摘要：Objectives. We determined the effectiveness of primary care–based, and pre- and postnatal interventions to increase breastfeeding. Methods. We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP. Results. In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7). Conclusions. LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum. Breastfeeding is associated with improved health outcomes for both mother and child. 1,2 All major medical organizations recommend exclusive breastfeeding for the first 6 months after birth, with continued breastfeeding for at least 1 year. 3,4 Nationally, 36% of infants born in 2009 were exclusively breastfed at 3 months and 16% at 6 months, 5 falling short of Healthy People 2020 targets of 46%, and 26%, respectively. 6 A recent study found that suboptimal breastfeeding rates incur $2.2 billion in direct pediatric medical costs each year. 7 There are also substantial disparities, with the lowest breastfeeding rates seen among non-Hispanic Black, younger, and less-educated mothers. 8 Interventions are therefore needed to increase breastfeeding exclusivity and intensity, defined as the proportion of feedings that are breast milk. The United States Preventive Services Task Force (USPSTF) conducted a meta-analysis of randomized controlled trials of primary care–based breastfeeding promotion interventions. Interventions consistently increased rates of any and exclusive breastfeeding, although most findings were not statistically significant, and many studies were of poor quality. 9 Overall, systematic reviews supported the effectiveness of combined pre- and postnatal interventions, 8 scheduled, face-to-face visits, 10 and, for low-income women, on-going personal contact with a health professional. 11 In our previous trial, a pre- and postnatal intervention delivered by lactation specialists certified by the International Board of Certified Lactation Consultants (IBCLCs) had positive effects. However, IBCLCs were not a routine presence at prenatal care, intervention contact rates were suboptimal, and there was no provider involvement. 12 IBCLCs increase breastfeeding rates when integrated in primary care 13,14 and hospitals. 15 Ensuring access to IBCLCs is an action step in the surgeon general’s call to action to support breastfeeding. 16 We conducted 2 randomized controlled trials at urban, prenatal care sites in the Bronx, New York City. The present trials improve upon our previous work by integrating lactation consultants (LCs) into routine practice, 17 in combination with electronically prompted (EP) anticipatory guidance from prenatal care providers. We hypothesized that these interventions would increase breastfeeding intensity and exclusivity at 1, 3, and 6 months postpartum, compared with usual care.
