Lactation consultant visits spur breastfeeding among women who usually resist it

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first six months after birth, followed by continued breastfeeding for one year or longer as other foods are introduced. However, according to the Centers for Disease Control and Prevention (CDC), fewer than 75 percent of infants nationwide are breastfed at all and fewer than half are still being breastfed at six months. Health benefits of breastfeeding can include reduced incidence of ear infections, stomach illness and lower obesity rates for children and, for mothers, a reduced risk for pre-menopausal breast cancer, type 2 diabetes and heart disease.

In one of the two trials included in this paper, women who were regularly encouraged and given instruction and support for breastfeeding were more than four times as likely to exclusively breastfeed their infant at one month and nearly three times more likely to do so at three months, compared with the control group.

"The effects of the interventions in our trials -- and our use of lactation consultants in particular -- were more impressive than those reported by two recent reviews that evaluated the effects of the numerous previous trials aimed at improving breastfeeding rates," said Karen Bonuck, Ph.D., professor of family and social medicine and of obstetrics & gynecology and women's health at Einstein.

Some of the lowest rates of breastfeeding are known to occur among Black/non-Hispanic, younger, overweight and less-educated mothers -- together those women made up a large majority of those enrolled in the two trials. Patients included in the trials received their care at Montefiore Medical Center, Einstein's University Hospital.

Both clinical trials tested the same interventions for effectiveness in encouraging women to breastfeed: (1) support from a lactation consultant (LC) consisting of two prenatal sessions and one post-birth hospital session, plus regular phone calls post-partum for three months or until breastfeeding ceased; and (2) use of electronic prompts (EP) to remind physicians and midwives to discuss breastfeeding with the women during five prenatal visits.

"Two-thirds of the women in the trials were either overweight or obese, which means they're not inclined to breast feed," said Dr. Bonuck. "There are physical difficulties with the baby latching on, many of these women have difficulty producing enough milk, and there may be psychological barriers as well. Yet we showed that support from a lactation consultant significantly improves their chances of breastfeeding for three months -- sufficient time for mother and baby to obtain important health benefits."

The larger of the two trials, involving 666 primarily low-income women, was called BINGO (Best Infant Nutrition for Good Outcomes). The women were randomly assigned to one of four different groups: LC alone; LC + EP; EP alone; and usual care (the control group). They were contacted by phone one, three and six months post-partum to assess whether they were breastfeeding. The researchers primarily assessed the four groups with respect to breastfeeding intensity three months after birth. ("Intensity" was defined as the percentage of all feedings over the past seven days that were breast milk. High intensity was defined as 80 percent or more of feedings involving breast milk; medium intensity, 20 percent-79 percent; and low intensity, 19 percent or fewer).

With respect to breastfeeding intensity at three months, infants of women in the LC and LC + EP BINGO groups were about three times more likely to receive high-intensity breastfeeding than were infants of control-group women. Also compared with the control group, the LC + EP group was more likely to (a) initiate breastfeeding; (b) have "any" breastfeeding women (vs. none) at one month; and (c) breastfeed exclusively at three months postpartum. Interestingly, the EP group did not differ from the control group on any outcome.

The smaller of the two clinical trials was called PAIRINGS (Provider Approaches to Improved Rates of Infant Nutrition & Growth Study). The 275 women in PAIRINGS were more economically diverse than the BINGO enrollees and many more of them planned to breastfeed exclusively (62 percent vs. 37 percent for BINGO participants). The PAIRINGS women were randomly divided into two groups: a control group and a group receiving both the LC and EP interventions.

For the PAIRINGS trial, the researchers primarily assessed whether women were exclusively breastfeeding at three months. Compared with the control group, exclusive breastfeeding was more than four times as common in the intervention group at one month and nearly three times as common at three months. Any breastfeeding was significantly more likely to occur at one, three and six months in the intervention group than in the control group. Finally, regarding intensity, high-intensity breastfeeding was significantly more likely in the intervention group at one and three months, and medium-intensity breastfeeding was significantly more likely at six months, than in the control group.

Neither trial came close to attaining exclusive breastfeeding for six months, as advocated by the AAP: Just 16 of 850 (1.9 percent) of participants in both trials combined were exclusively breastfeeding at six months. Dr. Bonuck points out that about 95 percent of the women in the two trials at least initiated breastfeeding -- which exceeds the goal of 82 percent that the CDC has proposed in its Healthy People 2020 report. She also says that the odds that the women enrolled in these trials would achieve long-term, exclusive breastfeeding were quite low.

"This study is significant because it shows that integrating lactation consultants into prenatal care increases breastfeeding rates among low income racial/ethnic minority women," says Tonse N.K. Raju, M.D., D.C.H., chief of the National Institutes of Health's Pregnancy and Perinatology Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). "We need additional studies to see if this and other interventions can enhance breastfeeding by these women beyond a few months."

Dr. Bonuck is optimistic that professional lactation support might soon become more widely available, since private insurers must cover it under the Affordable Care Act (ACA). But she's concerned that the ACA doesn't stipulate which providers qualify for reimbursement. New York State, she notes, interprets the ACA to mean that licensed healthcare providers, such as M.D.s, are reimbursed for lactation support, but international board-certified lactation consultants (the type who participated in her clinical trials) are not.

In its 2012 policy statement on breastfeeding, the AAP states that "any breastfeeding" is associated with: a 23 percent reduction in the incidence of middle ear infections; a 64 percent reduction in the incidence of gastrointestinal tract infections; a 45 percent reduction in the incidence of sudden infant death syndrome; and a 15 percent to 30 percent reduction in adolescent and adult obesity rates.