# Presentation: 480083

## Educating Physicians about Breastfeeding: Building a Foundation

- Lori Feldman-Winter, MD, MPH
- Associate Professor of Pediatrics
- Children’s Regional Hospital at Cooper
- UMDNJ-RWJMS

**Notes:**
When it comes to physicians we are starting from the basic building blocks, our residents!
From there the skies the limit. Once we educate the residents and create a culture of knowledgeable and confident physicians we expect that all of the other maternal and child health care practitioners will be more eager to collaborate effectively to support more women to breastfeed. Once we build the foundation, the skies the limit.  

## Disclosure

- I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.
- I _do not_ intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

## Thank You!

**Notes:**
MCHB has funded the BPPOP initiatives for the past 9 years, now concluded phase 3 with a one year extension. 

## Outline

- Breastfeeding Matters
- Evidence that physicians need education
- Why physicians matter in breastfeeding promotion
- Promising strategies
- What physicians can/should do

## Learning Objective

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

## Breastfeeding Matters: Top 10AHRQ Evidence Based Review

**AOM 50% less EBF>3-6 months**
**Atopic Dermatitis less 42% EBF>3 months**
**Gastro less 64% with any BF vs. none**
**LRTI and hospitalization less 72% with EBF>4 months**
**Asthma less 40% for BF>3 months**
**Obesity less 4-24%**** **

**T1DM less 19-27% BF>3 months**
**T2DM less 39% with any BF vs. none**
**Cancer:**
**ALL less 19% with BF>6 months**
**AML less 15% with BF>6 months**
**SIDS less 36% with any BF vs. none**

## History of Physicians’ Knowledge and Attitudes 

- Hollen BK

- Freed GL

- Schanler RJ

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

**Notes:**
IN 1974-75 when breastfeeding rates were recovering from an all time low (1971) only 30% of physicians routinely encouraged breastfeeding, and only 52% said they would encourage breastfeeding if the mother was already interested. Twenty years later Gary Freed demonstrated improvement in attitudes in that 90% encouraged breastfeeding but only 50% said they felt confident in their ability to counsel breastfeeding patients. Practicing physicians and residents report inadequacies in training and preparation to help breastfeeding mothers. Using the AAP periodic survey Schanler and colleagues demonstrated lack of knowledge, confidence and attitudes in breastfeeding counseling. Only 65% recommended breastfeeding exclusively, and only 37% recommended breastfeeding for one year. Most pediatricians in the study thought  that breastfeeding and formula feeding were equally acceptable options. IN an unpublished follow up study to the PS in 1995, pediatricians were surveyed in 2004. Even though more pediatricians recommended exclusive breastfeeding, pediatricians reported more reasons why mothers should not breastfeed or discontinue breastfeeding.    

## Knowledge and Attitudes

- Sometimes it is what we don’t say or are “too vague” in saying
- Sometimes it’s not what we say... but what we do
- give out formula company literature and portray bottle feeding as the norm in the office setting

**Notes:**
Additional studies were done to evaluate other ways pediatricians may influence mother’s decisions to breastfeed or to continue breastfeeding. IN 1991 Frank Greer and colleagues was one of the first to report in a commentary published in Pediatrics the potential influence of infant formula company marketing on practices and behaviors of US pediatricians. The combination of marketing and “educational support” from the industry seeped uncontrollably into scientific meetings. Medical research, and social events at medical meetings. IN 1997 a study was conducted to determine the potential influence of formula company publications and products directly from physicians’ offices. Most of the materials uncovered that were being distributed freely in physician offices had incorrect or outdated breastfeeding information, or had statements making it seem impossible for mothers to exclusively breastfeed, that formula feeding to some extent was inevitable.     

## Why Physicians matter?

- Research has shown that that encouragement from health care providers is associated with breastfeeding initiation
- Lu MC, Lange L, Slusser W, Hamilton J, Halfon N. Provider encouragement of breast-feeding: evidence from a national survey. *Obstet Gynecol.*2001; 97 :290 –295
- ...and continuation
- Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. *Pediatrics.*2003; 112 :108 –115

## Pediatric clinician factor 	AOR    CI          p    

**Continuation of Exclusive Breastfeeding. PEDIATRICS Vol. 113 No. 4**
**April 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 important
- 					2.2 (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?

- Specific practices and opinions of pediatricians were associated with the likelihood of continuation of exclusive breastfeeding
- Clinicians who recommended formula supplementation or who do not think their advice is very important may be sending signals that exclusive breastfeeding is not something that mothers should value highly
- In addition, many clinicians do not feel confident in their skills to support breastfeeding and may have limited time to address the issue during preventive visits.

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

## Why Physicians Matter?

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

## Promising Strategies

- AAP BPPOP III Residency Curriculum
- Includes three major sections:
- Advocacy
- Clinical Management
- Delivering Culturally Competent Breastfeeding Care
- 7 test sites; 7 comparison sites

## Outcome Measures 

- Knowledge: mean difference in scores on posttest minus pretest
- Confidence: Two measures of confidence-promotion of breastfeeding and management of problems; Scale 1 – 5 (1 = Not At All Confident, 5 = Very Confident)
- Practice Patterns: mean difference s**cale** 1 – 4 (1 = Never, 2 = Once or Twice, 3 = Three or Four times, and 4 = Greater than 5 times) for 10 items of practice “How many times did you ________ in the past 6 months?”

## Change in KnowledgeTest vs. Comparison

|  | Test Sites N = 154 | Comparison Sites N = 106 |
| --- | --- | --- |
| Mean Difference Pre vs. Post | .159 | .080
 |
| Statistically significant difference p<.001;  Knowledge of the test and comparison increased their overall scores, exhibiting a Hawthorne effect.  |  |  |

## Change in Confidence Test vs. Comparison

|  | Test Sites N = 152 | Comparison Sites N = 103 |
| --- | --- | --- |
| Mean Difference Pre vs. Post | 1.135 | .515
 |
| Statistically significant difference p<.001 confidence in breastfeeding care improved for all, exhibiting a Hawthorne effect.   |  |  |

**Notes:**
This difference rendered the mean response from neutral to confident among intervention residents.

## Change in Practice Patterns  Test vs. Comparison

|  | Test Sites N = 152 | Comparison Sites N = 103 |
| --- | --- | --- |
| Mean Difference Pre vs. Post | .443 | .326
 |
| This difference between the test and comparison sites was not statistically significant for overall practice patters but p<.03 when topic of cultural practices eliminated (0.43 vs. 0.26) |  |  |

**Notes:**
This difference rendered the mean response practice pattern going from never to once or twice in the past 6 months. 

## Breastfeeding Rates

- 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.

## Additional BPPOP III Activities

- Development of Poster for Physicians’ Offices
- Teleconferences:
- First Teleconference –
*Breastfeeding Basics: Generalist to Generalist* presented by Sharon Mass, MD (OB), Jenny Thomas, MD (Ped), and Margreete Johnston, MD (Ped) – 58 participants.
- Second Teleconference –
*Breastfeeding Promotion Tailored to the Needs of a Diverse Society* presented by Lori Feldman-Winter, MD (Ped), MaryAnn O’Hara, MD (FP), and Michal Young (Ped) – 35 participants.

## Poster: Breastfeeding is the First Immunization

- Created in collaboration with the AAP Section on Breastfeeding and the Childhood Immunization Support Program, a program funded by the CDC.
- Available during World Breastfeeding Week to physicians, hospitals, WIC sites, and public health agencies.

## What Physicians Can/Should Do

- Learn: Attend a workshops on breastfeeding management: AAP, NCE, ABM, LLL Physicians’ Seminar; Use the physicians’ handbook (AAP/ACOG/AAFP)
- See one do one teach one
- Eliminate...formula company’s influence
- Decorate...use breastfeeding posters with images of multiple cultures

## Learn

## See one... do one... teach one

- Photo courtesy of Jane Morton, MD

## Eliminate

## Decorate