Interventions to promote breast-feeding: applying the evidence in clinical practice
===================================================================================

* Valerie A. Palda
* Jeanne-Marie Guise
* C. Nadine Wathen

In this document, the Canadian Task Force on Preventive Health Care (CTFPHC) updates its earlier breast-feeding recommendations1 by presenting evidence on interventions that improve the initiation or duration of breast-feeding (or both). Breast-feeding has been shown in both developing and developed countries to improve the health of infants and their mothers, making it the optimal method of infant nutrition.2,3 Although the prevalence of breast-feeding in Canada has risen, with over three-quarters of mothers now initiating breast-feeding, the duration of this practice remains short of the recommended World Health Organization (WHO) targets of exclusive breast-feeding for 6 months and partial breast-feeding for up to 2 years.4,5 Recent Canadian data indicate that 22% of recent mothers aged 15–49 years breast-feed for less than 3 months, and 35% do so for at least 3 months.6 This premature discontinuation is more a result of difficulty with breast-feeding, including lack of information and support, than of women's choice.7 In fact, the number of Canadian hospitals that would qualify as “baby-friendly” according to WHO–UNICEF criteria8 was 5 of 523 hospitals responding to a 1993 survey,9 and according to UNICEF only a single hospital had that designation in 2002.10

In a joint endeavour, the CTFPHC and the US Preventive Services Task Force systematically reviewed the randomized trial evidence for the effectiveness of all counselling interventions originating in a clinician's practice (such as antepartum and postpartum support groups, education, telephone support or peer counsellors) to increase the rate of initiation or the duration of breast-feeding.11,12 We present here the new CTFPHC recommendations, based on the joint systematic review as well as a key Canadian trial13 published after that review and tailored to the Canadian health care setting (Table 1). Definitions of the levels of evidence and grades of recommendations used in Table 1 are available in an online appendix to this article ([www.cmaj.ca/cgi/content/full/170/6/976/DC1](http://www.cmaj.ca/cgi/content/full/170/6/976/DC1)).

View this table:
[Table1](http://www.cmaj.ca/content/170/6/976/T1)

Table 1. 

Interventions consisting of antepartum structured breast-feeding education are effective at improving both initiation and continuation of breast-feeding during the first 2 months postpartum, compared with usual care.14,15,16,17,18,19,20,21,22,23,24,25,26,27,28These interventions, consisting of individual or group instruction about breast-feeding knowledge, practical skills and problem-solving techniques, were effective when provided by lactation specialists or nurses, and both single sessions and multiple sessions were effective. Postpartum telephone or in-person support by lactation specialists, nurses or peer counsellors enhanced the effectiveness of these interventions. In addition, the use of peer counsellors improved breast-feeding rates and duration, and these types of programs may represent a cost-effective alternative to professionally delivered services, especially in locations or settings where professional services are scarce or not available.13,20,29,30,31,32 The CTFPHC recommends against the use of written materials (which have not been shown to be effective when used alone,16,19,22,26,33,34,35,36 although no harm was demonstrated) and commercial discharge packages (which have been shown to decrease breast-feeding rates).37 Unfortunately, advice from a woman's primary clinician (such as family physician, obstetrician or midwife) has not been sufficiently evaluated, and a research gap remains in this area.

The recommendations presented here (Table 1) do not address the clinical benefits of breast-feeding, which the CTFPHC felt had been established by its earlier breast-feeding recommendations;1 instead, we have concentrated on recommendations about interventions that change the initiation and duration of breast-feeding.

The Canadian Paediatric Society, Dieticians of Canada and Health Canada have recommended exclusive breast-feeding for at least the first 4 months of life, then continuation of breast-feeding along with complementary foods for up to 2 years and beyond.43 The American Academy of Pediatrics has recommended exclusive breast-feeding for approximately the first 6 months after birth and continued breast-feeding for at least 12 months and thereafter for as long as mutually desired.44 Provision of adequate individual and systems-based supports, such as recommended in the Baby-Friendly Hospital Initiative,8 are also recommended by most groups.

## Footnotes

*   This article has been peer reviewed.
    
    *Contributors:* Valerie Palda reviewed the evidence and drafted the recommendations and this commentary. Jeanne-Marie Guise and Nadine Wathen reviewed the evidence and draft recommendations, critically revised the current article and reviewed subsequent revisions. The Canadian Task Force on Preventive Health Care critically reviewed the evidence and developed the recommendations according to its methodology and consensus development process. The Canadian Task Force on Preventive Health Care is an independent panel funded by Health Canada.
    
    *Competing interests:* None declared.
    
    ***Correspondence to:**** Canadian Task Force on Preventive Health Care, 117–700 Collip Circle, London ON N6G 4X8; fax 519 858–5112;* ctf{at}ctfphc.org

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