CTF Structured Abstract: Breast Feeding

Canadian Task Force on Preventive Health Care

Structured Abstract

Breast Feeding

Prepared by Elaine E.L. Wang, MD, CM, FRCPC, Department of Pediatrics, University of Toronto

These recommendations were finalized by the Task Force in January 1994

Objective
Burden of Suffering
Options
Outcomes

Evidence
Values
Benefits, Harms, and Costs
Recommendations

Validation
Sponsors
Selected References

Objective

To assess the benefits of breast feeding and to make recommendations for encouraging Canadian women to breast feed their infants.

Burden of Suffering

For the purpose of this paper, breast-feeding refers to exclusive breast-feeding unless otherwise stated. Rates of breast-feeding in one-week-old infants in the U.S. increased from 29% in 1955 to 52% in 1989. This increase, however, reached a peak in 1982 when 62% of infants were breast fed at age one week. This pattern is matched by rates of breast-feeding at 5-6 months, which rose from 5% in 1971 to 28% in 1984 and fell to 18% in 1989. Certain groups are at greater risk of not breast-feeding, including young mothers and those in lower socioeconomic groups, particularly those receiving social insurance benefits.

Options

Interventions to encourage breast feeding include breast feeding classes, individual teaching, nursing immediately after delivery (early contact), avoidance of bottle supplementation, and avoidance of provision of infant formula samples at birth.

Outcomes

Gastrointestinal and respiratory infections, otitis media, atopic disease, diabetes mellitus, infant body weight, maternal bonding, and duration of breast feeding.

Evidence

MEDLINE was searched up to December 1993 with the terms breast feeding, counselling, infections, allergy, nutrition, and infant development, Bibliographies of relevant papers were also checked. Studies with clinical outcomes that evaluated mothers and children in developed countries were selected.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs

1 systematic review from 1986 found no differences in infections in participants in developed countries for any outcomes measured. Since then, 1 British cohort study found fewer gastrointestinal and respiratory infections in breast-fed infants. 1 Danish study found no differences, and a third cohort study found that infants who were exclusively breast fed for 4 or more months were protected against acute (odds ratio [OR] 0.72) and recurrent otitis media (OR 0.54).

Several cohort studies and 1 RCT found no increase in length of time to development of atopy in preterm infants although 1 study found infants who were at risk for atopy (positive family history or positive cord blood for immunoglobulin E) were protected with breast feeding. Dietary restrictions for the mother may also protect against atopy in infants who are breast fed (1 cohort and 2 trials).

Case-control studies have shown breast feeding protects against the development of diabetes mellitus, particularly in persons who have genetic markers for the development of diabetes.

Growth and development are not affected by breast feeding although some studies show lower body weight and higher intelligence in infants who were breast fed.

Studies of maternal bonding provide inconclusive data on the importance of breast feeding.

1 meta-analysis (2 RCTs) of breast feeding education showed higher rates of breast feeding with education. An RCT found individual teaching was more effective than group teaching for increasing the rates of breast feeding. Postnatal support reduced the OR to 0.75 (95% CI 0.62 to 0.91) for stopping breast feeding. 1 RCT of early contact found breast feeding to be a median of 77 days longer when early contact occurred. A small Canadian study found early contact increased the rate of breast feeding continuation (60% vs 20%, P < 0.001) at the end of the study. 2 other studies had mixed results although a meta-analysis showed an overall increase in breast feeding with early contact.

Bottle supplementation studies are difficult to interpret. 2 RCTs found free samples distributed during hospital stay decreased the rate of breast feeding at 2 or 3 months.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is good evidence to counsel women to breast feed their infants [A, II-2].
There is good evidence to implement peripartum interventions (early, frequent mother-infant contact; rooming in; and banning provision of free formula samples) that promote breast feeding [A, I].

Validation

This report was externally peer reviewed. The American Academy of Pediatrics and the Canadian Pediatrics Society recommend breast feeding as the preferred method of infant feeding, and encourage public education programs, promotion of breast feeding at prenatal visits and during maternity ward care, and provision of facilities to allow breast feeding at work and day care centres. The World Health Organization and the UNICEF encourage breast feeding and support the above mentioned programs.

Selected References

Source Document

Wang E.E.L. Breast feeding. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 232-42.

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

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A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.