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The NP's role in promoting and supporting breastfeeding

Coffman, Lindsay, MSN, RN, CRNP, FNP-BC

doi: 10.1097/01.NPR.0000553401.96471.77

Abstract: This article reinforces the many health benefits associated with breastfeeding and exposes lactation barriers for mothers and healthcare practitioners. NPs can use various strategies outlined in this article to help patients overcome these barriers.

This article reinforces the many health benefits associated with breastfeeding and exposes lactation barriers for mothers and healthcare practitioners. NPs can use various strategies outlined in this article to help patients overcome these barriers.

Lindsay Coffman is a clinical nurse editor at Wolters Kluwer Health in Philadelphia, Pa.

The author has disclosed no financial relationships related to this article.



Breastfeeding offers countless benefits to the mother-infant dyad. Breastfed infants have a decreased risk of asthma, obesity, type 2 diabetes mellitus (T2DM), ear and respiratory infections, and sudden infant death syndrome. Mothers who breastfeed also experience health benefits, such as a decreased risk of heart disease, breast cancer, ovarian cancer, postpartum depression, and T2DM.1 Breastfeeding also enhances childbirth recovery and weight loss.2

Aside from the added health benefits, breastfeeding creates a unique bond between the mother and infant (see Bonding between a mother and infant). It provides a closeness and comfort that is hard to replicate. Human milk is matchlessly composed for each neonate, containing all the nutrients, calories, growth factors, and fluids needed by the growing infant. It is the gold standard for infant feeding and best positions the infant for healthy growth and development. It requires no preparation. These are all key factors in the continued success and popularity of breastfeeding for many women and their infants.1,3

The American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists, the World Health Organization (WHO), and the United States Preventive Services Task Force (USPSTF) all recommend that infants be exclusively breastfed for the first 6 months of life.4-8 The AAP recommends continuing breastfeeding for the first year or longer.7 The WHO recommends continued breastfeeding until the child is age 2 or older.6

In the US, 83% of infants start out breastfeeding, but despite the recommendation to breastfeed exclusively, after 6 months only 25% are exclusively breastfed.1 Healthy People 2020, an initiative by the US Office of Disease Prevention and Health Promotion, established an objective to increase the number of infants who are breastfed, setting a target goal for initiation of breastfeeding at 81.9% and 60.6% for infants who are exclusively breastfed for up to 6 months.9 Low success rates of breastfeeding in the US contribute to over $3 billion in medical costs per year.1 A single family can save over $1,000 in a year by breastfeeding compared with using formula feeding.2 To improve the success rates of mothers who wish to breastfeed, NPs can promote breastfeeding and provide support throughout the dyad's breastfeeding journey.

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Evidence-based findings and needs

The literature shows that early cessation of exclusive breastfeeding has been linked to:

  • breastfeeding difficulties, such as problems with latching4,10-13
  • maternal perception of low milk supply4,12,13
  • maternal perception that their infant's needs are not being met (for example, breastfeeding is thought of as being too challenging for the infant or the infant is not perceived to be satisfied after feeds)4,11
  • insufficient knowledge about breastfeeding12,13
  • sore nipples4
  • mode of delivery (vaginal births have higher breastfeeding rates than cesarean births)14
  • concerns about medications taken by the mother11
  • lack of support in the workplace4,10,12-14
  • lack of practitioner and family support10,12,13
  • lack of maternal self-efficacy12,13
  • maternal depression15
  • socioeconomic background4,10,14
  • cultural norm.10,16

Current research cites a lack of breastfeeding support as the main reason for early cessation.13 With all these additional challenges, it is even more important for NPs to be supportive figures for their patients who are breastfeeding. Evidence-based interventions shown to be most effective include early and persistent lactation support, education (maternal and healthcare practitioner), and maternal confidence reassurance.17,18 A multidimensional and collaborative approach has been shown to produce optimal breastfeeding rates and outcomes.19



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Overcoming common barriers

Healthcare practitioners face many barriers related to breastfeeding. The main barrier is the lack of experience and training in lactation, which is imperative to the initiation and continuation of breastfeeding. Some healthcare practitioners are unsure how to reimburse for lactation services or even unaware of coverage of equipment and services, such as lactation counseling. This is especially important for working mothers who express milk, or pump, in the workplace.

Overcoming these common barriers involves asking about breastfeeding on intake forms, identifying lactation experts in the area, providing lactation-specific training, and having a process in place for billing and reimbursement. By identifying local experts in lactation, NPs can expand their network of resources. In addition to gaining supplementary support, expertise becomes available for patients facing complicated issues who need to be referred. Training should include standards for reimbursement, follow-up and referral, problem solving related to breastfeeding issues, and ways to incorporate the topic of breastfeeding into routine visits.20

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Recommended interventions

Successful breastfeeding is greatly dependent on education and support provided to the patient. The USPSTF recommends the implementation of lactation interventions for all women during pregnancy and after giving birth to promote and support breastfeeding. This recommendation has a Grade B endorsement, which indicates that the overall benefit is moderate to substantial.21

Effective strategies to endorse breastfeeding consist of direct collaboration, proper education for mothers and their families (including prenatal and postnatal programs with behavior-orientated counseling), and practical skills training for all healthcare practitioners. Written handouts can be effective but should be combined with educational programs. Formula packages should not be distributed initially because they can discourage the initiation of breastfeeding. Interventions should be provided collaboratively by various healthcare practitioners, including the primary care practitioner, obstetrician, pediatrician, and others who care for the mother before and after delivery. Support must be ongoing into the postpartum period.5,20,21

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The Surgeon General's call to action

The Surgeon General's call to action outlines steps that can be taken to support breastfeeding. The goal is to remove the obstacles encountered by the mother-infant dyad and promote breastfeeding. Key players in this approach include employers, healthcare practitioners, hospitals, International Board-Certified Lactation Consultants (IBCLCs), community leaders, and families and friends.10



Patient support. Provide support to mothers and their infants. Pregnant women should be introduced to the significance and benefits of breastfeeding. Furthermore, they should be taught how to breastfeed. Mothers should feel comfortable discussing their breastfeeding plans with their maternity care practitioner. Healthcare practitioners must inspire mothers to ask for help when in need.10

Knowledge and skills. Foster formal education and training for all healthcare practitioners who care for women and children. The Surgeon General recommends improving educational training on lactation, particularly in undergraduate and graduate programs. They propose minimal requirements in lactation for credentialing, licensing, and/or certification. Opportunities for continuing education about breastfeeding are easily accessible and available to everyone (see Lactation resources for healthcare practitioners).10

Finally, the Surgeon General emphasizes becoming a part of national efforts, endorsing healthcare changes that support breastfeeding, writing healthcare standards and policies, and being a leader.10

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The Tri-Core Breastfeeding Conceptual Model

The Tri-Core Breastfeeding Conceptual Model comprises best-practice guidelines developed in support of the National Association of Pediatric Nurse Practitioner's (NAPNAP's) Position Statement on Breastfeeding, the Surgeon General's 2011 call to action to support breastfeeding, the WHO's international Baby Friendly Ten-Steps initiative, and breastfeeding objectives from Healthy People 2020.19 This model can be applied to enhance breastfeeding rates and outcomes for mothers and infants. This approach can be used to promote and sustain breastfeeding through evidence-based practice and education in a primary care setting. The Tri-Core Model considers three key principles used to care for the mother and infant dyad: self-efficacy, lactation support, and lactation education (see How can you support your patients?).19

Self-efficacy. Mothers can gain self-assurance about breastfeeding through various strategies promoted by the healthcare practitioner. Offering networks, such as support groups or peer counseling, can empower and positively influence breastfeeding mothers. Breastfeeding does not need to be an independent journey; it is beneficial to include partners and family members in different ways. Mothers can include their loved ones by encouraging them to participate in other aspects of the infant's care, such as by washing pump parts or helping with positioning to ensure a proper latch. Empathetic listening, offering thorough guidance, and providing encouragement and affirmation are all great ways to help a mother become more confident with breastfeeding.19

Discussing lactation with mothers is a great first step in introducing the concept of breastfeeding. Sharing the numerous benefits breastfeeding provides to the mother and infant can often be a positive conversation starter.4 Barriers to support, previous experiences, and future challenges that may arise, such as returning to work, should all be identified upfront.19 For women returning to work, the NP should provide empowerment by discussing mothers' rights in the workplace.14 If the mother is taking any medications, their safety should be verified using an evidence-based reference. Moreover, barriers to breastfeeding should be identified to recognize factors that may have a negative impact on breastfeeding and help direct programs and resources to families of women who may not otherwise breastfeed. Discussions regarding lactation can begin during pregnancy and continue until breastfeeding stops.4

Lactation support. It is important for the mother to know what to expect and feel supported by her healthcare team throughout. NPs can influence their patients to choose breastfeeding by guiding them and providing inspiration to start and extend their breastfeeding journey. The mother should be reassured to seek help if any issues should arise, regardless of whether problems encountered are large or small. Some women stop breastfeeding prematurely because they do not know where to go or who to ask when these issues come up.1

Mothers often need initial support to troubleshoot lactation problems during the first few months postpartum. This is a fragile time, and it is essential for the NP to know how to address common lactation problems and where to refer patients if needed. Patients should have access to an IBCLC in their area. Factors to consider with lactation consultant referrals include proximity to the patient, whether the IBCLC makes house calls, what types of insurance are taken, and the consultant's hours. In addition, peer counselors are available in many communities. These are trained and motivated volunteers looking to help mothers succeed in breastfeeding.1



A prenatal breast assessment can be performed during a physical and can identify women who might have trouble breastfeeding because of certain conditions, which may include hypoplastic breast tissue, nipple abnormalities, and history of breast surgery. These conditions do not guarantee that the woman will face lactation difficulties, but being prepared to handle them if they do arise is useful.1 A comprehensive breastfeeding assessment during the postpartum period is helpful as well. Factors to include as part of this assessment are lactogenesis, proper latch, infant weight gain and output, and feeding activity. Identifying each mother's unique needs and forming an individualized breastfeeding care plan is essential in managing interventions for lactation.19

Lactation education. Education must be patient-centered and evidence-based. Resources should be offered and provided in various formats, such as online and handouts. Guidance and resources should cover common topics such as feeding cues, proper latch, human milk production, infant-mother separation, and any other specific concerns the mother may have. Demonstration of positions can be helpful for patients who are visual learners (see Breastfeeding positions). It is important to cover different organizations' recommendations about length of breastfeeding in addition to anticipatory guidance during each visit.19



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Breastfeeding is the gold standard for infant feeding and nutrition, providing numerous unique health benefits to both mother and infant.4 Barriers for mothers and healthcare providers must be identified to help meet the goals of the mother as well as those outlined in Healthy People 2020. Education for NPs about how they can play a role in supporting breastfeeding is essential. Members of the healthcare team who provide care for the mother before and after delivery are at the forefront of promoting breastfeeding. It is imperative for these practitioners to provide the support and care that is needed for mothers to initiate and continue breastfeeding.

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1. Centers for Disease Control and Prevention. Breastfeeding. 2018.
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18. Joanna Briggs Institute. Best practice information sheet: women's perceptions and experiences of breastfeeding support. Nurs Health Sci. 2012;14(1):133–135.
19. Busch DW, Logan K, Wilkinson A. Clinical practice breastfeeding recommendations for primary care: applying a tri-core breastfeeding conceptual model. J Pediatr Health Care. 2014;28(6):486–496.
20. Agency for Healthcare Research and Quality. Primary care interventions to promote breastfeeding. 2015.
21. U.S. Preventative Services Task Force. Breastfeeding: primary care interventions. 2016.

breastfeeding; infant; lactation; primary care; support; Tri-Core Breastfeeding Conceptual Model

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