Use of Telehealth to Increase Breastfeeding Exclusivity and Duration

Background

Breast milk provides the optimal and preferred nutrition for infants, and offers both infant and maternal benefits that have been well established (Bomer-Norton, 2014). The American Academy of Pediatrics (AAP, 2012) recommends exclusive breastfeeding for the first 6 months of age and to continue breastfeeding with complementary foods until at least 1 year of age. Other national organizations, including the Centers for Disease Control and Prevention (CDC) and the Office of Disease Prevention and Health Promotion (ODPHP), have also identified the importance of breast milk and breastfeeding. These organizations have incorporated national goals related to breastfeeding into Healthy People 2020, a federal program that establishes 10-year science-based objectives aimed at improving the health of Americans (ODPHP, 2016). Furthermore, the importance of breast milk and breastfeeding is recognized on the global level by the World Health Organization (WHO). The WHO, like the AAP, recommends exclusive breastfeeding for the first 6 months of age, and further recommends breastfeeding for at least 2 years of age (WHO, 2016).

Despite the well-known benefits, and national and global recommendations related to breastfeeding, only 22.3% of newborns are exclusively breastfeeding at 6 months in the United States (CDC, 2016). This is below the Healthy People 2020 target goal of 25.5%. Many strategies to achieve the Healthy People 2020 goal have been studied, including maternal education related to breastfeeding and a combination of lay and professional support (Meedya, Fahy, & Kable, 2010).

To further identify strategies to reach the Healthy People 2020 goal, a systematic review and meta-analysis was completed in 2003 for the United States Preventive Services Task Force (USPSTF). This review found that educational programs and support interventions were the single most effective interventions to increase breastfeeding exclusivity and duration up to 6 months, and that policy and research should focus on how to better implement these practices into diverse care settings (Guise et al., 2003). Content in the identified interventions included benefits of breastfeeding, main principles of lactation, common problems, myths related to breastfeeding, and skills training (Guise et al., 2003).

Integrative Literature Review

This integrative review explores and evaluates strengths and limitations of the current research evidence supporting the effectiveness of telehealth to deliver breastfeeding education and support. This review includes all articles related to breastfeeding women and children and telehealth published from January 2009 to April 2016. Using the terms breastfeeding telehealth, lactation telehealth, breastfeeding telemedicine, and lactation telemedicine, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Science Direct, Cohrane Library, PubMed, and Medline electronic databases were searched. Inclusion criteria included primary levels of evidence from January 2009 to April 2016. Exclusion criteria included non-English language and articles before 2009. The initial search resulted in 284 articles. After application of screening and exclusion criteria, 11 articles were included in this review (Figure 1).

Figure 1.

Manuscript selection methodology.

Results are grouped in two categories: exclusivity and duration of breastfeeding with telehealth breastfeeding education and support (Table 1), and perception of telehealth breastfeeding education and support (Table 2).

Discussion

This review suggests that telehealth breastfeeding education and support can increase exclusivity and duration, and is perceived as an acceptable and beneficial modality. Outcomes from these studies are important; however, limitations and inconsistencies must be evaluated.

Six of the 11 studies use a sample size of less than 110 participants. Four of those include less than 40 participants. Additionally, out of the 11 primary studies, only 2, Seguranyes et al. (2014) and Ahmed et al. (2016), are designed as a randomized control trial and only Ahmed et al. (2016) found an increase in exclusivity and duration. The Seguranyes et al. (2014) study states similar outcomes in the intervention and control group. It is important to note that the control group in the Seguranyes et al. (2014) study also receives intervention in the form of face-to-face office support and therefore not considered telehealth intervention strategy. This study requires careful attention as both groups receive breastfeeding support, listing similar outcomes related to exclusivity and duration, leading results to suggest telehealth support has similar efficacy as face-to-face support in the studied population.

Small, focused, and nonrandomized samples in this review leave it unclear if support through telehealth has a similar relation with breastfeeding exclusivity and duration on larger, more diverse populations. Additionally, differing implementation strategies in the various studies limit comparisons. Five of the studies use videoconferencing, two use phone services, two use internet-based resources, and two use varied methods that include videoconference, phone, and internet resources. Ten of the 11 studies describe increased exclusivity and duration or perceived acceptance. This suggests that telehealth is effective and useful; however, it is difficult to recommend which telehealth modality is most closely related to the desired outcomes.

Other considerations include varied educational content. Although varied, content includes topics related to anticipatory guidance, latch and positioning, and more. Sources of education and support content differ greatly between the selected studies and include healthcare professionals, IBCLC, peer counselors, internet-based nonprofessional resources, social networking groups, and print information. Habibi et al. (2012) and Guijarro et al. (2014) do not list the content of the breastfeeding support. The content and source of education and support lack consistency between the selected studies, making it difficult to define which modalities and delivery methods are most effective.

Further studies are recommended with tightly controlled variables related to randomized sample, telehealth modality, and breastfeeding education and support content. These further studies should also tightly control the quality of content, including use of IBCLC to better understand the relationship to breastfeeding exclusivity and duration when delivered through telehealth.

Conclusion

Postpartum women should have breastfeeding education and support as it is clearly associated with increased breastfeeding exclusivity and duration (Guise et al., 2003). Use of telehealth to deliver this support provides a modern way to reach postpartum families and increase breastfeeding outcomes related to exclusivity and duration. Furthermore, telehealth is perceived as an acceptable and beneficial modality to receive sensitive health education. This is important as it promotes its successful use with postpartum families regarding personal information related to infant feeding and the maternal infant dyad.

In addition to the improved breastfeeding outcomes the use of telehealth provides postpartum families, it also provides an alternative intervention strategy for breastfeeding and lactation professionals. Differing from traditional face-to-face delivery of breastfeeding support, telehealth can allow professionals flexibility in delivery of education as location and distance are less present as barriers. Other implications to consider for professionals include possible increased continuity of care and access to clients through telehealth compared to face-to-face interactions.

Further considerations that would be important to explore include barriers to telehealth, financial implications, and disparities present. In this modern age of rapidly growing population and developing technology, telehealth presents as a promising modality to deliver breastfeeding education and support, promoting improved breastfeeding outcomes.