Breast-Feeding Protocol in the Primary Care Setting News Author: Troy Brown CME Author: Laurie Barclay, MD » CLINICAL CONTEXT Numerous known risks have been associated with not breast-feeding. Breast-feeding should be an important public health initiative rather than a lifestyle choice, according to The 2012 American Academy of Pediatrics Policy Statement on Breastfeeding and the Use of Human Milk. However, a gap exists with lack of programs to help mothers to breast-feed. The Academy of Breastfeeding Medicine (ABM) protocol offers a template including interventions supported by available evidence. The goal of this study by Corriveau and colleagues was to assess the effects of implementing a program based on the ABM clinical protocol on breast-feeding. STUDY SYNOPSIS AND PERSPECTIVE A breast-feeding–friendly clinical protocol used in a primary care setting may increase rates of exclusive (no formula) breast-feeding in infants up to 6 months of age, according to a retrospective before-and-after study of 757 mother-infant dyads. Sharon K. Corriveau, DNP, RN, CFNP, IBCLC, a nurse practitioner and lactation consultant at Loudoun Pediatric Associates in Leesburg, Virginia, and colleagues published their findings in an article published online April 1 in Pediatrics. The American Academy of Pediatrics recommends exclusive breast-feeding for the first 6 months of age, with the addition of solid foods for the second 6 months. According to the Centers for Disease Control and Prevention, 76.9% of women initiate breast-feeding in the early postpartum period, but exclusivity and duration of breast-feeding decline quickly within a short time. The study was conducted in a large pediatric practice with 2 clinics that serve multicultural urban and rural populations. The researchers used the ABM clinical protocol (The Breastfeeding-Friendly Physicians Office, Part 1: Optimizing Care for Infants and Children) as a template. The academys protocol follows guidelines from the World Health Organization and United Nations Childrens Fund Baby-Friendly Hospital Initiative. The study protocol includes staff training, written policies, support from an on-site lactation consultant, community outreach, and data tracking. The preintervention group included 376 mother-infant pairs, and the postintervention group included 381 mother-infant pairs. The investigators collected data during the hospital stay; the newborn visit; and the 2-, 4-, and 6-month health maintenance visits. The postintervention protocol included training for the medical staff, as well as a monthly meet-and-greet session at the clinic for the community that included a discussion of breast-feeding services, including breast-feeding classes and a support group. For patients, the intervention began at the newborn visit, when a registered nurse who is also a lactation consultant meets with the mother-infant pair for up to 1 hour. All breast-feeding concerns are referred to the lactation consultant at subsequent visits, and lactation support is available as needed. Exclusive breast-feeding rates were significantly higher in the postintervention group compared with the preintervention group at all 5 times (P < .01). Exclusive breast-feeding rates were at least 10 percentage points higher in the postintervention group at all 5 times. Rates for any breast-feeding were also higher in the postintervention group compared with in the preintervention group at every point, but these differences were significant only at the 1-week point (P = .021). The proportion of primiparous mothers was higher in the postintervention group (53.8%) compared with the preintervention group (40.4%), and this increase was significant (P < .001). The researchers conducted χ2 tests separately for primiparous and multiparous mothers to compare exclusive breast-feeding and any breast-feeding in both groups at all times. The results were similar to those of the combined parity groups, except at week 1, the exclusive breast-feeding rate for the multiparous mothers increased by only 9.6 percentage points, which was not statistically significant. The results from this study suggest that the use of a breastfeeding-friendly clinical protocol in the primary care setting may help increase exclusive (no formula) breastfeeding rates up to 6 months of age, the authors write. Further studies should explore use of this protocol, inclusive of patient populations and/or regions known to have low breastfeeding rates, to help expand its use and address this important public health initiative, the authors conclude. The authors have disclosed no relevant financial relationships. Pediatrics. Published online April 1, 2013. Abstract STUDY HIGHLIGHTS The investigators used the ABM clinical protocol (The Breastfeeding-Friendly Physicians Office, Part 1: Optimizing Care for Infants and Children) as a template to improve provision of breast-feeding services in their pediatric primary care clinic. Components of the protocol included establishing a written breast-feeding office policy by a lactation team of 3 nurse practitioners and 1 registered nurse who were also International Board Certified Lactation Consultants. Exclusive breast-feeding (no formula) was encouraged to 6 months unless medically necessary. Medical care providers were required to complete an American Academy of Pediatrics–approved breast-feeding training program. Other features were culturally competent care with availability of Spanish interpreters, available prenatal breast-feeding classes and monthly meet-and-greet with the breast-feeding services providers, and collaboration with the local hospital and community. Mothers had access to a lactation consultant for up to 1 hour at the 48- to 72-hour newborn visit and as needed, as well as telephone support, a weekly support group, and educational and community resources. Open breast-feeding was encouraged, with breast-feeding supported in the waiting room and space provided for mothers who prefer privacy. A worksite policy included space and break-time for mothers to pump and store milk, and a going-back-to-work class was made available. Lactation consultant visits were billed to insurance with use of American Academy of Pediatrics breast-feeding Current Procedural Terminology and International Classification of Diseases, Ninth Revision, billing codes. Breast-feeding rates were tracked for surveillance and were entered into a database. This retrospective before-and-after study included 757 mother-infant pairs, with data collected at the hospital stay; the newborn visit; and the 2-, 4-, and 6-month health maintenance visits. Implementation of the protocol began in December 2009 and continued for 10 months. To assess the effects of the protocol on increasing breast-feeding rates, the investigators compared the preintervention group vs the postintervention group. After implementation of the ABMs breast-feeding–friendly protocol, rates of breast-feeding initiation and exclusive breast-feeding increased. At all 5 time points, a statistically significant increase in exclusive breast-feeding rates was associated with use of the protocol. The initiation rate for the exclusively breast-feeding postintervention group was much higher (78%) vs the preintervention group (59%). Increases in rates for any breast-feeding were not significant except for the 1-week time point. On the basis of their findings, the study authors concluded that within a diverse patient population in a pediatric primary care setting, implementation of the ABM breast-feeding–friendly clinical protocol appeared to be associated with increased rates of exclusive breast-feeding up to age 6 months. Limitations of this study include lack of data regarding other factors that may affect breast-feeding, such as mothers educational level, social support, smoking, work, and socioeconomic status. In addition, this study was a retrospective before-and-after study rather than a randomized controlled trial. The investigators recommend further studies regarding use of this protocol, including patient populations and/or regions known to have low breast-feeding rates, to promote its use and address this important public health initiative. CLINICAL IMPLICATIONS A clinical protocol designed to improve breast-feeding rates within a pediatric primary care setting, according to interventions recommended by the ABM, included staff training, written policies, on-site lactation consultant support, community outreach, and data tracking. A retrospective before-and-after study showed that families who receive care in a large, diverse pediatric primary care setting after implementation of a breast-feeding–friendly office protocol may have increased rates of exclusive breast-feeding. Medscape Education © 2013 Medscape, LLC
Posted on: Tue, 05 Nov 2013 13:37:26 +0000
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