Too often, new families get unsupportive or uninformed care regarding breastfeeding from their providers. Systems of healthcare vary all around the world, but that lack of breastfeeding education doesn’t seem to be confined to any one profession, country, and type of healthcare delivery system or model of care. I’m going to stick with American allopathic medical care, and probably pediatrics in general, since that’s what I am and what I know.
We have given much of the power of parenting away to “experts.” My wish is for mothers to take that incredible power back and to feel empowered and confident enough to speak up. I know that the responsibility of listening should rest with the provider, and ideally, the mother should not have to struggle to make herself heard. But it seems as if maybe that doesn’t always happen (she writes, facetiously).
Acknowledging that physicians, pediatricians especially, should absolutely know something about breastfeeding, and if they don’t, should do something to remedy that or at the very least, find someone to whom to refer, we have a while to wait and work before that happens. The information is out there, as is the help. Getting those resources to the provider and having them pay attention to them is the stumbling block. I’m convinced that the key to getting providers to pay attention ismothers.
Here’s the thing: providers are the hired help. We are the people that family has chosen to help them through their journey. We are not the arbiters of right or wrong, good or bad. We are the people who are supposed to give the information they need to make an informed decision, to help aid in the encouragement of and confidence in parenting choices. If we don’t have that info, we aren’t doing our job.
But we are responsible for lots of information. We need to learn that infant feeding is a priority in that knowledge base for the families that have entrusted their care to us. Lots of agencies and organizations are working to help providers see that infant feeding is an absolute priority and the provision of excellent care.
But we need to have that reinforced by our patients. Does it suck that mothers need to speak up despite the fact that nearly 80% of new mothers choose to breastfeed? Yes, of course. Yes, yes, yes. Do we need mothers to help? YES!
I have heard from many of you that providers with whom you have worked have responded to “evidence” …meaning studies, policy statement, protocols, etc. So I embark on a subject on which that I have never written very well- changing provider practices. I’m going to start with what kind of evidence that may be the most persuasive.
This is from the United State Preventive Services Task Force (USPSTF).
The USPSTF is an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists).
The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."
They use this “quality of evidence” ranking. So we need to as well.
Quality of Evidence
I:
Evidence obtained from at least one properly randomized controlled trial.
II-1:
Evidence obtained from well-designed controlled trials without randomization.
II-2:
Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3:
Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III:
Opinions of respected authorities, based on clinical experience descriptive studies and case reports or reports of expert committees.
I’ll tackle (I) today: the randomized, controlled trial: the “gold standard” for evaluating treatment or preventive interventions.
All research starts with a question. In this study, http://www.liebertonline.com/doi/pdfplus/10.1089/bfm.2006.1.27
The research question is:” Is high-dose vitamin D effective in increasing 25(OH)D levels in fully breastfeeding mothers to optimal levels without evidence of toxicity?”
They answered this question with a randomized controlled study. This type of study has an intervention (high-dose vitamin D supplementation) and an outcome to measure (serum vitamin D levels). In fact, this study is the best of the best: it’s randomized, doubled-blinded and prospective.
First, subjects are recruited, and then randomized or put into the experimental groups based on nothing but chance. This helps eliminate any biases that may be introduced if we got to pick who was put into each experimental group. If we got to pick, we could sway the results in our favor.
The subject is randomly assigned to either the intervention group (the one who gets vitamin D) or the control group (the group that gets nothing or a placebo). In this study, they randomized groups to receive 2000 IU or 4000 IU of vitamin D and had the mothers be their own control group. Then you measure a baseline for the study, like a baseline vitamin D level. In this study, the mothers could be their own controls; after the intervention (taking the vitamin D) they were compared to themselves at baseline before they took the vitamin D. Slick.
Then they took the Vitamin D and the blood levels were measured and the authors drew their conclusions.
So, for a randomized controlled trail you get participants, randomize them, do something to one group, then figure out what happened to the group you did something to. If you can find these types of studies, they would be the most persuasive for those needing to be persuaded.
Of course, it’s not as easy as this. Another post will have to address problems with these and other studies.
Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM