 6 months.
We found maternal mental and emotional health to be significantly associated with exclusive breastfeeding for 6 months but not associated with breastfeeding initiation.
In a previous study, postpartum depression was shown to increase the odds of early breastfeeding cessation 28 ; however, early recognition of depressive symptoms and provision of appropriate treatment have been shown to reduce the risk of adverse maternal health outcomes 29 and to increase the likelihood that affected mothers will continue breastfeeding.
For example, telephone-based peer support was shown to increase the duration of breastfeeding among all women who received it 31 and to increase rates of exclusive breastfeeding among adolescents.
Our adjusted findings showing that the mother's age was strongly associated with the likelihood of breastfeeding exclusively for 6 months is of particular relevance to pediatricians.
Improvements in this area can be made, as Feldman-Winter et al 34 found that rates of 6-month exclusive breastfeeding increased significantly at institutions that implemented the AAP breastfeeding residency curriculum.
A main study limitation was our reliance on parental reports of breastfeeding behaviors. Although mothers' recall of breastfeeding initiation and duration has been found to be reliable and valid when investigated within 3 years after the practice, 35 our study included children through 5 years of age.
Measuring breastfeeding exclusivity presents unique challenges, as Li et al 35 found that the validity and reliability of mothers' recall of introducing foods and fluids other than breast milk were less satisfactory than those for other breastfeeding behaviors.
Furthermore, our study was limited in that the data were collected by using a landline-based telephone survey. Noncoverage of households without landlines might have biased our results by excluding families who use cell phones exclusively.
However, sampling weights provided by the NCHS are adjusted to match sociodemographic population estimates from the Census Bureau. This adjustment reduces the likelihood of coverage bias.
It is important to note that some factors, such as mother's education level, mother's mental and emotional health status, and household income at the time of the survey, might not reflect accurately the conditions of the child's infancy.
Other limitations included our use of breastfeeding data collected from survey respondents other than the biological mothers of the study subjects and the lack of detailed data on maternal employment.
Early breastfeeding cessation has been associated with decreased maternity leave, 37 and employment-related challenges to breastfeeding may be more pronounced among younger mothers who lack job control, paid maternity leave, and the financial resources necessary to make use of the Family Medical Leave Act, which does not provide for paid leave.
Despite a substantial increase in the national rate of breastfeeding initiation over the past 25 years, we found that few US children are breastfed exclusively for the first 6 months of their lives. The determinants of exclusive breastfeeding for 6 months differ somewhat from those of breastfeeding initiation; therefore, significant differences in breastfeeding initiation rates according to sociodemographic factors do not necessarily result in differences in rates of exclusive breastfeeding.
Younger mothers, mothers with poor mental or emotional health, and mothers of VLBW infants are the least likely to breastfed exclusively; however, population-wide promotion of exclusive breastfeeding will be necessary to achieve national Healthy People targets.
The views expressed are the authors' and do not necessarily reflect those of the Health Resources and Services Administration or the Centers for Disease Control and Prevention.
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