Tip sheet for Oct. 21, 2008, issue of Annals of Internal Medicine

October 20, 2008

1. U.S. Preventive Services Task Force Recommends Primary Care Interventions to Promote Breastfeeding

PHILADELPHIA, October 21, 2008 -- Following an extensive evidence review, the U.S. Preventive Services Task Force (USPSTF) concluded that doctors, nurses, hospitals and health systems have a role to play in encouraging and supporting breastfeeding. In an update to its 2003 recommendation on counseling to promote breastfeeding, the USPSTF recommends primary care interventions before, around, and after child birth to encourage and support breastfeeding. The recommendation appears in the October 21, 2008, issue of Annals of Internal Medicine, the American College of Physicians' flagship journal.

For the study, the Task Force evaluated more than 25 randomized trials of breastfeeding interventions conducted in the United States and in developed countries around the world. The Task Force concluded that coordinated interventions throughout pregnancy, birth, and infancy can increase breastfeeding initiation, duration, and exclusivity. For example, a cluster-randomized trial of more than 17,000 mother-infant pairs in the Republic of Belarus found that breastfeeding interventions increased the duration and degree (exclusivity) of breastfeeding. Infants in the intervention group were significantly more likely than those in the control group to be exclusively breastfed (exclusive breastfeeding is when an infant receives no other food or drink besides breast milk). The intervention emphasized health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support.

"Our review produced adequate evidence that multifaceted breastfeeding interventions work," said Task Force Chair Ned Calonge, MD, MPH, who is also Chief Medical Officer for the Colorado Department of Public Health and Environment, Denver. "We found that interventions that include both prenatal and postnatal components may be the most effective at increasing breastfeeding duration. Many successful programs include peer support, prenatal breastfeeding education, or both."

In 2005, 73 percent of new mothers initiated breastfeeding, nearly reaching the U.S. Healthy People 2010 goal of 75 percent. However, only 14 percent of infants were exclusively breastfed for their first six months, as recommended by the American Academy of Pediatrics, the American Academy of Family Physicians, and the U.S. Surgeon General.

Breastfeeding has substantial health benefits to babies and their mothers. Babies who are breastfed have fewer infections and allergic skin rashes than formula-fed babies and also are less likely to have sudden infant death syndrome (SIDS). After breastfeeding ends, children who were breastfed are less likely to develop asthma, diabetes, obesity, and childhood leukemia. Women who breastfeed have a lower risk for type 2 diabetes, breast cancer, and ovarian cancer than women who have never breastfed.

"We hope that these recommendations will help women and their physicians understand what they need to do to start and continue breastfeeding their babies," said Dr. Calonge. "Simply telling mothers they should breastfeed or giving them pamphlets is not enough."

2. Combining Therapies May Improve Outcomes in Patients with Pulmonary Hypertension

Pulmonary hypertension is a rare but serious and often fatal disease. The most commonly prescribed medication for pulmonary hypertension is epoprostenol given daily by intravenous infusion. However, even on therapy, many patients do poorly. Researchers conducted an open-label randomized study of 267 patients to determine whether a combination of sildenafil (Viagra) and epoprostenol could improve outcomes more than epoprostenol alone. All of the patients in the study had been receiving intravenous epoprostenol for at least three months, and were randomly assigned either oral sildenafil or placebo for 16 weeks. At the end of the study, patients given sildenafil could walk longer distances and had a longer period of time before getting worse than those given placebo. Researchers concluded that adding sildenafil to epoprostenol therapy may improve some outcomes for patients with pulmonary hypertension.

3. Nurse-led Disease Management Reduces Cost, Burden of Heart Failure in Ethnically Diverse Urban Community

Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. However, there is less evidence about the cost-effectiveness of these programs. Researchers looked at cost data from a randomized trial of 203 usual care patients versus 203 nurse-managed patients with heart failure. The study consisted mainly of black and Hispanic patients with lower socioeconomic status. Patients in the nurse-managed group maintained better physical functioning throughout the 12-month intervention than did usual care patients. In addition, nurse-led case management was cost-effective (it cost $20,000 per additional year of survival in good health). Researchers concluded that nurse-led disease management was a reasonably cost-effective way to reduce the burden of heart failure in an ethnically diverse urban setting. The results might not apply to patients in other communities.

American College of Physicians

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