Educating Physicians about Educating Physicians about BreastfeedingBreastfeeding: :

Building a FoundationBuilding a Foundation

Lori Feldman-Winter, MD, MPHLori Feldman-Winter, MD, MPHAssociate Professor of PediatricsAssociate Professor of PediatricsChildren’s Regional Hospital at Children’s Regional Hospital at

CooperCooperUMDNJ-RWJMSUMDNJ-RWJMS

DisclosureDisclosure

• I have no relevant financial relationships I have no relevant financial relationships with the manufacturers(s) of any with the manufacturers(s) of any commercial products(s) and/or provider of commercial products(s) and/or provider of commercial services discussed in this CME commercial services discussed in this CME activity.activity.

• I I do notdo not intend to discuss an intend to discuss an unapproved/investigative use of a unapproved/investigative use of a commercial product/device in my commercial product/device in my presentationpresentation..

Thank You!Thank You!

OutlineOutline

• Breastfeeding MattersBreastfeeding Matters

• Evidence that physicians need Evidence that physicians need educationeducation

• Why physicians matter in Why physicians matter in breastfeeding promotionbreastfeeding promotion

• Promising strategiesPromising strategies

• What physicians can/should doWhat physicians can/should do

Learning ObjectiveLearning Objective

• Understand the critical importance of Understand the critical importance of physicians in providing consistent physicians in providing consistent and positive breastfeeding advocacy and positive breastfeeding advocacy and support, and be familiar with and support, and be familiar with initiatives in resident training initiatives in resident training

Breastfeeding Matters: Top Breastfeeding Matters: Top 1010

AHRQ Evidence Based ReviewAHRQ Evidence Based Review• AOM 50% less EBF>3-6 AOM 50% less EBF>3-6

monthsmonths• Atopic Dermatitis less Atopic Dermatitis less

42% EBF>3 months42% EBF>3 months• Gastro less 64% with Gastro less 64% with

any BF vs. noneany BF vs. none• LRTI and LRTI and

hospitalization less hospitalization less 72% with EBF>4 72% with EBF>4 monthsmonths

• Asthma less 40% for Asthma less 40% for BF>3 monthsBF>3 months

• Obesity less 4-24%Obesity less 4-24%

• T1DM less 19-27% T1DM less 19-27% BF>3 monthsBF>3 months

• T2DM less 39% with T2DM less 39% with any BF vs. noneany BF vs. none

• Cancer:Cancer:– ALL less 19% with ALL less 19% with

BF>6 monthsBF>6 months– AML less 15% with AML less 15% with

BF>6 monthsBF>6 months

• SIDS less 36% with SIDS less 36% with any BF vs. noneany BF vs. none

History of Physicians’ History of Physicians’ Knowledge and Attitudes Knowledge and Attitudes

Hollen BK

Freed GL

Schanler RJ

Graph data from the Mother’s Survey, Ross Products Division of Abbott

Knowledge and AttitudesKnowledge and Attitudes

• Sometimes it is what we don’t say or Sometimes it is what we don’t say or are “too vague” in sayingare “too vague” in saying

• Sometimes it’s not what we say… Sometimes it’s not what we say… but what we do but what we do – give out formula company literature and give out formula company literature and

portray bottle feeding as the norm in the portray bottle feeding as the norm in the office settingoffice setting

Why Physicians matter?Why Physicians matter?

• Research has shown that that Research has shown that that encouragement from health care providers encouragement from health care providers is associated with breastfeeding initiationis associated with breastfeeding initiation– Lu MC, Lange L, Slusser W, Hamilton J, Halfon Lu MC, Lange L, Slusser W, Hamilton J, Halfon

N. Provider encouragement of breast-feeding: N. Provider encouragement of breast-feeding: evidence from a national survey. evidence from a national survey. Obstet Obstet Gynecol.Gynecol.2001; 97 :290 –295 2001; 97 :290 –295

• ……and continuationand continuation– Taveras EM, Capra AM, Braveman PA, Jensvold Taveras EM, Capra AM, Braveman PA, Jensvold

NG, Escobar GJ, Lieu TA. Clinician support and NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with psychosocial risk factors associated with breastfeeding discontinuation. breastfeeding discontinuation. Pediatrics.Pediatrics.2003; 2003; 112 :108 –115 112 :108 –115

Taveras E. et al. Opinions and Practices of Clinicians Associated With Continuation of Exclusive Breastfeeding. PEDIATRICS Vol. 113 No. 4April 2004, pp. e283-e290

Pediatric clinician factor AOR CI p Predictors of Not Exclusively Breastfeeding at 12 Weeks, From Multivariate Models Among Mothers Who Were BF at 4 Weeks  

Recommend formula supplementation if infant is not gaining enough weight

3.2 (1.04–9.7) .04 Reported advice to mothers on breastfeeding duration

is not very important2.2 (1.2–3.9) .01 

Does not recommend exclusive breastfeeding during the first month of life

2.1 (0.95–4.7) .07

Why Pediatricians Matter?Why Pediatricians Matter?• Specific practices and opinions of pediatricians Specific practices and opinions of pediatricians

were associated with the likelihood of continuation were associated with the likelihood of continuation of exclusive breastfeeding of exclusive breastfeeding

• Clinicians who recommended formula Clinicians who recommended formula supplementation or who do not think their advice is supplementation or who do not think their advice is very important may be sending signals that very important may be sending signals that exclusive breastfeeding is not something that exclusive breastfeeding is not something that mothers should value highlymothers should value highly

• In addition, many clinicians do not feel confident in In addition, many clinicians do not feel confident in their skills to support breastfeeding and may have their skills to support breastfeeding and may have limited time to address the issue during preventive limited time to address the issue during preventive visits.visits.

Taveras E. et al. Opinions and Practices of Clinicians Associated With Continuation of Exclusive Breastfeeding. PEDIATRICS Vol. 113 No. 4April 2004, pp. e283-e290

Why Physicians Matter?Why Physicians Matter?

Labarere J. et al. Pediatrics. Feb 2005;115(2):e139-e146

Promising StrategiesPromising Strategies

• AAP BPPOP III Residency CurriculumAAP BPPOP III Residency Curriculum

• Includes three major sections: Includes three major sections: – AdvocacyAdvocacy– Clinical ManagementClinical Management– Delivering Culturally Competent Delivering Culturally Competent

Breastfeeding Care Breastfeeding Care

7 test sites; 7 comparison sites7 test sites; 7 comparison sites

Outcome Measures Outcome Measures

• KnowledgeKnowledge: mean difference in scores on : mean difference in scores on posttest minus pretestposttest minus pretest

• ConfidenceConfidence: Two measures of confidence-: Two measures of confidence-promotion of breastfeeding and promotion of breastfeeding and management of problems; management of problems; Scale 1 – 5 (1 = Not Scale 1 – 5 (1 = Not At All Confident, 5 = Very Confident)At All Confident, 5 = Very Confident)

• Practice PatternsPractice Patterns: mean difference s: mean difference scalecale 1 – 4 1 – 4 (1 = Never, 2 = Once or Twice, 3 = Three or Four (1 = Never, 2 = Once or Twice, 3 = Three or Four times, and 4 = Greater than 5 times)times, and 4 = Greater than 5 times) for 10 items for 10 items of practice “How many times did you of practice “How many times did you ________ in the past 6 months?”________ in the past 6 months?”

Change in KnowledgeChange in KnowledgeTest vs. ComparisonTest vs. Comparison

Test Test Sites N = Sites N = 154154

ComparisoComparison Sites N = n Sites N = 106106

Mean Mean Difference Pre Difference Pre vs. Postvs. Post

.159.159 .080.080

Statistically significant difference Statistically significant difference p<.001; Knowledge of the test and p<.001; Knowledge of the test and comparison increased their overall comparison increased their overall scores, exhibiting a Hawthorne scores, exhibiting a Hawthorne effect. effect.

Change in Confidence Change in Confidence Test vs. ComparisonTest vs. Comparison

Test Test Sites N = Sites N = 152152

ComparisoComparison Sites N = n Sites N = 103103

Mean Mean Difference Difference Pre vs. PostPre vs. Post

1.1351.135 .515.515

Statistically significant difference Statistically significant difference p<.001 confidence in breastfeeding p<.001 confidence in breastfeeding care improved for all, exhibiting a care improved for all, exhibiting a Hawthorne effect. Hawthorne effect.

Change in Practice Patterns Change in Practice Patterns Test vs. Comparison Test vs. Comparison

Test Sites Test Sites N = 152N = 152

Comparison Comparison Sites N = Sites N = 103103

Mean Mean Difference Pre Difference Pre vs. Postvs. Post

.443.443 .326.326

This difference between the test and This difference between the test and comparison sites was not statistically comparison sites was not statistically significant for overall practice patters significant for overall practice patters but p<.03 when topic of cultural but p<.03 when topic of cultural practices eliminated (0.43 vs. 0.26)practices eliminated (0.43 vs. 0.26)

Breastfeeding RatesBreastfeeding RatesExclusive Breastfeeding

(Pre- and Post-Intervention)

0

5

10

15

20

25

30

35

Pre-Intervention Post-Intervention

Per

cen

tag

e

Test Sites Comparison Sites

Significant difference (p<.001) in breastfeeding rates pre- to post- for the comparison sites vs. test sites. Although both improved, the test sites improved significantly more. The main difference was seen in Caucasians and Hispanics, and African Americans approached significance, but other groups numbers were too small in numbers to determine.

Overall Breastfeeding(Pre- and Post-Intervention)

0

20

40

60

80

100

Pre-Intervention Post-Intervention

Test Sites Comparison Sites

Additional BPPOP III Additional BPPOP III ActivitiesActivities• Development of Poster for Development of Poster for

Physicians’ OfficesPhysicians’ Offices• Teleconferences:Teleconferences:

– First TeleconferenceFirst Teleconference – – – Breastfeeding Basics: Generalist to GeneralistBreastfeeding Basics: Generalist to Generalist presented presented

by Sharon Mass, MD (OB), Jenny Thomas, MD (Ped), and by Sharon Mass, MD (OB), Jenny Thomas, MD (Ped), and Margreete Johnston, MD (Ped) – 58 participants. Margreete Johnston, MD (Ped) – 58 participants.

– Second TeleconferenceSecond Teleconference – – – Breastfeeding Promotion Tailored to the Needs of a Breastfeeding Promotion Tailored to the Needs of a

Diverse SocietyDiverse Society presented by Lori Feldman-Winter, MD presented by Lori Feldman-Winter, MD (Ped), MaryAnn O’Hara, MD (FP), and Michal Young (Ped) (Ped), MaryAnn O’Hara, MD (FP), and Michal Young (Ped) – 35 participants.– 35 participants.

Poster: Breastfeeding is the Poster: Breastfeeding is the First ImmunizationFirst Immunization

• Created in collaboration with the AAP Created in collaboration with the AAP Section on Breastfeeding and the Section on Breastfeeding and the Childhood Immunization Support Childhood Immunization Support Program, a program funded by the Program, a program funded by the CDC. CDC.

• Available during World Breastfeeding Available during World Breastfeeding Week to physicians, hospitals, WIC Week to physicians, hospitals, WIC sites, and public health agencies.sites, and public health agencies.

What Physicians Can/Should What Physicians Can/Should DoDo• Learn: Attend a workshops on Learn: Attend a workshops on

breastfeeding management: AAP, NCE, breastfeeding management: AAP, NCE, ABM, LLL Physicians’ Seminar; Use the ABM, LLL Physicians’ Seminar; Use the physicians’ handbook (AAP/ACOG/AAFP) physicians’ handbook (AAP/ACOG/AAFP)

• See one do one teach oneSee one do one teach one• Eliminate…formula company’s influenceEliminate…formula company’s influence• Decorate…use breastfeeding posters Decorate…use breastfeeding posters

with images of multiple cultureswith images of multiple cultures

LearnLearn

See one… do one… teach See one… do one… teach oneone

Photo courtesy of Jane Morton, MD

EliminateEliminate

                                           

DecorateDecorate