1. Educating Physicians about Breastfeeding : Building a Foundation Lori Feldman-Winter, MD, MPH Associate Professor of Pediatrics Children’s Regional Hospital at Cooper UMDNJ-RWJMS

2. 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 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. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3. Thank You!

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

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

6. Breastfeeding Matters: Top 10 AHRQ Evidence Based Review AOM 50% less EBF>3- 6 months AOM 50% less EBF>3- 6 months Atopic Dermatitis less 42% EBF>3 months Atopic Dermatitis less 42% EBF>3 months Gastro less 64% with any BF vs. none Gastro less 64% with any BF vs. none LRTI and hospitalization less 72% with EBF>4 months LRTI and hospitalization less 72% with EBF>4 months Asthma less 40% for BF>3 months Asthma less 40% for BF>3 months Obesity less 4-24% Obesity less 4-24% T1DM less 19-27% BF>3 months T1DM less 19-27% BF>3 months T2DM less 39% with any BF vs. none T2DM less 39% with any BF vs. none Cancer: Cancer: –ALL less 19% with BF>6 months –AML less 15% with BF>6 months SIDS less 36% with any BF vs. none SIDS less 36% with any BF vs. none

7. History of Physicians’ Knowledge and Attitudes Hollen BK Freed GL Schanler RJ Graph data from the Mother’s Survey, Ross Products Division of Abbott

8. Knowledge and Attitudes Sometimes it is what we don’t say or are “too vague” in saying 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 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

9. Why Physicians matter? Research has shown that that encouragement from health care providers is associated with breastfeeding initiation 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 …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

10. 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 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

11. Why Pediatricians Matter? Specific practices and opinions of pediatricians were associated with the likelihood of continuation of exclusive breastfeeding 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 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. 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

12. Why Physicians Matter? Labarere J. et al. Pediatrics. Feb 2005;115(2):e139-e146

13. Promising Strategies AAP BPPOP III Residency Curriculum AAP BPPOP III Residency Curriculum Includes three major sections: Includes three major sections: –Advocacy –Clinical Management –Delivering Culturally Competent Breastfeeding Care 7 test sites; 7 comparison sites

14. Outcome Measures Knowledge: mean difference in scores on posttest minus pretest 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) 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?” 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?”

15. 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.

16. 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.

17. 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)

18. 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.

19. Additional BPPOP III Activities Development of Poster for Physicians’ Offices Development of Poster for Physicians’ Offices Teleconferences: 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.

20. 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. 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. Available during World Breastfeeding Week to physicians, hospitals, WIC sites, and public health agencies.

21. 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) 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 See one do one teach one Eliminate…formula company’s influence Eliminate…formula company’s influence Decorate…use breastfeeding posters with images of multiple cultures Decorate…use breastfeeding posters with images of multiple cultures

22. Learn

23. See one… do one… teach one Photo courtesy of Jane Morton, MD

24. Eliminate

25. Decorate