Question

• A national study of physicians report that despite strong support for breastfeeding promotion, may pediatricians report inadequate knowledge and limited training in breastfeeding management. Would a “hands-on” educational intervention for pediatricians increase their rates of breastfeeding counseling?

Clinical Bottom Lines

1. Breastfeeding confers superior nutritional and immunologic protection to young infants.
   
2. Despite the benefits of breastfeeding, the number of mothers breastfeeding immediately post-partum and at the 6-month visit is lower than desired.
   
3. Surveyed pediatricians demonstrated significant knowledge deficits and reported inadequate training in breastfeeding benefits and clinical management.(2,3,4)
   
4. A multimedia educational intervention increases physicians’ knowledge. However, it is unclear if it also increases physicians’ counseling behaviors.(1)

Summary of Key Evidence

1. A prospective interventional study was performed.(1)
   
2. Participants were Pediatric and Medicine-Pediatric residents in training at the University Health Systems of Eastern Carolina (n=49) Patient population was breastfeeding mothers who were either insured by Medicaid, underinsured or uninsured (n= 40).
   
3. Residents were included who participated in outpatient clinics during the study period Residents who only participated in the per/post questionnaires were included and assessed for knowledge and confidence, but not behavior. Residents were excluded if they did not take the pretest nor saw any breastfeeding infants in clinic.
   
4. 4-session multi-media curriculum was administered to residents. Pre and post intervention questionnaires were used to assess knowledge and confidence. To assess behavior pre and post telephone surveys of breastfeeding mothers seen in clinic by residents were performed.
   
5. Residents’ composite knowledge score increased from 69% to 80 % (P <0.01).
   
6. Confidence score increased post intervention. 53% residents reported low confidence at the beginning of the survey. 94% of residents reported an increase in their confidence.
   
7. Active counseling of mothers increased at least short term. Post intervention, residents performed acceptable numbers of behaviors 65% of the time compared to 22 % pre-intervention.
   
8. Resident behaviors increased even if they did not attend any of the educational sessions.
   
9. Even though the percentage of acceptable counseling behaviors increased at individual visits, we do not know if the actually number of patients counseled by each resident increased.
   
10. Limitations of the study: there was no control group for comparison. Residents’ behaviors were assessed by follow-up telephone interviews of breastfeeding mothers. This relied on mother accurately re-calling what the resident actually did during the encounter. We do not know if the residents were similar at the beginning of the intervention in regards to their prior knowledge, training and personal experience with breastfeeding.

Additional Comments

• Healthy People 2010 Objectives: Increase in number of mothers who breastfeed from 64%-75% early post-partum, from 29% to 50% at age 6 months.
  
• Although new mothers place a high value on the advice of their health care provider, they typically receive minimal advice about breastfeeding from a physician.
  
• Longitudinal studies looking at physician counseling behaviors over time would be more helpful to assess if the intervention truly made an impact on their rates of counseling.
  

Citation

1. Hillenbrand KM, Larsen PG. Effects of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians. Pediatrics 2002; 110:e59-65.
   
2. Freed GL, et al. National Assessment of Physicians’ Breast-feeding Knowledge, Attitudes, Training, and Experience. JAMA 1995; 273:472-476.
   
3. Freed GL, et al. Pediatrician Involvement in Breast-Feeding Promotions: A National Study of Residents and Practitioners. Pediatrics 1995; 96: 490-494.
   
4. Schanler RJ, et al. Pediatricians’ Practices and Attitudes Regarding Breastfeeding Promotion. Pediatrics 1999; 103(3) e35.

CAT Author: Faye Holder, MD

CAT Appraisers: John G. Frohna, MD

Date appraised: February 10, 2003