Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Educational Material, Individual Supports, Social Supports, Lactation Consultant

Intervention Description: The current statement updates the evidence for this conclusion and serves as a basis for AAP publications that detail breastfeeding management and infant nutrition, including the AAP Breastfeeding Handbook for Physicians,2 AAP Sample Hospital Breastfeeding Policy for Newborns,3 AAP Breastfeeding Residency Curriculum,4 and the AAP Safe and Healthy Beginnings Toolkit.

Intervention Results: Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Infant growth should be monitored with the World Health Organization (WHO) Growth Curve Standards to avoid mislabeling infants as underweight or failing to thrive. Hospital routines to encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the American Academy of Pediatrics-endorsed WHO/UNICEF “Ten Steps to Successful Breastfeeding.” National strategies supported by the US Surgeon General’s Call to Action, the Centers for Disease Control and Prevention, and The Joint Commission are involved to facilitate breastfeeding practices in US hospitals and communities. Pediatricians play a critical role in their practices and communities as advocates of breastfeeding and thus should be knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and the techniques for managing and supporting the breastfeeding dyad. The “Business Case for Breastfeeding” details how mothers can maintain lactation in the workplace and the benefits to employers who facilitate this practice.

Conclusion: Research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Home Visits, Telephone Support

Intervention Description: To determine whether infants of women randomized to a prenatal and postpartum lactation support intervention incur fewer otitis media-, respiratory tract-, or gastrointestinal-related visits than controls.

Intervention Results: There was a significant interaction between treatment and Medicaid; among those not receiving Medicaid, the number of otitis media visits was higher among controls (P

Conclusion: Only the number of otitis media visits was reduced, in a subset of the intervention group. The intervention did not reduce visits for respiratory tract or gastrointestinal illness. Limited intervention contact and low exclusive breastfeeding rates may have attenuated intervention effects. Future interventions designed to yield markedly increased breastfeeding rates may show greater effects in low-income multiethnic samples. Health coverage for visits may moderate intervention effects.

Study Design: RCT

Setting: 2 urban community health centers in the Bronx, NY

Population of Focus: Women who were ≤ 24 weeks GA, spoke English or Spanish, had a twin or singleton birth, and who did not have medical or obstetric complications or longterm use of medications incompatible with breastfeeding

Data Source: Mother self-report

Sample Size: Randomized • Intervention (n=188) • Control (n=194) 26-Week Follow-Up • Intervention (n=115) • Control (n=136)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Home Visits, Telephone Support, Provision of Breastfeeding Item, PROVIDER/PRACTICE, Other (Provider Practice)

Intervention Description: Determined the effectiveness of primary care-based, and pre- and postnatal interventions to increase breastfeeding.

Intervention Results: In Best Infant Nutrition for Good Outcomes (BINGO) at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7).

Conclusion: LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum.

Study Design: RCT

Setting: Urban, prenatal clinic in the Bronx, NY

Population of Focus: Women who spoke English or Spanish, ≥ 18 years old, in the first or second trimester of a singleton pregnancy, without risk factors for a premature birth or maternal/infant condition that would prevent or complicate breastfeeding

Data Source: Mother self-report

Sample Size: Best Infant Nutrition for Good Outcomes (BINGO) • Lactation Consultant (LC) (n=77/73) • Electronically Prompted (EP) Guidance by Prenatal Care provider (n=236/223) • LC + EP (n=238/226) • Control (n=77/73)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, PROVIDER/PRACTICE, Provider Training/Education

Intervention Description: To evaluate the efficacy of an intervention program to increase breast-feeding in a low-income, inner-city population.

Intervention Results: There was a markedly higher incidence of breast-feeding in the intervention group, as compared with that of the control group (61% vs 32%, respectively; P = .002). The duration of breast-feeding was also significantly longer in the intervention group (P = .005).

Conclusion: This lactation program increased the incidence and duration of breast-feeding in our low-income cohort. We suggest that similar efforts that are applied to analogous populations may increase the incidence and duration of breast-feeding in low-income populations in the United States.

Study Design: RCT

Setting: Maternal-Infant Lactation Center of Pittsburgh (PA)

Population of Focus: Women attending the prenatal clinic of The Mercy Hospital of Pittsburgh, English-speaking, and nulliparous

Data Source: Mother self-report

Sample Size: Intervention (n=51) Control (n=57)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Telephone Support

Intervention Description: Evaluated whether telephone-based support could increase the duration of breastfeeding in obese women and, thereby, reduce offspring growth.

Intervention Results: The support group breastfed exclusively for a median of 120 d (25th-75th percentiles: 14-142 d) compared with 41 d (3-133 d) for control subjects (P = 0.003). Any breastfeeding was maintained for a median of 184 d (92-185 d) for the support group compared with 108 d (16-185 d) for control subjects (P = 0.002). Support increased the adjusted ORs for exclusive breastfeeding at 3 mo and the ratios for partial breastfeeding at 6 mo to 2.45 (95% CI: 1.36, 4.41; P = 0.003) and 2.25 (95% CI: 1.24, 4.08; P = 0.008, respectively). Although the duration of exclusive breastfeeding was inversely associated with infant weight (β = -4.39 g/d; 95% CI: -0.66, -8.11 g/d; P = 0.021) and infant length at 6 mo (β = -0. 012 cm/d; 95% CI: -0.004, -0.02 cm/d; P = 0.004), the breastfeeding support did not achieve a significant effect on infant growth at 6 mo (n = 192).

Conclusion: Telephone-based advisory support was very effective in prolonging breastfeeding in obese mothers who often terminate the breastfeeding of their infants prematurely. A longer duration of breastfeeding may decrease risk of noncommunicable diseases in these infants.

Study Design: RCT

Setting: Hvidovre Hospital in Copenhagen, Denmark

Population of Focus: Women who had previously participated in the Treatment of Obese Pregnant Women study, were <38 years old postpartum, with singleton, healthy infants born at term

Data Source: Mother self-report

Sample Size: Randomized • Intervention (n=108) • Control (n=118) 1,3,6-Month Follow-Up • Intervention (n=105) • Control (n=102)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Telephone Support, Hospital Policies, PROVIDER/PRACTICE, Other (Provider Practice)

Intervention Description: The purpose of this study was to determine whether implementing a program based on a clinical protocol affects breastfeeding rates within a pediatric primary care setting. Increasing breastfeeding rates is an important public health initiative identified by multiple agencies.

Intervention Results: The results of this evaluation were positive for exclusive breastfeeding, with group comparisons showing a statistically significant increase in exclusive breastfeeding rates at all 5 time points.

Conclusion: Our diverse patient population within a pediatric practice had increased initiation rates and exclusive breastfeeding rates after implementation of the ABM's breastfeeding-friendly protocol. Families who receive care in a pediatric primary care setting that has implemented the ABM clinical protocol may have increased rates of exclusive breastfeeding.

Study Design: QE: pretest-posttest

Setting: 2 locations (1 suburban, 1 rural) of a single practice in northern VA

Population of Focus: Women with healthy, singleton births of ≥ 37 GA , who entered the practice within the first week of birth and returned for health maintenance visits at 2, 4, and 6 months

Data Source: Medical record review

Sample Size: Pre-Intervention (n=376) Post-Intervention (n=381)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Lactation Consultant, Educational Material, Assessment (PATIENT_CONSUMER)

Intervention Description: Primary prevention utilizing consistent visits with lactation professionals with a group of new mothers may efficiently address a care gap to meet breastfeeding goals. Mother-infant dyads attending a newborn care clinic for 6 weeks received feeding assessment and standard-of-care guidance from an Internationally Board-Certified Lactation Consultant (IBCLC). This study is an evaluation of a cost-effective easy-to-deliver strategy provided to an at-risk population attending a primary care clinic in the normal course of postnatal care.

Intervention Results: The number and timing of IBCLC visits was correlated with EDB at 6 weeks PP. Maternal/infant dyads seen at day 3 had 2.5 times higher odds of EDB at 6 weeks than those not receiving IBCLC standard-of-care feeding assessment. Dyads seen at days 3 and 14 had 3.4 times higher odds of EDB than those with less follow-up. Bottle use correlated with decreased odds of AB at 6 weeks PP; similarly, dyads seen only at day 14 PP had decreased odds of EDB. When looking at timing of the first involvement, dyads seen at 3 days had higher odds of EDB than dyads first seen at day 14 PP.

Conclusion: This primary prevention strategy of early minimal intervention using an IBCLC increased the odds of EDB and AB at 6 weeks PP. These data support the conclusion that early feeding assessment the first 2 weeks PP with an IBCLC may increase breastfeeding at 6 weeks PP.

Study Design: Retrospective comparison cohort study

Setting: Hospital-affiliated primary care clinic serving the underinsured and uninsured in the community

Population of Focus: Mother-infant dyads attending a newborn care clinic

Sample Size: 640 mother-infant dyads

Age Range: Infants at 6 weeks postpartum

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Lactation Consultant, Provision of Breastfeeding Item, Group Education, Incentives, Professional Support, COMMUNITY, Individual Supports,

Intervention Description: The Canada Prenatal Nutrition Program (CPNP) aims to improve birth outcomes and promote and support breastfeeding among vulnerable women. Using charitable donations, the Parkdale Parents' Primary Prevention Project (5Ps) CPNP provides postnatal lactation support to its clients in addition to standard prenatal services (group education workshops, individualized support from public health nurses and dieticians, community referrals, snacks, two public transit tokens, grocery store gift card, self-serve food bank, and childcare). This lactation support program was designed and implemented by 5Ps CPNP staff and includes three components: 1) gift package of breastfeeding and infant care supplies; 2) IBCLC visits within 48 h of referral; and 3) double electric breast pump.

Intervention Results: Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump.

Conclusion: This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women.

Study Design: Evaluation data

Setting: A Canada Prenatal Nutrition Program site in Toronto

Population of Focus: Pregnant women in the catchment area

Sample Size: 199 women

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Educational Material

Intervention Description: The aim of this study was to evaluate the effect of a breastfeeding support Internet intervention on breastfeeding outcomes on women living in regional Western Australia.

Intervention Results: Women enrolled in the intervention were significantly more likely to be exclusively breastfeeding at 6 months postpartum compared with control group participants. Those women experiencing breastfeeding problems were more likely to access the Internet.

Conclusion: This breastfeeding support intervention study demonstrated a positive effect on longer-term exclusive breastfeeding for those enrolled in the intervention group. Together with more traditional methods of support, the Internet provides another possible method for promoting positive long-term breastfeeding outcomes.

Study Design: QE: non-equivalent control group

Setting: Western Australia

Population of Focus: Women who delivered an infant without serious illness, could read and understand English, and lived in a regional area in western Australia6

Data Source: Mother self-report

Sample Size: Intervention (n=207) Control (n=207)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Home Visits, Lactation Consultants, Peer Counselor, Professional Support,

Intervention Description: Breastfeeding education and support are core services provided by WIC, and numerous policies and initiatives ensure breastfeeding support is provided throughout the prenatal period and first year postpartum. Site-level characteristics related to staffing, policies, and practices that support breastfeeding were collected for the WIC Infant and Toddler Feeding Practices Study-2 (WIC ITEPS-2). Study data included interviews with 27 WIC state agency representatives affiliated with study sites, site visits to all 80 sites to collect data on facilities and staffing and a one hour interview with a site supervisor or coordinator, and surveys with staff (n=802) working in each of the 80 sites during the period when participants were enrolled in the study.

Intervention Results: Five WIC site-level supports were significantly and independently associated with any and fully breastfeeding: access to breastfeeding peer counselors, access to International Board Certified Lactation Consultants, postnatal home visits, allowing any WIC staff member to provide breast pump education, and having a policy not to provide formula during the first 30 days postpartum. Likelihood of any and fully breastfeeding increased with each additional site-level support present (odds ratio = 1.09, 95% confidence interval, 1.06–1.12; and odds ratio = 1.26, 95% confidence interval, 1.21–1.31, respectively).

Conclusion: Positive associations between site-level supports and breastfeeding at 2, 6, and 12 months were observed. Additional research is needed to understand how site-level supports interrelate and whether specific combinations are more effective, and to identify variations in implementation of breastfeeding supports.

Study Design: Secondary analysis

Setting: WIC programs in 27 states

Population of Focus: Women enrolled in WIC for the first time for that pregnancy prenatally or before their infant was 2.5 months old in 80 WIC sites across 27 states and territories during the 20 week recruitment period

Sample Size: 1,235 mothers and their infants (80 WIC sites; 802 staff surveys)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Other Education, Telephone Support, Peer Counselor, Lactation Consultant, Technology-Based Support, COMMUNITY, Individual Supports,

Intervention Description: LATCH -- Lactation Advice thru Texting Can Help is a pilot, web-based texting intervention designed to improve breastfeeding rates among mothers receiving WIC. The two-way texting intervention provided both evidence-based breastfeeding education through automated texts adn a mode for mothers to freely exchange texts with breastfeeding peer counselor (PC). In addition to providing breastfeeding education, the automated texts were personalized by addressing the mother by name and signed by the PC. These automatic personalized texts were sent out regularly both prenatally and in the immediate post-partum period to increase peer counselor points of contact with mom via text. The web-based texting platform allowed all text messages to be recorded, and thus, the on-site lactation consultants and WIC supervisors were able to monitor and supervise all text-based communication regularly.

Intervention Results: Primary outcomes included early post-partum (PP) contact and exclusive breastfeeding (EBF) rates at 2 weeks PP. Feasibility outcomes included text messaging engagement and mother's satisfaction with texting platform. Fifty-eight women were enrolled, 52 of whom were available for intention-to-treat analysis (n = 30 texting, n = 22 control). Contact between mothers and PCs within 48 hr of delivery was greater in the texting group (86.6% vs. 27.3%, p < .001). EBF rates at 2 weeks PP among participants in the texting intervention was 50% versus 31.8% in the control arm (p = .197). Intervention group mothers tended to be more likely to meet their breastfeeding goals (p = .06).

Conclusion: Participants were highly satisfied with the Lactation Advice thru Texting Can Help intervention, and findings suggest that it may improve early post-delivery contact and increase EBF rates among mothers enrolled in WIC who receive PC. A large, multicentre trial is feasible and warranted.

Study Design: Pilot RCT

Setting: WIC breastfeeding programs at a hospital-based primary care center and a federally qualified community health center/Cell phone

Population of Focus: Pregnant women at 18-30 weeks gestation from local WIC breastfeeding peer counselor programs

Sample Size: 52 women (30 texting and 22 control)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Educational Material, Home Visits

Intervention Description: This study examined the effectiveness of a breast-feeding promotion program to increase the continuation of breast-feeding.

Intervention Results: The 3-month breast-feeding rate was 32% in the intervention and 38% in the control groups (OR = 0.79, 95% CI = 0.58-1.08).

Conclusion: The program was not effective. We discuss possible explanations from the design and execution of the trial and give some points for improvement of our program, such as the categories of caregivers involved and the number and duration of contacts after parturition.

Study Design: Cluster RCT

Setting: 10 maternity and child health centers within home health care organizations in Limburg

Population of Focus: Pregnant women who applied for maternity care in one of the participating centers who gave birth to infants ≥2000 g

Data Source: Mother self-report

Sample Size: • Intervention (n=5) • Control (n=5) N=clinics • Intervention (n=371) • Control (n=330) N=women

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Home Visits, Telephone Support

Intervention Description: To determine the effectiveness of a breastfeeding support service attached to a general practice.

Intervention Results: There was a high, breastfeeding initiation rate for both baseline (94.6%) and intervention (93.4%) groups. There were significantly higher breastfeeding rates in the intervention group at 24 and 26 weeks (63.3% vs 51.2% at 24 weeks [p = 0.015] and 64.7% vs 50.6% at 26 weeks [p = 0.018]). While there was no significant difference in the total number of breastfeeding problems encountered by either group significantly more mothers from the baseline group suffered from engorgement and/or too much milk. Evaluation of the service indicated a high degree of satisfaction. Over 94% of the mothers found the service friendly, supportive, and useful.

Conclusion: This service provides an effective method for the support and protection of breastfeeding.

Study Design: QE: non-equivalent control group

Setting: A general practice in Happy Valley, Adelaide

Population of Focus: Pregnant patients registered in the practice

Data Source: Mother self-report

Sample Size: Intervention (n=119) Control (n=168)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Peer Counselor, Telephone Support, Lactation Consultant, Home Visits,

Intervention Description: The establishment of Loving Support Peer Counseling Programs (LSPCP) services in Washington State began in April 2005 when 5 local WIC agencies accepted USDA funding to implement the program. The model is structured according to evidence-based curricula with a focus on benefiting WIC recipients via mother-to-mother support regarding breastfeeding initiation and continuation. Peer counselors typically consist of women who were or are WIC clients and who successfully breastfed their children. An important characteristic of this program is the ability of peer counselors to provide breastfeeding support off-site and after clinic hours.

Intervention Results: Both PHSKC and CHIFMG clinics with a LSPCP expressed significant (P < .001) improvement in BF initiation and BF duration for >6 months. The likelihood that women enrolled in WIC would initiate BF at PHSKC clinics increased by 3%, whereas those in CHIFMG clinics increased by 6.8%. Women receiving services in smaller PHSKC clinics (n < 60 women) were likely to breastfeed their infants at >1 week. The proportionalities of non-Hispanic and black participants in PHSKC clinics were the primary and secondary predictors of the likelihood of BF discontinuing between 7 and 28 days' duration. In addition, clinics serving participants who spoke Tigrigna had increased rates of BF for a minimum of 6 months.

Conclusion: Findings may be used to reevaluate funding allocations, secure grants to reduce program constraints to stabilize LSPCP, develop strategies to reduce BF cessation at larger clinics, and improve peer counseling and other BF support to black and non-Hispanic women in the early postpartum period. The findings contribute to the study of the effects of LSPCP on BF initiation and duration while furthering a scholarly understanding of the way in which the WIC program interacts with participant characteristics at 2 local WIC agencies in Washington State.

Study Design: Nonrandomized treatment and control

Setting: Public Health-Seattle and King County (PHSKC), Catholic Health Initiatives Franscian Medical Group (CHIFMG)

Population of Focus: Women enrolled in WIC

Sample Size: PHSKC: n=15,290 women; CHIFMG: n=3582 women

Age Range: Infants from birth through 8 months of age

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Lactation Consultant, Provision of Breastfeeding Item, Group Education, NATIONAL, Policy/Guideline (National),

Intervention Description: Workplace breastfeeding resources (e.g., break times and private spaces) help working mothers exclusively breastfeed for 6 months. This study is one of the few studies to include and measure access to breastfeeding support such as breast pumps, worksite programs, educational materials, support groups, lactation consultants, and workplace policies. To meet the 6 month recommendation, employers can provide additional resources (i.e. lactation consultants and support groups) to help mothers transition back to work and continue breastfeeding. The ACA was an important first step for establishing minimum resources to support breastfeeding mothers; however, it needs to be expanded to cover all employer and workers.

Intervention Results: Fifty-two participants met the inclusion criteria for the study and completed the survey. Most of the participants in the study were White, college-educated women who worked in clerical or administration support and education occupations. Approximately 78.8% of the participants reported access to private spaces and 65.4% reported access to break times for breastfeeding. Fewer participants reported access to breast pumps, lactation consultants, and support groups.

Conclusion: There are gaps in access to workplace breastfeeding resources, but occupational health nurses can inform and help employers implement lactation resources to reduce breastfeeding disparities.

Study Design: Online, cross sectional survey

Setting: Policy

Population of Focus: Working mothers between the ages of 18 and 50 years old who gave birth in the previous two years

Sample Size: 52 women

Age Range: 18-50 year old women

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Peer Counselor, Telephone Support, Lactation Consultant, Home Visits,

Intervention Description: As part of its ongoing efforts to promote and support breastfeeding, Minnesota WIC in 2005 began offering peer counseling through local programs, utilizing the Loving Support model. By 2012, peer counselor programs in Minnesota were active in 14 local agencies, covering 23 counties, and 2 tribes. Peers provide telephone counseling to pregnant and postpartum women up until the infant's first birthday, with referral to an International Board Certified Lactation Consultant when necessary. Other program components such as face-to-face meetings, text messaging, and home visiting vary across agencies.

Intervention Results: Among women who accepted referral into a PC program, odds of initiation were significantly higher among those who received peer services (Odds Ratio (OR): 1.66; 95% CI 1.19–2.32), after adjusting for confounders. Women who received peer services had a significantly lower hazard of breastfeeding discontinuation from birth through 12 months postpartum than women who did not receive services. (Hazard Ratio (HR) month one: 0.45; 95% CI 0.33–0.61; months two through twelve: 0.33; 95% CI 0.18–0.60). The effect of peer counseling did not differ significantly by race and ethnicity, taking into account mother’s country of origin.

Conclusion: Receipt of peer services was positively associated with breastfeeding initiation and continued breastfeeding from birth through 12 months postpartum. Making peer services available to more women, especially in communities with low initiation and duration, could improve maternal and child health in Minnesota.

Study Design: Retrospective analysis of observational data

Setting: Minnesota's WIC program

Population of Focus: WIC-enrolled women who accepted referral to a peer counseling program while pregnant

Sample Size: 2,219 women and their infants

Age Range: Infants birth through 12 months of age

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Lactation Consultant, Educational Material, Group Education, Telephone Support

Intervention Description: The aim of this study was to evaluate the effectiveness of a multiphased midwifery intervention called the 'Milky Way' on any breastfeeding rates until six months.

Intervention Results: There were no significant differences in the antenatal baseline data between the groups. Compared to standard care, women in the Milky Way group had higher rates of breast feeding at one (83.7%, n=144 versus 61.3%, n=119, p<0.001), four (64.5%, n=111 versus 37.1%, n=72, p<0.001) and six months (54.3%, n=94 versus 31.4%, n=61 p<0.001).

Conclusion: Assignment to the Milky Way intervention was associated with significantly higher rates of breastfeeding compared with assignment to standard care only.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: Tertiary hospital in South Western Sydney Area Health Services

Population of Focus: Nulliparous women ≥19 years old with basic English literacy

Data Source: Mother self-report

Sample Size: Enrolled • Intervention (n=172) • Control (n=194) 6-Month Follow-Up • Intervention (n=149) • Control (n=189)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Lactation Consultant, Other Education, Technology-Based Support, HEALTH_CARE_PROVIDER_PRACTICE, Other (Provider Practice),

Intervention Description: Telelactation is one tool that can be leveraged to increase access to International Board Certified Lactation Consultants (IBCLCs) in rural settings. Telelactation services connect breastfeeding women to remotely located IBCLCs through audio-visual technology. The Telehealth for Mothers to Improve Lactation Confidence (Tele-MILC) randomized controlled trial evaluated the feasbility and impact of telelactation via personal electronic devices on breastfeeding duration and exclusivity among rural mothers. Participants randomized to the telelactation arm were given an orientation to Pacify Health's telelactation app by hospital nurses. The nurses showed participants how to download the app on a personal device (smartphone or tablet), provided a coupon code for free, umlimited video calls, and encouraged participants to conduct a test call on their own device or on a demonstration device. After the orientation, participants could request umlimited, on-demand video calls with IBCLCs through the app for as long as they desired. The app used in the trial aimed to provide video calls within seconds of a visit request by a mother. The app is also HIPAA-compliant, and the telelactation services it provides involves a large network of geographically dispersed IBCLCs available to take video calls 24 hours a day.

Intervention Results: Among participants in the telelactation arm, 50% (47/94) reported participating in video calls. At 12 weeks, 71% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the ITT model (3% difference, P = .73), whereas 73% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the IV model (5% difference, P = .74). Among participants who were still breastfeeding at 12 weeks, 51% participants in the telelactation arm were breastfeeding exclusively versus 46% of control participants in the ITT model (5% difference, P = .47), whereas 56% of participants in the telelactation arm were breastfeeding exclusively versus 45% of control participants in the IV model (11% difference, P = .48). In all models, participants in the telelactation arm were breastfeeding at higher rates; however, differences were not statistically significant.

Conclusion: This trial demonstrated that telelactation can be implemented with a rural underserved population. Though this trial was not powered to detect differences in breastfeeding duration and exclusivity, and none were observed, telelactation remains a promising approach for further investigation. ClinicalTrials.gov Identifier: NCT02870413.

Study Design: RCT

Setting: Critical Access Hospital in North-Central PA/Online

Population of Focus: Postpartum women who had initiated breastfeeding and planned to contine after hospital discharge

Sample Size: 203 women (102 for intervention and 101 for control)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Lactation Consultant, Telephone Support, Partner-Level Intervention, Professional Support,

Intervention Description: The study examines the effectiveness of a comprehensive, evidence-based, professional support intervention for breastfeeding that was implemented in the Netherlands: the Breastfeeding Support Program (BSP). The BSP tries to increase the proportion of mothers who breastfeed exclusively for six months or longer by positively influencing 1) the mother's attitude towards breastfeeding (by focusing on the positive effects of exclusive breastfeeding for 6 months or longer for mother and child), 2) the subjective norm (by explicitly involving the father and by forming a reliable source of support and positive messages about breastfeeding throughout the program), and 3) the mother's perceived behavioral control (by providing information, encouragement, and practical support to improve breastfeeding skills). The BSP combines both education and support, extends from pregnancy to the postnatal period, and uses a protocolled series of six individual consults delivered by an IBCLC. The sixth and final consult is held 10 weeks after delivery by telpehone and focuses on further support for returning to work.

Intervention Results: The effect of the BSP on survival rates for any and exclusive breastfeeding were significant while controlling for differences between the two groups at baseline (respectively HR = 0.34, p < .001 [95% CI = 0.18–0.61] and HR = 0.46, p < .001 [95% CI = 0.29–0.72]). Among mothers in the BSP group there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point in time compared to those in the control group.

Conclusion: The BSP appears to be an effective means to delay cessation of any and exclusive breastfeeding cessation and therefore to increase breastfeeding duration and exclusivity. This is an important finding, because earlier cessation of breastfeeding than desired is a common problem in many countries. Future research into the effectiveness of the BSP could consider random assignment to conditions and test the effectiveness of the intervention in other populations to investigate further whether wide-scale implementation of this intervention could be useful to promote breastfeeding.

Study Design: Quasi-experimental study

Setting: Breastfeeding Support Program in the Netherlands

Population of Focus: Pregnant women who were planning to breastfeed and who made a personal decision to enroll in the BSP

Sample Size: 138 women (66 mothers in the intervention group and 72 mothers in the control group)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): Lactation Consultant, PATIENT_CONSUMER, ,

Intervention Description: The objective of this study is to examine associations between state-level breastfeeding support and breastfeeding practices, controlling for women’s status, in the U.S.

Intervention Results: After controlling for women’s status, only IBCLCs were positively associated with rates of exclusive breastfeeding at 6 months and continued breastfeeding at 12 months. For every additional IBCLC per 1000 live births, the rate of exclusive breastfeeding at 6 months increased by 5 percent (95% CI 1.03, 1.07) and the rate of breastfeeding at 12 months increased by 4 percent (95% CI 1.02, 1.06). Political participation, poverty, and employment and earnings were associated with breastfeeding practices, indicating a relationship between women’s political and economic status and their breastfeeding practices in the U.S.

Conclusion: Given the influence of women’s status, increasing the number of IBCLCs may improve breastfeeding practices.