BREASTFEEDING MEDICINE Volume 10, Number 10, 2015 ABM Protocol ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2015.29016.ros ABM Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Setting, Revision 2015 Casey Rosen-Carole,1 Scott Hartman,2 and the Academy of Breastfeeding Medicine A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. Background Have a written breastfeeding policy to facilitate such support.9 (III) reastfeeding provides ideal infant nutrition and is Literature and samples provided by artificial infant physiologic for mothers and children.1–4 Pregnant women B formula companies should not be used in health- often make a decision regarding breastfeeding early in preg- care settings, as this advertising has been demon- nancy, and many have already decided whether to breastfeed strated to decrease breastfeeding initiation and prior to conception.5–7 Encouragement and education from shorten duration, and it constitutes a breach of the healthcare providers result in increased breastfeeding initia- World Health Organization’s International Code of tion, exclusivity, and duration.8–16 Yet, healthcare providers Marketing of Breast-milk Substitutes.29–33 (I, II-2, consistently overestimate the amount and adequacy of coun- II-3, III) seling and support that pregnant women receive.17–24 Al- Intention to breastfeed should be included as part though the focus of this protocol is on the prenatal setting, of all transfer-of-care materials, including pre- programs or interventions that include preconception, prenatal, natal records and hospital and birth center and postnatal components should be strongly considered as discharge summaries. they appear to yield larger positive results on breastfeeding Create breastfeeding friendly office spaces, includ- duration and exclusivity.8,10,25–27 ing safe, clean, and comfortable spaces for patients The quality of evidence (levels of evidence I, II-1, II-2, II-3, and staff to breastfeed or express milk, as well as and III) is based on the U.S. Preventive Services Task Force posters and artwork supporting breastfeeding. For Appendix A Task Force Ratings28 and is noted throughout this more details see the Academy of Breastfeeding protocol in parentheses. Medicine’s Protocol #14: ‘‘Breastfeeding Friendly 9 Recommendations Physician’s Office.’’ (III) B. Breastfeeding friendly community: 1. Create a breastfeeding friendly office and community. Community-based interventions have shown A. Breastfeeding friendly office9: significant success in improving breastfeeding The primary healthcare provider should be in- outcomes.34–38 (I, II-1, II-2, III) volved in each of the following steps, in cooper- Partner with local and regional organizations in ation with a multidisciplinary team that includes order to maximize patient services and support other healthcare professionals and healthcare (e.g., local, regional, and national maternal– workers (e.g., including, but not limited to, doctors, child organizations, local La Leche League nurses, midwives, medical assistants, various lac- International groups, community health workers, tation specialists/consultants [International Board health departments, local or regional maternity Certified Lactation Consultants, in particular when hospitals or birth centers, not-for-profit organi- their expertise is needed], nutritionists, doulas, zations, breastfeeding peer counseling programs; health and breastfeeding educators, and peer supplemental food programs [such as the Special support). Supplemental Nutrition Program for Women, Educate staff to promote, protect, and support Infant and Children in the United States], and breastfeeding. home visiting programs). Departments of 1General Pediatrics and 2Family Medicine, University of Rochester, Rochester, New York. 451 452 ABM PROTOCOL Be aware of local community and professional do you know about breastfeeding?’’ and ‘‘What are breastfeeding support services and understand your reasons for breastfeeding your baby?’’ the particular content and services provided. 2. Helping to think through barriers: ‘‘Can you Make available current listings of such support think of anything that might get in the way of to women throughout their pregnancy. you reaching your goal?’’ or Consider the use of prenatal home-visiting 3. Helping to associate breastfeeding with other suc- programs, particularly in underserved areas or cesses in a woman’s life: ‘‘Are there other areas in populations, while ensuring that providers have your life when you have been successful in reach- been adequately trained.34,36,39–46 (I, II-1, III) ing a goal you set out to achieve?’’64,65 (II-3) 2. Consider the background, ethnicity, and culture of Consider strengthening routine prenatal education individual women, families, and communities. on postpartum symptoms (bleeding, mood changes, Learn about patients’ family and community struc- pain, hair loss, incontinence, infant colic, breastfeed- ture. Social support, or the lack thereof, is likely to ing, etc.) and opportunities for social support and self- play a large role in feeding decisions of many management, as qualitative work shows insufficient women, particularly adolescents.7,47 (I, II-2) maternal preparation,66 and this behavioral interven- Understand that perspectives and beliefs of partners tion has been shown to improve breastfeeding duration and support persons may affect breastfeeding suc- in one minority population.67 (I, III) cess and educate where appropriate.45,48–51 Atten- 4. Integrate breastfeeding promotion, education, and sup- tion to gender dynamics and targeted behavioral port throughout prenatal care. interventions (e.g., education, counseling, sharing Support of breastfeeding should be actively stated in the housework) may improve breastfeeding duration preconception period,68 or as early as possible in pre- and exclusivity.48 (I, II-2, III) natal care, with acknowledgement that there are risks to In some cultures, enlisting the cooperation of an artificial infant formula feeding.2 Consider a statement important family member may greatly assist in the such as ‘‘As your healthcare provider, I want you to promotion of breastfeeding.51 (I) know that I recommend breastfeeding. Formula feeding Ensure that parents from diverse cultures understand has many health risks for mothers and babies.’’ (I, III) the importance of exclusive breastfeeding to their Use of electronic medical record prompts may be children’s growth and development.51 (I) Ac- used to improve consistency of healthcare provider culturation or assimilation of immigrant populations support statements.69,70 (I, III) should be considered with respect to a family’s Strongly consider integrating lactation consultant 52 71 current feeding choices. (I) support and education into the prenatal office visits, Cultural traditions and taboos associated with lac- as it is noted for its effect on improving breastfeeding tation should be respected, adapting cultural beliefs initiation and exclusivity.69,70,72 (I, III) to facilitate optimal breastfeeding, while sensitively Strongly consider offering group prenatal care or educating about traditions that may be detrimental to connecting women with a group prenatal care pro- breastfeeding.52,53 (I, II-1) gram as these groups have been noted for their pos- Whenever possible, provide all information and itive impact on breastfeeding initiation.73,74 (I, II-3) instructions in patients’ native language and assess At this point, there is no evidence to determine for literacy level when appropriate. Instructional what role Internet education can play in breast- photos and pictures can also be used where literacy feeding support.75 However, many mothers will is a concern. seek information on the Internet and may find Web Understand the specific financial, work, time, and sites with little medical oversight and factual errors. sociocultural obstacles to breastfeeding and work Patients should be directed to appropriate online with families to overcome them. sources of support and information, such as the Healthcare providers should be aware of their own World Health Organization’s Web site on breast- personal cultural attitudes when interacting with feeding: www.who.int/topics/breastfeeding (II-2) patients.2 (III) Consider using novel technological approaches such 3. Consider behavioral and psycho-educational approaches as education and networking through text-messaging/ to breastfeeding support. mobile phones as preliminary international data Self-efficacy and breastfeeding confidence play a suggest improved breastfeeding duration and exclu- large role in women’s breastfeeding initiation, du- sivity with this approach.76,77 (I) ration, and exclusivity.50,54–57 (I, II-2) 5. Take a detailed breastfeeding history as a part of the Cognitive-behavioral counseling, social-cognitive prenatal history.2,9,78 (III) theory–based influential models, competence theory, For each previous child, ask about breastfeeding and workbook-based or group self-efficacy interven- initiation, duration of exclusive/any breastfeeding, tions can be considered and have shown to improve sources of prior breastfeeding