Introduction Show
The American Academy of Family Physicians (AAFP) has long supported breastfeeding. All family physicians, whether they provide maternity care or not, have a unique role in the promotion of breastfeeding. They understand the advantages of family-centered care and are well positioned to provide breastfeeding support in that context. Because they provide comprehensive care to the whole family, family physicians have an opportunity to provide breastfeeding education and support throughout the course of life to all members of the family. However, despite growing evidence of the health risks of not breastfeeding, physicians—including family physicians—do not receive adequate training about supporting breastfeeding.1-4 History By the late 19th century, infant mortality from unsafe artificial feeding became an acknowledged public health problem. Public health nurses addressed this by promoting breastfeeding and home pasteurization of cows’ milk. In the early 20th century, commercial formula companies found a market for artificial baby milks as safer alternatives to cows’ milk. During this same period, infant feeding recommendations became the purview of the newly organized medical profession. Partially because of physician support and a vision of “scientific” infant care, the widespread promotion of formula as a breast milk substitute for healthy parents and babies emerged.7, 8 Throughout the mid-20th century, most physicians did not advocate breastfeeding and most parents did not choose to breastfeed. An entire generation of parents—and physicians—grew up not viewing breastfeeding as the normal way to feed babies. Despite the resurgence of breastfeeding in the late 20th century in the United States, breastfeeding and formula feeding continued to be considered virtually equivalent, representing merely a lifestyle choice parents could make without significant health sequelae.9 Currently, the AAFP, the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), the World Health Organization (WHO), and others recommend that infants exclusively receive breast milk for their first six months of life, with continued breastfeeding for at least the first year and beyond.10-13 The U.S. Public Health Service’s Healthy People 2020 initiative set national goals of 81.9% of babies breastfeeding at birth, 60.6% at six months, and 34.1% at one year.14 Targets for exclusive breastfeeding were 46.2% at three months and 25.5% at six months. The United States has not yet met all of its breastfeeding goals. Data published by the Centers for Disease Control and Prevention (CDC) for infants born in 2017 show that 84.1% of U.S. parents initiated breastfeeding; 58.3% of babies were breastfeeding—and 25.6% were exclusively breastfeeding—at six months; and 35.3% of babies were breastfeeding at 12 months. Although some subpopulations come close to Healthy People 2020 initiation goals, most do not, and few breastfeed exclusively.15 Healthy People 2030 goals have been published with two targets to increase the number of infants breastfed at six and 12 months.15 Breastfeeding rates quoted for the United States reflect data that do not always distinguish between exclusive breastfeeding, breastfeeding with supplementation, and minimal breastfeeding. Benefits of Breastfeeding Breastfeeding also has broader economic and social benefits. Health care costs for both children and parents are increased when breastfeeding duration is suboptimal (or a child not breastfed).24, 25 In addition, breastfeeding is environmentally friendly since it involves no use of grazing land for cows, no product transportation or packaging, and no waste.5 Health Equity and Breastfeeding For family physicians, it is important to note that there is a lower rate of evidence-based maternity care practices in health care facilities in underserved areas. 29, 30 Specifically, health care facilities in areas with a higher percentage of Black residents were shown to be less likely to meet key indicators for supporting breastfeeding, including early initiation of breastfeeding, avoidance of supplementation with formula, and rooming-in for patient and infant. 29, 30 These are metrics that can be addressed, as demonstrated by a quality improvement project that provided education and technical assistance to a number of hospitals in order to improve their compliance with the “Ten Steps to Successful Breastfeeding.”30 This intervention resulted in increased breastfeeding initiation and exclusive breastfeeding among African American infants.30 Recognizing the Diversity of
Families Call to Action for Family Physicians Physician Level
Practice Level
Advocacy and Education
AAFP Efforts to Support Breastfeeding Policies The AAFP has several policies and resources available to support breastfeeding. The AAFP’s policy on breastfeeding recommends that all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first six months of life.11 The AAFP also supports breastfeeding beyond this time frame for as long as mutually desired. Family physicians should have the knowledge to promote, protect, and support breastfeeding. In order to support and encourage breastfeeding, the AAFP discourages the distribution of formula or coupons for formula during hospital discharge or in physician office packets to parents who choose to breastfeed exclusively. In addition, hospital staff are encouraged to respect the decision of the breastfeeding parent and avoid offering formula,
water, or pacifiers.41 Vitamin D supplementation is important for infants who are breastfeeding or receiving formula. The AAFP recommends vitamin D supplementation and supports coverage by third-party payers.42 Breastfeeding has demonstrable health and economic benefits. However, many parents stop breastfeeding earlier than they intended due to lack of support
from family, friends, and colleagues. Working outside the home is associated with shortened duration of breastfeeding,43-45 and conditions in the workplace further impact this duration.46, 47 Medical trainees are educated about the benefits of breastfeeding and taught to encourage and support their patients in their breastfeeding efforts. However, when medical trainees and physicians choose to breastfeed, they often do not receive adequate support from their colleagues and
institutions and many do not meet their breastfeeding goals.48, 49 The AAFP advocates for support of trainees and practicing physicians who are breastfeeding and issued a model policy outlining key recommendations for medical schools, residency and fellowship programs, and health care facilities.42 Key items needed include adequate lactation facilities,
protected time for expression of breast milk or breastfeeding, and policies outlining roles and responsibilities to provide an environment of support for breastfeeding trainees. Education The family medicine residency curriculum should reinforce the concept that breastfeeding is the physiologic norm. All aspects of normal breastfeeding and management of common problems should be covered and integrated longitudinally in the three-year residency curriculum. The AAP has developed a residency curriculum
that is easily modified for use in family medicine residencies.50 This curriculum, which includes advocacy, community outreach, coordination of care, anatomy and physiology, basic skills, peripartum support, ambulatory management, and cultural competency, has been shown to improve breastfeeding outcomes for patients cared for by family medicine residents, pediatrics residents, and OB-GYN residents.3 Member Resources and National Initiatives The AAFP has an established member interest group (MIG) focused on breastfeeding medicine that provides opportunities for education and peer-to-peer training and support. Appendix 1: Specific Recommendations for Clinical Management References Appendix 1: Specific Recommendations for Clinical Management 1. Preconception and prenatal education
2. Intrapartum support
3. Early postpartum education and support52, 60
4. Ongoing support and management
Appendix 2: Additional
Breastfeeding Considerations Infant Health Neonatal illnesses such as hyperbilirubinemia and hypoglycemia may be due to poor milk transfer and warrant an urgent consultation with a skilled lactation consultant. Infants born with defects such as cleft lip and palate can breastfeed in many cases, but they may require consultation with an experienced lactation professional to ensure success. Infants who have other anomalies or syndromes that cause hypotonia also will benefit from such consultation. However, infants who have type 1 galactosemia are unable to breastfeed and must be on a lactose-free diet. Infants who have phenylketonuria should breastfeed; however, if supplementation is needed, they must receive supplementation with a low-phenylalanine formula.67, 68 Infants who have phenylketonuria who are breastfed have better developmental outcomes compared with those exclusively fed low-phenylalanine formulas.69 Health of the Breastfeeding Parent For most infections, breastfeeding helps protect the infant against the disease or decreases the severity of the illness because of anti-infective components in human milk. Only a few infections preclude breastfeeding. In the United States, parents who have human immunodeficiency virus (HIV) are currently advised not to breastfeed because of the potential risk of transmission to the child. In countries with high infant mortality rates caused by infectious illnesses or malnutrition, the benefits of breastfeeding may outweigh the risk of HIV transmission. Other infections that are less prevalent in the United States but also contraindicate breastfeeding are human T-cell lymphotropic virus (HTLV) type I and type II, and untreated brucellosis.72, 73 Most infections do not preclude breastfeeding, but, in a few specific infections, certain considerations apply. In parents who have active tuberculosis, separation should be instituted until both the parent and infant are receiving appropriate anti-tuberculosis therapy, the parent wears a mask, and the parent understands and is willing to adhere to infection control measures. The breastfeeding parent’s expressed milk may be given to the infant. Once the infant is receiving isoniazid, separation is not necessary unless multidrug-resistant Mycobacterium tuberculosis is present, or the parent has poor adherence to treatment and direct-observation treatment is not possible.74 Limited evidence suggests that SARS-CoV-2, the virus that causes COVID-19, is spread via respiratory droplets. To date, studies have not detected SARS-CoV-2 and similar coronavirus infections in breast milk. Therefore, the American Academy of Family Physicians (AAFP) recommends promotion of breastfeeding and parent-infant bonding, and avoidance of parent-infant separation whenever possible.75 If a parent who is breastfeeding has been exposed to COVID-19, breastfeeding is a reasonable choice. The parent should use a mask and careful hand hygiene to reduce the risk of exposing the infant to respiratory secretions. If the parent is unable to breastfeed due to illness, it is an option to use expressed milk with appropriate hygiene to keep the pump and bottles free of virus. During active herpes simplex outbreaks, it is safe to nurse unless lesions are present on the breasts. If lesions are present, it is recommended to avoid feeding from the affected breast until they resolve.71 Babies born to parents who develop chickenpox within five days antepartum or within two days postpartum are at risk of more serious chickenpox infections. It is recommended separation occur until the parent is no longer infectious, but expressed milk may be provided, as long as it does not come into contact with active lesions.71 Transmission of hepatitis C through human milk has not been established. The risk of infection from parents who has hepatitis C is the same in breast- or bottle-fed infants. However, if a parent who has hepatitis C has bleeding or cracked nipples, it may put the breastfeeding infant at risk of transmission of the virus.76 Parents acutely infected with H1N1 virus should be isolated from their infants during the febrile period, but their milk is safe to provide.77 Some other uncommon serious infections, such as Ebola virus may require temporary interruption or complete avoidance of breastfeeding.78, 79 In the event of severe trauma or acute life-threatening illness, a parent may be too ill to nurse or express milk. If illness causes separation, assistance with maintaining lactation should be provided, if desired by the breastfeeding parent. Anesthesia rarely contraindicates breastfeeding.58 Local anesthetics enter the bloodstream in minute quantities that are too small for significant amounts to be present in milk. Most agents used for general anesthesia have short half-lives and clear the maternal circulation rapidly. There is no need to delay breastfeeding after general anesthesia for a procedure done within the first two to three days postpartum (e.g., tubal ligation) because the amount of colostrum is too small to carry a significant quantity of the anesthetic agents. For surgical procedures done later, the decision about resuming breastfeeding depends on the condition of the infant. Parents of healthy term neonates can resume feeding once they are awake and able to hold the infant. In the case of a preterm or otherwise compromised neonate, pumping and discarding the milk for 12 to 24 hours after the procedure may be warranted.58 It is rarely necessary to interrupt breastfeeding for radiologic procedures. The radioiodines used as intravenous contrast agents for some radiography and computed tomography scanning have an extremely short half-life and virtually no oral bioavailability.80 Therefore, they pose an insignificant risk to a breastfed infant. Similarly, gadopentetate used as contrast for magnetic resonance imaging (MRI) has such minimal excretion in the milk—and even lower oral absorption—that only extremely small amounts are available to the nursing infant.80 Knowledgeable family physicians can reassure patients undergoing such procedures that there is no need to interrupt breastfeeding, and they may need to intervene on a patient’s behalf if the radiologist recommends temporary cessation based on misleading manufacturer’s literature. Similarly, most diagnostic procedures using radioisotopes do not require interruption of breastfeeding.81, 82 However, there are some that may require temporary interruption or— rarely—cessation of breastfeeding.80 References are available that outline the effects of various radioisotopes.83 For most diagnostic radioactive scanning, it is possible to find a radioisotope that does not require interruption, or at least to select one with the shortest half-life. The duration of breastfeeding cessation should be five times the half-life. The breastfeeding parent has the option of pumping and storing milk before the procedure. To maintain supply, the parent should continue to express milk after the procedure. This milk can be discarded until it is safe to resume breastfeeding or stored in a freezer that is not opened often. Once all of the radiation is gone, this milk can be given to the baby. The nuclear medicine radiologist can provide guidance regarding when the radioactivity would be depleted in the milk, and it may be tested for residual radioactivity. Breast Surgery Breast biopsy with circumareolar incision can interfere with milk supply and transfer in the affected breast.88 Patients who undergo this procedure should be encouraged to breastfeed with close monitoring to ensure that the infant has an adequate milk intake. Patients who develop a suspicious breast mass during lactation should not wean for the purpose of evaluating the mass. Mammography and breast mass biopsy can be done without interfering with lactation. A milk fistula occasionally develops after breast surgery; this condition is benign and generally resolves without intervention. Family physicians should assist their patients with decisions about breast surgery. They should communicate with the surgeon to advocate for their patient’s future breastfeeding needs and breastfeeding conservation surgeries whenever medically feasible. Medication
and Substances Contraception Parents who wish to avoid hormones can be instructed in fertility awareness methods; however, menses may remain irregular during lactation, which makes use of these methods more challenging. Additional contraceptive options include barrier methods, long-acting reversible contraceptive (LARC) methods (e.g., intrauterine devices [IUDs], the implant), and other hormonal methods (e.g., pills, patches, rings). The main advantage of barrier methods (e.g., condoms, diaphragms) is the lack of potential adverse effects to milk, whereas their main disadvantage is lower effectiveness. They may have their greatest use as a complement to lactational amenorrhea or fertility awareness methods. Diaphragms must be refitted at least six weeks postpartum. Hormonal choices for breastfeeding parents include progestin-only and estrogen-containing contraceptives. It is recommended to avoid estrogen-containing contraceptives in the initial postpartum period because of added risk of blood clots; however, this risk is significantly reduced after six weeks.96 Clinical studies support the safety of hormonal contraceptive use during breastfeeding, with no significant effects on infant growth or health noted. Indeed, recent data suggest even immediate placement of the etonogestrel implant has no effect on the quality or quantity of breast milk.96 Individuals who choose to use hormonal methods should be encouraged to breastfeed. Tobacco, Alcohol, and Marijuana Use Parents who breastfeed are advised not to smoke. If parents who smoke cannot quit, it is still more valuable to breastfeed. They should be advised not to smoke in the infant’s environment, to smoke as little as possible, and to smoke immediately after nursing (rather than before) to minimize the nicotine levels in their milk. U.S. Food and Drug Administration (FDA)-approved nicotine replacement products can be used to aid in tobacco cessation, although it is best to use the lowest possible dose because of the adverse effects of nicotine on the infant and milk supply.102 Alcohol passes easily into breast milk but is also cleared from breast milk as rapidly as it is cleared from the bloodstream. Although it is safest for nursing parents to consume no alcohol, small amounts of alcohol (e.g., one serving of wine or beer per day) appear to be safe. It is ideal to advise waiting two to two-and-a-half hours after finishing the alcoholic beverage before nursing again.103 Similarly, breastfeeding individuals who use marijuana or CBD products should be encouraged to reduce their intake; ideally, they should stop using these products altogether. Though tetrahydrocannabinol (THC) is excreted in breast milk in small quantities, it is stored in body fat and slowly released, which could expose a breastfed infant over an extended period of time. Data are insufficient to determine the health effects on breastfed infants; however, there is concern about possible effects on nervous system development.104 Toxins and Pollutants Many people are concerned about chemicals in breast milk. Unfortunately, reporting of chemicals in breast milk may lead to early termination of breastfeeding.106 It is important for family physicians to educate parents that formula contains many of the same toxins, phthalates, heavy metals, and pesticides, and potentially many more. Using formula does not reduce an infant’s exposure to environmental toxins, and the risk of cancers and less-than-optimal neurologic development remains higher in formula-fed babies compared with breastfed babies in similar environments.107, 108 Individuals who have average environmental exposure do not need to have their milk screened for pollutants. On the other hand, for those who have known poisonous exposures, testing of breast milk may be necessary. Bisphenol A (BPA) is a common chemical used to make many plastics, including baby bottles. Further study is needed on the exact effects of BPA in humans. BPA-free bottles are common, and parents may choose to use those to limit exposure.109 However, it is unclear whether the BPA substitutes also pose a risk. Concerns have been raised about heavy metal toxins—primarily mercury—in fish, causing some people to reduce fish consumption during pregnancy and lactation. Given the beneficial effects of increased consumption of fish during pregnancy on cognitive development in children, the Environmental Protection Agency (EPA) now encourages those who are pregnant or breastfeeding to eat more fish that are lower in mercury.110 The FDA has updated its guidance for fish consumption to reflect this change.111 The EPA maintains information on mercury levels in fish (available online at https://www.epa.gov/mercury/guidelines-eating-fish-contain-mercury), and most states, U.S. territories, and Native American tribes also provide information on mercury levels in fish. Employment The AAFP advocates for support of trainees and practicing physicians who are breastfeeding and issued a model policy outlining key recommendations for medical schools, fellowships, and health care facilities.40 Lactation support is highly desired by breastfeeding employees who return to work after childbirth; it also can improve a company’s return on investment by saving money in health care and employee expenses.114 Employer benefits include the following113:
Resources to help family physicians educate employers in their communities are available.The Business Case for Breastfeeding is a comprehensive program designed by the U.S. Department of Health and Human Services to educate employers about the value of supporting breastfeeding employees in the workplace.112 The program highlights how such support contributes to the success of the entire business. It also offers tools to help employers provide worksite lactation support and privacy for breastfeeding parents to express milk. In addition, it provides guidance on employees’ rights and responsibilities regarding breastfeeding and working. Pumping, Expressing, and Storage Guidelines Breast milk can be stored safely for longer periods than were previously recommended.115 For working parents with healthy, term infants, the milk can be stored at room temperature for six to eight hours, in an insulated cooler bag with ice packs for 24 hours, and in the refrigerator for up to five days. Milk can routinely be stored in a freezer for up to six months, and storing milk in a freezer for up to 12 months may be acceptable. Small amounts of milk can be added to previously expressed milk, but the fresh milk should be chilled before it is added to already frozen milk. Room should be left in the container to allow for expansion during freezing.116 The best storage containers are hard plastic or glass containers. It is best to avoid clear plastic containers because of the possible leaching of BPA into the milk during warming. Warming and thawing of milk should not be done in the microwave. Thawing can be accomplished by placing the frozen milk in the refrigerator overnight, by placing it in a bowl of warm water, or by holding it under warm running water.116 Once thawed, the milk should not be refrozen but can be stored in the refrigerator for 24 hours. Because any thawed milk that has been partially consumed must be discarded, it is advisable to use small containers (2-4 oz) to avoid unnecessary waste. Supplementation Supplementation may be done with expressed milk, pasteurized human milk from a donor, or infant formula. Methods of supplementation include cup feeding, finger feeding with a syringe attached to a feeding tube, using a supplemental feeding tube at the breast, and bottle feeding. One method is not necessarily more suitable than another, and the choice of method depends on individual evaluation of latch, infant feeding, and parent comfort. When supplementation is necessary, parents need professional guidance and consultation with a certified lactation consultant or other knowledgeable health care professional is recommended. Sunlight has historically been the primary source of vitamin D for humans. However, people receive much less sun exposure in modern times because of urban/indoor lifestyles, migration, and sun avoidance or use of sunscreens to prevent skin cancer. As human breast milk contains low levels of vitamin D, the AAFP recommends that babies who are exclusively or partially breastfed be supplemented with 400 IU of vitamin D daily until one year of age.42 Infants given formula should also receive vitamin D supplementation until they are consuming more than 32 ounces of formula per day.42 Breastfeeding and the Preterm Infant Premature infants who receive breast milk have a decreased risk of necrotizing enterocolitis, improved gut motility and maturation, improved neurodevelopmental outcomes,118 and reduced rates of sepsis119 and retinopathy of prematurity120 compared with infants who receive milk substitutes. The decrease in necrotizing enterocolitis appears to outweigh any short-term increase in growth achieved with preterm formula feeding.121 Evidence of improved feeding tolerance, earlier full enteral feeds, and decreased risk of atopic diseases has been inconsistent to date. A meta-analysis of 20 studies concluded that breastfeeding is associated with long-term cognitive advantages and that preterm infants derive more benefits in cognitive development from breast milk than full-term infants do.122 Other benefits of breastfeeding for preterm infants later in life include decreased risk of metabolic syndrome and hypertension,123 decreased insulin and leptin resistance,124 and lower low-density lipoprotein levels.125 Preterm infants who are provided human milk in the neonatal intensive care unit (NICU) have lower rates of rehospitalization.126 Human milk also has been associated with enhanced retinal development and visual acuity in preterm infants. However, protein fortification may be necessary for smaller or more fragile preterm infants. In addition to promoting physiologic stability in premature infants, skin-to-skin contact (i.e., “kangaroo care”)increases maternal milk supply and breastfeeding rates.32, 127 Parents of preterm infants should be presented with information about the benefits of breastfeeding and human milk for the premature infant. Individuals who are hesitant to make a long-term commitment to breastfeeding can be encouraged to nurse or express colostrum and milk for their infant until hospital discharge. Breastfeeding parents of preterm infants face many challenges, such as infant illness, parent-infant separation, infant feeding difficulties at the breast, the possibility of prolonged pumping, and the emotional and physical stress of juggling personal care with other commitments to family, job, and newborn. When family physicians work as part of a medical team of neonatologists, nurses, social workers, dietitians, and lactation consultants, they can be effective in supporting the successful initiation and continuation of breastfeeding the preterm infant. Breastfeeding
the Late Preterm Infant Donor Milk In recent years, a new trend of casual milk sharing—in which unpasteurized milk is shared with or sold to other parents, without benefit of medical screening—has emerged among some people. One study found that milk purchased anonymously over the internet frequently was contaminated,133 though these results may not be generalizable to situations in which donor and recipient are acquainted and shipping is not necessary.134 Individuals accepting milk from unscreened donors should be warned of the potential dangers, including possible transmission of HIV, and other infectious diseases; unknown hygiene of collection and storage techniques; and unknown medication history of the donor. Age and health status of the recipient baby should also be considered, and parents should make a fully informed decision in their particular situation, weighing the risks of unscreened and unpasteurized human milk from a donor versus risks of infant formula. Breastfeeding Multiples Parents of multiples will need additional support for breastfeeding. Most can exclusively breastfeed twins. Success with breastfeeding triplets and even quadruplets has been reported.137 A consistent concern about breastfeeding multiples is whether there will be enough supply. However, simultaneous feeding may help with milk production.138 Prior to delivery, physicians should provide education and resources for parents to support breastfeeding, including reassurance that adequate milk supply is possible although parents may need additional techniques, support, or help. Physicians should be familiar with techniques for increasing milk supply and recognize that even partial breastfeeding is beneficial. Adoptive Breastfeeding A knowledgeable physician or lactation consultant may help the adoptive parent develop a milk supply before or after an adoption.The family physician who is supporting lactation induction or relactation should begin as early as possible in the adoptive process.139 Many adoptive parents are physiologically capable of producing milk. Although the adoptive parent may not develop a full milk supply, with induced lactation techniques and the use of galactagogues, it is often possible to provide a significant amount of breast milk.139 It is also important to be knowledgeable about the informal milk-sharing resources in communities and on the internet and to counsel adoptive parents about the potential risks of such arrangements. The opportunity to emotionally bond during nursing provides benefit of breastfeeding for adoptive parents and babies.140 Breastfeeding Beyond Infancy Weaning The role of the family physician involves knowing the physiologic norm for weaning and providing culturally sensitive anticipatory guidance and counseling to parents and families during the process. It is important to recognize and counsel parents about the difference between weaning and a sudden refusal to nurse (i.e., nursing strike). Medications to decrease or stop milk production are not necessary and should be avoided. Gradual or partial weaning can be encouraged. In rare cases in which abrupt weaning is necessary, the advice of a lactation consultant should be sought to minimize the risks. Regardless of the reasons for weaning, whether it is premature and abrupt or gradual and parent- or child-led, many breastfeeding parents feel a sense of grief or loss as breastfeeding ends.145 The family physician can provide anticipatory guidance and support for the patient and the family during this phase. Partner’s Role in
Breastfeeding Support Five main partner attributes associated with successful breastfeeding have been identified: (1) knowledge about breastfeeding; (2) positive attitude toward breastfeeding; (3) involvement in the decision-making process; (4) practical support; and (5) emotional support.38 Family physicians should be prepared to help educate partners on the benefits of breastfeeding and to dispel any myths and misperceptions they may have. Partners need to understand that what they may perceive as problems, such as the breastfeeding parent’s soreness, physiologic infant weight loss, jaundice, baby fussiness, and frequency of feedings, especially at night, do not necessitate a switch to formula. Adolescents and
Breastfeeding Although teenage parents share barriers to breastfeeding with their adult peers, they also face many unique pressures. The family physician can help pregnant teenagers cope with these issues and encourage breastfeeding. Enlisting and educating the teenager’s support system (e.g., their own parents and other relatives, peers, friends, and their partner) is important and may make a difference.151 Teens living with their own parents may be at especially high risk of early weaning.152 Ideally, a teen’s parents should be encouraged to participate in counseling sessions on breastfeeding. Peer counseling by other breastfeeding teenagers can be powerful. Adolescents usually are interested in learning about the practical issues of breastfeeding and learn quickly. However, they often have an incorrect understanding, so dispelling myths is key.153 Pregnant and breastfeeding adolescents often have significant concerns about exposure of their breasts during breastfeeding. These concerns can be addressed by providing positive images of discreet breastfeeding and educating teens about changes that will occur during pregnancy and breastfeeding. Often, teenagers are disinclined to bring up such concerns, but, if asked, they are willing to discuss body image concerns, as well as issues such as sexuality and contraception. Because teenagers worry about their changing bodies, it is important to share information about proper nutrition, diet, exercise, and weight loss proactively.154 Continued support of the adolescent parent will help them maintain breastfeeding. It is also important to help create environments supportive of success in breastfeeding, so the physician may need to advocate on the patient’s behalf at school and/or work to ensure time for breastfeeding and pumping is provided. In addition, anticipatory guidance about the infant’s growth and development, as well as ongoing parenting education, will further help maintain breastfeeding as part of the patient’s lifestyle. Breastfeeding in Underserved Populations Unfortunately, the ACA’s requirement for coverage of breastfeeding support, supplies, and counseling applies only to private health care plans. It does not apply to Medicaid; rather, coverage decisions for Medicaid are managed at the state level. The United States Breastfeeding Committee (USBC) encourages states to go beyond current requirements to include lactation services as separately reimbursed pregnancy-related services and provides examples of current state practices.156 Family physicians should understand the specific financial, work, and time obstacles to breastfeeding, work with families to overcome them, and provide specific means to address the obstacles. Issues of Ethnicity and Culture Family physicians can promote lactation among their patients of various ethnicities in a number of ways, including the following:
Military Issues Family Physicians and Breastfeeding Advocacy The AAFP supports the “Ten Steps to Successful Breastfeeding” for making hospitals and staff more breastfeeding friendly (see Appendix 3, under “National and International Breastfeeding Initiatives”).159 These 10 steps are the core of the Baby-Friendly Hospital Initiative (BFHI). While BFHI-designated facilities have been shown to increase breastfeeding rates, successful breastfeeding requires prenatal and post-delivery education and support.160 Family physicians can play an important role in helping their hospital or birthing facility implement the provisions of the 10 steps. Studies have shown that a physician’s recommendation to breastfeed increases breastfeeding initiation and duration rates.161, 162 Eliminating formula company literature, advertising, and distribution of samples encourages breastfeeding as normal infant feeding.163 Family physicians need to ensure that office and hospital policies support breastfeeding patients. Family physicians can advocate for breastfeeding in their offices by making their office and staff breastfeeding friendly. The Academy of Breastfeeding Medicine (ABM) has published a clinical protocol that offers guidance for establishing a breastfeeding-friendly office.52 In advocacy for breastfeeding issues related to insurance coverage and workplace changes, the economic benefits of breastfeeding are essential points. Several studies have shown a substantial increase in cost to families, communities, health care systems, and employers when babies are not breastfed.25, 164, 165 Physicians must be aware of these data to be effective advocates in promoting change in policies regarding breastfeeding. Family physicians have assumed many administrative roles in hospitals, managed care plans, insurance companies, and large physician organizations. In these roles, family physicians are in a position to promote breastfeeding and ensure appropriate payment for lactation services provided by physicians or lactation consultants. Family physicians should advocate for improved access to lactation services, encouraging increased availability of and payment for lactation consultants. Family physicians are active and influential in their communities. By projecting a positive attitude toward breastfeeding in the office and the community, they can strongly affect a patient’s decision to breastfeed. The AAFP supports the U.S. Preventive Services Task Force (USPSTF) recommendations for structured breastfeeding education and counseling to improve breastfeeding rates.166 Family physicians provide a wealth of patient education in their offices. As a part of their health education and promotion activities in schools, family physicians should incorporate information about breastfeeding. Making breastfeeding education available to all family and community members will help make breastfeeding the community norm. Appendix 3: Resources From External Organizations ORGANIZATIONS AND EDUCATIONAL RESOURCES FOR PHYSICIANS American Academy of Family Physicians (AAFP)
Academy of Breastfeeding Medicine (ABM)
American Academy of Pediatrics
American College of Obstetricians and Gynecologists (ACOG) www.acog.org/breastfeeding Resources:
Breastfeeding Basics An online short course on the fundamentals of breastfeeding; geared primarily for the medical professional Centers for Disease Control and Prevention (CDC) www.cdc.gov/growthcharts/who_charts.htm
International Board of Lactation Consultant Examiners International Lactation
Consultant Association
La Leche League International
The Joint Commission
The National Women’s
Health Information Center
United States Breastfeeding Committee Wellstart International
World Alliance for Breastfeeding Action NATIONAL AND INTERNATIONAL BREASTFEEDING INITIATIVES The Baby-Friendly Hospital Initiative (BFHI) Baby-Friendly facility designation is awarded after a comprehensive process of self-assessment, policy development, staff training, data collection, quality improvement, and BFUSA on-site assessment. The process is guided by the BFHI Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation. Baby-Friendly designation requires successful implementation of the “Ten Steps to Successful Breastfeeding” and the International Code of Marketing of Breast-milk Substitutes. Ten Steps to Successful Breastfeeding www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/ (Supported by the American Academy of Family Physicians)
International Code of Marketing of Breast-milk Substitutes
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(2001) (April 2021 BOD) Which is the priority nursing intervention when providing care for a high risk infant?With every newborn contact, respiratory evaluation is necessary because this is the highest priority in newborn care.
Which statement by the nursing student about the prevention of health care associated infections Hals in a nursery unit indicates effective learning?Which statement by the nursing student about the prevention of health care-associated infections (HAIs) in a nursery unit indicates effective learning? "Hand washing helps prevent HAIs in a nursery unit."
Which condition may be seen in an infant born to a patient who consumes excessive alcohol during pregnancy quizlet?Fetal Alcohol Syndrome (FAS) was the first form of FASD discovered and is the most well-known. Heavy alcohol use during the first trimester of pregnancy can disrupt normal development of the face and the brain.
Which infant has a higher possibility of sustaining a birth trauma?In general, larger infants are more susceptible to birth trauma. Higher rates are reported for infants who weigh more than 4500g. Most birth traumas are self-limiting and have a favorable outcome. Nearly one half are potentially avoidable with recognition and anticipation of obstetric risk factors.
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