• Clinical Preventive Service Recommendations
• The Value of Prevention
• Condition / Disease Specific Information
• Preventive Intervention Information
• Strength of Evidence

• Summary Plan Description
• CPT Codes

• Business Group Resource(s)
• CDC Resource

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation

The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.¹

Evidence Rating: B (Recommended/At Least Fair Evidence)
The USPSTF found convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women. The USPSTF notes that the most effective programs have both prenatal and postnatal components.¹

The USPSTF also found adequate evidence that interventions to promote and support breastfeeding increase the rates of initiation, duration, and exclusivity of breastfeeding.¹

CDC Recommendation
The CDC Guide to Breastfeeding Interventions recognizes the critical role returning to work plays in women's infant feeding decisions, and identifies a strong need to establish lactation support in the workplace.²

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The Value of Prevention

Economic Burden of Condition/Disease

Healthcare costs of treating respiratory tract infections, ear infections, and gastrointestinal illnesses represent the majority of healthcare expenses for children less than one year of age.⁷ Because all of these illnesses are significantly more common among formula-fed infants than breastfed infants, support of breastfeeding initiation and continuation saves healthcare dollars.⁸ Indirect costs include time and income lost from work to take care of a sick child.

Workplace Burden of Condition/Disease

Children who are not breastfed contribute to huge additional healthcare expenditures for the employers of their parents. Their parents are also responsible for significant productivity losses in the workplace associated with absenteeism and presenteeism. A study that compared infant feeding among employed mothers found that 75% of all 1-day maternal absences were among formula-feeding mothers.⁸ The study also found that infants who were formula fed were much more likely to fall ill. In fact, only 14% of infants with no illnesses were formula-fed (comparatively 86% of infants with no illnesses were breastfed).⁸

Economic Benefit of Preventive Intervention

Breastfeeding offers important economic benefits to families, employers, and society at large. Breastfeeding allows the family to save the money that otherwise would be spent on infant formula, other human milk substitutes, and feeding equipment.

Further, a 2001 U.S. Department of Agriculture (USDA) study estimated that at least $3.6 billion (in year 1998 dollars) would be saved if breastfeeding rates were increased from the current rates to those recommended by the U.S. Surgeon General (75% in-hospital and 50% at 6 months). This estimate includes $3.1 billion is savings from prevented premature deaths, $500 million in savings from reduced healthcare costs (e.g., hospital visits, etc), and savings from averted indirect costs such as forgone earnings of parents.⁷

Estimated Cost of Preventive Intervention

In 2004, the private-sector cost of counseling to promote breastfeeding initiation and continuation averaged $23 per session; approximately 95% of all paid claims fell within the range of $0 to $81 per session.⁹

Estimated Cost of Treatment

Not Applicable

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention

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Condition / Disease Specific Information

Epidemiology of Condition/Disease

Breastfeeding provides protective immune globulins from the mother to the infant, completing the development of the infant's immune system after birth and thereby reducing the risk that the infant will acquire some serious infections. This immunologic protection is impossible to replicate with infant formula. Infants who are breastfed are thus better prepared to fight off infections and allergens than their non-breastfed counterparts. Additionally, human breast milk is universally recognized to be the optimal food for infants and is nutritionally superior to formula. Evidence suggests that breastfed infants are less likely to develop obesity, and type 1 and type 2 diabetes than bottle-fed infants.² Further, children who were breastfed have lower rates of otitis media (ear infections), respiratory infections, gastroenteritis, and eczema (a skin disorder).²

Despite the benefits of breastfeeding for both women and infants, breastfeeding rates in the United States remain suboptimal, especially among certain subpopulations. Data from 2005 show that 72.9% of all new mothers initiated breastfeeding and 39.1% continued to breastfeed for 6 months.⁴ However, only 63.5% of low income mothers and 55.4% of African-American mothers initiated breastfeeding. Further, only 29.7% of low income mothers and 24.8% of African-American mothers continued to breastfeed their infants for the recommend 6-month period.⁴

The Healthy People 2020 goals for breastfeeding aim to increase breastfeeding rates so that 81.9% of all new mothers initiate breastfeeding, 60.6% continue breastfeeding for at least 6 months postpartum, and 34.1% continue to breastfeed at least 1 year postpartum.⁵

Breastfeeding rates should be of paramount importance to employers as working outside the home negatively affects initiation and duration of breastfeeding.⁶ Furthermore, one-third of working mothers return to work within 3 months of the birth of their child, and two-thirds return within 6 months, the exact time period when breastfeeding is most critical.⁶

Condition/Disease Risk Factors

The mothers at highest risk for not breastfeeding are first-time mothers, those who have less formal education, those who are non-white, and those who are ill postpartum.⁶

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Preventive Intervention Information

Preventive Intervention: Purpose of Counseling

The purpose of counseling is to educate women on the benefits of breastfeeding and to provide support and skills-training for women who choose to breastfeed, thereby increasing the number of women who initiate and maintain breastfeeding for the minimum recommended period of 12 months.

Benefits and Risks of Intervention

Breastfeeding has important short- and long-term health outcomes for children. Research shows that children who were breastfed are at significantly lower risk for childhood obesity as well as type 1 and type 2 diabetes than their non-breastfed peers. Breastfed infants and children also have lower rates of otitis media (ear infections), respiratory infections, gastroenteritis, and eczema (a skin disorder).¹¹

Breastfeeding also has important short- and long-term health benefits for the mother. A woman's risk of breast cancer is decreased 4.3% for every 12-month increment of breastfeeding over her lifetime.¹¹ Her risk of ovarian and endometrial cancer is decreased by breastfeeding as well. Breastfeeding improves uterine tone, helps to stop post-birth bleeding, assists postpartum weight loss, and temporarily suppresses ovulation to aid in child-spacing.²

Educational programs have been shown to increase the proportion of women who initiate breastfeeding immediately after birth by 23% and the number of women who continue to breastfeed for 1 to 3 months by 39%. The efficacy of education programs is enhanced by ongoing support for breastfeeding initiation and continuation.¹²

There are no known risks of counseling to promote breastfeeding. In the United States, only women with the following conditions should be advised to avoid breastfeeding: women who are HIV positive; are taking antiretroviral medications; have untreated, active tuberculosis; are infected with human T-cell lymphotropic virus type I or type II; are using illicit drugs; are taking prescribed cancer chemotherapy agents that interfere with DNA replication; and whose infants who are diagnosed with galactosemia. Women undergoing radiation therapies need to temporarily interrupt breastfeeding but do not need to discontinue breastfeeding permanently.¹³

Initiation, Cessation, and Interval of Counseling

Counseling to promote breastfeeding should be offered to all women of childbearing age. It should begin during prenatal care and continue throughout the intrapartum hospital stay and into the postpartum period. Counseling should be given, according to need, throughout the course of lactation.

Intervention Process Counseling

Counseling should include breastfeeding initiation advice as well as skills and referrals to support breastfeeding continuation. The most effective breastfeeding education and counseling interventions last approximately 30 to 90 minutes and feature directive health education combined with behaviorally-oriented skills training and problem-solving.¹

Effective breastfeeding education and behavioral counseling programs¹:

• Begin during the prenatal period.
• Use face-to-face individual or group sessions.
• Are led by specially trained nurses, midwives, or lactation specialists.
• Sessions last 30 to 90 minutes.
• Include education on the benefits of breastfeeding for mother and infant, basic physiology, technical training on positioning and latch-on techniques, skills on how to overcome common barriers, skills to garner social support, how to use basic lactation support equipment such as breast pumps, etc.

Treatment Information

Not Applicable

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Strength of Evidence

The level of evidence supporting the recommendations contained in this section is described below.

Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: B (Recommended/At Least Fair Evidence)

• The USPSTF found at adequate evidence to suggest that coordinated interventions throughout pregnancy, birth, and infancy can increase breastfeeding initiation, duration, and exclusivity.¹

The American Academy of Family Physicians (AAFP)
Strength of Evidence: R (Recommended)

• AAPF recommends structured breastfeeding education and behavioral counseling programs to promote breastfeeding. Although evidence exists which demonstrates the net benefit of counseling to promote breastfeeding, either the benefit is only moderate in magnitude or the evidence supporting a substantial benefit is only fair. The intervention is perceived to be cost-effective and acceptable to most patients.³

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Summary Plan Description

Covered Counseling

Structured breastfeeding education and behavioral counseling is a covered benefit for all pregnant and lactating women. Counseling may be provided in an office setting, during hospitalization for labor/delivery, or in the patient's home after the birth of their child.

Initiation, Cessation, and Interval

Counseling to promote breastfeeding initiation and continuation is a covered benefit for all pregnant women and all lactating women. There is no maximum number of sessions, provided that the care is medically necessary.

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CPT Codes

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Other Information and Resources

Business Group Resource(s)

• Pregnancy-Related Health

CDC Resource

• Breastfeeding

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Author(s)

Campbell KP, Chattopadhyay S. Breastfeeding evidence-statement: counseling. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.

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References

1. U.S. Preventive Services Task Force. Primary Care Interventions to Promote Breastfeeding: U.S. Preventive Services Task Force Recommendation Statement. Originally published in Ann Intern Med 2008;149:560-4. AHRQ Publication No. 09-05126-EF-2, October 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/breastfeeding/brfeedrs.htm.
2. Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM. The CDC Guide to Breastfeeding Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.
3. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examinations. AAFP Policy Action. Revision 6.0; August 2005.
4. Centers for Disease Control and Prevention. National Immunization Survey. [cited 2006 Aug 31]. Available from: http://www.cdc.gov/breastfeeding/data/NIS_data/.
5. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. [cited 2011 July 23]. Available from: http://healthypeople.gov/2020.6 United States Breastfeeding Committee. Workplace breastfeeding support. Issue paper. Raleigh, NC: United States Breastfeeding Committee; 2002.
6. Donnelly A, Snowden HM, Renfew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women (Cochrane review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
7. Weimer J. The economical cost of breastfeeding: A review and an analysis. ERS Food Assistance and Nutrition Research Report No. 13, Washington, DC: Economic Research Services, U.S. Department of Agriculture; 2001.
8. Cohen R, Mrtek MB, Mrtek RG. Comparison of maternal absenteeism and infant illness rates among breast-feeding and formula-feeding women in two corporations. Am J Health Promot 1995:10(2):148-53.
9. Donnelly A, Snowden HM, Renfew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women (Cochrane review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
10. Bartick, M and Reinhold, A. The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics 2010; 125(5): e1048-e1056.
11. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50,302 women with breast cancer and 96,973 without the disease. Lancet 2002; 360: 187-95.
12. Guise JM, Palda V, Westhoff C, Chan BKS, Helfand M, Lieu TA. The effectiveness of primary care-based interventions to promote breastfeeding. U.S. Preventive Services Task Force. Ann Fam Med 2003; 1(2): 70-78.
13. Centers for Disease Control and Prevention. Breastfeeding: Infectious diseases and specific conditions affecting human milk: When should a mother avoid breastfeeding. [cited 2005 Dec 21]. Available from: http://www.cdc.gov/breastfeeding/disease/contraindicators.htm.