- Email: [email protected]
Provider Encouragement of Breastfeeding: Efficacy and Ethics
COMMENTARY Provider Encouragement of Breastfeeding: Efficacy and Ethics Donna J. Miracle, RNC, CLE, PhD, and Valita Fredland, JD, MA The health and economic benefits of breastfeeding are well documented, and mothers’ milk is considered the optimal feeding method for almost all infants.1– 4 Reports of benefits for breastfed infants and children include decreases in otitis media,5–7 atopic dermatitis,8 and gastroenteritis,9 –11 as well as a lower risk of obesity12,13 and asthma.14 –17 Additional benefits include a reduced incidence of sudden infant death syndrome,18,19 type 1 and type 2 diabetes mellitus,20 –23 and childhood leukemia.24,25 In addition, there are maternal health benefits of breastfeeding that include reduction in the risk of breast cancer,26,27 ovarian cancer,28 –31 type 2 diabetes mellitus,32 and an association between not breastfeeding and postpartum depression.33–35 Given this evidence, health care providers should take an assertive stance in promoting, protecting, and recommending breastfeeding to expectant and new mothers. This is consistent with current professional policy statements1– 4 on breastfeeding and the use of human milk. This commentary discusses the ethical obligation for provider encouragement of breastfeeding, given the state of the science regarding the health benefits of breastfeeding. MOTHERS’ NEEDS FOR INFORMATION Mothers often present to the clinical setting without enough information to make an informed decision about infant feeding. They often lack knowledge about the differences between feeding methods or how to go about learning the skill of breastfeeding,36 and look to health care providers for this information.37,38 Studies36,39 report that women who chose formula feeding knew that human milk was “best” but felt that formula was “adequate.” In one study of mothers of preterm infants,36 the participants reported not knowing that there was a difference between formula and breast milk and appreciated being given this information. Because health care providers offered evidence about these differences, all participants in this study changed their initial decision
Address correspondence to Donna J. Miracle, RNC, CLE, PhD, 6820 Parkdale Place, Ste 109, Indianapolis, IN 46254. E-mail: dmiracle@ clarian.org
Journal of Midwifery & Women’s Health • www.jmwh.org © 2007 by the American College of Nurse-Midwives Issued by Elsevier Inc.
from formula feeding and provided their own milk to their infants for a minimum period of 30 days after birth. Mothers also expressed the opinion that health care providers who told them that breast milk and formula were the same had failed to do their job. This study illustrates how mothers depend on health care providers for knowledge and information about the differences between human milk and formula feedings, and the relationship of infant feeding method to health outcomes. FACTORS THAT AFFECT THE MATERNAL DECISION TO BREASTFEED Studies of maternal choice about infant feeding methods40 –52 consistently find that mothers who elect to breastfeed are, on average, older, have more years of formal education, and report higher household incomes than women who formula feed. In addition, these women tend to have social support, such as mothers, family, and/or friends, and live with the baby’s father. Women choose their feeding method based on perceived benefits to themselves and/or their infants. In addition, mothers report choosing to breastfeed for consistency with traditional values,41 convenience,49,51 and self-efficacy.45,48 Other studies have documented mothers’ awareness that human milk confers unique infant health benefits and for many women, this is the most important rationale for choosing to breastfeed.36,41,42 Mothers are influenced to choose breast or formula-feeding based on the preferences of others such as fathers,45– 47 mothers, relatives, friends,45– 49 and health care providers.36,37,42– 44 A large national survey found that provider encouragement exerted an independent positive influence on breastfeeding initiation across all strata of the sample.50 This study found that women who were encouraged by health care providers to breastfeed were more than four times as likely to initiate breastfeeding than women who did not receive this encouragement. More importantly, provider encouragement significantly increased breastfeeding initiation by more than threefold among lowincome, young, and less educated women, by nearly fivefold among black women, and nearly elevenfold among single women.50 A recent Cochrane review37 of support for breastfeed545 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.08.013
ing evaluated 34 randomized trials that included 29,385 women. The analysis found that women who were encouraged by health care providers to breastfeed were less likely to stop breastfeeding at 4 months after birth (16 trials, relative risk [RR], 0.94, 95% confidence interval [CI], 0.87–1.01), and more likely to breastfeed exclusively in the first 3 months after birth (RR, 0.91, 95% CI, 0.84 – 0.98). Because health care providers can and do influence their patients’ decisions about the choice of infant feeding, it is important to consider how to translate the evidence into a message health care providers can deliver. It is important that health care providers, individually and collectively, make a comprehensive, strategic plan to protect, support, and recommend breastfeeding. This plan should be in place from the initial patient contact and throughout the prenatal course. Then, a collaborative approach with the hospital system would ensure follow through with education and breastfeeding management. ETHICS OF HEALTH CARE PROVIDERS: WHAT IS THE ROLE AND RESPONSIBILITY? Based on scientific evidence that human milk confers unique health benefits to both the mother and the infant, health care providers caring for an expectant or new mother and her infant have an ethical obligation to discuss all appropriate and applicable issues related to breastfeeding. First and foremost, a mother is not able to exercise her right to autonomy and a self-determined decision about breastfeeding for herself and her infant if her health care provider does not ensure that she has the relevant information. Informed consent is a “shared medical decision-making . . . process in which the provider shares with the patient all relevant risk and benefit information on all treatment alternatives and the patient shares with the provider all relevant personal information that might make one treatment or side effect more or less tolerable than others.”53 To meet the obligation of shared medical decision-making, health care providers must provide scientific evidence known about the risks and benefits of breastfeeding as well as alternative infant feeding methods. Health care providers must carefully consider the content of their informed consent discussion with women who are in a position to consider breastfeeding. Honesty and respect are fundamental to any exchange between two people. In the context of breastfeeding, they bear greater weight because of the different power positions of
Donna J. Miracle, RNC, CLE, PhD, is in clinical practice at Indiana Mothers’ Milk Bank, Inc., Indianapolis, IN and a faculty member at Indiana Wesleyan University. Valita Fredland, JD, MA, is an attorney in the legal services department at Clarian Health Partners, Inc., Indianapolis, IN.
546
the health care provider and the patient. Health care providers should consider and disclose any relationship with entities that could unduly influence their recommendations for or discussions about feeding methods with new and expectant mothers. The most obvious conflict of interest would involve a health care provider who receives money from any industry with a conflicting interest in regard to breastfeeding promotion. Health care providers should also consider their involvement in research, commerce, and/or politics that may influence their ability to share honest and accurate information about breast or formula feeding.39,53 Health care providers are also obligated to disclose evidence of potential harm related to infant feeding method when counseling mothers about the risks and benefits of all feeding options for infants. Clinicians offer evidence-based counseling about the risks of tobacco use and not using car seats, seat belts, or other preventive health measures, they should take a similar stand when discussing breastfeeding. Breastfeeding information should be presented as a preventive health strategy. This is especially important for vulnerable populations who are statistically less likely to breastfeed and who are most influenced by health care providers. CONCLUSION Health care providers can and do influence women’s decisions about the choice of infant feeding. They have an ethical obligation to provide adequate information about the benefits of breastfeeding and the potential harms associated with not breastfeeding so that mothers can make an informed decision. Therefore, providers need to consider how to translate the evidence into a message that is easily and consistently delivered. Health care providers should work collaboratively to develop a comprehensive, strategic plan to protect, support, and recommend breastfeeding. This plan should be in place from the initial patient contact and throughout the prenatal course. Then, a collaborative approach with the hospital system would ensure follow through with education and breastfeeding management. To optimize infant and maternal health outcomes through human milk feedings, it is imperative that all health care providers working with new mothers be knowledgeable about human milk feedings and breastfeeding management, it should not be left to a unique group of professionals. Midwives and women’s health professionals should be competent to provide assistance with the breastfeeding fundamentals, such as latch and positioning, as well as assistance with common breastfeeding and lactation problems ranging from sore nipples to delayed lactogenesis. All office and hospital personnel should have training on what exemplifies a breastfeeding friendly environment. Art work and patient literature should be reviewed to ensure that content and messages Volume 52, No. 6, November/December 2007
portray breastfeeding as the optimal feeding method, in a positive, culturally appropriate manner. To provide breastfeeding friendly care means to continually evaluate and raise awareness about the environment so that mothers feel comfortable and accepted when breastfeeding throughout waiting room and office spaces. In addition, hospital practices should promote and support the unique needs of breastfeeding mothers and infants from an evidence-based perspective. Finally, evidence-based breastfeeding practice means that health care providers are aware of current professional policy statements related to breastfeeding and incorporate these recommendations into the clinical setting. It is through access and dissemination of knowledge from health care providers that mothers are then empowered to make a fully informed decision about a feeding method. A strategic plan such as described above promotes patient advocacy, conforms to ethical principles, and emphasizes the responsibility for all health care providers to actively recommend and promote breastfeeding to expectant and new mothers. Implementing evidencebased provider encouragement of breastfeeding is essential in the current health care environment that emphasizes clinical excellence, improved quality of patient care, informed decision making, and optimal patient outcomes. REFERENCES 1. American Academy of Pediatrics Policy Statement. Breastfeeding and the use of human milk. Pediatrics 2005;115:496 –506.
atic review and meta-analysis of prospective studies. J Am Acad Dermatol 2001;45:520 –7. 9. Morrow A, Ruiz-Palacios G, Jiang X, Newburg D. Humanmilk glycans that inhibit pathogen binding protect breast-feeding infants against symptomatic rotavirus infection. J Nutr 2005;135: 1304 –7. 10. Newburg D, Peterson J, Ruiz-Palacios G, Matson D, Morrow A, Shults J, et al. Role of human-milk lactadherin in protection against symptomatic rotavirus infection. Lancet 1998;351: 1160 – 4. 11. Quigley M, Cumberland P, Cowden J, Rodrigues L. How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study. Arch Dis Child 2006;91: 245–50. 12. Armstong J, Reilly J. Breastfeeding and lowering the risk of childhood obesity. Lancet 2002;359:1249 –50. 13. Butte N. The role of breastfeeding in obesity. Pediatr Clin North Am 2001;48:189 –98. 14. Kull I, Almqvist C, Lilja G. Breast-feeding reduces the risk of asthma during the first 4 years of life. J Allergy Clin Immunol 2004;114:755– 60. 15. Sears M, Greene J, Willan A, Taylor D, Flannery E, Cowan J. Long-term relation between breastfeeding and development of atopy and asthma in children and young adults: A longitudinal study. Lancet 2002;360:901–7. 16. Wright A, Holberg C, Taussig L, Martinez F. Factors influencing the relation of infant feeding to asthma and recurrent wheeze in childhood. Thorax 2001;56:192–7. 17. Burgess S, Dakin C, O’Callaghan M. Breastfeeding does not increase the risk of asthma at 14 years. Pediatrics 2006; 117:e787–92.
2. American Academy of Family Physicians Web site. Breastfeeding (policy statement). Available from: www.aafp.org/online/ en/home/policy/policies/b/breastfeedingpolicy.html [Accessed June 1, 2007].
18. Chen A, Rogan W. Breastfeeding and the risk of neonatal death in the United States. Pediatrics 2004;113:e435–9.
3. American College of Nurse Midwives. Position statement: Breastfeeding, 2004. Available from: www.midwife.org [Accessed June 14, 2007].
20. Eurodias S. Rapid early growth is associated with increased risk of childhood type I diabetes in various European populations. Diabetes Care 2002;25:1755– 60.
4. Association of Women’s Health, Obstetric and Neonatal Nurses. Breastfeeding clinical position statement, 1999. Available from: www.awhonn.org/awhonn/?pg⫽875-4730-7240 [Accessed June 14, 2007].
21. Monetini L, Cavallo M, Stefanni L, Ferrazzoli F, Bizzarri C, Marietti G. Bovine beta casein antibodies in breast and bottle fed infants: Their relevance in Type I diabetes. Diabetes Metab Res Rev 2001;17:51– 4.
5. Brown C, Magnusson B. On the physics of the infant feeding bottle and middle ear sequella: Ear disease in infant can be associated with bottle-feeding. Int J Pediatr Otorhinolaryngol 2000;54: 13–20.
22. Patterson C. Rapid early growth is associated with increased risk of childhood type I diabetes in various European populations. Diabetes Care 2002;25:1755– 60.
6. Vernacchio L, Lesko S, Vezina R, Corwin M, Hunt C, Hoffman H, et al. Racial/ethnic disparities in the diagnosis of otitis media in infancy. Int J Pediatr Otorhinolaryngol 2004;68:795– 804. 7. Duffy L, Faden H, Wasielewski R, Wolf J, Krystofik D. Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. Pediatrics 2004;100:E7. 8. Gdalevich M, Mimouni D, David M, Mimouni M. Breastfeeding and the onset of atopic dermatitis in childhood: A systemJournal of Midwifery & Women’s Health • www.jmwh.org
19. McVea K, Turner P, Peppler D. The role of breastfeeding in sudden infant death syndrome. J Hum Lact 2000;16:13–20.
23. Owen C, Martin R, Whincup P, Smith G, Cook D. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Am J Clin Nutr 2006; 8495:1043–54. 24. Guise J, Austin D, Morris C. Review of case-control studies related to breastfeeding and reduced risk of childhood leukemia. Pediatrics 2005;116:e724 –31. 25. Kwan M, Buffler P, Abrams B, Kiley V. Breastfeeding and the risk of childhood leukemia: A meta-analysis. Public Health Rep 2004;119:521–35.
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26. Biernier M, Plu-Bureau G, Bossard N, Ayzac L, Thalabard J. Breastfeeding and risk of breast cancer: A metaanalysis of published studies. Hum Reprod Update 2000;6:374 – 86. 27. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: Collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet 2002;360:187–95. 28. Chiaffarino F, Pelucchi C, Negri E, Parazzini F, Franceschi S, Talamini R. Breastfeeding and the risk of epithelial ovarian cancer in an Italian population. Gynecol Oncol 2005;98:304 – 8. 29. Modugno F, Ness R, Wheeler J. Reproductive risk factors for epithelial ovarian cancer according to histologic type and invasiveness. Ann Epidemiol 2001;11:568 –74. 30. Tung K, Goodman M, Wu A, McDuffie K, Wilkens L, Kolonel L. Reproductive factors and epithelial ovarian cancer risk by histologic type: A multiethnic case-control study. Am J Epidemiol 2003;158:629 –38. 31. Tung K, Wilkens L, Wu A, McDuffie K, Nomura A, Kolonel L. Effect of anovulation factors on pre- and postmenopausal ovarian cancer risk: Revisiting the incessant ovulation hypothesis. Am J Epidemiol 2005;161:321–9. 32. Taylor J, Kacmar J, Nothnagle M, Lawrence R. A systematic review of the literature associating breastfeeding with type 2 diabetes and gestational diabetes. J Am Coll Nutr 2005;24:320 – 6. 33. Warner R, Appleby L, Whitton A, Faragher B. Demographic and obstetric risk factors for postnatal psychiatric morbidity. Br J Psychiatry 1996;168:607–11. 34. Chaudron L, Klein M, Remington P, Palta M, Allen C, Essex M. Predictors, prodromes and incidence of postpartum depression. J Psychosom Obstet Gynecol 2001;22:103–12. 35. Henderson J, Evans S, Straton J, Priest S, Hagan R. Impact of postnatal depression on breastfeeding duration. Birth 2003;30: 175– 80. 36. Miracle D, Meier P, Bennett P. Mothers’ decisions to change from formula to mothers’ milk for very-low-birth-weight infants. J Obstet Gynecol Neonatal Nurs 2004;33:692–703. 37. Britton C, McCormick F, Renfrew M, Wade A, King S. Support for breastfeeding mothers. Cochrane Database Syst Rev 2007;1:CD001141. 38. Gill S. The little things: Perceptions of breastfeeding support. J Obstet Gynecol Neonatal Nurs 2001;30:401–9. 39. Li R, Rock V, Grummer-Strawn L. Changes in public atti-
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tudes toward breastfeeding in the United States, 1999 –2003. J Am Diet Assoc 2007;107:122–7. 40. Forste R, Weiss J, Lippincott E. The decision to breastfeed in the United States: Does race matter? Pediatrics 2001;108: 291– 6. 41. Duclos C, Dabadie A, Branger B, Poulain P, Grall J, LeGall E. Factors associated with the choice of breast or bottle-feeding for hospitalized newborns. Arch Pediatr 2002;9:1031– 8. 42. Hannon P, Willis S, Bishop-Townsend V, Martinez I, Scrimshaw S. African-American and Latina adolescent mothers’ infant feeding decisions and breastfeeding practices: A qualitative study. J Adolesc Health 2000;26:399 – 407. 43. Wiemann C, DuBois J, Berenson A. Strategies to promote breast-feeding among adolescent mothers. Arch Ped Adoles Med 1998;152:862–9. 44. Williams P, Innis S, Vogel A, Stephen L. Factors influencing infant feeding practices of mothers in Vancouver. Canadian J Public Health 1999;90:114 –9. 45. Bentley M, Caulfield L, Gross S, Bronner Y, Jensen J, Kessler L. Sources of influence on intention to breastfeed among African-American women at entry to WIC. J Hum Lact 1999;15: 27–34. 46. Black R, Blair J, Jones V, DuRant R. Infant feeding decisions among pregnant women from a WIC population in Georgia. J Am Diet Assoc 1990;90:255–59. 47. Giugliani E, Caiaffa W, Vogelhut J, Witter F, Perman J. Effect of breastfeeding support from different sources on mothers’ decisions to breastfeed. J Hum Lact 1994;10:157– 61. 48. Kessler L, Gielen A, Diener-West M, Paige D. The effect of a woman’s significant other on her breastfeeding decision. J Hum Lact 1995;11:103–9. 49. Matich J, Sims L. A comparison of social support variables between women who intend to breast or bottle feed. Soc Sci Med 1992;34:919 –27. 50. Lu M, Lange L, Slusser W, Hamilton J, Halfon N. Provider encouragement of breastfeeding: Evidence from a national survey. Obstet Gynecol 2001;97:290 – 4. 51. Alexy B, Carter Martin A. Breastfeeding: Perceived barriers and benefits/enhancers in a rural and urban setting. Public Health Nurs 1994;11:214 – 8. 52. Maehr J, Lizarraga J, Wingard D, Felice M. A comparative study of adolescent and adult mothers who intend to breastfeed. J Adolesc Health 1993;14:453–7. 53. Staples King J, Moulton B. Rethinking informed consent: The case for shared medical decision-making. Am J Law Med 2006;32:431.
Volume 52, No. 6, November/December 2007
Address correspondence to Donna J. Miracle, RNC, CLE, PhD, 6820 Parkdale Place, Ste 109, Indianapolis, IN 46254. E-mail: dmiracle@ clarian.org
Journal of Midwifery & Women’s Health • www.jmwh.org © 2007 by the American College of Nurse-Midwives Issued by Elsevier Inc.
from formula feeding and provided their own milk to their infants for a minimum period of 30 days after birth. Mothers also expressed the opinion that health care providers who told them that breast milk and formula were the same had failed to do their job. This study illustrates how mothers depend on health care providers for knowledge and information about the differences between human milk and formula feedings, and the relationship of infant feeding method to health outcomes. FACTORS THAT AFFECT THE MATERNAL DECISION TO BREASTFEED Studies of maternal choice about infant feeding methods40 –52 consistently find that mothers who elect to breastfeed are, on average, older, have more years of formal education, and report higher household incomes than women who formula feed. In addition, these women tend to have social support, such as mothers, family, and/or friends, and live with the baby’s father. Women choose their feeding method based on perceived benefits to themselves and/or their infants. In addition, mothers report choosing to breastfeed for consistency with traditional values,41 convenience,49,51 and self-efficacy.45,48 Other studies have documented mothers’ awareness that human milk confers unique infant health benefits and for many women, this is the most important rationale for choosing to breastfeed.36,41,42 Mothers are influenced to choose breast or formula-feeding based on the preferences of others such as fathers,45– 47 mothers, relatives, friends,45– 49 and health care providers.36,37,42– 44 A large national survey found that provider encouragement exerted an independent positive influence on breastfeeding initiation across all strata of the sample.50 This study found that women who were encouraged by health care providers to breastfeed were more than four times as likely to initiate breastfeeding than women who did not receive this encouragement. More importantly, provider encouragement significantly increased breastfeeding initiation by more than threefold among lowincome, young, and less educated women, by nearly fivefold among black women, and nearly elevenfold among single women.50 A recent Cochrane review37 of support for breastfeed545 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.08.013
ing evaluated 34 randomized trials that included 29,385 women. The analysis found that women who were encouraged by health care providers to breastfeed were less likely to stop breastfeeding at 4 months after birth (16 trials, relative risk [RR], 0.94, 95% confidence interval [CI], 0.87–1.01), and more likely to breastfeed exclusively in the first 3 months after birth (RR, 0.91, 95% CI, 0.84 – 0.98). Because health care providers can and do influence their patients’ decisions about the choice of infant feeding, it is important to consider how to translate the evidence into a message health care providers can deliver. It is important that health care providers, individually and collectively, make a comprehensive, strategic plan to protect, support, and recommend breastfeeding. This plan should be in place from the initial patient contact and throughout the prenatal course. Then, a collaborative approach with the hospital system would ensure follow through with education and breastfeeding management. ETHICS OF HEALTH CARE PROVIDERS: WHAT IS THE ROLE AND RESPONSIBILITY? Based on scientific evidence that human milk confers unique health benefits to both the mother and the infant, health care providers caring for an expectant or new mother and her infant have an ethical obligation to discuss all appropriate and applicable issues related to breastfeeding. First and foremost, a mother is not able to exercise her right to autonomy and a self-determined decision about breastfeeding for herself and her infant if her health care provider does not ensure that she has the relevant information. Informed consent is a “shared medical decision-making . . . process in which the provider shares with the patient all relevant risk and benefit information on all treatment alternatives and the patient shares with the provider all relevant personal information that might make one treatment or side effect more or less tolerable than others.”53 To meet the obligation of shared medical decision-making, health care providers must provide scientific evidence known about the risks and benefits of breastfeeding as well as alternative infant feeding methods. Health care providers must carefully consider the content of their informed consent discussion with women who are in a position to consider breastfeeding. Honesty and respect are fundamental to any exchange between two people. In the context of breastfeeding, they bear greater weight because of the different power positions of
Donna J. Miracle, RNC, CLE, PhD, is in clinical practice at Indiana Mothers’ Milk Bank, Inc., Indianapolis, IN and a faculty member at Indiana Wesleyan University. Valita Fredland, JD, MA, is an attorney in the legal services department at Clarian Health Partners, Inc., Indianapolis, IN.
546
the health care provider and the patient. Health care providers should consider and disclose any relationship with entities that could unduly influence their recommendations for or discussions about feeding methods with new and expectant mothers. The most obvious conflict of interest would involve a health care provider who receives money from any industry with a conflicting interest in regard to breastfeeding promotion. Health care providers should also consider their involvement in research, commerce, and/or politics that may influence their ability to share honest and accurate information about breast or formula feeding.39,53 Health care providers are also obligated to disclose evidence of potential harm related to infant feeding method when counseling mothers about the risks and benefits of all feeding options for infants. Clinicians offer evidence-based counseling about the risks of tobacco use and not using car seats, seat belts, or other preventive health measures, they should take a similar stand when discussing breastfeeding. Breastfeeding information should be presented as a preventive health strategy. This is especially important for vulnerable populations who are statistically less likely to breastfeed and who are most influenced by health care providers. CONCLUSION Health care providers can and do influence women’s decisions about the choice of infant feeding. They have an ethical obligation to provide adequate information about the benefits of breastfeeding and the potential harms associated with not breastfeeding so that mothers can make an informed decision. Therefore, providers need to consider how to translate the evidence into a message that is easily and consistently delivered. Health care providers should work collaboratively to develop a comprehensive, strategic plan to protect, support, and recommend breastfeeding. This plan should be in place from the initial patient contact and throughout the prenatal course. Then, a collaborative approach with the hospital system would ensure follow through with education and breastfeeding management. To optimize infant and maternal health outcomes through human milk feedings, it is imperative that all health care providers working with new mothers be knowledgeable about human milk feedings and breastfeeding management, it should not be left to a unique group of professionals. Midwives and women’s health professionals should be competent to provide assistance with the breastfeeding fundamentals, such as latch and positioning, as well as assistance with common breastfeeding and lactation problems ranging from sore nipples to delayed lactogenesis. All office and hospital personnel should have training on what exemplifies a breastfeeding friendly environment. Art work and patient literature should be reviewed to ensure that content and messages Volume 52, No. 6, November/December 2007
portray breastfeeding as the optimal feeding method, in a positive, culturally appropriate manner. To provide breastfeeding friendly care means to continually evaluate and raise awareness about the environment so that mothers feel comfortable and accepted when breastfeeding throughout waiting room and office spaces. In addition, hospital practices should promote and support the unique needs of breastfeeding mothers and infants from an evidence-based perspective. Finally, evidence-based breastfeeding practice means that health care providers are aware of current professional policy statements related to breastfeeding and incorporate these recommendations into the clinical setting. It is through access and dissemination of knowledge from health care providers that mothers are then empowered to make a fully informed decision about a feeding method. A strategic plan such as described above promotes patient advocacy, conforms to ethical principles, and emphasizes the responsibility for all health care providers to actively recommend and promote breastfeeding to expectant and new mothers. Implementing evidencebased provider encouragement of breastfeeding is essential in the current health care environment that emphasizes clinical excellence, improved quality of patient care, informed decision making, and optimal patient outcomes. REFERENCES 1. American Academy of Pediatrics Policy Statement. Breastfeeding and the use of human milk. Pediatrics 2005;115:496 –506.
atic review and meta-analysis of prospective studies. J Am Acad Dermatol 2001;45:520 –7. 9. Morrow A, Ruiz-Palacios G, Jiang X, Newburg D. Humanmilk glycans that inhibit pathogen binding protect breast-feeding infants against symptomatic rotavirus infection. J Nutr 2005;135: 1304 –7. 10. Newburg D, Peterson J, Ruiz-Palacios G, Matson D, Morrow A, Shults J, et al. Role of human-milk lactadherin in protection against symptomatic rotavirus infection. Lancet 1998;351: 1160 – 4. 11. Quigley M, Cumberland P, Cowden J, Rodrigues L. How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study. Arch Dis Child 2006;91: 245–50. 12. Armstong J, Reilly J. Breastfeeding and lowering the risk of childhood obesity. Lancet 2002;359:1249 –50. 13. Butte N. The role of breastfeeding in obesity. Pediatr Clin North Am 2001;48:189 –98. 14. Kull I, Almqvist C, Lilja G. Breast-feeding reduces the risk of asthma during the first 4 years of life. J Allergy Clin Immunol 2004;114:755– 60. 15. Sears M, Greene J, Willan A, Taylor D, Flannery E, Cowan J. Long-term relation between breastfeeding and development of atopy and asthma in children and young adults: A longitudinal study. Lancet 2002;360:901–7. 16. Wright A, Holberg C, Taussig L, Martinez F. Factors influencing the relation of infant feeding to asthma and recurrent wheeze in childhood. Thorax 2001;56:192–7. 17. Burgess S, Dakin C, O’Callaghan M. Breastfeeding does not increase the risk of asthma at 14 years. Pediatrics 2006; 117:e787–92.
2. American Academy of Family Physicians Web site. Breastfeeding (policy statement). Available from: www.aafp.org/online/ en/home/policy/policies/b/breastfeedingpolicy.html [Accessed June 1, 2007].
18. Chen A, Rogan W. Breastfeeding and the risk of neonatal death in the United States. Pediatrics 2004;113:e435–9.
3. American College of Nurse Midwives. Position statement: Breastfeeding, 2004. Available from: www.midwife.org [Accessed June 14, 2007].
20. Eurodias S. Rapid early growth is associated with increased risk of childhood type I diabetes in various European populations. Diabetes Care 2002;25:1755– 60.
4. Association of Women’s Health, Obstetric and Neonatal Nurses. Breastfeeding clinical position statement, 1999. Available from: www.awhonn.org/awhonn/?pg⫽875-4730-7240 [Accessed June 14, 2007].
21. Monetini L, Cavallo M, Stefanni L, Ferrazzoli F, Bizzarri C, Marietti G. Bovine beta casein antibodies in breast and bottle fed infants: Their relevance in Type I diabetes. Diabetes Metab Res Rev 2001;17:51– 4.
5. Brown C, Magnusson B. On the physics of the infant feeding bottle and middle ear sequella: Ear disease in infant can be associated with bottle-feeding. Int J Pediatr Otorhinolaryngol 2000;54: 13–20.
22. Patterson C. Rapid early growth is associated with increased risk of childhood type I diabetes in various European populations. Diabetes Care 2002;25:1755– 60.
6. Vernacchio L, Lesko S, Vezina R, Corwin M, Hunt C, Hoffman H, et al. Racial/ethnic disparities in the diagnosis of otitis media in infancy. Int J Pediatr Otorhinolaryngol 2004;68:795– 804. 7. Duffy L, Faden H, Wasielewski R, Wolf J, Krystofik D. Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. Pediatrics 2004;100:E7. 8. Gdalevich M, Mimouni D, David M, Mimouni M. Breastfeeding and the onset of atopic dermatitis in childhood: A systemJournal of Midwifery & Women’s Health • www.jmwh.org
19. McVea K, Turner P, Peppler D. The role of breastfeeding in sudden infant death syndrome. J Hum Lact 2000;16:13–20.
23. Owen C, Martin R, Whincup P, Smith G, Cook D. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Am J Clin Nutr 2006; 8495:1043–54. 24. Guise J, Austin D, Morris C. Review of case-control studies related to breastfeeding and reduced risk of childhood leukemia. Pediatrics 2005;116:e724 –31. 25. Kwan M, Buffler P, Abrams B, Kiley V. Breastfeeding and the risk of childhood leukemia: A meta-analysis. Public Health Rep 2004;119:521–35.
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Volume 52, No. 6, November/December 2007